**3.2 Assessment of the pain**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

malignancy, producing a poor quality of life.

**3. New approaches of pain treatment**

individual tailoring of the therapy to the real needs [21].

**3.1 The multimodal approach to pain management**

perspective.

sparing effect [24].

the variety of experiencing pain [25, 26].

different physiological causes of the pain.

of the leading symptoms of terminal states and often concomitant symptom of the

Pain is a common symptom in many advanced illnesses [18]. Nowadays, the treatment of pain is approached from neurobiological, clinical, and behavioral

The main goals of the pain management are early recognition, early proper pain relief, monitoring and documentation. New approaches to the management of pain in palliative care integrate the standard pain relief methods with complementary health techniques [19]. The expectations of the patients at a Hospice are to have an active, pain-free life. The potential to reach these expectations is though the patients tailored analgesia and the integrations of alternatives with medical treatment in multimodal analgesic approach. A multimodal flexible approach to pain relief therapy for palliative care provides the best results. It consists of the use of more therapeutic abilities at the same time frame, at different time intervals. The main characteristic of this therapy is a continuum of analgesic management [20]. The last advancement in pain management treatment is multimodal analgesia with

The multimodal approach to pain management which was introduced in 1993 by Kehlet and Dahl as an analgesic model for postoperative pain is already well established [22]. The fact that nearly 10–30% of patients with cancer pain were not satisfied with the standard pain relief treatment (use of systemic analgesics alone) [23] commanded research for new analgesic approaches for more severe pain. The complex mechanism of pain in which physical and psychological disorders are involved need corresponding therapeutic approaches; complex and focused on pain relief, improvement of mental status, psychological treatment, education, and socialization. It seems that multimodal approach in pain management can reach all those necessities providing less use of opioids for 10–20%

The multimodal analgesia (MMA) and its opioids sparing effect, provides a significant efficacy in pain treatment and takes an important place for curing acute or chronic pain in palliative medicine. It involves multiple combinations of drugs (opioids, non-opioids, and sedatives), non-pharmacological therapies and some specialized techniques to provide better analgesia.A variety of fixed combinations of analgesic drugs are available on the market. In those combinations, the paracetamol, and non-steroidal anti-inflammatory drugs (NSAIDS) play important part of the multimodal approach to analgesia. Used in palliative setting the multimodal approach may meet the individual patient needs of altered nociception and

The main goal of this therapeutic approach is the treatment of pain by targeting

Data about genetic polymorphism speaks about the necessity to tailor the pain management according to the real patients' need [27]. According to the ladder algorithm, selection of non-opioid, opioid, and adjuvant analgesic therapy should be adapted to the intensity of the pain [28]. Identification of opioid receptor gene regulation, its transcription factors and post-transcriptional events are considered as alternative variations in mRNA stability and translation efficiency.

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The assessment of the pain is the most important part of pain treatment. It is an initial step in the evaluation of the level of pain and continues during all pain relief episodes, as constant reevaluation of the effects of pain management. An effective relief of pain depends mainly on a comprehensive assessment to identify the different physical, psychological, social, and spiritual aspects. The oral description of the presence of pain is insufficient to express the real patients' suffering. It is more visible by other objective, autonomic and behavioral sights that are expressed through mimics, sweating, tears, or with changes in vital parameters in the person [4].

The subjective feeling of pain is difficult to be measured, but its effects on vital parameters may be measured. Based on this, the evaluation of the pain is being based. Generally, there are two main principles: objective (Type I) and subjective (Type II) method for pain evaluation. The difference between those two methods is the opportunity to present the individual feelings of pain in measurable values. The objective evaluation is measurable by the detection of the changes in physiological, neuropharmacological, and neurological parameters. In the Type II evaluation approach, the subjective patients' feelings of pain, measured by self-evaluation, are presented in measurable values- scores. In practice, for PC use, more applicable are the less invasive methods, which are present in Type II evaluation [30].

Taking anamnesis is the first step which helps enormously, where the patient must describe the pain in detail. It is necessary to provide information about the severity of the pain, the history – when, where, how the pain appeared, examine the location of pain, and to investigate the state of the other systems (imaging, organ function). To assign the appropriate management, it is important to discover: the origin of the pain, the states in which the pain is more intensive, the quality of the pain, the route of propagation of the pain, and the degree and the intensity of the pain. In assessing the symptoms, one can use the OPQRSTUV mnemonic (O- Onset, P- Position, Q- Quality, R- Radiation, S- Severity, T- Timing, A- Associated features, A- Aggravating Factors, A- Alleviating Factors) [19].

The received information helps in understanding the pathophysiology and in classification of the pain as nociceptive or neuropathic. An objective evaluation of the pain during palliative care is difficult; it is caused by the lack of communication with the patients so the use of conventional scales for measurement of pain is almost impossible [31]. For this reason, for patients in palliative care and in children, a multidimensional approach is accepted worldwide [4]. It works by using subjective explanations or common methods for self-evaluation of the level of pain, and objective signs from behavior and other vital parameters. Subjective feelings of the pain are measured with self-evaluation using several scales that help in the evaluation of the severity of the pain or pain questionnaires useful for children and older people (**Table 1**). In multidimensional approach the subjective methods in Type II evaluation are supplemented with the objective reports of the medical staff, relatives, parents, guardian, and others involved in the palliative care [32].


*Legend: BP-blood pressure; CVP-central venous pressure; RR-respiratory rate; VC-vital capacity. FEV-forcefully expired volume; TV-tidal volume*.
