VOL: 98, ISSUE: 43, PAGE NO: 36
Ursula O’Leary, MSc (pain management), RGN, is palliative care clinical nurse specialist (Macmillan), Watford General Hospital
Pain is a unique experience for each individual and is affected by a range of physical, psychological and social factors (Field, 1996; Carr, 1997). Although there is a body of literature on factors that influence pain, there is scant evidence that the findings are incorporated into pain assessment and management practices (Ferrell et al, 1995; McCaffery and Ferrell, 1995).
The age and physical vulnerability of an older person affect the perception of pain in different ways. In the UK, 70% of people with cancer are over 75 years old (Faithful, 1993). Older patients experiencing pain from advanced cancer also have higher rates of concurrent physical illnesses, psychological symptoms such as depression (Ferrell et al, 1990) and are affected by the social implications of ageing.
Although there is little clinical information on the physiological changes of ageing, it is known that drug absorption and distribution in an older person vary because of the changes in blood flow, plasma proteins and altered body composition that occur with age (Egorin, 1993).
This may influence the effectiveness or toxicity of medication, and may have serious implications for those with advanced cancer, as analgesic management often includes opioid preparations. Such drugs can cause confusion and drowsiness, especially in older people, so it is vital for health care professionals to be aware of these effects to ensure that they administer appropriate drugs and correct dosages to manage pain effectively in older people.
This patient group can also experience changes in the perception and expression of pain. The chance of cognitive impairment increases with advancing age, which may affect an individual’s ability to respond to, and express, pain.
Brockopp et al (1996) found that 80% of respondents held negative views on the use of analgesia. For example, some had an irrational fear of opioids and addiction and were hesitant to report pain. Health care professionals need to devise pain management strategies that allow for the ageing process without stereotyping this group.
Although there are suggestions of a gender difference in pain thresholds, tolerance and intensity (Carr, 1997), the evidence is mixed. McCaffery and Ferrell (1992) suggest that women have a lower pain threshold and complain of pain more than men, yet comparative studies (Walding, 1991; Lautenbacher, 1993) show such small differences that it is reasonable to conclude that men and women are more alike than they are different in the way that they react to pain.
Walding (1991) suggests the presumed differences in pain perception between men and women may arise because of the expectations of the health care team. If true, it could mean that clinical management is influenced by irrelevant and biased opinions, resulting in compromised treatment.
Furthermore, few studies have been conducted in clinical environments. Traditionally, pain research has been carried out in laboratory settings, with subjects exposed to physical stimuli (Lautenbacher, 1993). This may result in misconceptions, and health professionals need to be aware that this could lead to mismanagement of pain relief.
Some authors suggest that cultural factors play a part in the pain experience (Jordan-Marsh et al, 1994; Waddie, 1996). However, as with the work on gender-defined responses to pain, many studies on cultural factors have been conducted in a non-clinical setting and so may be skewed. However, several reports, both anecdotal and empirical (Walding, 1991; Jordan-Marsh et al, 1994; Waddie, 1996), highlight the link between culture and the expression of pain.
Honeyman and Jacobs (1996) posit that responses to pain differ not only between, but also within, ethnic groups. Therefore, meaning associated with symptoms such as pain cannot be taken for granted across cultures.
Nurses must be aware that culture can affect perceptions and expressions of pain, to ensure they do not misunderstand pain behaviours and inadvertently deny a patient analgesia. During life-threatening illness, cultural expressions may be exaggerated because of the reaction to major life changes and fear for the future. Patients need to be assured that their expressions of pain are understood, and not be berated for acting outside the perceived norm.
The experience of pain is unique to the individual and it is important that people are encouraged to communicate their perceptions to ensure pain is managed appropriately.
The literature suggests that expression of pain is linked to communication skills. Differences in the way people express their pain could mean that those who do not share similar life experiences, or language, may not be able to relate to the experience of the person in pain. Heath (1989) comments that many patients are obliged to express themselves in analytical terms in order to provide reasonable grounds for requiring help.
While this may be true in some cases, many patients with advanced cancer give vivid accounts of their pain, often describing a sense of ‘being eaten’ or ‘gnawed’ (Jackson, 1994). Health care professionals should not openly show undue distress with such descriptions, as this could result in the patient failing to give further descriptions, thus tacitly implying the pain is less severe when it is not.
While pain expression and communication are linked, verbal cues are not the sole indicators of pain. Shannon et al (1995) argue that language ability can affect the individual’s expression and, for some, verbal expression of pain is inappropriate. It must not be assumed that silence indicates an absence of pain. Staff need to be aware that people with poor verbal skills require assistance and support to enable them to communicate and ensure that the pain assessment accurately represents the patient’s experience.
The area of the body that is the focus of pain will affect how the pain is perceived and expressed. Redler (1994) states that pain in certain parts of the body is culturally more acceptable. In many countries, the sexual organs are considered a taboo subject (Lanceley, 1995).
Beliefs, values and spirituality
Attitudes to pain may be influenced by beliefs that may offer a rationale for pain. Despite the lack of research in this area, some authors such as Elsdon (1995) suggest that patients need to make sense of their lives, especially where there are concerns regarding serious illness and impending death.
Brown (1988) states that religious beliefs and practices can be disrupting during illness, citing the example of Judaism in which believers are encouraged to have a healthy body at all times. This often means that they must strive to eat, even when appetites and energy are lacking. Furthermore, facing a life-threatening illness can result in conflict between patients and relatives, and carers need to be aware of these aspects.
Spirituality is central to holistic health care, and is linked to physical, psychological and social factors. Furthermore, Elsdon (1995) says that as physical health recedes in the dying person, their spiritual needs may grow in importance. Price et al (1995) state that ‘good management of pain is married to a genuine understanding of suffering’. However, Zerwekh (1993) argues that the complex issues surrounding spirituality may give rise to conflicts in understanding and management.
Boutell and Bozett (1990) state that effective symptom control is vital, as patients will not be able to sort out their emotional anguish if they are distracted by problems such as physical pain. Such concepts pose enormous challenges to staff, as many feel ill-prepared to deal with such issues.
However, Elsdon (1995) argues that, in the dying person, hope depends on the knowledge that help is available through simple means, such as listening or hugging, rather than through sophisticated psychological interventions. Therefore, health care professionals should recognise the need to assist and support patients to find their own answers.
The meaning of pain to the individual
Pain has different connotations, depending on its cause, and a cancer diagnosis can have a devastating impact on patients and their families. Some will experience home management and financial problems (Otto, 1994), while others will express anxieties regarding their physical limitations and social isolation.
Other patients may view chronic malignant pain as a punishment (Atkinson, 1993), so may not wish to receive analgesia. Health care professionals need to understand this rationale to enable them to offer support or to reassure the patient that they are not being punished.
Yet for others the confirmation of a cancer diagnosis, or secondary spread, offers an explanation for the pain and gives them permission to receive adequate analgesia. Shortly before his death in 1994, the dramatist Dennis Potter wrote in The Guardian of his experience of being diagnosed with cancer, and of the realisation that he had been trying to manage severe pain with paracetamol.
Previous exposure to pain also influences the individual’s experiences and understanding of pain (Carr, 1997). One person may describe their pain as mild to moderate, while another may describe the same level of pain as severe. Constant, unrelieved pain can also result in disturbances, such as insomnia, poor appetite, irritability and depression, all of which can lead to exacerbated pain syndromes. It is important for staff to manage pain effectively and minimise the possibility of a cycle developing.
Several authors identify the positive relationship between anxiety and pain perception among surgical patients (Paice, 1991) and people with chronic pain syndromes (Kelsen et al, 1995). It appears that individuals with advanced disease experience modifications in pain perception that correlate to levels of anxiety and depression (Jackson, 1994).
Although not fully understood, it is thought that anxiety states are caused by activation of the sympathetic nervous system, potentiated by adrenaline and noradrenaline from the adrenal medulla, stimulated by the hypothalamus (Walding, 1991). This is similar to the mechanisms that produce pain (Talbot et al, 1991). Thus, anxiety may have a role in potentiating pain by enhancing physical symptoms.
Paice (1991) states that fear of death and uncertainty for the future, as well as family and financial concerns, may contribute to increased anxiety in people with cancer.
In many respects, a diagnosis of cancer could epitomise such a theory where there is not only doubt surrounding the individual’s ability to remain independent, but regarding life itself.
Patients with cancer experience emotional distress in addition to physical symptoms, and are susceptible to states of anxiety, depression and fear. Strang (1997) demonstrates that while pain caused by cancer reminds individuals of the active nature of the malignancy, it is not the only cause of increased pain intensity, and that anxiety and pain are closely linked. Consequently staff should recognise that, in advanced cancer, the treatment of physical and emotional problems should be co-joined.
An individual’s experience of pain is unique. The intensity of perceived pain is based not only on physical factors, but also on psychological and social ones. These influences determine the way people express pain. In addition, where a diagnosis of cancer exists, these factors can have serious and long-term consequences.
It is important for health care professionals to be aware of these variations if the total pain experience is to be understood and managed.