“There’s a Catch-22”. The complexities of pain management for people with advanced dementia nearing the end of life: a qualitative exploration of physicians’ perspectives

Background: Pain management is a cornerstone of palliative care. The clinical issues 76 encountered by physicians when managing pain in patients dying with advanced 77 dementia, and how these may impact on prescribing and treatment, are unknown. Aim: 78 To explore physicians’ experiences of pain management for patients nearing the end of 79 life, the impact of these on prescribing and treatment approaches, and the methods 80 employed to overcome these challenges. Design: Qualitative, semi-structured interview 81 study exploring: barriers to and facilitators of pain management, prescribing and 82 treatment decisions, and training needs. Thematic analysis was used to elicit key themes. 83 Settings/Participants: Twenty-three physicians, responsible for treating patients with 84 advanced dementia approaching the end of life, were recruited from primary care (n=9), 85 psychiatry (n=7) and hospice care (n=7). Results: Six themes emerged: diagnosing pain, 86 complex prescribing and treatment approaches, side-effects and adverse events, route of 87 administration, importance of sharing knowledge and training needs. Knowledge 88 exchange was often practised through liaison with physicians from other specialties. 89 Cross-specialty mentoring, and the creation of knowledge networks were believed to 906improve pain management in this patient population. Conclusions: Pain management in 91 end-stage dementia is complex, requiring cross-population of knowledge between 92 palliative care specialists and non-specialists, in addition to collateral information 93 provided by other health professionals and patients’ families. Regular, cost- and time-94 effective mentoring and ongoing professional development are perceived to be essential 95 in empowering physicians to meet clinical challenges in this area.