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Pain management: An Interdisciplinary Approach | VITAS Healthcare


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Pain management is first and foremost in a hospice patient’s plan of care. Hospice provides comfort and quality of life near the end of life, and hospice providers are experts at managing pain. The goal of this webinar is to help healthcare professionals understand all aspects of a patient’s pain as a symptom near the end of life, and how to utilize an interdisciplinary approach to provide the most effective pain management.

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Pain management: An Interdisciplinary Approach | VITAS Healthcare

  1. 1. Today’s Presenter: Joseph Shega, M.D. National Medical Director VITAS® Healthcare Welcome! We are glad you are able to join us for today’s presentation on Pain Management – An Interdisciplinary Approach. The presentation will begin at 2:00 EDT. Attendee phone lines will be muted upon entry to the Webinar, so you may experience a period of silence prior to the start time. Any questions may be submitted to the host via the chat box (open by clicking on the icon at the top right of your screen). Objectives: After attending this program attendees should be able to: 1. List causes of total pain syndrome in patients with advanced illness 2. Define pain and its various characteristics 3. Describe the principle of a pain assessment and interdisciplinary pain approach This Webinar is intended to provide general educational information only. The information presented should not be viewed as specific medical advice regarding a particular patient. It is always a medical provider’s responsibility to individually assess and evaluate each patient before providing that patient medical advice or initiating any medical intervention.
  2. 2. Pain Management: An Interdisciplinary Approach Presented by: Joseph Shega, M.D. National Medical Director VITAS Healthcare Developed by: Barry M. Kinzbrunner, M.D., FACP Chief Medical Officer VITAS Healthcare
  3. 3. Pain Management for Patients Near the End of Life Primary Reference: Friedman TC, Kinzbrunner BM, Weinreb NJ, Clark M: Management of Pain at the End of Life. Chapter 6 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 125.
  4. 4. Goals • To understand all aspects of a patient’s pain as a symptom near the end of life • To recognize physical, social, emotional and spiritual components of total pain • To utilize an interdisciplinary approach to promote effective pain management and quality of life
  5. 5. Objectives At the end of the presentation participants will be able to: • List various causes of pain in terminally ill patients with cancer and non-malignant illnesses • Understand the different factors involved in “total pain” and how the interdisciplinary team is necessary to effectively treat total pain • Define pain and its various characteristics • Describe the components necessary to perform a full pain assessment in both cognitively intact and cognitively impaired patients
  6. 6. Causes of Pain Cancer: Direct • Bone metastases • Tumor mass compression & edema Cancer: Abdominal • Bowel obstruction • Peritoneal carcinomat. • Pelvic malignancies • Pancreatic cancer Cancer: Neuropathic • Spinal cord compression • Plexopathies – Cervical – Brachial – Lumbosacral – Celiac • Peripheral neuropathy • Headache due to inc ICP
  7. 7. Causes of Pain (Cont.) Cancer: ChemoRx • Oral mucositis • Peripheral neuropathy • Osteonecrosis • Tissue injury due to extravasation of drug Cancer: Radiation Rx • Osteonecrosis • Myelopathy • Plexopathies Cancer: Post-surgical • Stump and phantom limb • Post-mastectomy and “phantom breast” • Post-thoracotomy • Post-laparotomy • Post-radical neck dissec. Cancer: Procedures • Bone and marrow bx • LP and venipuncture • Imaging procedures
  8. 8. Causes of Pain (Cont.) Cancer: Indirect • Shingles and post-herpetic neuralgia • Oral or esophageal infectious mucositis • Paraneoplastic neuropathy or myelo. • Hypertrophic pulmonary osteoarthro. • Medication related constipation or urinary retention
  9. 9. Causes of Pain (Cont.) Non-Cancer Pain • Arthritis • Metabolic neuropathies • Chest pain • Post-traumatic injury • Post-stroke pain – Contractures – Muscle spasms • Immobility • Abdominal pain • Peripheral vascular disease • Decubitus ulcers and other skin disorders
  10. 10. Causes of Pain (Cont.) Non-Physical Causes of Pain • Individual’s basic psychological make-up and tolerance to pain • Loss of work • Physical disability • Change in social and familial roles and relationships • Fear of death • Cultural, ethnic and religious background and issues • Financial concerns
  11. 11. Source: Portenoy R., Practical aspects of pain control in the patient with cancer. CA-A Journal for Clinicians. 38:332, 1988. Total PAIN Pain Neuropathic Mechanisms Psychosocial Influences Somatic or Visceral Nociceptive Psychological State & Traits Loss of Work Physical Disabilities Fear of Death Social/Family Functioning Financial Concerns Suffering The Portenoy Model Total Pain
  12. 12. Factors that Affect the Pain Threshold Factors that lower the pain threshold • Anxiety • Depression • Fear • Isolation • Fatigue • Anger • Sleeplessness • Persistent pain Factors that raise the pain threshold • Symptom relief • Rest • Sleep • Diversion • Empathy • Sympathy • Medications: analgesics, anxiolytics, anti-depressants
  13. 13. Barriers To Effective Pain Management Professional barriers • Inadequate pain assessment • Excessive state and federal regulations • Fear of respiratory depression with opioids Patient/family barriers  Reluctance to report pain  Not wanting to “give in” to pain  Fear increasing pain means disease progression  Fear doctor will not believe them or will view them weak, difficult, or as complainers  Reluctance to take opioids • Fear of potential addiction • Inadequate knowledge base
  14. 14. What is PAIN? A Scientific Definition of Pain “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” Source: International Association for the Study of Pain, 1979.
  15. 15. What is PAIN? “Pain is always subjective. Each individual learns the application through experiences related to injury in early life… it is also always unpleasant and therefore an emotional experience” Source: International Association for the Study of Pain, 1979.
  16. 16. What is PAIN? An operative definition of pain “Pain is whatever the patient says it is, existing when s/he says it does” McCaffery M: Nursing Management of the patient with pain. Philadelphia:JB Lippincott, 1986.
  17. 17. Acute vs. Chronic Pain (Cont.) Acute Pain Chronic Pain Onset Usually sudden Long duration Characteristics Sharp, localized, may radiate Dull, aching, persistent, diffuse Signs and Symptoms Autonomic response Hyperactivity Emotional response Anxiety, restlessness Autonomic response Often absent Emotional response Flat, depressed
  18. 18. Acute vs. Chronic Pain Acute Pain Chronic Pain Goal of therapy Pain relief Sedation often desirable Pain prevention Sedation not desirable Timing As needed (prn) Around the clock Dosing Standardized Individualized Route Parenteral/oral Oral preferred
  19. 19. Nociceptive vs. Neuropathic Pain Nociceptive Neuropathic Pathophysiology Nerve stimulation from tissue injury Direct nerve injury Description Dull, aching, cramping, throbbing, pressure-like Burning, shooting, tingling, stabbing, vise- like, electric shock-like Examples Somatic: Bone mets Visceral: Angina Brachial plexopathy Diabetic neuropathy Pharmacological Therapy Opioids, NSAIDs Opioids + Adjuvants Tricyclic antidepr. Anti-seizure meds
  20. 20. Pain Assessment • Pain history – Pain treatment history • Full medical history – Psychosocial and spiritual history – Medication history • Physical examination – Areas of pain • Mental status examination
  21. 21. Pain Assessment (Cont.) • Pain classification(s) • Extent of disease and options for primary therapy • Related psychosocial dysfunction that is contributing to the patient’s perception of pain • Available medical, psychosocial and spiritual support systems
  22. 22. Pain Assessment (Cont.) • Pain diagnosis(es) • Therapeutic plan – Physical pain • Pharmacologic • Non-pharmacologic – Psychosocial pain and suffering • Psychosocial interventions • Spiritual interventions
  23. 23. “P Q R S T” Characteristics of Pain • P = Palliative, Provocative – What make the pain better or worse? • Q = Quality – How is the pain described? • R = Radiation – Does the pain travel or spread anywhere else? – If so, where? • S = Severity – What is the intensity of the pain? (on 0 -10 scale) • T = Temporal – Is the pain constant, or does it come and go?
  24. 24. Medical & Psychosocial History • History of all prior and current medical illnesses including diagnosis and treatment • A psychosocial history including: – The patient’s perception of pain – The patient’s basic psychological make-up – Any potential factors that may contribute to “total pain” such as loss of work, financial concerns, physical disability, change in social or family roles or relationships, fear of death, cultural, ethnic and /or religious background
  25. 25. Spiritual History “FICA” • “F”: Faith or beliefs – What things do you believe in that give meaning to your life? • “I”: Importance or influence in one’s life – What role do your beliefs play in your illness? • “C”: Community – How does your faith community support you? • “A”: Address – How would like us to address these issues in your care? Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Pall Med 3:129, 2000.
  26. 26. Medication History • Complete drug history including OTC, prescription, and recreational drug use • Drug, strength, route, intervals • PRN or scheduled • Duration of therapy • Allergies (obtain full description) • Side/adverse effects • Health food store, self remedies • Patient’s preferences
  27. 27. Pain Intensity Scale The gold standard for assessing pain is to ask about the patient’s pain severity using the 0-10 pain severity scale. The Wong/Baker faces rating scale was originally developed for pediatric patients. It is also very useful in the elderly patient and patients with language and reading challenges. ® Worst Pain Possible No Pain Moderate Pain 0 1 2 3 4 5 6 7 8 9 10
  28. 28. Role of Assessment in Patient Management Pain Management Pain Listen & Believe Assess PQRST Involve Enhance Quality of Life PQRST Reassess Cancer pain management slide and lecture program, Pain service, Department of NeurologyMemorial Sloan-Kettering Cancer Center, 1990.
  29. 29. Pain Assessment in Non-verbal Patients • Pain assessment in the non-verbal patient may be challenging but is certainly achievable and important • Indications of pain in a patient who is unable to speak or describe their pain may include: – Moaning, groaning, a gasp or scream when touched – Crying, restlessness, rigid posture, lack of ability to concentrate, grimace, increased immobility – Change in sleep patterns
  30. 30. Pain Assessment in Cognitively Impaired Patients: University of Michigan FLACC Item 0 1 2 Face No particular expression or smile Occasional grimace or frown, withdrawn disinterested Frequent to constant frown, clenched jaw, quivering chin Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching hugging or talking to, distractible Difficult to console or comfort
  31. 31. Pain Assessment in Advanced Dementia: Miami VA Hospital Item 0 1 2 Breathing independent of vocalization Normal Occasional labored breathing Short period of hyperventilation Noisy labored breathing Long period of hyper- ventilation Cheyne-Stokes respirations Negative vocalization None Occasional moan or groan Low-level speech with a negative or disapproving quality Repeated troubled calling out Loud moaning or groaning Crying Facial expression Smiling or inexpressive Sad, frightened, frowning Facial grimacing Body language Relaxed Tense, fidgeting, distressed pacing Rigid Fists clenched Knees pulled up Pulling or pushing away Striking out Consolability No need to console Distracted or reassured by voice or touch. Unable to console, distract or reassure