Step 2. Raise the pain threshold
As we know from the discussion above about the experience of pain, emotional influences on pain perception need to be taken into account with pain assessment. This was best exemplified by soldiers in battle who had horrendous injuries with little perception of pain. It is thought that due to the excitement of the surrounding battle, their bodies produced sufficient endorphins to mediate the pain perception to the point where they may not have even realised they were injured.
The opposite case is generally true of palliative care patients, where anxiety, anger, depression, frustration etc, work to lower the pain threshold and so worsening the pain, which in turn is a reminder of the disease, which in turn worsens the depression and so on.
Often, simply acknowledging the problems and fears the patient has can be enough to give some relief. Occasionally the use of professional support such as social workers, counsellors, pastoral care workers may be required for ongoing support.
However, given that most palliative care patients are in the community, this support will often fall to the GP and community nurses. The downside for the GPs is generally lack of time to deal conclusively with such issues. The upside is that they may have cared for patients and their families for many years and therefore be well aware of and able to tackle psychosocial issues. In this situation, the community nurse can be an invaluable support person for the patient and family.
The use of drugs for emotional issues needs to be considered. Anxiolytics can be of great benefit without the concerns about addiction or tolerance for palliative care patients. Of course depression is a common feature in this patient group and can be quite difficult to diagnose because of crossed symptomology, eg. lack of appetite, low mood, asthenia, morbid thoughts, and so on. The difference between appropriate sadness and depression can be blurred. However, two distinguishing questions to ask are:
- 1. Are you depressed? Generally, depressed patients will say they are depressed, whereas sad patients will admit being sad, but deny being depressed.
- 2. Are you the person you used to be? A clinically depressed patient will generally say they are not.
Finally, the easiest way to raise patient threshold for pain is to make sure they are getting a good night's sleep. Having a progressive, incurable illness is a process of having your reserves stripped away. Be they reserves for dealing with pain, tiredness, stress, loss of autonomy, or whatever. Getting back a good night's sleep is often a simple way of restoring some of those reserves. In fact if you don't ask about sleep you have not completed the pain assessment.
Step 3. Consider an opioid
Whilst negotiating steps 1 and 2, adding an analgesic is the next logical step. As there is a library of books on this subject alone, justice cannot be done in this article, therefore it will be discussed in the next issue.
Step 4. Neuropathic pain
Neuropathic pain is seen as a separate entity primarily because it presents differently from other pains and treatment options differ. Again this is a complex subject which will be dealt with in later issues.
In summary, using the Stickman model for pain assessment is holistic, inclusive and likely to keep you out of trouble. In the next article, the nitty gritty of opioid analgesics will be tackled.
Any comments/queries to Dr Joanne Doran - jdoran@nor.com.au
Dr Doran is director of the Palliative Care Service, Northern rivers of NSW.
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