Sunday, March 13, 2011

Pain Assessment and Symptom Management

In Ontario, we are organized into 14 regional Local Health Integration Networks (LHIN). It is an important part of our healthcare system, as there are many differences between care in urban Toronto or Ottawa, versus rural areas, such as the one where I live, S. E. Ontario (LHIN 10).

That said, while local Boards of Directors shape the policies and spending priorities of each LHIN. There are provincial initiatives that serve to shape the LHIN delivery of services.

For example, each LHIN now has a Pain Assessment and Symptom Management specialist whose job it is to educate and consult with caregivers in their homes, to educate physicians, social workers, as well as these exclusive consultations. They are also going into long-term care (LTC) to do these client assessments. To access these nurse specialists, you either phone your local Community Care Access Centre (CCAC) office, if you are a caregiver, or the charge nurse of the institution where your loved one resides is responsible for inviting them in.

As I know from my father's case, often the physicians are only visiting particular clients in long-term care (LTC) twice a month. For those homebound, it is difficult getting up the energy in getting out to see the physician. That said, it is primarily nurses who are requesting pain management and particular medicines. This is fine, if your visiting nurse, or charge nurse (in LTC), has much experience with your individual medical situation and palliative care, in particular cases. But, for many care recipients, they have multiple comorbidities and should have a full assessment of the medications, and determine if they are all necessary. For example, why keep a palliative client on statins, cholesterol medications, or keep them away from high cholesterol foods? (As happened to both my late father, and others.)

Definition: Pain vs. Suffering
Pain is what the patient perceives. Assessing pain is an individual process. There is a difference, too, between pain and suffering. Pain is immediate. Suffering often relates to the past or future, and goes beyond; pain can incorporate thoughts, feelings, and emotions. Those who suffer can benefit from an end-of-life review.
*A good death is one in which the four dimensions of dying are met:
  1. Physical (pain control, breathing, fatigue, bedsores), 
  2. Spiritual (accepting death, doing a life review, seeing meaning on one's life, finding peace), 
  3. Social (being conscious; communicating with family/friends, careworkers; communicating needs, wishes; sharing thoughts, feelings; having closure; saying farewell; a quiet, private atmosphere) and 
  4. Emotional/psychological needs (accepting help; not being a burden; being peaceful; having self-esteem; enjoying simple pleasure by releasing hope by gaining peace; making choices).

There are other types of pain, depending upon its causes: 
  • anticipatory pain - fear of the unknown, expected experience, causes fear and anxiety
  • incident pain - when a patient is shifted in bed
  • remembered pain - triggered at certain times of day by particular past events

You can see pain in my father's face
All of the research tells us that we cannot interpret another's pain, and determine what the patient feels, but that we can identify what the signs are of pain for clients who are unable to recognize their own pain, or to articulate their pain: particular facial expressions, twisting up of clothes, etc., read more about this here. Pain is an abstract concept for some with particular disorders. I fought for months with nursing staff for more pain management for my father. His dementia diminished his cognitive functioning and he could not recognize it.

Susceptive Pain vs. Neuropathic Pain
Susceptive pain is pain in the muscles: from a sports injury, a toothache, tissue damage. Neuropathic pain feels like pins and needles, after chemotherapy, shingles, or diabetic neuropathy.
Treating pain requires that the doctor prescribing understands the type of pain. In some cases, creative pain management is a must. And there are up-to-date findings which your physician must be aware. For example, Haldol, an antipsychotic with side effects, is useful in some pain management.

In terms of pain definitions, the World Health Organization (WHO) not identifies Total Pain, in an impeccable assessment.

Treatment needs to be addressed rapidly with a comprehensive management approach.All of this pain must be considered. We know that the more we manage Total Pain, the less pain a patient feels.

The NOPQRSTUV of pain
I attended an education seminar, given by one of our local Pain Management nurses. She explained this concept to us.
N: the numerical value patient assigns to the pain, between 1 and 10
O: onset or origins of pain
P: palliativate or provoke: what provokes the pain?
Q: qualify the pain: is it neuropathic, or susceptive?
R: regions or pain. Does it radiate, my physiotherapist also uses the word 'referring' pain, as it spreads down the body.
S: severity of the pain according to times of the day, or situational, or anticipatory pain
Edmonton Symptom Assessment (see below)
T: treatment, timing, trendss
U: understanding, does the care recipient and family understand everything going on? Do they need more information, e.g., the use of Halidol, rather than another medication.
V: value, what is the importance value of pain for you? If you have pain currently at a level 9, for example, are you able to live with it if it can be reduced to a level 4? Can you live a better quality of life at a level 4, go outside, relate to family and friends?

There are many barriers to pain management. WHO, according to Dr. Sirianni, says that 70% of cancer patients have pain, and the 80% of those die with uncontrolled pain. Pain is often poorly managed due to many factors: myths, misunderstandings, and barriers to access to quality palliative care.
In the final days of life, pain may be difficult to assess due to unconscious, or comatose patients. Family members must be aware of what they might expect, e.g., Cheynes-Stokes breathing.
Physical/behavioural signs: agitation, confusion, delirium, twitching.
Cardiovascular signs: decreasing blood pressure, rapid, weak heart rate, edema.
In addition, family members must understand that the body is shutting down, and that mouth care is crucial, as the mouth becomes dry.
Skin: pale, blue, mottled, cool, with possible skin breakdown.
Food and liquid intake may be counterproductive in those whose organs are shutting down, eventually it will decrease to zero. It is amazing how long we can go without food (2 weeks - one nurse told me), water (2 days) and oxygen (2 minutes). This is when a specialist is crucial.
Genitourinary: (urinary tract, genitals) incontinence, reduced urine output, dark colored urine.


Pain Management at the End of Life Dr. Giovanna Sirianni Staff

File Format: Microsoft Powerpoint - Quick View
... by means of early identification and impeccable assessment and treatment of other ...Take home point: When assessing and managing pain, especially in the ... of pain related to more than somatic factors; Components of “Total Pain

La Belle Mort en Milieu Rural: a report of an ethnographic study of the good death for Quebec rural francophones.

Veillette AMFillion LWilson DMThomas RDumont S., Centre de recherche de l'Hôtel-Dieu de Québec, 9 McMahon Street, Quebec City, Quebec, Canada G1R 2J6. 

Bruera, E., et al. 1991. The Edmonton symptom assessment system (ESAS): A simple method for the assessment of palliative care patients. Journal of Palliative Care. 7 (2): 6–9. Retrieved March 13, 2011, from

Palliative care, in part:
  • provides relief from pain and other distressing symptoms;
  • affirms life and regards dying as a normal process;
  • intends neither to hasten or postpone death;
  • integrates the psychological and spiritual aspects of patient care;
  • offers a support system to help patients live as actively as possible until death;

1 comment:

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