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 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 patients 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

Presentation Empathy Respect Support Organisation Non judgmental Alliance

KEY SKILLS

LISTENING OBSERVING

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
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
Seech - language, verbal Paralinguistic vocalisation, tone, choice of words Non-verbal

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

Vocal crying, moaning Physiological pallor, sweating, muscle tension Expressions- grimacing, smiling Posture rubbing area, guarding, withdrawal

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 nonverbal communication

Vulnerable to habituation - learn to respond Contextually driven Some under voluntary control

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

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
Why do we need pain?

How would you define pain?

What is the difference between acute and chronic 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 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?
Pain results in disability :
difficulty experienced in accomplishing tasks of daily living these tasks relate to core beliefs, expectations, aspirations and life goals

Although a personal experience it results in observable pain behaviour

What is pain?
pain is more than an simple threat to physical integrity and a cause of disability it is a threat to self and identity pain threatens who I am, who I want to be and what I might do.

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
What 9 features of pain do you need to establish? What other data do you need to ascertain?

Taking a Pain History

Character Severity Site, radiation Duration, periodicity Provoking factors Relieving factors Associated factors

Pain History
Past medical history Past dental history Family history

Pain affected by
Anxiety Fear Catastrophising Attention Learning Personality Coping

Exercise 3
Why measure pain ? How would you 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?

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

Brief Pain Inventory

Non verbal pain diary

1. Crying with or without tears 2. Screaming , yelling, groaning, moaning 3. Screwed up or distressed looking face 4. Body appears stiff or tense

5. Difficult to comfort or console

6. Flinches or moves away if touched

Date

Activity

Score
1 = not at all, 2 = a little 3 = often, 4 = all the time

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

the relationship between the patient and the clinician affects the pain this relationship is a story

Pain is complicated took years to find out what pain was

How you look when in pain, screw up your face Makes you tense Pain makes you loose sense of control as it prevents you doing certain things

Dark Period Negative 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

Geometrical summing up of where pain moves out and radiates

Shooting throbbing sensation

Pain at some time would be like: red hot stabbings red hot needles electric shocks when really bad

Relaxing 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 everyones imagination can hopefully realise the extremities of your pain a picture is worth a thousand words

Perceptions of pain Padfield

Rosa Sepple

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 and you " 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

How stories remake what pain unmakes

Frank AW 2003

Can you now help people in pain find their moment in front of their version of Franks window?