Pain management is arguably one of the most complex topics in medicine today, and is a priority at Covenant Health Systems From dealing with acute and chronic pain to providing compassionate end-of-life care, caregivers are faced with myriad physiological, emotional and spiritual issues that extend far beyond the question of which medication to administer. In a recent issue of "Connections," we explored several aspects of pain management, including an interview with Fr. James A O’Donohoe, Covenant ‘s ethicist, that appeared in the February issue of "Health Progress" and is reprinted here with permission of the Catholic Health Association. We also a look at what several Covenant facilities are doing in this important area.

In August of l999 the Joint Commission on Accreditation of Healthcare Organizations set new standards for the Assessment and Management of Pain. These standards call upon hospitals, home care agencies, nursing homes, behavioral health facilities, outpatient clinics and health plans to:

• Recognize the right of patients to receive appropriate assessment and management of pain;
• Assess the existence and, if so, the nature and intensity of pain in all patients;
• Record the results of the assessment in a way that facilitates regular reassessment and follow up;
• Determine and assure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff;
• Establish policies and procedures which support the appropriate prescription or ordering of effective pain medications;
• Educate patents and their families about effective pain management, and;
• Address patient needs for symptom management in the discharge planning process.

These standards underscore the importance that Covenant Health Systems places on pain management for we believe that effective pain management is a crucial component of good care.

Simply put, pain is a sensation that hurts. It can be described in several ways… throbbing, steady, aching, pinching, dull, piercing. Pain can be acute or chronic. Acute pain is severe and lasts a relatively short amount of time. It is usually a signal that body tissue is being injured in some way. When the injury heals, the pain generally goes away. Chronic pain may range from mile to severe, and it is present to some degree over longer periods of time.

The experience of pain and how someone expresses the level of their pain is unique and is an interplay of a person’s own particular biological, psychological and cultural makeup.

"We rely on the MDS (Minimum Data Set) as a triggering mechanism to assess a patient's pain on admission," explains Maryann Hiscock, RNc, BSN, director of nursing at Maristhill in Waltham, MA, referring to the HCFA-mandated assessment tool. "It has a section that helps us assess the frequency and intensity of a patient's pain.

"If this initial evaluation finds that the patient is at a moderate level of pain or higher, that triggers a more formal pain assessment process using a pain flow sheet," she continues. "We look at the source of the pain, what and how frequently meds are needed, what other interventions work. Then we contact the physicians, nurse practitioners and others involved in the patient's care and initiate pain management as part of the overall care plan." Youville Hospital also takes a systematic approach, starting with an initial assessment upon a patient's admission. Myra McDonald, RN, MEd, nursing educator, explains: "We utilize what we call a pain reference sheet to help us identify where and how severe a patient's pain is. We ask the patient to rank his or her level of pain on a scale of one to 10, and also prompt with words like 'mild' or 'strong' and descriptive words such as 'tingly' or 'sharp.' Other questions include: "Where are you feeling your pain;" "What relieves your pain?" "What makes the pain worse?" "Is the pain constant?"

"Then we follow the patient for three days, documenting on a flow sheet his or her level of pain along with other vital signs," she adds. "In fact, we call the measurement of pain the 'fifth vital sign.' We also document what modalities provide relief, and when. This flow sheet is on every patient's clipboard.

"We stress to caregivers that it's the patient's perception of pain that's important," McDonald says. "A patient may be at the number seven level of pain, but the nurse sees him laughing during a family visit and wonders how that's possible. The patient was probably distracted by his family's visit; it's hard to teach, and there's a lot of education [about pain management] still to be done."

McDonald cites publications on pain management issued by the U.S. Department of Health & Human Services' AHCPR (Agency on Health Care Policy & Research, now called the Agency on Healthcare Quality Research) as invaluable references for caregivers. "They cover how to assess pain, pharmacology, physical and psychosocial aspects of pain, interventions, alternative therapies, special populations, and how to monitor pain. One covers cancer pain; another is for acute pain. Anyone who reads them will have a good understanding of pain management."

"We didn't have a formal pain management protocol until about a year ago," explains Sandy Sarcione, RN, director of nursing at the Berkeley Retirement Home and Nursing Center. "We attended a pain management seminar sponsored by Covenant and adopted the assessment forms presented there; they're very similar to hospice forms. Now we assess everyone [for pain] on admission regardless of their diagnosis. For patients who are already here, pain assessment is ongoing, and documented on every shift."

What if the patient suffers from a dementing illness and can't articulate his or her pain? "If a patient's not able to verbalize pain, we show the patient a series of faces with expressions that relate to levels of pain, instead of numbers," says McDonald. "We ask the patient to point to the facial expression that relates to how much pain he or she is feeling." "We use an objective scale if the patient isn't alert," adds Maristhill's Hiscock. That includes evaluating the patient's own facial expressions and talking with family members who, she says, are a good guide when something's wrong with the patient. Maristhill also utilizes the "faces" to which McDonald referred. "If they can't verbalize, they can simply point to the face that matches their pain level," she says.

Sue Bryant, RNc, director of nurses at St. Joseph Manor in Brockton, describes her facility's approach with long-term care patients:

"Dementia patients can be combative, and it's important to sort out whether it's the dementia creating behavioral problems or pain. We look at all our dementia patients who also have a pain diagnosis, such as osteoporosis, and have trained our CNAs - who have close daily contact with patients - to use a behavioral flow sheet to monitor them. "The flow sheet asks five yes-or-no questions," says Bryant. "Is the patient combative with care? Does he/she complain of pain, or is there increased restlessness, grimacing? Does the patient eat more or less than usual? Is there any difference in the patient's level of participation in normal activities? Is there anything about the patient's behavior or appearance that's different from the day before? A 'yes' answer to any question triggers a more in-depth pain assessment by a nurse."By sorting out if it's pain or behavioral, we can administer the most appropriate medication - Tylenol versus psychotropic drugs, for example," she adds. "There's simply no need for anyone to suffer, or to take meds that aren't needed."

In regard to unnecessary medication, Sarcione relates a case at BerkeleyNursing Center: "An elderly couple came to us from another nursing home; they'd been admitted there because they couldn't live independently. The husband was well enough to go into our retirement home, but the wife needed skilled nursing care.

"As part of our initial assessment, we discovered that she had been on Serax
(prescribed for treatment of anxiety) for 17 years," Sarcione continues. "She also had a morphine patch, and was taking antidepressants and Tylenol. She's now off all meds except Tylenol, and she's well enough to move over to the retirement center to be with her husband again."

There is increasing awareness among health professionals that effective pain management requires a multidisciplinary approach that includes clinicians, therapists, pastoral care, counselors, and even family and friends.

"Pain is multi-faceted, and each member of a patient's care team has a unique role in assessing that pain," says Virginia Seary, RN, a Youville nurse practioner who serves on the hospital's pain management committee. Youville established its pain management committee in 1998; its members include physicians, nurses, therapists and pastoral care staff who are available to do consults throughout the hospital.

"We stress that each member of a patient's care team is responsible for talking to the patient about pain, then sharing that information with the entire team," Seary explains. "For example, the chaplain may have a very different perspective on a patient's pain than the doctor." The flow sheet to which McDonald referred - the one that's on every patient's clipboard - supports this process.

Seary's Youville colleague McDonald says, "Some patients simply don't believe in telling the doctor or nurse about their pain; they think that's just the way it is. But they might confide in the chaplain, or comment to the physical therapist about how much better they feel after getting a hot pack."

Hiscock from Maristhill adds, "You need to make everyone on the care team
aware of what works when it comes to pain management. If listening to music on headphones relaxes the patient and helps the meds to work, we all need to know that."

"One of our patients was admitted with end-stage pancreatic cancer and was in extreme pain," says Berkeley's Sarcione. "We did a lot to help divert her attention from the pain, such as walking outside and taking her home to visit her condo, which she loved. We got hospice involved right away, too. We also worked closely with family members - from an elderly brother to her grandchildren - to get them involved in keeping her mind off the pain.

"In addition to her physical pain there was also the pain of letting go, so it was a great help that the family stayed involved," Sarcione continues. "It relieved a lot of anxiety. And it points to how important it is to look at the whole picture."

While pain is the number one symptom to control in most cases, there's more to it than that, explains Don McDonah, MD, a family physician at St. Joseph's Family Medical Center in Nashua, NH. McDonah is board-certified in hospice
and palliative care.

"We spend a lot of time on pain management," he says. "But if I am to help
someone be as comfortable as possible for as long as possible, I need to look at relieving other symptoms, too, such as nausea and vomiting, shortness of breath, fatigue and anorexia. Shortness of breath is very common at the end of life, and it can be very frightening. There's a lot we can do for people.

"Pain itself is very complicated; it's multifactorial and multisensorial," McDonah continues. He refers to the work of Cicely Saunders, MD, who founded St. Christopher's Hospice in London and started the entire hospice movement. "Dr. Saunders coined the term 'total pain,' which has three components: physical, psychological and spiritual. We really must look at all three, and listen to the patient.

"Not everyone presents the same way, or the way we were taught in medical or nursing school," he adds. "Just because someone's not writhing on the bed doesn't mean he's not in pain."

Many people still believe that if they use narcotics for pain relief they will become addicted. The National Cancer Institute explains that narcotic addiction is defined as dependence on the regular use of narcotics to satisfy physical, emotional and psychological needs rather than for medical reasons. Pain relief is a medical reason for taking narcotics. Therefore, if a person takes narcotics to relive pain, they are not an "addict," no matter how much or how often they take narcotic medicines.

Drug addiction in cancer patients is rare. Generally, when narcotics are used under proper medical supervision the chance of addiction is very small. Most patients who take narcotics for pain relief can stop taking these drugs if their pain can be controlled by other means. It is important to remember that if narcotics are the only effective way to relieve pain, the patient’s comfort is more important than any possibility of addiction.

Patients' religious or cultural beliefs can affect their attitudes toward pain management. Religious elderly, for example, sometimes believe that they should offer up their suffering. Youville Chaplain Betty Walsh gives an example:

"We had an elderly patient who refused medication even though she was in so much pain she couldn't complete her physical therapy. She was deeply devout and thought she should be able to deal with her pain. But she wouldn't talk to the nurse about it."

"I talked with her a lot about the Church's position on pain and suffering, and how Jesus didn't want people to be in pain," Walsh continues. "I suggested that she give the medication a chance, that God wanted her to be as well as possible. She did start listening to me, and I asked her permission to share what she had confided in me with the care team so that everyone involved would be aware of what was going on."

Walsh also cites the importance of understanding how different cultural beliefs can affect a patient's interaction with caregivers. "Here in a very diversified Cambridge, we could have a patient who's a Harvard professor in the room next to someone who's been living in his car," she says. We have a
large Portuguese population as well as other cultural traditions. For example, one patient was a Muslim man who wouldn't let a woman into his room and insisted on another man being with him at all times.

"We need to be familiar - or become familiar - with peoples’ traditions, and know their experience regarding suffering," she adds. "They all have spiritual needs, and feel scared, anxious, sad or confused. It's our job to find where there is hope, and help them come to acceptance."

"Contrary to the popular belief that pain management is all about medication, it's really all about holistic care," states Youville Chaplain Betty Walsh. "Someone's emotional or spiritual well-being affects his or her physical well-being. Loneliness, anxiety or fear are all exacerbating factors, and when a person is in spiritual or emotional pain, traditional approaches - meds - may be ineffective in relieving that pain."

As a result, a growing number of healthcare professionals are recognizing that pastoral care and complementary therapies can be valuable tools in the field of pain management. Virginia Seary, RN, from Youville Hospital, comments:

"Drugs are sometimes a component of pain management, but they aren't always the only answer," she says. "It's important to take a holistic approach and look beyond meds to alternative therapies. For example, if a person is in emotional or spiritual pain, counseling may help. So can imagery, biofeedback or acupuncture."

"There's 'spiritual medication,' too," adds Walsh. "Reflective listening, helps a patient to identify his hopes and fears. Pastoral care has sometimes been seen as outside of pain management since it's not 'medicine,' but at Youville it's just the opposite."

"The traditional model is important," says Tom Brown, CEO at St. Joseph's Manor in Brockton, Massachusetts, referring to conventional Western medicine. "But its success is in acute, trauma cases. Chronic conditions usually don't need such high-tech interventions. We need to take a more holistic approach and look at the spiritual and mental components of pain. This is where complementary therapies can be helpful."

Dr. Don McDonah, looks at it this way: "There's a big role for complementary therapies, from music therapy to pet therapy to therapeutic touch. I could be skeptical because there's not much scientific background regarding complementary therapies, yet I see that it works. And I believe the reason it works is that most complementary therapies are one-on-one. They reaffirm the person as an individual, and there is time and attention directed toward just that one person. But there needs to be a lot more research to get the science behind it."

Brown agrees. His facility is introducing Reiki (pronounced "Ray-key") to its adult day health patients. Reiki, which means "universal life force," is a gentle, non-invasive, hands-on energy transfer technique developed by a Christian minister in Kyoto, Japan in the 1800s (and can be traced back to ancient Tibet thousands of years ago). It made its appearance in the U.S. in the 1970s. Brown himself is a Reiki Master, which means that he has undergone three levels of Reiki training and is a teacher of Reiki.

"Reiki is a healing modality that's similar to therapeutic touch," he explains. "Its goal is to channel the universal life force energy to a client. When we're stressed or in pain, we disconnect from this energy. After about an hour of Reiki, a client will move into a highly relaxed state, and there's a feeling of heat - energy - being transferred from the practitioner.

Brown says that his facility has entered into an agreement with Stonehill College to undertake a 12-week research project that will measure Reiki's efficacy in the adult day health setting at St. Joseph Manor. Three undergraduates in healthcare administration not only will document patient outcomes but also go through Reiki training so that they understand the modality first-hand.

"The documentation will be invaluable," says Brown. "Change is hard, even when it is good and necessary. People have a natural tendency to resist change, and we're hopeful that this research will help.

"I stress that Reiki is in addition to our complement of medical services, not a replacement for them," he adds. "I think we all recognize that there's more we can do for patients, so why not try it?"

To Brown's knowledge, St. Joseph Manor is the only long-term care facility in the region to introduce Reiki. There has been good buy-in from the staff, he notes, with ten employees trained in Reiki to date, and three more slated for training in the first quarter of 2000. In addition, Brown performed Reiki on the St. Joseph Manor board of trustees last summer by way of introducing the modality. "They all wanted a second session!" he says.

Almost half of all Americans seek treatment for pain each year, 7 million from newly diagnosed back pain alo

-- Mayo Clinic newsletter

The American Academy of Pediatrics and the Canadian Pediatric Society have recently identified that newborns do, in fact, feel pain and have outlined strategies on how to recognize and relieve pain in newborn infants. These include simple strategies such as swaddling, or sucking on a pacifier or sugary solution can help relieve their pain during medical procedures.

-- Pediatrics 2000:105; 454-461

Top selling textbooks generally offer little helpful information on caring for patients at the end of life. Most disease oriented chapters had no or minimal end of life care content. Specifically textbooks with information about particular diseases often did not contain helpful information on caring for patients dying from those diseases.

-- JAMA 2000:283:771-778

Quite a few studies have shown that writing about your pain can be a form of therapy. Studies done at North Dakota State University published in the Journal of the American Medical Association, found that people with asthma or rheumatoid arthritis who wrote about the stress in their lives found that their symptoms were reduced. In an editorial accompanying the JAMA report, Standford University’s David Spiegel, M.D., a leading researcher of mind-body interactions applauded the study as a welcome addition to growing evidence that stress management through writing can make medical treatment more effective.

The latest study involved 112 patients with either asthma or rheumatoid arthritis. Researchers assigned the patients to write about either the most stressful event in their lives or emotionally neutral topics, described either as "confessional writing" or "expressive writing." After four months, the researchers found that the patients who wrote about stressful subjects were significantly better. The asthma patients showed improved lung function and on average, the severity of disease among those with rheumatoid arthritis patients was reduced by 28 percent. Overall 47 percent of the patients who wrote about traumatic events had clinically relevant improvements compared to only 24.3 of the patients in the control group who wrote about neutral subjects.

---

The National Cancer Institutes discusses how relaxation can relieve pain or keep it from getting worse by reducing tension in the muscles. They say that relaxation techniques can help you fall asleep, give you more energy, make you less tired, reduce your anxiety and make other pain relief methods work better. Basic Guidelines for using relaxation techniques include:

• Understand that your ability to relax may vary from time to time and that relaxation cannot be forced.
  
• Remember that it may take up to two weeks of practice to feel the first results of relaxation.
• Stick with the same method so that it becomes easy and routine for you. Use it regularly for at least five to ten minutes twice a day.
• Check for tension throughout the day by noticing tightness in each part of your body from head to foot. Relax any tense muscles. You may use a quick technique such as inhale/tense, exhale/relax.

Relaxation may be done sitting up or lying down. Choose a quiet place whenever possible. Close your eyes. Do not cross your arms and legs because that may cut off circulation and cause numbness or tingling. If you are lying down, be sure you are comfortable. Put a small pill under your neck and under your knees or use a low stool to support your lower legs.

Visual concentration and rhythmic massage;
Open your eyes and stare at an object, or close your eyes and think of a peaceful, calm scene. With the palm of y our hand, massage near the area of pain in a circular, firm manner. Avoid red, raw, swollen or tender areas. You may with to ask a family member or friend to do this for you.

1. Breathe in (inhale) deeply. At the same time, tense your muscles or a group of muscles. For example you can squeeze your eyes shut, frown, clench your teeth, make a fist, stiffen your arms and legs, or draw up your arms and legs as tightly as you can.
2. Hold your breath and keep your muscles tense for a second or two.
3. Let go. Breathe out (exhale) and let your body go limp.

1. Close your eyes. Breathe slowly and feel yourself relax.
2. Concentrate on your breathing. Breathe slowly and comfortably from abdomen.
3. As you breathe in, say silently and slowly to yourself
   -------------- "In, one, two." As you breathe out, say: "Out, one, two." Breathe in this slow rhythm for a few minutes.
4. Imagine a ball of healing energy forming in your lungs or on your chest. It may be like a white light. It can be vague. It does not have to be vivid. Imagine this ball forming, taking shape.
5. When you are ready, imagine that the air you breathe in blows this healing ball of energy to the area of your pain. Once there, the ball heals and relaxes you.
6. When you breathe out, imagine the air blows the ball away from your body. As it goes, the ball takes your pain with it. (Be careful: Do not blow as you breathe out; breathe out naturally.)
7. Repeat the lst two steps each time you breathe in and out.
8. You may imagine that the ball gets bigger and bigger as it takes more and more discomfort away from your body.
9. To end the imagery, count slowly to three, breathe in deeply, open your eyes, and say silently to yourself: "I feel alert and relaxed." Begin moving about slowly.

< Back to the resources page.