Understanding the relationship between pain and suffering

1. Understanding the relationship between pain and suffering Kathleen Fitzgerald, PhD Melinda Blazar, MHS, PA-C

2. Writing activity • Think of a time when you were in pain really in pain – what had caused the pain and what was happening to you? • Think of a time when you were suffering really suffering – what had caused the suffering and what was happening to you? • What helped relieve your pain? • What helped relieve your suffering?

3. Writing activity • Was the treatment for the pain the same as the treatment for the suffering? Yes or No. • Would the treatment for the pain have relieved your suffering – and would the treatment of the suffering have relieved your pain? • Which took longer to deal with – the pain or the suffering? • Which was harder for you to deal with the pain or the suffering?

4. Pain

5. What is PAIN? • Definition: “a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action “ Merriam-Webster Dictionary

6. Why do we care about pain? • Why do we care? • Accounts for 20% of outpatient visits, 12% of all rx’s • 76.2 million Americans suffer from chronic pain • Most common cause of long term disability

7. How do we assess pain? • Take a good thorough history • Pain score • Location, radiation, quality • Temporal aspects: duration, onset, changes since onset • Constancy or intermittency • Characteristics of any breakthrough pain • Exacerbating/triggering factors • Palliative/relieving factors • Associated symptoms • Impact of pain

8. Assessing the IMPACT of pain • Assessment of pain’s impact on overall QOL • Social functioning • Mood, affect, anxiety • Relationships • Work • Sleep • Exercise • Activities of daily living

9. Why pain management is difficult • Every patient is different • Treatment is constantly changing • Options for treatment • NSAIDs, acetaminophen, regular dosing vs. prn, relaxation, bodywork (chiropractic manipulation, massage, acupuncture), narcotics • What works for the patient • Pain is constantly changing • Acute on chronic pain • Worsening chronic pain • Effective pain management involves TRUST

10. Tools to help • Establish a pain contract • Gives clear rules/boundaries • Protects your medical license • NC Controlled Substance database • https://nccsrsph.hidinc.com • Referral to pain specialist • They’ll advise, you manage • Can offer additional pain management modalities • Address co-morbid conditions • Psychiatric, chronic medical conditions • Bring awareness to attitudes/perceptions towards pain • Help them to be realistic

11. Association of pain and suffering Pain Suffering

12. Suffering When suffering, treat with validation

13. Suffering Patients suffer when there is: • A crisis of meaning and identity • Fear • Vulnerability • A scary, bleak, unpredictable future • Their sense of wholeness, intactness, integrity is threatened

14. What happens to the doctors • Feel helpless • Too uncomfortable to ask these questions • Feel vulnerable – so they numb: drink, smoke, withdraw, get angry, bring certainty to uncertainty • Doctors invalidate – don’t worry, that’s no reason to get upset, etc.

15. Invalidation Invalidation can lead to less adherence, withdrawal, and or anger Patients may feel invalidated when a clinician • trivializes • discounts, • Dismisses • finds easy solutions to complicated problems • focusses solely on change and motivation

16. Validation Encompasses and surpasses empathy Clinician communicates: • Patient’s responses make sense • Acceptance – it is what it is – the patient thinks, senses and feels the way she does • Takes patients experiences seriously To validate clinician must: Search Recognize Reflect There is truth inherent in the patient’s responses

17. What validation is not • Making something valid that isn’t • It is not scientific • Controlled, replicable • It does not need agreement or approval • You as the clinician may see it differently – acceptance of the patient’s experience

18. 6 levels of validation 1) Stay awake and pay attention • Eye contact, nod • Ask questions Language for suffering different than language of pain Ask: • Are you suffering/ struggling? • What about this illness is scary for you? • What does this mean to you? • What has this illness done to your life, work, family, friendships? • What are you worried it will do to your life, work, family friendships? • What has happened to your spirit?

19. Level 2 and 3 2) Accurate reflection • Use the NURSE model - • Paraphrase (don’t parrot) what patient shared • Be non-judgmental – matter of fact • You don’t have to agree or like what you hear 3) State what hasn’t been said • Educated guess – based on reading patient’s behavior and imagine what they are not saying • clinician risks being wrong -

20. Level 4 4) Use past history or biology • More holistic view - how mind and body are connected • “Of course you feel fatigue now that you are dealing with knee pain – and you can’t run with your son.” • Clinician demonstrates understanding of the patient’s circumstances

21. Level 5 Normalizing • Clinician communicates the feeling, or thought is normal • Anyone is your situation may feel that way • We all have those moments • Don’t validate the invalid – that can lead to lack of trust • Look for grain of truth

22. Level 6 • Radical Genuineness • Treat patient as equal in status and respect • Don’t fragilize • Recognize strengths and limits • Admit the truth of your feelings in a way that shows respect

23. Interactive role play

24. References • Smith H. “Definition and pathogenesis of chronic pain.” Up To Date. Accessed 12/22/12. • Smith H. “Evaluation of chronic pain in adults.” Up To Date. Accessed 1/5/12. • Coulehan JL, Schulberg CH, Block MR, Madonia MJ, Rodriguez E. “Treating depressed primary care patients improves their physical, mental, and social functioning.” Ach Intern Med. 1997;157: 1113-1120.

25. References • Linehan, MM (1997). Validation & Psychotherapy. In A. Bohart & L Greensberg (Eds.), Empathy Reconsidered: New Directions in… Washington, DC: APA. • The Lancet. Volume 374. Issue 9699 Page 1414-1415, 24 October 2009 doi:10. 1016/S0140-6736(09)61851-1. • Meir et al., 2001 Meier D, Black A. Morrison R. The inner life of physicians and the care of the seriously ill. JAMA; 286: 3001-3014. PubMed

26. References • Egan, G. (2001). Exercises in Helping Skills: A Training Manual to Accompany the Skilled Helper. (6th Edition). Belmont: CA: Wadsworth Publishing Co. • Maslach and Leither, 1997 Maslach C, Leither MP. The truth about burnout. San Francisco: Jossey-Bass, 1997. • Cassell, E.J. Diagnosing Suffering: A Perspective. Ann Intern. Med. 1999; 131:531-534.