Improving our communication with patients with pain

1. Improving our communication with patients with pain Joanna M. Zakrzewska

2. 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

3. 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

4. How to ensure good communication • Presentation • Empathy • Respect • Support • Organisation • Non judgmental • Alliance

5. KEY SKILLS LISTENING OBSERVING

6. 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

7. 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

8. Ways of communicating • Seech - language, verbal • Paralinguistic vocalisation, tone, choice of words • Non-verbal

9. 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.

10. Non Verbal Communication • Vocal – crying, moaning • Physiological – pallor, sweating, muscle tension • Expressions- grimacing, smiling • Posture – rubbing area, guarding, withdrawal

11. Advantages of non-verbal communication • Reflective and spontaneous • Audible and visible • Specific information • Encodes severity • Able to differentiate emotions such as anger and fear

12. Disadvantages of non-verbal communication • Vulnerable to habituation - learn to respond • Contextually driven • Some under voluntary control

13. 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

14. 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

15. Exercise 1 • Why do we need pain? • How would you define pain? • What is the difference between acute and chronic pain?

16. 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

17. 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

18. 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

19. 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.

20. 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

21. Exercise 2 • What 9 features of pain do you need to establish? What other data do you need to ascertain?

22. Taking a Pain History • Character • Severity • Site, radiation • Duration, periodicity • Provoking factors • Relieving factors • Associated factors

23. Pain History • Past medical history • Past dental history • Family history

24. Pain affected by • Anxiety • Fear • Catastrophising • Attention • Learning • Personality • Coping

25. Exercise 3 • Why measure pain ? • How would you measure pain?

26. 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

27. How to measure pain? Verbal descriptor rating scales • Mild • Moderate • Severe • Most severe Numeric rating scale • Pain out of 10 Reliable in the elderly

28. Visual analogue scales anchors : no pain max pain no relief max relief no distress max distress 10 cm line

29. Not reliable in the elderly Gagliese 2001 Children over 8 can use these

31. McGill Pain Questionnaire Reliable in elderly Gagliese 2001

32. Brief Pain Inventory

33. 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

34. 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

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

37. 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

38. 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

39. 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

40. Relaxing I feel much better as a person Free, calm Feels lovely the flowers, living would love to be there

41. 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

42. 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

43. Rosa Sepple

44. 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

45. How stories remake what pain unmakes Frank AW 2003

46. Can you now help people in pain find their moment in front of their version of Frank’s window?