Five practical pain management tools in hospice care

Disclaimer: Carmack is a member of the Clinical Advisory Board for RxActuator

Pain management looks different at the end of life. The risk-benefit calculus shifts, the timeline shortens, and comfort becomes the primary goal rather than one consideration among many. Drawing on more than a decade of hospice and palliative care practice, the author has built a toolkit that blends physical medicine, integrative modalities, and pharmaceuticals — always layered together — to keep patients comfortable through life's final chapter. Here are the five tools hospice and palliative care practitioners reach for most often, and how they are used.

1. Exercise and bonding time

Movement is medicine. It may seem counterintuitive to prescribe activity to a patient nearing the end of life, but appropriate, gentle movement is one of the most underused tools in palliative pain management. Short, frequent leash walks, supported standing exercises, and range-of-motion work help maintain muscle mass, joint mobility, and circulation, reducing the stiffness and secondary pain that come with prolonged rest. Movement also triggers endogenous opioid release, giving patients a natural analgesic boost.

Just as important is what this tool does for the family. Caregivers of geriatric patients often feel helpless, watching a pet decline with no active role to play. Prescribing a modified exercise plan, even five minutes of assisted walking or a gentle massage routine, gives them something concrete to do that directly benefits their pet. It reinforces the human-animal bond when families need that connection most, and gives the veterinary team a built-in, low-cost way to track mobility and pain trends between visits. A structured group obedience class for senior dogs has even been shown to slow the progression of cognitive dysfunction signs, underscoring how much benefit gentle, consistent activity and engagement can offer aging and declining patients.¹ Prescribing exercise and cognitive enrichment for all senior pets can likely delay their frailty symptoms and keep them with their families longer.

2. Pulsed electromagnetic field therapy for inflammatory pain

Pulsed electromagnetic field (PEMF) therapy has become a go-to modality for patients with osteoarthritis, intervertebral disk disease, and other inflammatory pain conditions. PEMF is thought to work by altering cell membrane permeability and increasing nitric oxide production, thereby improving local blood flow and downregulating inflammatory mediators.² Clinical studies in dogs with radiographically confirmed osteoarthritis have shown measurable improvements in gait symmetry, with some research suggesting the benefits can outlast those seen with NSAID therapy alone.²

What makes PEMF especially valuable in hospice care is its safety profile: it is noninvasive, requires no sedation, and can be administered at home by caregivers using devices such as the Assisi Loop, a real advantage for patients too fragile or anxious for frequent clinic visits. Consistent, scheduled sessions are recommended for chronic pain conditions as anti-inflammatory benefits build over 1 to 2 weeks rather than providing maximum relief immediately. These interventions can also be an easy-to-reach tool during acute-on-chronic pain escalations.

3. Acetaminophen for pain flares and adjunctive control

Acetaminophen has earned a top spot in the author's formulary for canine patients. It is toxic and potentially fatal in cats at any dose, as they lack the hepatic enzyme needed to metabolize it safely, and it should never be dispensed to feline patients or households with cats that could access it.³ In dogs, the author doses acetaminophen at 10 to 15 mg/kg orally every 8 to 12 hours, an extra-label use in the United States. Combination products are also available pairing acetaminophen with either codeine or hydrocodone. Oral bioavailability of the opioid component is poor in both; however, the author has had more success with the hydrocodone combination and reserves it for acute-on-chronic flares rather than routine daily use, given its constipating effects. Because it has minimal anti-inflammatory activity, it works best as an adjunct alongside NSAIDs, steroids, or other multimodal analgesics rather than as a standalone therapy.

Acetaminophen can be particularly useful during acute pain flares and during washout periods when transitioning a patient between an NSAID and a steroid, since it provides a bridge of analgesic coverage without the drug interaction concerns of overlapping anti-inflammatories. Baseline and periodic hepatic and renal monitoring are recommended, though in true end-of-life cases this is often reasonably waived in favor of comfort-focused care.

4. Subanesthetic ketamine for central sensitization

Subanesthetic ketamine has transformed how many hospice and palliative care veterinarians manage central sensitization and wind-up pain in hospice patients. As an NMDA receptor antagonist, it dampens the amplified pain signaling that develops with chronic, maladaptive pain, the kind of pain that no longer responds predictably to opioids or NSAIDs alone.⁴

Because so little research exists on subanesthetic ketamine and chronic pain in veterinary patients, protocols remain anecdotal, varied, and clinician-selected based on the case at hand. For patients able to tolerate hospitalization, an IV infusion offers the most titratable option, with published research backing this approach.^5,6 For stable but progressive chronic pain in home-bound hospice and palliative care patients, the author starts with intermittent subcutaneous (SQ) injections at 0.5 mg/kg, typically every three to four weeks initially, titrating dose and frequency based on patient response and sometimes advancing to every 24 to 48 hours as disease progresses.⁴

For patients presenting with significant signs attributable to central sensitization, such as allodynia or hyperalgesia, the author often takes a more front-loaded approach. These patients frequently have untreated or undertreated chronic pain and benefit from breaking the maladaptive pain cycle sooner rather than later. This may mean a 48-hour SQ infusion (at 3-4 ug/kg/min) to start or a SQ intermittent injection protocol — giving a 0.5 - 1.0 mg/kg injection 2 to 3 times a week for two to three weeks, weekly for 2 to 3 weeks, then tapering to every other week or monthly, depending on response. Forty-eight-hour subcutaneous infusions can be delivered at home or in hospital through the RxActuator Mini-infuser, which allows continuous low-dose delivery without repeated injections. This initial step in breaking the central sensitization cycle allows a thorough review and reassessment of the daily pain management protocol. Having multiple routes of administration and dosing protocols available allows practitioners to match the subanesthetic ketamine intervention to each patient's actual pain trajectory rather than fitting every case into one protocol.

5. Emergency medication kits for true pain crises

The final tool in the kit isn't for everyday pain control; it's insurance against the moments families fear most. Emergency medication, or "comfort," kits, similar to those provided to human hospice patients, are prescribed for veterinary patients at risk of an acute pain crisis, and they typically contain prefilled, clearly labeled syringes of medications selected based on the patient's anticipated crisis scenario.⁷

Because these kits place controlled substances directly in a caregiver's home, practitioners hold them to a strict standard: childproof, tamper-evident packaging; labeling that meets DEA and state pharmacy board requirements; a signed informed consent document explaining exactly when and how to administer each medication; and clear instructions for safe disposal of any unused product. The author also walks every family through what the kit is not: a tool that will hasten their pet's death. She then explains what it is: a way to relieve suffering immediately until veterinary assistance can be obtained. Families consistently describe the peace of mind these kits provide as invaluable, even if they never use them. Emergency medication kits facilitate a conversation with the veterinary team around anticipated end-of-life crises, and often allow families to look for early warning signs and create consensus regarding euthanasia before those crises occur.

Conclusion

These 5 tools rarely work in isolation and build upon foundational pain management steps (NSAIDs and other core interventions). The most effective palliative pain plans layer physical, integrative, and pharmaceutical approaches, adjusting the approach as a patient's disease and psychosocial needs evolve. Strong communication with a patient's primary care team remains essential to coordinating this kind of plan safely. As hospice and palliative care grows as a discipline within veterinary medicine, a broad, flexible pain management toolkit is what allows clinicians to meet each patient, and each family, exactly where they are.

References:

1. O'Brian ML, Herron ME, Smith AM, Aarnes TK. Effects of a four-week group class created for dogs at least eight years of age on the development and progression of signs of cognitive dysfunction syndrome. J Am Vet Med Assoc. 2021;259(6):637-643.
2. Influence of pulsed electromagnetic field (PEMF) therapy on osteoarthritis in dogs. PMC website. Accessed July 31, 2026. https://pmc.ncbi.nlm.nih.gov/articles/PMC12492814/
3. Acetaminophen. American College of Veterinary Pharmacists website. Accessed July 31, 2026. https://vetmeds.org/pet-poison-control-list/acetaminophen/
4. Subcutaneous ketamine for analgesia. Zero Pain Philosophy website. Accessed July 31, 2026. https://www.zeropainphilosophy.com/post/subcutaneous-ketamine-for-analgesia
5. Iocolano KE, Looney A, Balkman CE, Hume KR, Boesch JM, Sylvester SR. Retrospective evaluation of outpatient intravenous ketamine-lidocaine infusions for the palliation of cancer pain in dogs and cats. J Am Vet Med Assoc. 2025;263(4):499–506. https://doi.org/10.2460/javma.24.09.0595
6. Fry L, Rychel J, Tearney C, Guedes A. Preliminary study of intravenous ketamine infusions for the management of chronic pain in dogs. Vet Anaesth Analg. 2025;52(1):124.e3–124.e4. https://www.vaajournal.org/article/S1467-2987(24)00353-2/abstract
7. Bailey FA, Williams BR, Goode PS, et al. Impact of a hospice emergency kit for veterans and their caregivers: a prospective cohort study. J Palliat Med. 2014;17(8):931-938. doi:10.1089/jpm.2013.0395