1. Pain and Symptom Management
Palliative Care Education
for Front-Line Workers
in First Nation
Communities
cerah.lakeheadu.ca

2. A few assumptions A good care plan can almost always alleviate pain
Every member of the care team has a responsibility to participate in pain management
It is impossible to have high quality end-of-life care when a person is in pain
People facing death have a profound fear of pain
These assumptions guide the palliative care team in working to manage an individual’s pain.
There needs to be a plan which not only involves the palliative care team and the patient but also supports the family.
All team members play an important role in the assessment of an individual’s pain and working to keep it under control.
It is almost impossible to provide psychosocial care when an individual is in physical pain.
The fear of pain can increase an individual’s pain experience.

3. “Pain is whatever the person experiencing it says it is, and it exists wherever the person says it does”. - Margo McCaffery, nurse and pain management expert
Perhaps ask if it has been most people’s experience that death was excluded from their experience as they grew up. If this was not the case, how was death included?
Do most people feel that death is something to be feared and avoided/postponed at all cost?

4. Pain Belongs to the person Is enough to make them uncomfortable
Caring for the Terminally Ill: Honouring the Choices of the People, p
It is essential to always believe the person and their pain experience.
It is important to note that there are different types of pain; acute pain and chronic pain are two very different kinds of pain.

5. Acute pain Easier to recognize than chronic pain
Examples: broken bones, sudden abdominal pain
CHPCA, 2008
Signs of acute pain include:
- Recent onset, change
- New pain complaint
- Anxiety, grimacing
- Restless movement
- Increased pulse and blood pressure (BP)
- Muscle tension, sweating

6. Chronic pain Examples: arthritis, tooth decay, osteoporosis
Often more challenging to diagnose and treat than acute pain
Signs:
- Old or no complaint
- Mood depressed
- Withdrawn, listless
- No change in vital signs
- May not appear to be in pain

7. Breakthrough pain
Pain that re-emerges before the next dose of pain medication
A spontaneous episode or manifestation of pain experienced by the person even though s/he is taking regular pain medication
May be caused by movement.
Pain may not always remain at constant levels.
Can occur in conjunction with acute or chronic pain.

8. Perception of and response to pain will vary depending on:
The meaning of pain to the individual
Prior experience with pain
Cultural background
Age and gender
Sometimes it is helpful to ask patients what their pain means to them.
Ask the participants what types or kinds of meaning people can attach to the pain of someone who is dying i.e.) I was a bad person so therefore I deserve this pain.
Older people may be stoic and unwilling to admit to feeling pain.

9. Total pain An individual may experience total pain from:
the actual physical pain of the disease process
intellectual pain from knowledge (or lack of knowledge) of her/his condition and prognosis
emotional pain from feelings of anger or loneliness
spiritual pain arising from the awareness of impending death
This idea of total pain shows why pain can be situated in all four quadrants of the medicine wheel.

10. Myths and misconceptions (1 of 2)
Health care providers are the experts on assessing pain and determining if pain is real
Opioids should only be used for the management of cancer pain
Opioid addiction (psychological dependence) is common in people taking opioids for treatment of moderate to severe pain
The healthcare provider isn’t the expert on the pain – the individual who is experiencing it is.
Opioids have other uses than just cancer pain.
Addiction is not an issue when an individual is dying.

11. Myths and misconceptions (2 of 2)
Opioid tolerance develops rapidly, necessitating progressively higher doses
If one opioid doesn’t work for a patient, none of them will

12. Emotional pain Symbolizes threats the individual is facing
Is a constant reminder of the seriousness of the situation
Change in the pain may mean the disease is progressing
Pain may lead to fears
Klee, 2004
Emotional pain is often a big part of the dying process and is every bit as real as physical pain.
This list should also include the fear of death and all the losses that accompany it.
Many patients may have seen loved ones dying in pain and may fear that this will also happen to them

13. Psychological pain Pain may cause depression
The stress of pain may cause anxiety
Anxiety and depression often aggravate pain
Klee, 2004
If pain is persistent it may cause depression with symptoms such as the feeling of hopelessness, irritability, and no joy in life.
Anxiety may present with symptoms such as abnormal fears, restlessness, tension.
It is important to diagnose and treat anxiety and depression at the same time.

14. Existential Pain (1 of 2)
It is not unusual for pain to provoke existential questions regardless of the individual's religious and spiritual background
Pain may make it difficult to find the peace of mind needed to think through complicated issues
Klee, 2004
Existential pain is pain resulting from not having answers to the “big questions” in life. It occurs when the foundations of how we understand our own life and the world around us have been changed.
Individuals who are dying may question “Why me?” “Why now,” “What’s next,” “What is the meaning?” etc.

15. Existential Pain (2 of 2) The pain may be seen as a punishment
Existential suffering may provoke strong emotions that aggravate the pain, making it more difficult to alleviate
Klee, 2004
Ask the group how we might best support an individual with existential pain:
(Presence, listening, meditation, call a spiritual support person with permission from the individual, music, creative arts, etc.)
Are there any traditional ways which are effective? (Medicines, drumming, sweats, smudge, etc.)

16. Social pain The family will be affected by the individual’s pain
They may experience feelings of helplessness, hopelessness
Pain may result in social isolation
Unresolved family issues may surface
(Klee, 2004)
Often individuals who are dying and their families report feeling isolated as others do not know how to respond to their pain – they don’t know what to say and are afraid to say the wrong thing.

17. Some barriers to treating pain
The myth that pain is to be expected and that pain cannot be managed
Patient factors
Caregiver factors
System factors
The most common barrier is caregiver failure to ask about and assess pain
Patient:
belief that pain is normal part of aging
concern not acceptable to show pain or take meds for pain
dementia, speech, language problems make it difficult to describe pain
Caregiver:
difficulty in recognizing different types of pain
fear of administering medications
fear of addiction or overdose
System:
lack of easily accessible pain meds
inadequate staff education about pain management
inadequate numbers of staff to assess and treat pain in all patients

18. Three pain myths Addiction Tolerance Hallucination
Caring for the Terminally Ill: Honouring the Choices of the People, p
Addiction is generally not a concern in palliative care. Families and individuals need to be educated re pain management.

19. Pain Characteristics Ways to describe pain
Aching
Dull
Sore
Shooting
Burning
Stabbing
Ask participants how they might describe pain they have had or an example that they’ve heard.
Are there any culturally significant responses?

20. Signs of pain (1 of 2) Grimacing or wincing
Bracing (i.e. holding an arm)
Guarding/protecting painful area
Rubbing
Changes in activity level
Sleeplessness, restlessness
Resistance to movement
Withdrawal/depression
Decreased appetite
Patients do not always complain about pain. As a caregiver you should consider the possibility that the person is having pain if you see some of these signs.
CHPCA, 2008

21. Signs of pain (2 of 2)
General body tension (clenched hands, hunched shoulders, etc.)
Tense facial expressions
Constant fidgeting or nervous habits such as lip-biting
Unexplained withdrawal
Strained or higher-pitched tone of voice
Increased agitation, anger, etc.
It is essential to always assess for pain.
Pain should be assessed along with an individual’s vital signs.

22. Vocalized pain cues
Words or statements such as “ouch,” or “that hurts”
Verbal protests during care or transfers
Moans
Cries

23. When to observe for pain
During personal care
During transfers and walking
Following activities
At appropriate intervals after administering pain management interventions
It is important to always be aware and assess for all types of pain – the “Total Pain” experience.

24. Support Worker role in pain management
Ask the individual if they are experiencing pain
Watch for signs of pain
Observe for side effects of medications
Re-assess to evaluate the effectiveness of therapies
Administer non-drug treatments
Advocate for persons in pain
Caring for the Terminally Ill: Honouring the Choices of the People, p. 57
Pain is the responsibility of every member of the team – not just the physician or nurse; all caregivers can play a role in assessment of pain and in pain management.
Reports of pain should always be documented in the individual’s chart and/or reported to the professional most responsible for the patient i.e. a nurse or physician).

25. Non-drug Interventions Physical (1 of 2)
Massage
Cold
Heat
Complementary Therapy (i.e.. massage)
Positioning
Exercise
Caring for the Terminally Ill: Honouring the Choices of the People, p
Non-pharmacological interventions may empower individuals to feel that they have a greater role in their pain management.
Families can also play a role in supporting an individual’s pain management by using these techniques.

26. Non drug interventions Psychological (2 of 2)
Distraction
Relaxation
Music
Comfort foods
Imagery
Controlled breathing
Imagery is based on the concept of meditation and involves thinking of a beautiful place or memory or object that can assist an individual in relaxing.
Controlled breathing involves an individual focusing on their breathing in an attempt to relax.

27. Advantages of non-drug interventions
Low cost
Less potential for negative side effects
Decreases emotional response to pain
Provides clients with a sense
of control or involvement

28. “Pain is a more terrible lord of mankind than even death itself.”
- Albert Schweitzer
Imagery is based on the concept of meditation and involves thinking of a beautiful place or memory or object that can assist an individual in relaxing.
Controlled breathing involves an individual focusing on their breathing in an attempt to relax.