1. Module 3 Pain, Suffering, and Symptom Management

2. 1)To increase awareness of the different factors that affect a person’s pain experience, and to learn some practical pain management techniques 2)To discuss the elements of suffering 3)To identify common symptoms/side effects experienced by people who are dying, and to discuss symptom management methods 4)To learn relaxation techniques 5)To identify common symptom and functional assessment tools Goals

3. What is Pain? A physical sensation relayed to the brain through the nervous system. Subjective. Difficult to determine exact cause. Two people experiencing the same pain will react differently. Pain is what the person says it is. Acute pain is different from chronic pain. I. The Experience of Pain and Pain Management

4. Brainstorm: What signs tell you someone is in pain? What influences how a person perceives pain and responds to pain? What is the difference between acute pain and chronic pain? Exercise: Understanding Pain

5. Past experience Cultural background Gender “Meaning” of pain Life experiences Other symptoms Anxiety Rest and sleep Factors Affecting Pain

6. A person may experience: Acute pain Chronic or persistent pain Breakthrough pain Referred Radiating Pain at End of Life

7. To recognize pain, home support workers should: Observe the person carefully for signs of pain Ask some simple questions to determine the type of pain and how to relieve it: Are you experiencing pain? When did it start? Where do you feel it? Is it sharp/dull/shooting/stabbing etc.? What is the intensity (0-10)? What makes it better or worse? Any other symptoms (dizziness, nausea, etc.)? What can I do to help? Use the pain chart to document and describe the pain. Recognizing Pain

8. Persons nearing end of life should receive ongoing pain assessments: Usually by nurses and physicians, but support workers should have the knowledge and tools to assess pain Symptoms to be rated include: “guarding”, tiredness, drowsiness, nausea, appetite, breathing, depression, anxiety, well-being Characterize by location, intensity, etiology, and other factors Assessing Pain

9. Visual Analog Scale (VAS) for Pain A VAS is usually a horizontal line, 100 mm in length, anchored by word descriptors at each end. The patient marks on the line the point that they feel represents their perception of their current pain. The VAS score is determined by measuring in millimetres from the left hand end of the line to the point that the patient marks. Pain Assessment Tools

10. Wong-Baker FACES Pain Rating Scale This scale is often used with children. The person is asked to choose the face that best describes how he or she is feeling. Pain Assessment Tools

11. Edmonton Symptom Assessment System – revised The ESAS-r can be used to assess a number of symptoms Pain Assessment Tools

12. Pain – grimacing, guarding Tiredness – more time spent resting Drowsiness – less alert Nausea – retching, vomiting Loss of appetite – less intake Shortness of breath – increased effort to breathe Depression – tearfulness, flat affect, social withdrawal, less concentration, disturbed sleep Anxiety – agitation, restlessness, increased heart rate Signs of Different Symptoms

13. Group Discussion: What helps to relieve pain? Exercise: Alleviating Pain I

14. Case Study Mrs. V. is a 70 year old female recently diagnosed with Stage 4 breast cancer. She requires assistance with meal preparation and personal care. During your visit today, Mrs. V. is quieter than usual. She looks very unhappy but tells you everything is fine. You notice her grimacing during her shower whenever you move her right arm. You ask if she is in pain and she tells you just a little. 1. How would you manage this situation? 2. How can you help Mrs. V. with her pain? Exercise: Alleviating Pain II

15. Prescription drugs Non-prescription drugs Distraction Relaxation techniques Imagery Skin stimulation Chemotherapy or radiation Nerve blocks, neurosurgery, or acupuncture Techniques to Manage Pain

16. Myth 1 Pain medication – particularly opioids – will cause addiction. Reality People do not become dependent when pain medication is used for pain control. Myth 2 People will become tolerant of pain medications so they will no longer help. Reality People who are dying can get pain relief by taking narcotics every four hours for up to a year without having to increase the dosage. Myths about Pain Management

17. Myth 3 Pain medications often cause hallucinations. Reality Only about 1% of people experience hallucinations. Hallucinations may occur when a person is first put on opioids or when the dosage is increased. This side effect typically lasts 24 to 72 hours, and then disappears. Myths about Pain Management

18. Ensure client has received medication at the appropriate time. Ensure client has good body alignment. Use appropriate turning, lifting and moving techniques. Use touch to provide comfort. Provide a calm, quiet environment. Avoid sudden movements. Provide soft music if desired. Ensure body temperature is not too warm or cold. Measures to Promote Comfort and Relieve Pan

19. “Suffering” includes: Physical pain and other symptoms Psychological pain Social issues such as changed roles, family issues, isolation and financial worries Spiritual/existential aspects of life, including beliefs and fears. II. Understanding Suffering

20. Support workers can help by: Providing a committed presence Affirming the person’s value Being compassionate Demonstrating acts of kindness Asking questions: What are you most proud of? What things did you do that were most important to you? What part of you is strongest now? What takes your mind away from illness and gives you comfort? Is there anything in the way you are treated that is undermining your sense of dignity? Reducing Suffering

21. III. Symptoms and Symptom Management Possible Symptoms Include: Anorexia – loss of appetite Weakness Thirst Fever Jaundice Nausea/vomiting Constipation Insomnia Hiccups Skin irritation Incontinence Fatigue

22. Support Worker’s Role in Symptom Management Follow the care plan Use a tool like the ESAS-r to assess intensity of symptoms Create a comfortable physical environment Help with details that can increase comfort Encourage relaxation techniques

23. The Palliative Performance Scale version 2 (PPSv2) is used to describe a client’s functional status. The PPS is done by doctors and nurses. However, the support worker should know the general meaning of the PPS scores on five observable parameters: 1)Degree of ambulation 2)Ability to do activities and evidence of disease 3)Ability to do self-care 4)Intake 5)Level of consciousness Understanding the Client’s Needs

24. Palliative Performance Scale

25. Ambulation: How is the client’s mobility? Is he/she fully mobile or is the ability to walk decreasing? Activity level: How active is the client? Is the client able to do his/her normal hobby, job or work? Self care: Is the client independent with self-care? How much help does he/she need? Is this declining? Intake: How much is the client eating or drinking? Is it normal or reduced? Consciousness level: Is the client lucid or fully alert? Does the client have confusion? Is he/she drowsy? Has the client’s consciousness level declined? What does the PPS Score Mean?

26. Do you have a better understanding of pain and how to help clients manage pain? Do you have a better understanding of suffering? Are you better able to recognize symptoms experienced by people nearing end of life? Do you have a better understanding of the support worker’s role in symptom management? Learning Outcomes