Anesthesiology, Pain and Palliative Medicine

01Purpose and scope

• This manual supports the course Anesthesiology, Pain and Palliative Medicine. It is written as a working reference for anesthesia clinicians, nurses, pharmacists, surgeons and trainees who share responsibility for patients undergoing procedures, living with pain, or approaching the end of life.
• The scope covers perioperative anesthetic care, procedural and postoperative pain control, referral and early management of chronic pain, and palliative symptom control with goals of care conversations. It does not set out legal authority to prescribe or administer controlled substances, which varies by jurisdiction and by employer. Check the current rules from your licensing board, drug enforcement agency or national equivalent, and your institution's policies.
• This guidance does not replace qualified professional judgment, approved local procedures or required authorization. Anesthesia, opioid prescribing and end-of-life decisions carry direct risk of serious harm, so every step described here should be adapted by a licensed clinician who has examined the patient and knows the local formulary and equipment.

02Core principles

• Treat the patient, not the number. Pain and symptom scores are useful trend tools, but they only mean something when they are read alongside function, sleep, mood, the patient's own goals and the findings on examination. A patient who rates pain at 4 out of 10 and cannot walk to the bathroom has a different problem from one who rates it the same and is walking the corridor.
• Use layered safety. No single monitor, checklist or clinician catches everything. Anesthesia depends on equipment alarms, trained staff, standardized drug labeling, double checks for high-alert drugs and clear escalation paths working together. When one layer fails, another should still stand between the patient and harm.
• Prefer multimodal analgesia where it fits. Combining non-opioid agents, regional techniques and opioids at lower doses often gives better pain control with fewer side effects than high-dose opioid monotherapy. The trade-off is complexity: more drugs mean more interactions, more monitoring and more places for errors in dosing or timing.
• Match the goal to the stage of illness. In acute perioperative care, the aim is a safe anesthetic, rapid recovery and early return to function. In palliative care, the aim is comfort, dignity and the patient's priorities, even when that means accepting some drowsiness or fewer life-prolonging interventions.
• Communicate plainly and early. Patients and families tolerate uncertainty better than surprise. Explain what will be done, what the common risks are, what the plan is if pain or symptoms are not controlled, and who to call.

03Planning and preparation

• Preoperative assessment is where most anesthetic risk is identified or missed. Review the history, prior anesthetic records, current medications including anticoagulants and antiplatelet agents, herbal supplements, allergies, and the presence of conditions such as obstructive sleep apnea, obesity, cardiac disease, renal or hepatic impairment, and frailty. Record the American Society of Anesthesiologists physical status classification, which is a widely used shorthand for overall fitness for anesthesia, while recognizing that it is a rough grouping and not a complete risk score.
• Airway examination should be documented before every case where sedation or general anesthesia is planned. Note mouth opening, neck mobility, dentition, and any prior difficult airway. Confirm that the equipment and backup airway devices are available and that the team knows the plan if intubation or ventilation proves difficult.
• Medication reconciliation needs a specific plan for each drug. Opioid users may need their baseline dose continued, and those on long-term opioids or benzodiazepines are at higher risk of respiratory depression when multiple sedating agents are combined. Decisions about holding anticoagulants, metformin, angiotensin-converting enzyme inhibitors or other agents depend on the procedure, the patient's kidney function and local protocols, so they should be made with the surgeon and prescriber rather than by default.
• Palliative needs should be screened even in a surgical or procedural setting. Ask about serious illness, prognosis, advance directives, code status, and whether the patient has a surrogate decision maker. A brief screen at this stage often prevents a crisis later and gives the palliative team time to see the patient before symptoms escalate.
• Consent and goals should be confirmed before the day of the procedure where possible. The consent conversation should cover the anesthetic technique, the common and serious risks, alternatives including no treatment, and how postoperative pain will be managed. For regional techniques, mention the possibility of nerve injury, bleeding, failure of the block and the need for rescue care.

04Recommended workflow

1. 1
   : Confirm identity, procedure, consent and site marking before any drug is given. Use the local time-out process, which in many hospitals follows the structure of the World Health Organization Surgical Safety Checklist. Do not skip this step when the case is urgent or the team is familiar with the patient.
2. 2
   : Perform the pre-induction check. Confirm that the anesthesia machine, suction, oxygen supply, monitors, difficult airway cart and emergency drugs are working and within date. Verify that high-alert drugs are labeled and that the infusion pumps are programmed with the correct concentrations.
3. 3
   : Establish monitoring appropriate to the level of sedation or anesthesia. The American Society of Anesthesiologists publishes basic intraoperative monitoring standards that include continuous electrocardiography, noninvasive blood pressure, pulse oximetry and capnography for patients under general anesthesia or deep sedation. Adjust to the procedure, the patient and local policy, and document any deviation.
4. 4
   : Induce and maintain anesthesia or sedation according to the plan. Titrate drugs to effect, not to a fixed schedule alone. Reassess depth, ventilation, hemodynamics and temperature at regular intervals and after each significant change in surgical stimulus.
5. 5
   : Start analgesia before the procedure ends where feasible. Preemptive or early multimodal analgesia, including regional blocks when suitable, reduces the amount of rescue opioid needed in recovery. Document what was given, when, and by whom, including the total dose of any opioid used intraoperatively.
6. 6
   : Hand over to the recovery team using a structured tool such as SBAR, which covers situation, background, assessment and recommendation. Include the airway status, the last opioid and sedative doses, the planned analgesia, any blocks placed and the expected course in recovery.
7. 7
   : Reassess in the recovery area using a validated pain scale, sedation score such as the Richmond Agitation-Sedation Scale, respiratory rate, oxygen saturation and level of consciousness. Continue reassessment after each opioid dose, and at intervals that match the risk profile of the patient. Patients with obstructive sleep apnea or concurrent sedative use usually need longer observation and continuous oximetry.
8. 8
   : Transition to the ward or home with a written plan. For inpatients, this includes scheduled non-opioid analgesia, a clear as-needed regimen, a bowel regimen where opioids are used, and a named clinician to call. For ambulatory patients, give written discharge instructions, a responsible adult contact and clear criteria for returning or calling emergency services.
9. 9
   : For palliative symptom control, begin with a full assessment of each symptom, including its severity, timing and effect on function. Match the treatment to the cause where possible, using the World Health Organization analgesic ladder as a general framework for pain, adjusted for renal function, opioid tolerance and the patient's swallowing ability. Review response within a defined interval and adjust the plan rather than adding drugs without reassessment.
10. 10
    : Hold a goals of care conversation when the prognosis is uncertain or changing. Use plain language, invite the patient and family to share what matters most, and document the outcome including code status, preferred place of care and the surrogate decision maker. Revisit the plan when the clinical picture changes.

05Quality checks, risk controls and compliance

• Controlled substances carry legal and clinical risk. Keep accurate records of every dose, waste and return, following the institution's procedures and the requirements of the relevant national or regional authority. Logs should be reconciled at the end of each shift, and any discrepancy should be reported and investigated before the next case begins. Requirements for storage, witnessing and waste vary by jurisdiction, so confirm them against current official guidance rather than memory.
• Opioid risk is highest when several sedating drugs are used together, when patients are older or frail, when they have sleep apnea or renal impairment, and when the dose is increased quickly. Use continuous monitoring where local policy requires it, and have naloxone available on wards that give opioids. Set a clear process for escalation when sedation scores rise or respiratory rate falls.
• Regional anesthesia requires its own checks. Confirm the site, the laterality, the local anesthetic dose and the maximum safe dose for the patient's weight. Have lipid emulsion and resuscitation equipment available where local protocols require them, and know the signs of local anesthetic systemic toxicity. Ultrasound guidance and nerve stimulation are used in various combinations depending on local training and equipment.
• High-alert drugs such as neuromuscular blockers, concentrated potassium, and some infusions require independent double checks or standardized labels. Use barcode or pump safety features where they exist, and report near misses so the wider team can learn from them.
• Compliance with accreditation and professional standards is part of routine practice. Keep records of equipment checks, drug audits and training, because these are often examined during external review. Where a specific standard is mentioned in your local policy, confirm the current version with the body that issues it, since guidance is revised over time.
• Limits should be stated openly. Pain measurement tools are subjective, monitors can fail or give false readings, and palliative prognosis is an estimate. Build these limits into the plan by setting reassessment points, backup options and a clear path to specialist input.

06Collaboration and documentation

• Anesthesia and palliative care work across many roles. The anesthesiologist or anesthetist leads the intraoperative plan, the surgeon controls the operative field and timing, the nurse manages monitoring and recovery, the pharmacist checks doses and interactions, and the palliative team supports symptom control and goals. Good care depends on clear roles, so each person should know who owns each decision, especially when priorities conflict, for example when a surgeon wants a longer block but the patient has low respiratory reserve.
• Documentation should be contemporaneous and specific. A useful anesthetic record shows the times of key events, drug doses, fluids, blood loss, airway details, complications and handover details. Pain and sedation scores should be recorded with the time and the action taken. Vague entries such as stable or comfortable do not help the next clinician.
• Structured handover reduces information loss. Use the same format every time so that the receiving team knows where to look for information. Include the code status, advance directive, allergies, the most recent opioid dose and any planned changes.
• Goals of care and advance directives should be visible in the record and easy to find. Document the discussion, who was present, the patient's stated preferences and any limits on treatment. Where the patient lacks capacity, record the surrogate decision maker and the basis for their authority, following local law.
• Families and caregivers are often the people who see pain and symptoms at home. Give them written instructions on medicines, warning signs and who to call. Ask them what they have observed, because their account often explains what the clinical record misses.

07Measures and continuous improvement

• Track indicators that reflect both safety and patient experience. Useful measures include time to discharge from recovery, unplanned admission to intensive care within a defined period after surgery, incidence of postoperative nausea and vomiting, rate of inadequate analgesia on ward rounds, opioid consumption per procedure, sedation or respiratory events requiring intervention, and patient-reported satisfaction with pain control. Define each measure carefully before collecting it so that results can be compared over time.
• For palliative care, track symptom burden using a validated tool such as the Edmonton Symptom Assessment System, the proportion of patients with a documented goals of care conversation, the timing of specialist referral relative to admission, and the proportion of patients who die in their preferred place of care where this is recorded locally.
• Audit should lead to action. When a measure shows a problem, identify the cause using a short review of cases, then test a change such as a revised handover tool, a new opioid order set or a different monitoring schedule. Check whether the change worked before making it permanent.
• Be cautious about trade-offs. Reducing opioid use can increase pain if it is not replaced by other analgesia. Increasing monitoring can increase alarm fatigue. Shortening recovery times can increase early readmission if patients leave before they are stable. Look at several measures together rather than optimizing one at the expense of others.
• Benchmarks differ by setting, case mix and local policy. Compare your results with your own past performance and with peers in similar services, rather than with national averages you cannot verify.

08Common mistakes and how to prevent them

• Relying on a single pain score. A patient can score pain as low while being unable to mobilize or sleep, and the reverse can also be true. Prevent this by asking about function and checking what the patient is trying to do, not only what number they give.
• Failing to account for opioid tolerance. Patients taking regular opioids often need higher doses for the same effect, but they are also at risk from sedative combinations. Review the baseline dose, the time of the last dose and the plan for continuing it before adding new drugs.
• Overlooking sleep apnea and obesity. These conditions raise the risk of airway obstruction and hypoventilation with sedatives and opioids. Identify them during assessment and plan monitoring and observation to match.
• Stacking doses without reassessment. Giving a second dose of an opioid or sedative before the effect of the first has been measured is a common cause of harm. Set a minimum interval, document the time and reassess before repeating.
• Delaying palliative referral until the patient is dying. Early involvement often improves symptom control and allows better planning. Screen for palliative needs at the first contact and make the referral when the need is identified rather than when the situation has become urgent.
• Incomplete handover. Missing information about the last opioid dose, the block placed or the code status can cause real harm in recovery. Use a structured tool and ask the receiving clinician to repeat back the key points.
• Poor documentation of consent and goals. A signed form does not replace a documented discussion. Record what was explained, what the patient understood and what they chose.

09Practical checklist

• Confirm identity, procedure, consent and site marking before any drug is given.
• Review the airway, medications, allergies and anticoagulant status, and record the physical status classification.
• Screen for palliative needs, advance directives, code status and surrogate decision maker.
• Check that equipment, emergency drugs and backup airway devices are working and available.
• Verify labels, pump programming and independent double checks for high-alert drugs.
• Start monitoring appropriate to the sedation or anesthetic depth and document any deviation.
• Plan analgesia before the procedure ends, including regional techniques where suitable.
• Use a structured handover that includes the last opioid and sedative doses and the planned analgesia.
• Reassess sedation, respiratory status and pain after each opioid dose and at set intervals.
• Reconcile controlled substance records at the end of the shift and report any discrepancy.
• Give written discharge or ward instructions with a named contact and clear return criteria.
• Document goals of care changes, symptom responses and the reasons for each major decision.

10Frequently asked questions

★Learning sources

• Micro Degree: Anesthesiology, Pain and Palliative Medicine
• Micro Degree: Healthcare Administration Practice
• Micro Degree: Physiotherapy Assistant Operations
• Micro Degree: Cardiac Care Support