Objective 2: Know the key steps in pain assessment.
Unfortunately, poorly controlled pain is common in patients with advanced illness. While physicians are by no means the only contributors to the problem of inadequate pain relief, we do contribute substantially. Our most common deficits, all seemingly simple to remedy, are failures to:
- Recognize that the patient is in pain
- Prescribe adequate dosing of opioids,
- Treat side effects of opioids effectively
- Reassess pain after initial treatment.
Patient characteristics may increase the risk of being inadequately treated pain. These characteristics include:
- age (elders and children both)
- race/ethnicity (minority groups)
- gender (female at higher risk)
- impaired cognitive status.
Studies show that the effect of pain on a patient’s quality of life and functional status is determined more by the severity of the worst pain they experience over a 24 hour period than the average pain they experience.
A. "ABCDE" Clinical Approach
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A clinical approach to pain assessment and management is summarized by the mnemonic "ABCDE" (Weissman and Dahl, 1995):
- Ask about pain regularly and Assess pain systematically. - see example questions C. below
- Believe the patient and family in their reports of pain (along with their reports of what works and what doesn’t).
- Choose pain control options appropriate for the patient, family, and setting.
- Deliver interventions in a timely and coordinated fashion.
- Empower patients and their families and Enable them to control their treatment to the greatest extent possible.
B. The Use of Pain Scales
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Use of rating scales can be very helpful. However, it must be clear that the purpose of the scales is not to give an arbitrary evaluation of pain or to calculate the correct dose of an opioid; rather it is to assist in understanding the patient's experience of the pain.
Most importantly, using the same rating system over time helps us to assess how effective our treatment is at relieving the patient’s pain and to make adjustments for maximum benefit. It is key to have a communication tool to help us understand how effective our treatment is and what changes are needed.
Patients can use a 0 to 10 numeric scale or a scale that depicts facial expressions (happy -> grimacing).
Facial expression scales:
Numerical scales: no painworst pain imaginable
Some people find it easiest to use a simple range of words to describe their pain:
--no pain, a little pain, lots of pain, too much pain
--mild, medium and severe
Pain scales are now a standard tool in most hospitals and other clinical settings, typically the 0-10 numerical scale.
C. Pain History
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A careful pain history is central to good pain assessment. The key components (PPQRST) are:
- Palliating factors: What makes the pain better? What do you do to get relief? What helps you?
- Provocative factors: What makes the pain worse? What brings it on? What aggravates it?
- Quality of pain: What does the pain feel like? What words would you use to describe it?
Examples: aching, throbbing, sharp, squeezing, shooting, burning, dull, stabbing, deep, cramping.
D. Total Pain
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- Radiation: Where is the pain? Does the pain spread or travel anywhere else?
- Severity: How bad is the pain? At its worst? At its best?
- Temporal course: When did the pain start? How often does it hurt? Has it gotten better? Worse? Is it worse at certain times of the day?
- Treatment: What have you tried to relieve the pain? How effective was it? Why did you stop it?
"Total pain" is comprised of many factors:
- Environmental (crowding, noise, temperature control)
- Physical (nociceptive, neuropathic)
- Psychological (depression, anxiety)
- Social (family conflicts, job worries)
- Spiritual (why me? abandoned by God? meaning of life and illness?)
- Financial/legal (job loss, family security, estate planning)
Good pain management addresses all the components of a patient's pain, often with the help of an interdisciplinary team. Although all these components play a role in the experience of pain, we should be wary about attributing pain entirely to any one component (e.g. “his pain is all psychological). This is virtually never an accurate judgment in the clinical setting. Furthermore, pain hurts and needs relief, no matter what its components are. Recognizing the pain of the “whole person” should lead us to a multiple-dimensional treatment plan, not to rejection or abandonment of the patient.
E. Other Important Points about Pain Assessment
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Often experts use the term "suffering" for this set of complex sources of distress (Cassell EJ).
- It is VERY important to treat the pain during the assessment process – you do not need to wait until your "thorough assessment" is complete before you begin to provide pain relief for most patients.
- As part of the assessment, take a careful history of analgesic use, including prior and present medications, analgesic response (time to onset of peak effect, duration of action, level of pain relief [0 to 10 scale]), and side effects.
- A focused physical exam is an important part of the assessment process
- When possible, determine the cause of the pain (bowel obstruction, epidural metastases, brachial plexopathy, etc.) and institute appropriate, diagnosis-specific therapy for the pain.
- Reevaluate the pain and the efficacy of treatment frequently, and adjust treatment accordingly.
- An appreciation of the patient’s social support system is critical to managing pain in advanced illness. Who does she live with? Does he belong to a religious or faith-based community? Does she have family nearby? What additional resources does he have for support?
- A trial of placebos to make sure pain is "real" is NEVER appropriate. The rate of placebo response to all types of pain is relatively high; therefore this provides no insight into the nature of the pain. Furthermore, a placebo trial without patient consent can be very destructive to the doctor-patient relationship (and it is considered unethical by most authorities). Finally, all pain is REAL to the person experiencing it.
Next: Choosing and Opioid