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Improving our communication with patients with pain . Joanna M. Zakrzewska. AIMS and OBJECTIVES. AIM: Change your perception about how you communicate with a patient in pain At the end of the presentation you should: Understand the need for good communication and how this can be improved

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aims and objectives

AIM: Change your perception about how you communicate with a patient in pain

At the end of the presentation you should:

  • Understand the need for good communication and how this can be improved
  • Recognise different ways of communicating and analyse their effectiveness
  • Be able to define pain in a holistic way
  • Recall the features of pain and factors that affect it
  • Be aware of the different measures used to measure pain and understand their limitations
  • Recognise the value of art and narrative in communicating with patients in pain
how quickly do we interrupt a patient s opening statement
How quickly do we interrupt a patient’s opening statement?

23 seconds!

How much time does the average patient need?

90 – 150 seconds

In a survey of 74 consultations patients were allowed to complete their opening statement in only 23% of cases

how to ensure good communication
How to ensure good communication
  • Presentation
  • Empathy
  • Respect
  • Support
  • Organisation
  • Non judgmental
  • Alliance
key skills




limited capacity to communicate
Limited capacity to communicate
  • CNS immaturity - infants, toddlers
  • CNS abnormalities or damage e.g. brain disease
  • CNS impairment, dementia, recovery from general anaesthetic, use of recreational drugs
  • Psychosocial conditions - inability to speak, mutism, behaviour disorders, speech disorders
magnitude of problem
Magnitude of problem
  • Intellectual disability in general population 2.5%
  • Cerebral palsy: 2-6 per thousand births in US
  • Dementia: 8% of people over 65 years
  • Brain damage: 5 - 1.9 million head injuries per year with 10% of these being serious
  • These people are all vulnerable to pain even more because of physical disability
ways of communicating
Ways of communicating
  • Seech - language, verbal
  • Paralinguistic vocalisation, tone, choice of words
  • Non-verbal
speech and communication
Speech and communication
  • reflects complexity of thought
  • selective
  • reflects best interest
  • cognitive
  • depends on communication competency
  • contextually driven
  • easy to cheat
  • People often use personal reference standards to compare their pain to another pain they previously had.
non verbal communication
Non Verbal Communication
  • Vocal – crying, moaning
  • Physiological – pallor, sweating, muscle tension
  • Expressions- grimacing, smiling
  • Posture – rubbing area, guarding, withdrawal
advantages of non verbal communication
Advantages of non-verbal communication
  • Reflective and spontaneous
  • Audible and visible
  • Specific information
  • Encodes severity
  • Able to differentiate emotions such as anger and fear
disadvantages of non verbal communication
Disadvantages of non-verbal communication
  • Vulnerable to habituation - learn to respond
  • Contextually driven
  • Some under voluntary control
factors affecting display of pain
Factors affecting display of pain
  • Exposure to events that start pain
  • Child characteristics and health status - history previous to illness, developmental
  • Contextual factors - other factors, hunger, fatigue, anger
  • Care giver factors - efforts to palliate, comfort, analgesic
  • Self report measures not helpful in those who cannot communicate
expression of pain in children with autism
Expression of pain in children with autism
  • Facial display of these children more vigorous
  • Child report incongruent with facial activity in comparison with controls, parents did not seem to pick up on these expressions
  • Cannot characterise their pain

Nader, Clinical J Pain 2003

exercise 1
Exercise 1
  • Why do we need pain?
  • How would you define pain?
  • What is the difference between acute and chronic pain?
importance of pain
Importance of pain
  • To warn about impeding or actual damage
  • Motivate escape and preventive action
  • Alarm signals to others - warn about threat and danger
  • Instigate empathy, care in others
  • Social regulation - signify capabilities to contribute to social well-being, tells us how to relate
what is pain iasp definition
What is Pain? IASP definition

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

The inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need of appropriate pain relieving treatment .

Pain is ALWAYS accompanied by an emotion

what is pain
What is Pain?
  • Pain results in disability :
    • difficulty experienced in accomplishing tasks of daily living 
    • these tasks relate to core beliefs, expectations, aspirations andlife goals

Although a personal experience it results in observable pain behaviour

what is pain19
What is pain?
  • pain is more than an simple threat to physical integrity and a cause ofdisability
  • it is a threat to self and identity
  • pain threatens who I am, who Iwant to be and what I might do.
chronic pain
Chronic Pain

Pain that has outlived its usefulness

  • Often said to be pain that has been present for over three months
  • Pain that is unlikely to be cured but the disability it causes can be reduced
exercise 2
Exercise 2
  • What 9 features of pain do you need to establish?

What other data do you need to ascertain?

taking a pain history
Taking a Pain History
  • Character
  • Severity
  • Site, radiation
  • Duration, periodicity
  • Provoking factors
  • Relieving factors
  • Associated factors
pain history
Pain History
  • Past medical history
  • Past dental history
  • Family history
pain affected by
Pain affected by
  • Anxiety
  • Fear
  • Catastrophising
  • Attention
  • Learning
  • Personality
  • Coping
exercise 3
Exercise 3
  • Why measure pain ?
  • How would you measure pain?
why measure pain
Why Measure Pain?
  • Assess it at baseline
  • Assess what factors modify the pain
  • Use to assess outcome of treatment

Any measure is addressed to the listener , the clinician , so it requires a comment - shared trust

how to measure pain
How to measure pain?

Verbal descriptor rating scales

  • Mild
  • Moderate
  • Severe
  • Most severe

Numeric rating scale

  • Pain out of 10

Reliable in the elderly

Visual analogue scales

anchors : no pain max pain

no relief max relief

no distress max distress

10 cm line


Not reliable in the elderly Gagliese 2001

Children over 8 can use these


McGill Pain Questionnaire

Reliable in elderly

Gagliese 2001

non verbal pain diary
Non verbal pain diary
  • Crying with or without tears
  • Screaming , yelling, groaning, moaning
  • Screwed up or distressed looking face
  • Body appears stiff or tense
  • Difficult to comfort or console
  • Flinches or moves away if touched
depression and anxiety
Depression and Anxiety

In the last month have you

felt a lack of pleasure in life?

felt depressed ?

Hospital Anxiety and Depression Scale

Beck Depression Inventory

use of art and narrative in pain
Use of art and narrative in pain
  • the relationship between the patient and the clinician affects the pain
  • this relationship is a story

How you look when in pain, screw up your faceMakes you tensePain makes you loose sense of control as it prevents you doing certain things

Pain is complicated took years to find out what pain was


Dark Period


Nothing positive comes out of what I am going through

Deep depression, only see black and white

Avoiding, escaping

Want to hold head and scream just to release it


Pain at some time would be like:

  • red hot stabbings
  • red hot needles
  • electric shocks when really bad

Geometrical summing up of where pain moves out and radiates

Shooting throbbing sensation



I feel much better as a person

Free, calm

Feels lovely

the flowers, living

would love to be there


There are two pains : mental and physical

There is two of me

Its red but not solid, some bits are light some solid

The solid bits are worst

Perceptions of pain Padfield D


Like an animal pawing away inside me and tearing away the flesh from the inside out

With these pictures everyone’s imagination can hopefully realise the extremities of your pain – a picture is worth a thousand words

Perceptions of pain Padfield

the story of pain
The Story of Pain
  • patients tell stories to become who they are
  • patient stories are addressed to someone
  • clinician must listen
  • the quality of attention is important andyou " have to be caught up” – it is an act of surrender
  • Narrative provides meaning, context, and perspective for the patients pain

Greenhalgh and Hurwitz 1999