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Discussion with the patient in
pain
Discussion with the patient
in
pain is a frequent, important and often very difficult task for the
general practitioner. 11% of patients in general practices suffer from
chronic pain, and 10% of all prescriptions are those of pain medication.
There are about 3 million patients suffering from chronic pain in West
Germany, and of these, Zimmermann has estimated up to one half pose problems
for the doctor.
The "secret" of a discussion
which helps these patients in pain corresponds to the factors at the root
of every understanding discussion: emotional warmth, empathetic approach
and active listening, along with the ability to verbalize the feelings
of the patient.
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Acute versus chronic
pain
Most difficulties with patients
in pain arise from the fact that the majority of doctors only have experience
in treating acute pain. However there are very basic differences
between acute and chronic pain. Acute pain has an alarm or warning function,
and is like a "barking dog". Chronic pain has usually lost this
warning function. It determines his physical, mental and social attitudes
to life and to the disease: chronic pain overwhelms the characteristics
of a disease and itself becomes a disease entity.
For reasons which affect
therapy, it is useful to differentiate between chronic pain without (rheumatoid
arthritis) or with carcinoma, as pain due to cancer raises a series
of other considerations. In theses cases, there is no obvious reason or
end to the suffering, it continually reminds the patient of the disease
process and raises thoughts of death (E. Aulbert, 1990).
The objectives of
discussion with patients in pain are:
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to
make the subjective experience of the pain less unpleasant by the use of
communication |
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to make it possible
for the patient to come to terms with the pain as far as possible and |
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to make him aware
of certain ways of behaving and techniques for the control of pain by which
he himself can have an influence on it. |
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The perception of
pain
The pain introduces a signal
which psychologically alerts the body amid the "noise" of diffuse, non-specific
mixed impulses. This means that the alarm raised by the pain appears to
be less intense whenever the noise level of these diffuse non-specific
impulses can be raised. This can for example be achieved with distraction
techniques.
The perception of pain
includes various components:
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a
sensory component, which is referred to as the perception of pain itself |
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cognitive reactions
such as thoughts, graphic suppositions and accompanying emotions such as
anxiety, depression etc. |
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motor behaviour
to pain such as moaning, crying, writhing or pacing backwards and forwards. |
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The diagnosis of
pain
A thorough diagnosis of the
pain is vital for its effective treatment. The following points must
be established:
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localization
of the pain |
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intensity |
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type and character |
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development and
course over time |
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factors which
induced it |
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factors which
accentuate or ameliorate it |
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associated phenomena |
In order to grasp as clearly
as possible the subjective experience of the pain, the following questions
are important: "What has changed in your life because of the pain?" "What
is it that most relieves the pain?" "What is the worst thing about your
pain?"
An objective assessment
of the intensity of the pain should always be attempted, even though this
is only possible to a certain degree as pain by its very nature is markedly
subjective.
Means of being objective
include such methods as the VRS (Verbal Rating Scale). This scale
extends from 1 (= the most severe pain imaginable) over intermediate steps
such as 4 (= moderate pain) to 6 (= pain-free). A patient who finds it
difficult to verbalize his experience of pain may manage the VAS (Visual
Analogue Scale) better, where the perception of the pain can be graded
anywhere on a line between 0-100 mm with 0 meaning pain-free and 100 the
worst pain that can be thought of. A pain-diary is also important
for the assessment of the progress of the pain and the effect of therapy.
Taking a history of the pain
not only has a diagnostic component, but is also of therapeutic importance:
it shows the patient that the doctor takes his chronic pain seriously.
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Influencing the perception
of pain in discussion
There is a series of factors
which can lower the pain threshold. These include:
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anxiety |
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sleeplessness |
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worries |
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grieving |
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introversion |
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depression |
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social dependence |
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boredom |
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isolation (R.
Twycross). |
This implies that the threshold
for pain can be raised by measures which work in the other direction:
freedom from associated symptoms, mitigation of sleeplessness, mediation
of hope and understanding, involvement of others (especially to take time),
support of the family, occupation and distracting strategies.
In general the following
possibilities effect alleviation of pain:
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distraction
techniques |
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"suggestion"
strategies |
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reducing anxiety
(see chapter on discussion against anxiety  )
and insecurity, both of which otherwise increase pain |
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prayer and meditation |
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relaxation techniques |
Distraction techniques
have the objective of lowering self-awareness of the body and thereby of
pain. Imagination exercises teach the patient to separate body signals
from those of the surroundings and to allow pleasant ideas (which are incompatible
with pain) to grow. For example he can practice imagining a scene from
the sea shore "in complete details" (climate, landscape, deck-chairs, view
of the sea, cool drinks), and introduce this graphic scene when the pain
worsens.
Suggestion strategies are
carried out by verbal therapy, in some cases under hypnosis. The personality
of the doctor is very decisive here: the doctor who has charisma and vitality
is most likely to have success by radiating security and removing anxiety.
The motto: "the physician as physic" is particularly relevant here. Prayer
and meditation lower self-awareness to a minimum. They are particularly
appropriate for those who are very aware of themselves and of their pain.
Autogenic
training and the progressive relaxation techniques of Jacobson are
two relaxation techniques. However they, like all other techniques
for overcoming pain, should be learnt, if possible in groups, in moderately
pain-free periods in order that they can be introduced at the time they
are most needed.
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Treating pain in
those with tumors
About 40% of patients with advanced
cancer have pain, and 60% suffer from severe pain terminally. The problem
does not seem to lie so much in the severity of the pain as its persistence.
It continually reminds the patient that this disease will lead to his death.
The degree of freedom from pain is of major concern for the quality of
life of the patient (Aulbert). These patients have no need of "specialists".
Personal involvement, time and availability with sensitive and supportive
words are far more important. The relief of pain which can be achieved
by this intensive caring relationship of the doctor to his patient cannot
be rated highly enough. Nevertheless a prerequisite of this is that the
doctor himself has come to terms with his feelings towards suffering and
death, and does not convey insecurity and his own anxieties to the patient.
Treating pain in cancer patients at the very end of their illness is, as
Aulbert explains, "one of the most personal and basically one of the most
intimate tasks because it confronts one's own attitude to one's own death,
and stirs up one's own anxieties about suffering and death".
| The
basic rules
for treating pain due to cancer (mod. from E. Klaschik) are: |
| 1. |
Do
not
doubt what the patient says about the pain. |
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Do not keep
him waiting. |
| 3. |
Deal with one
problem at a time, always showing that you have time. |
| 4. |
Prescribe doses
of analgesic which you know will be effective. |
| 5. |
Create a therapy
plan. |
| 6. |
Discuss
the therapy plan with the patient and relatives. |
| 7. |
Check
how the patient is managing soon afterwards. |
| 8. |
Create a stable
relationship with the patient. |
| 9. |
Treat the psychological
and social background. |
| 10. |
Do not go
away, even if it appears (!) that you can do nothing more for this
patient. |
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Linus
Geisler: Doctor and patient - a partnership through dialogue
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©
Pharma Verlag Frankfurt/Germany, 1991
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URL
of this page: http://www.linus-geisler.de/dp/dp21_pain.html
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