Pain management can be accomplished in different ways. But special care is needed when it comes to terminally ill patients and clients with fatal conditions (Macintyre & Schug, 2007). In these special cases, normal pain management would no longer suffice. It is important to effectively manage pain but when the prognosis points to a low survival – especially when it comes to elderly patients that are suffering from fatal conditions – pain management must be upgraded to palliative care. However, there are barriers and enablers to pain assessment and pain management and the best way to deal with it is to increase the capability of nurses and health workers in order to improve their efficiency with regards to dealing with requirements necessary for pain management and palliative care.
Stages of pain treatment and Role of Nurses in Palliative Care
Pain management occurs in several stages. The first stage deals with assessment of pain. The second stage focuses on understanding the different reactions to pain. Different people have different pain thresholds. The third stage deals with the patient’s perception of the kind of pain they are suffering (Bijur et al., 2008). The fourth and final stage, which is known as pain behaviour, focuses on the various behavioural expressions that people with painful conditions exhibit (MacLellan, 2006, p.3). IN most cases, nursing staff are able to deal with pain successfully with the effective use of pain relievers if needed. In many cases, patients recover as expected (Fosnocht & Swanson, 2007, p.791-792; Hager & Brockopp, 2007, p.9).
During the early stages of pain treatment, psychosocial factors are also taken into account. Nevertheless, there are some exceptional cases linked to unsatisfactory pain treatment strategies that can result in negative outcomes such as anxiety, depression, hypochondriasis as well as somatisation (Todd, Ducharme, & Choiniere, 2007). Problems in pain management must alert nurses for the need to improve their assessment methodologies. It includes the ability to determine patients’ emotional status before they embark on treating these painful conditions. This is usually considered in a case where, after sustaining serious injuries, a patient appears to be extremely depressed, demands high level of opioids, ignores examination procedures or is totally non-compliant (Price, Fogh & Glynn, 2007, p.12). This kind of behavioural characteristic is common in patients with acute painful conditions. Such conditions depict the onset of a bio-psychosocial pain disorder, which is multidimensional and requires a level of expertise to achieve correct diagnosis (Fosnocht & Swanson, 2007, p.791-792).
The nursing staff must be able to deal with different types of pain but when it comes to terminally ill patients, a different skill-set is needed. In cases where the patients are already dying the treatment of the disease to eradicate pain is no longer the main priority but to manage the pain so that patients can experience the highest possible quality of life with their remaining time with loved ones. This type of pain management is called palliative care. But before going any further it is important to understand the barriers to pain management as well as the enablers of effective pain management.
Serious and Life-threatening Illness
Uninhibited pain considerably reduces the level of functioning, both physically and psychologically; eventually, this causes depression, minimal activities, sleeplessness, and a deprived quality of life. Therefore, nursing staff that are assigned to assist in pain management do everything to control/treat pain so as to promote a good quality of life (Payne, Seymour & Ingleton, 2008, p.10). There are different ways to deal with uninhibited pain however nurses must also understand how to deal with terminally ill patients. Pain management in this case goes beyond alleviation of pain and includes the ability to utilize principles that would help patients deal with death and dying. It is important to know recent developments with regards to palliative care such as those discussed in the following:
Many hospitals, hospices, long-term care facilities, and other medical facilities are transitioning from the DNR (Do Not Resuscitate) order to the AND (Allow Natural Death) order. The “Not” or negativism in DNR seems to confuse patients and their families into thinking that care for their loved one will be abandoned and all treatment stopped … an order to Allow Natural Death is positive. It relays the information to the patients, to the family, and to the staff that the patient is dying and we will do all we can to allow that to happen naturally without aggressive interference (Old & Swagerty, 2007, p.51).
The use of both DNR and AND sheds light on the pain of both the patient and family members. These methodologies in dealing with terminally ill patients can be a new concept for many people. It is therefore imperative that the patient and respective family members understand that when the end is inevitable palliation is more important than resuscitation.
Patient and family members must agree to AND before it can be authorized by the facility. One way to increase adherence to its use is to explain to the concerned parties that CPR has little effect when the person has reached the end of life and it would only prolong the agony. The ineffectiveness of CPR is more pronounced when it comes to elderly patients with serious illnesses because survival is less than five percent (Old & Swagerty, 2007, p.52). It is also important to highlight the fact that CPR causes complications such as a) chest trauma (fractured ribs, pneumothorax, etc.); b) aspiration; c) pain; and d) loss of dignity (Old & Swagerty, 2007, p.52). It is only when patients and family members understand that AND is all about quality of care and not withholding care will they allow for such an order to be authorized.
Advanced practice nursing (APN) plays a significant position in testing and treating pain (Disorbio, Bruns, & Barolat, 2006). This involves application of an advanced range of practical, theoretical, and research-oriented knowledge to phenomena witnessed by patients within a specific clinical area of nursing. All of the clinical areas of nursing have incorporated pain management in their programs. The fundamental elements of Advanced Clinical Nursing include guidance, consultancy, teamwork, research, principled decision-making, and leadership (Old & Swagerty, 2007, p.6-7; Hwang et al., 2006, p.271).
Pain assessment and management is a very complex phenomenon. Hypothetical support for the process of pain treatment is well elaborated in Jean Watson’s caring theory (Watson, 2008, p.3). This theory emphasises the importance of the relationship between the patient and his or her medical practitioners. Transpersonal caring relationship is like a spiritual link that creates in-depth awareness. Recognition of the patient’s pain by the medical practitioner helps in proper assessment and management of pain, subsequently promoting comfort (Shega et al., 2006, p.5; Old & Swagerty, 2007, p.9).
Besides transpersonal caring relationships, Watson’s theory also focuses on caring moment and core competencies (Shega et al., 2006, p.5). Caring moment refers to the event when the medical practitioner and the patient share experiences, views and thoughts, leading to a considerable and meaningful caring occasion beyond the operation itself. This also results into a mutual connection between the nursing staff and the patient, beyond their normal interaction. Such kind of interaction creates new opportunities for future prospects (Burgess, Crowley-Matoka & Phelan, 2008, p.1853).
The core competencies include human altruistic values, instilling faith and hope, cultivating sensitivity to self and others, developing trust, promoting and accepting positive/negative feelings, systematic use of scientific procedures, promoting transpersonal teaching-learning, providing bio-psychosocial support, offering assistance and allowing for existential phenomenological dimensions (Shega et al., 2006). In addition to pharmacological interventions, Watson’s theory provides an effective method of assessing and managing pain in clients with terminal conditions (Shega et al., 2006, p.6-7; Hwang et al., 2006, p.271; Watson, 2008, p.2-3).
Barriers of pain assessment and management of chronic pain
Barriers to effective pain assessment can be broken down into three major parts: a) insufficient knowledge; b) lack of skills when it comes to basic palliative care techniques; and c) lack of skills when it comes to standard assessments (Deandrea et al., 2008, p.1986). In the context of nursing, nurses assigned to palliative care service must be knowledgeable regarding palliative care. Thus, precious time is not wasted when it comes to miscommunication between nurse and family members. Ample preparation is needed before palliative care services can commence.
The lack of knowledge regarding effective and efficient pain management strategies would result in underutilization because the focus is usually on the use of aggressive interferences that does not guarantee ability to prolong life but simply add more pain and suffering to the lives of patients and their families. It is important to realize that palliative care is “medical care focused on relief of suffering and support for the best possible quality of life for patients facing serious, life-threatening illness and their families” (Hong et al., 2010, p.854). In order to correctly utilize the benefits of palliative care the following factors have to be dealt with from the point of view of the nursing staff: a) availability of palliative care services; b) timely identification of the need for palliative care; and c) family concordance around the illness prognosis (Ahluwali, 2007, p.38). The common denominator is awareness and expertise.
The barriers to effective pain management were analyzed with an eye towards general medical care. But it has to be pointed out that nursing homes are the common site for patient care especially when it comes to end of life care (Dumas & Ramadurai, 2009). In many nursing home care environments it is common to find patients that are suffering from daily and yet did not receive any pain medication (Fisch & Burton, 2007, p.53). The reason for the failure to deliver effective pain management is listed as follows: a) lack of pain management knowledge in nursing home staff; b) lack of standardized approaches and institutional commitment; c) fear of addiction and analgesic overdose; and d) difficulty in assessing cognitively impaired patients.
Nurse must not only master the basics of pain management in a home care setting, they must also be aware of standardized approaches and importance of institutional commitment in order to successfully assess pain and the impact of the analgesic on patients and family members who interact with the patients. Knowledge regarding these two areas would enable them to deal with the problems of the possibility of addiction and overdose. When it comes to cognitively impaired patients nurses must be proactive in linking up with other health experts to overcome this barrier (Woo et al., 2007).
Enablers of effective assessment and management of chronic pains
Technology and medical knowledge can be utilized to aid nurses in delivering pain management techniques but the existence of equipment and knowledge about recent medical breakthroughs can become a barrier if patients are not provided the correct method for dealing with the pain. In some cases, the focus must be on “providing the type of care that is appropriate for the individual patient and the patient’s family be it aggressive life-saving care or palliative end-of-life care” (Ferrell & Coyle, 2010, p.32). In other words conventional methods of pain management are no longer sufficient in certain cases.
Another important enabler of pain assessment and pain management is the ability of the nursing staff to interact effectively with those providing care. In hospices and hospitals with limited resources, the nurse is not the only caregiver but the family members, relatives, friends, and loved ones faithfully serving and assisting the patient in their hour of need (Lee, 2006). Thus, the nursing staff can increase the impact of this informal care giving role by providing all the support that they need. One way to do that is to help detect caregiver strain among the members of the family that are providing support and help solve that problem.
Enabling strategies must focus on education, expertise, and effective communication. The nursing staff must be aware of end-of-life palliative care. This knowledge is then communicated effectively to family members. Afterwards, palliative care services must be initiated as an alternative to aggressive life-saving interventions. It has to be made clear that aggressive life-saving strategies can no longer add value to the life of a terminally ill patient and therefore pain management must be the goal and no longer the need to prolong life.
Here is a list of steps that nurses must follow in order to master effective pain assessment strategies; the nurse’s role has been described as: a) describing pain; b) identifying aggravating and relieving factors; c) determining the meaning of pain; d) determining its cause; e) determining individual’s definition of optimal pain relief; f) deriving nursing diagnoses; g) assisting in selecting interventions; and h) evaluating efficacy of interventions” (Yarbro, Frogge & Goodman, 2005, p.650). It is imperative that nurses must learn how to evaluate the analgesic regimen has affected the patient and the family’s quality of life (Yarbro, Frogge & Goodman, 2005, p.650). This requires constant assessment of the effectiveness of the analgesic applied and the amount of relief obtained.
By carefully following these steps nurse are able to effectively gauge the reaction of the patients towards a particular analgesic. By using a standardized approach the nurses are able to determine if a patient is suffering from pain. At the same time they are able to know if a patient has experienced optimal pain relief. The nurses are also given the capability to find out if a certain analgesic is causing addiction or overdose. Thus, an effective use of assessment tools would enable nurses to eliminate the fear of addiction and overdose when it comes to their patients.
The standardized approach can be effectively enhanced by adding the concept of whole patient assessment because it involves “a complete assessment of a patient’s medical, psychological, spiritual and social history” (Hong et al, 2010, p.854). This is added to the standard assessment that includes “assessment of chief complaint; history of the present illness; past medical and surgical history” and then moves towards exploring patient’s “social and community support, impact of the cancer diagnosis and treatment on patient’s quality of life, spiritual and social well-being” (Hong et al., 2010, p.854). Aside from increasing the knowledge regarding the individual needs of the patients the whole person assessment approach also enhances the communication between nurse and patient.
It must be made clear that everything hinges on effective communication. The nurse must communicate well to understand what the patients are feeling with regards to the pain and the analgesic given to them. Effective communication is necessary to understand all the pertinent information regarding past history especially when it comes to dealing with pain and other medical needs. Effective communication also enables the nursing staff to work closely with the family in order to satisfy all the requirements. Therefore, the lack knowledge with regards to effective assessment, standardized approaches in pain management and effective communication must be identified as one of the primary barriers to effective pain management and palliative care.
End of life-care and life-threatening illnesses are medical problems that are synonymous to pain. Patients are battling pain on a daily basis. It is therefore important for the nursing staff to use effective pain management to alleviate the suffering of the patients and improve quality of life of the patient and their families. However, there are barriers to effective pain management and these are mostly related to the lack of knowledge regarding standardized approaches to pain management and effective assessment strategies. It is important to train nurses so that they would acquire the necessary skills to guide patients in revealing important information that would help nurses determine the level of pain and alleviation of suffering due to the correct application of pain relievers and other medication. Finally, nurses must learn the ability to perform whole person assessment to determine all other factors that can contribute to the effectiveness of a pain management plan.
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