Basic Principles

For the past few months, Associate Professor Dr. Yordanov (consultant of anesthesiology and resuscitation, pain treatment, and palliative care at Blocks Hospice) has been preparing several articles for our blog. In this article, we will delve deeper into the causes of pain, and more specifically, the pain experienced by cancer patients. Even though several experts and scientific literature discuss this topic, there is no better source of information than the patients themselves. None of us can compare a prolonged headache or other types of discomfort that we often find overwhelming to the pain that hospice patients experience. As you know, a hospice is a medical facility designed to alleviate the pain and suffering of people with serious health issues as they are entering the final stages of their lives.

But how do doctors and specialists deal with pain? How do they rate it, and how do they ease it to make the patients’ final days more comfortable and pain-free? Do they question the patients, trust their specific complaints or follow the medications that control the pain during certain stages? The answer to all these questions is yes. But sometimes, even knowing these answers is not enough. Sufferers of a particular disease may lose their motor and communication skills, which makes understanding the pain a lot more difficult even for professionals. Read more about its evaluation and treatment below in the article written by Associate Professor Dr. Yordanov.

Belief in the Patient’s Complaints

The most accurate description of the pain is given by patients themselves. Belief in the patient’s complaints is the first and most crucial step in building trust between the doctor and the patient and is the foundation for further joint work. Conversely, the team’s lack of interest or distrust is a reason for concealing information and unnecessarily intensifying the complaints from the patient.

Assessment of Different Types of Pain

The patients are encouraged to describe the pain they experience in their own words and how they feel. This description is a guide to the emotional-affective component of the suffering caused by pain.

Pain Assessment

It is essential to assess the intensity of the pain, its characteristics, its course over time, the factors that provoke it, and how to alleviate it. The treatment methods used so far and their effectiveness are evaluated. Attention is given to the type and dose of medications used, the appearance of side effects, and the relief they have provided. Changes caused by the patient’s lifestyle are assessed, and it is desirable to interview other family members.

The application of schemes that mark the location and intensity of pain, medical history, physical and neurological examinations, and appointed laboratory and imaging tests facilitate pain diagnosis.

It is characteristic that patients with advanced cancer experience more than one type of pain and often of a different nature. In these cases, a thorough assessment of each type of pain should be performed separately.

Assessment of the Primary Disease

The appearance of new or old pain that has increased in intensity often means that the disease has progressed. In this case, the patient’s condition requires a careful assessment before attempts are made to modify the course of the cancer. In instances where oncological disease treatment is not possible, aggressive treatment of the pain and the accompanying symptoms is implemented. Furthermore, if it is difficult to control the pain, palliative sedation of the patient is applied.

Assessment of the Factors Influencing the Pain – Clinical Pain

Routine assessment of the influence of psychogenic factors, such as fear, anxiety, depression, etc., on pain perception is part of good medical practice in treating pain. This also includes determining the influence of somatic symptoms, social needs, ethnic and cultural differences, and the need for spiritual support.

The assessment of the individual factors is based on the answers to the following questions:

Factor Question
Physiological
  • What changes in the patient so that he feels pain?
  • What is the cause of the pain?
  • How does the patient describe his pain?
Emotional
  • How does the patient’s emotional state affect his pain?
  • How does pain affect the patient’s mood and emotions?
Cognitive
  • How does the patient’s knowledge (etiology, pathogenesis, and therapeutic possibilities) and his beliefs affect the perception and expression of his pain?
  • What is the patient’s previous experience, and how does it affect his or her current pain?
Behavioral
  • • What are the patient’s reactions when experiencing pain? How and by what changes in the patient’s behavior do the caregivers understand that he is experiencing pain?
  • What techniques does the patient use to relieve his pain?
Ethnic and cultural
  • How do the patient’s ethnic background and cultural environment influence the perception and expression of pain?
Social
  • How does the social environment affect the patient’s perception and expression of pain?

Periodic Assessment of the Patient’s Condition and the Effects of Treatment

 The frequency of control examinations depends on the severity of the pain experienced and the success of the treatment given. Mild pain with an intensity of <4/10 allows monthly check-ups, with moderate pain of intensity between> 5/10 and <6/10 check-ups being recommended every 7-14 days until adequate control is achieved. Usually, pain with intensity over 7/10 is a condition that requires active medical care and hospital treatment. Follow-up examinations are performed with the same accuracy with which the initial pain assessment was performed.

Prognostic Factors for Achieving Effective Pain Control

More than ¾ of cancer patients complain of nociceptive pain, which is treated with opioid analgesics and NSAIDs. Therefore, it is entirely realistic to predict reasonable control of pain treatment with drugs in about 75% – 85% of cancer patients. However, patients whose pain does not respond well to analgesic treatment are much less common (15% -25%).

The prognosis for effective pain control with medication is poor in:

  • Patients with neuropathic pain
  • Patients with accidental provoked pain
  • Patients with impaired cognitive abilities
  • Patients with uncontrolled psychological suffering
  • History of alcohol and drug abuse (1)

 Measurement of Pain

The objective measurement of subjective experiences, such as pain, is performed with established tools for measuring both the various aspects of discomfort and pain in general. In addition, for the needs of daily practice, several techniques are used to measure the strength of the pain experienced, such as:

  • Digital scale – the most commonly used scale is from 0 to 10, where 0 = no pain and 10 = unbearable pain. A variant of the scale from 0 to 5 is also widely used
  • Verbal (descriptive) scale – uses descriptive criteria for the intensity of the pain experienced: – no pain; mild pain; moderate pain; severe pain; very severe pain; unbearable pain
  • There is a correlation between the numerical = descriptive scales, or: 0 = no pain; 1 = mild pain; 2 = moderate pain; 3 = severe pain; 4 = very severe pain; 5 = unbearable pain
  • It is even simpler to divide pain into the following three categories – mild, moderate, and severe. There is the following correlation with the numerical scale 0/10: mild pain <4/10; Moderate = 5/10 – 6/10; Strong> 7/10

The way that pain is categorized is easy for the patient to understand and straightforward for the team to apply. Moreover, it is similar to the other scales used to assess other physical symptoms. The scale’s regular application is helpful for:

  • Introduction of a common language in the communication between the medical team and the person who is sick
  • Increasing the level of trust between the patient and the team
  • Allows comparison of results and objectifies the effectiveness of the applied treatment

Tools used to assess pain in particular groups of patients, such as children, people with communication difficulties, and others, are also successfully applied in practice (2).

Assessment of Pain in Patients With Communication Difficulties

  • Is there a reason for the patient to experience pain, or are the changes in behavior due to other processes such as difficulty urinating, constipation, or metabolic disorders such as hypoglycemia?
  • Has the patient taken painkillers in the past? If yes, what were they, and what was the effect of the treatment?
  • What is the usual behavior of the patient during an attack of pain, how does he express his pain?
  • What does the patient’s caregiver think about the changes in behavior? Does he believe that the patient is really in pain and what makes him think so?
  • When establishing contact with the patients, specify how they will report the occurrence of pain. This can be closing your eyes, nodding, or moving your fingers. These methods should be known to those who are caring for the patients
  • If there is a suspicion of pain, start its treatment
  • If the applied therapy is effective and leads to a change in the patient’s behavior, it should be continued at regular intervals (clockwise)
  • If there is no effect from the applied measures, re-examine the condition and look for missed causes of suffering

The correct assessment of pain in patients with difficulty in communication relies on evaluating the so-called “pain behavior. Symptoms such as moaning and agitation are common in other conditions, such as metabolic disorders, urinary retention, or delirium. Therefore, abnormal patient behavior and returning to a normal state after analgesia may be the only evidence of the pain experienced. If there is no effect and if the “atypical behavior” persists, the condition is re-evaluated. Additionally, more reasons for the pain’s appearance will be investigated, such as problems with the pelvic reservoirs, metabolic disorders (hypercalcemia, hypoglycemia, uremia, delirium, liver encephalopathy, brain metastases), and other potential health issues.

Bibliography

  1. Subrata Banerjee LB, Heather Jewers AJP, Simpson. J. Pain in Adults – Best Practice Guidelines for the Management of Cancer-Related Pain In Adults. Province o. Nova Scotia ; Canada: Crown copyright; 2005.
  2. Hanna M, Zylicz Z Ben. Cancer Pain. Hanna M, Zylicz Z, editors. London: Springer London; 2013.
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