ONC-SOP-009: Pain and symptom assessment and control in cancer care

Standard operating procedure (SOP) · ONC-SOP-009 · Version 0.1 · Draft for local review

Supports: 51.10

1. Purpose

To make sure pain and other symptoms of cancer and its treatment (for example breathlessness, nausea, anxiety and agitation) are assessed with a validated tool on a set schedule, and treated with a written plan that is reviewed (51.10).

2. Scope

Item	Coverage
Applies to	Doctors, nurses, pharmacists and allied health staff who assess or treat symptoms in patients with cancer
Patients	Adults with cancer at any stage, on or off active treatment, in hospital, day units, outpatient services and at home where the service provides care
Symptoms	Pain, breathlessness, nausea and vomiting, constipation, anxiety, low mood, agitation and fatigue

3. Definitions

Term	Meaning in this SOP
Validated tool	A symptom assessment tool with known reliability, such as the numeric rating scale for pain and the Edmonton Symptom Assessment System (ESAS) for the wider symptom burden
Symptom plan	A written plan for each symptom: the target, the regular treatment, the breakthrough treatment, the non-drug measures, and the review date
Breakthrough dose	An extra dose given for pain or symptoms that flare between regular doses
Opioid rotation	Changing from one opioid to another when side effects or poor control make the first opioid unsuitable

4. Background

Pain and symptoms in cancer are common, often under-treated, and have a strong effect on quality of life, mood and ability to take treatment. Good assessment on a schedule, with a plan that is reviewed, improves control. The WHO principles of cancer pain relief remain the basis of treatment: by mouth, by the clock, by the ladder, for the individual and with attention to detail.

5. Responsibilities

Role	Responsibility
Prescriber	Writes the symptom plan, including the regular and breakthrough treatment, and reviews it at each visit
Nurse	Carries out the scheduled assessment with the validated tool, acts on scores above threshold, and gives the medicines as prescribed
Pharmacist	Checks opioid and high-alert prescriptions, advises on interactions and renal function, and reviews the plan
Palliative care team	Advises on complex pain and symptoms, and takes referrals
Service manager	Keeps the tools and the schedule in place, and audits compliance

6. Assessment schedule

Setting	When the tool is used
Inpatient	At each shift for pain, and once a day for the full symptom screen, plus after any change in treatment
Day unit or outpatient	At each visit, and by telephone where the patient is at home between visits
Home or community service	At each contact, with a symptom diary where the patient can use one

Assessment is also repeated within one hour of any analgesic or antiemetic given for a symptom that was over the threshold, and at any new symptom.

7. Procedure

7.1 Assessment

1. Ask the patient to rate pain and other symptoms on the validated scale, and record the score and the time.
2. Ask about the impact on sleep, mobility, eating and mood.
3. Check for red flags in ONC-SOP-007 (for example spinal cord compression or new neurological signs with pain).
4. Record the assessment in the notes and compare it with the last score.

7.2 Written symptom plan

1. For each symptom at or above the threshold, write a plan with: the target score, the regular medicine and dose, the breakthrough medicine and dose, the maximum daily dose of breakthrough, the non-drug measures, and the review date.
2. Use the WHO principles: regular medicine by mouth where possible, given by the clock, with the next step up the ladder if the target is not reached, and individualised doses.
3. Write the plan in plain language and give a copy to the patient and their carer, where they agree.
4. Tell the patient when to ask for help, including when pain is not controlled or they have side effects.

7.3 Opioid and high-alert medicines

1. Prescribe opioids with the route, dose, interval and the breakthrough maximum written in full.
2. The pharmacist checks the opioid prescription, including renal and liver function and interacting medicines.
3. Follow ONC-SOP-006 for the double check and storage of opioids given by infusion or patient-controlled analgesia.

7.4 Review and change

1. Reassess the patient at the scheduled interval, and within the time set in the plan after any change.
2. If the target is not reached, change the plan, document the reason, and reassess at the set interval.
3. If side effects appear, treat them and consider an opioid rotation or a different symptom approach. Record the decision.

8. Decision points

Situation	Action
Pain score above the threshold for more than one hour after breakthrough medicine	Inform the prescriber the same shift, and review the plan
Patient cannot swallow	Discuss an alternative route with the prescriber and pharmacist; do not change route without a prescriber decision
Severe nausea or vomiting preventing medicines	Review the anti-sickness plan and the route, and inform the prescriber
Anxiety or low mood affecting symptoms	Refer for psychological support and review the plan with the patient
Sedation, confusion or slow breathing	Stop opioid doses, check the patient at once, and inform the senior clinician and the on-call team

9. Escalation

• Uncontrolled severe pain or symptom: same-day review by the palliative care team or on-call clinician.
• Opioid toxicity: follow the facility's opioid toxicity protocol and inform the pharmacist.
• Missed or delayed breakthrough dose with serious harm: report under INC-SOP-001 within 24 hours.

10. Monitoring

The service manager audits 20 patient records each month for assessment frequency, plan completeness and review. Results go to the oncology governance meeting each quarter.

Measure	Target
Pain assessed with a validated tool at the scheduled interval	At least 95 percent
Written symptom plan for each symptom above threshold	100 percent
Plans reviewed by the due date	At least 95 percent
Opioid prescriptions with breakthrough maximum written	100 percent

11. Records

• Validated tool scores and the time of each assessment.
• Symptom plan with the review date.
• Prescription and administration records for all analgesics and antiemetics.
• Opioid prescription check record.
• Review and change records.

12. Training

All nurses and doctors who assess or treat cancer symptoms complete training on the validated tools, the WHO principles and opioid safety at induction and every year, with a practical assessment.

13. Related documents

Code	Document
ONC-SOP-005	Palliative care integrated with active cancer treatment
ONC-SOP-006	High-alert medicines on every ward
ONC-SOP-007	Urgent triage of patients with cancer
ONC-FRM-004	Patient goals, values and wishes record
HSP-POL-001	Symptom assessment and control

14. Evidence

This SOP is based on the reference sources listed below and on the requirement of criterion 51.10 of the ASF standards. The tools, thresholds and the opioid choices must be checked against the current national guidance and the facility's formulary at each review.

E-learning for this document

• No course linked yet. Request a pain and symptom management course from the academy (see the Standard 51 request list).

References

1. World Health Organization. Cancer pain relief: with a guide to opioid availability. Second edition. 1996.
2. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Current edition.
3. Bruera E, Kuehn N, Miller MJ, et al. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. Journal of Palliative Care. 1991.
4. Facility formulary and opioid guideline (to be inserted by the unit at adoption).

Change history

Version	Date	Change
0.1	2026-10-26	First draft for review. Not yet approved by the ASF Expert Committee.