Pain Management: A Moral Imperative

1. Pain Management: A Moral Imperative Carl L. Middleton, D.Min. Vice President of Theology and Ethics Catholic Health Initiatives

2. Objectives: • Discuss the meaning and the problem of pain management and pain management as a moral imperative. • Provide an overview of CHI’s Healing Therapies Program. • Explain Evidence Based Practice which includes Clinical Experience and Patient Preference and the results of outcomes research regarding complementary therapies. • Share implications of Evidence Based Practice and Guidelines for use of Complementary Therapies.

3. My pain is like a powerful relentless hurricane that rages wildly battering my very foundations. (A Patient)

5. Statistics: • 50 million people partially or completely disabled because of pain • Chronic pain affects 34 million people • $100 billion in medical expenses for pain • Global cancer rates are expected to double to 20 million in next 20 years • 70% of elderly in nursing homes have poorly managed pain • World Health Organization – 50 to 80% failed to receive proper pain treatment

6. Total Pain: • Physical • Emotional • Social • Spiritual

7. Importance of Controlling Pain: Inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families.

8. Challenges: • Pain management is – • A societal problem • A clinical practice problem

9. Challenges: • Fears of developing tolerance to opioids • Fears of addiction to opioids • Fears of opioids side effects • Fears of hastening a patient’s death Pain Management – A Societal Problem

10. Challenges: • Lack of physician education regarding opioids and proper pain management • Good pain assessment is not easy Pain Management – A Clinical Practice Problem

11. Crash: “Pain IS where it hurts!” Charlie Brown – “Peanuts”

12. Joint Commission: The Joint Commission developed pain standards for assessment and treatment based upon the recommendations in the Acute Pain Clinical Practice Guideline. The Joint Commission requires that hospitals select and use the same pain assessment tools across all departments. This standard suggests providing options among scales such as the NRS, the Wong-Baker FACES scale, and a verbal descriptor scale.

13. Joint Commission, Cont. Effective pain management is much more than pharmacological agents; considerations must be given to alternative and complementary therapies with support for additional research and development of standards. Standards and guidelines developed and shared with healthcare professionals should be extended to non-pharmacological, complementary, and alternative methods for pain management including massage, acupuncture, chiropractic, physical therapy, energy therapy, yoga, and aroma therapy. (Testimony delivered by Ann Purchase, Associate Director, New York State Nurses Association Practice & Governmental Affairs Program to the NYS Assembly Health Committee Hearing, Wednesday, Jan. 26, 2005.)

14. Healing Therapies Overview: Healing therapies is a person-centered approach to care which utilizes non-pharmacological means of alleviating pain, promoting relaxation in those who are experiencing anxiety, tension or stress and supporting those who are dying.

15. Healing Therapies Overview, Cont. Person Centered Care is CHI’sphilosophy of caring that is: • Comprehensive in scope(Assessing and responding to the needs of the whole person; Body, Mind and Spirit) • Personalized by design(Individualized according to a person’s values, needs and desires) • Delivered through Collaborative Partnerships(Partnerships with persons, families, providers and community stakeholders made possible by transparent communication)

16. Healing Therapies Overview, Cont. Healing therapies teaches how to provide person-centered care and thus continue the healing ministry of Jesus through the laying on of hands facilitating relief and relaxation. The course places a spiritual emphasis on Christ’s teachings of love and compassion but also embraces persons of all faith traditions. Course participants are taught non-pharmacological means of pain relief and relaxation including energy techniques of Therapeutic Touch (Delores Krieger) and Healing Touch (Hover-Kramer).

17. Healing Therapies Overview, Cont. In order to do this work it is paramount that we take good care of ourselves.  The Healing Therapies course encompasses all ways that we nurture ourselves and others through our diet, exercise, relationships, spirituality (prayer and meditation).  Healing Therapies includes the gentle healing arts of presence, positive affirmations, relaxation response conscious breathing, aromatherapy, guided imagery, comfort touch, massage, cutaneous stimulation, music, humor and laughter, distraction, prayer and meditation.

18. Healing Therapies Overview, Cont. Healing therapies is a way of caring and a sacred healing art that has continued from apostolic times to this day and therefore is not another separate/distinct program but is value added and to be integrated with current initiatives such as palliative care and pain management, etc.  Healing Therapies Training requires 50 to 60 hours of classroom education spread throughout 9 to 12 month period dependent upon the availability of participants.

19. Non-Pharmacological Means of Pain Management: • Affirmations are positive suggestions that a person may create and use to reach a desired result. Affirmations can lower anxiety by redirecting worrisome internal dialogue into positive self-talk. • Aromatherapy is the use of essential oils to enhance the healing experience. Aromatherapy is used under the guidance of a credentialed aromatherapist.

20. Non-Pharmacological Means of Pain Management, Cont. C. Conscious Breathing is the foundation for eliciting the relaxation response. The use of abdominal breathing enhances feelings of well-being.  D Energy Work is a process that uses the hands to direct energy (or the hands in gentle non-invasive placement both on and off the body) to help those in pain, to promote relaxation in those who are experiencing anxiety, tension or stress, and to support the dying process or to comfort those in the dying process.  

21. Non-Pharmacological Means of Pain Management, Cont. E. Guided Imagery is the use of thoughts, pictures and the imagination to develop images of healing in a safe and nurturing way. Imagery works best when all five senses are used. The following are ideas you can use with your patients. Encourage them to use their five senses to imagine seeing (colors, objects, and arrangements), hearing (sounds or silence), smelling (scents or aromas), touching (objects and physical sensations), and tasting (flavors).

22. Non-Pharmacological Means of Pain Management, Cont. F. Music Therapy complements traditional therapy by helping to achieve deep levels of relaxation thereby reducing stress, pain and anxiety. There is evidence that specific therapeutic musical forms increase the immune response and release endorphins. Also, music can distract our attention from the symptoms. G. Massage employs a variety of gentle techniques using touch to create a positive, caring connection. Massage can stimulate the blood and lymph circulation, increase body awareness and promote relaxation.

23. Non-Pharmacological Means of Pain Management, Cont. H. A comfort/touch session is individually designed for each person and is determined by the patient's diagnosis, indication for massage, tolerance to touch, and any precautions related to his or her condition. I. Prayer or Meditation honors personal, spiritual and philosophical beliefs through formal prayer or intentional affirmation of closely-held values. Members of the Spiritual Care or Integrative Care Services are happy to witness or share in prayer with the patient. J. Humor - Laughter releases chemicals into the body that boost the immune system, increases blood flow, and lowers blood pressure. Laughter can also create a diversion from pain. Pain relief lasts for 10 min. or longer after a good belly laugh.

24. Other Essential Elements to the Healing Therapies Course: • Healing our Sacred Calling • Life-Style Counseling • Pain & Suffering: A Pastoral Response’ • Introduction to Spiritual Care

25. Evidence Based Practice: (EBP) EBP at CHI integrates the best, most current research evidence, with clinical expertise, patient, family and community values and preferences, to guide health care decisions for providing optimal care to those served.(Adapted from combination of: Sackett et al. 19961, 20002 and, Honor Society of Nursing, Sigma, Theta Tau International, 20033)

26. Research Levels at Evidence: EBP at CHI integrates the best,most current research evidence… • If there are multiple types of evidence available for a complementary modality, an MBO should rely on the highest level of study as it is more rigorous and credible. • If the research evidence is absent or weak, at best, clinical expertise and patient preference will necessarily play a more prominent role in decisions regarding selection and use of complementary interventions. • Patients should be discouraged from using complementary therapies that are potentially harmful or may interfere with conventional treatments.

28. Clinical Experience: Clinical experience (which has not been subjected to the rigors of scientific proof) is a critical element in providing comprehensive, personalized care that assesses and responds to the mind/body/spirit needs of patients. CHI’s adoption and endorsement of EBP reinforces the importance of clinical experience and protects clinicians from the tyranny of “cookbook medicine.” The absence of research is not the same as the absence of efficacy – it is simply a gap in definitive knowledge that requires us to tread cautiously and rely on less definitive decision aids. This applies to the use of both conventional and complementary therapies.

29. Patient Preference: Patient preference is the final critical element of EBP and must be addressed in any treatment plan. Ignoring patient preference violates the ethical principle of autonomy. If patients request therapies that are not validated by scientific evidence, then both patient preference and clinician experience need to be weighed to make decisions as to their safety and appropriateness.

30. Patient Preference, Cont. In the case where complementary therapies are made available to patients at their request, no claims as to efficacy should be made that cannot be supported by scientific evidence. In addition to cultural and religious sensitivity, practitioners need to also be well-versed in the relevant scientific evidence (or lack thereof) when describing complementary therapies to patients. This sensitivity and understanding will allow practitioners to offer complementary therapies in response to patient requests and preferences in a manner that is honest and avoids controversy.

31. Outcomes Tracking: • We developed a CHI Complimentary Outcomes Tracking Tool. • Before the therapy is initiated the therapist has the patient to self assess pain and anxiety separately, using a 10 point scale both pre and post session. • The therapist takes the blood pressure and pulse of patient both pre and post session.

32. Sample Outcomes Tracking

33. Guided Imagery: For women (n=46) your pain scores, on average, went from 5.9 to 4.7 (decrease of 1.2) and your anxiety scores, on average, went from 4.6 to 2.6 (decrease of 2). The blood pressures decreased slightly and the heart rates went up slightly. For men (n=33) your pain scores, on average, went from 4.5 to 3 (decrease of 1.5) and your anxiety scores, on average, went from 2.9 to 0.7 (decrease of 2.2).  The blood pressures increased modestly and the heart rates went up slightly.

34. Guided Imagery, Cont. Women and men both had very similar responses except for the bump up in blood pressure for men.  There may not be any significance to this difference—time and more data will tell.

35. Energy Therapies: For energy therapies (n=37), on average, the pain scores went from 6.26 to 1.37 (reduction of 4.89) and the anxiety scores went, on average, from 5.45 to 1.74 (reduction of 3.95) while blood pressures went down, on average, 6.3/0.8.

36. Massage Therapy: For massage therapy (n=59), on average, the pain scores went from 4.57 to 1 (reduction of 3.57) and the anxiety scores went, on average, from 4.53 to 1.72 (reduction of 2.89) while blood pressures went down, on average, 5.4/1.3.

37. Reflexology: For reflexology (n=10), on average, the pain scores went from 1.5 to .25 (reduction of 1.25) and the anxiety scores went, on average, from 7 to 1.5 (reduction of 5.5) while blood pressures went down, on average, 1.8/3.2.

38. Implications of Evidence-Based Practice and Complementary Therapies: • Practitioners of complementary modalities should be carefully selected, screened and provided orientation to the Catholic heritage, tradition and cultural sensitivities of the facility. • Volunteer practitioners of complementary therapies should have proper supervision and accountability to fulfill their responsibilities in a professional manner, which includes respect for conventional medical treatments, scientific evidence and our Roman Catholic heritage and teachings.

39. Implications of Evidence-Based Practice and Complementary Therapies, Cont. • The facility should develop a framework and script for talking about energy modalities or other controversial therapies in a way that dissociates them from objectionable belief systems or other baggage that interferes with patients receiving therapies that they want. For example, a practitioner would refrain from the use of such terms as “channeling universal life force” or “universal energy.”

40. Implications of Evidence-Based Practice and Complementary Therapies, Cont. • Where research is non-existent and clinical expertise or patient preference determines appropriateness of a particular complementary modality, the facility/practitioner should track clinical outcomes and patient experience associated with that modality. While tracking clinical outcomes and patient experience does not constitute a formal research project, findings could lead to formal research if consistent benefits are noted. Conversely, the use of particular modalities may be discontinued if they show no benefits over time.

41. Conclusion: Evidence-Based Practice recognizes that many aspects of medical care depend on individual factors such as quality of life value judgments, which are only partially subject to scientific methods. EBP, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to promote the best possible outcomes.

42. Conclusion, Cont. Making energy modalities or other complementary therapies available to patients who want them (along with appropriate conventional treatments – not in place of them) is consistent with the definition of Evidence-Based Practice.

43. Conclusion, Cont. As we have seen, the three common elements among all EBP definitions are science/evidence, clinician experience and patient preference.  The patient preference element can accommodate energy work and other modalities that are safe but not yet scientifically validated.

44. Conclusion, Cont. Effective Pain Management is a moral imperative for Catholic Health Facilities and we should be using both pharmacological and non-pharmacological means to keep patients comfortable.

45. It Takes a Team

47. God is Present In our Joy, our Pain And our Suffering.