Think of a time when you were in pain really in pain – what had caused the pain and what was happening to you? Think of a time when you were suffering really suffering – what had caused the suffering and what was happening to you? What helped relieve your pain? What helped relieve your suffering?
Was the treatment for the pain the same as the treatment for the suffering? Yes or No. Would the treatment for the pain have relieved your suffering – and would the treatment of the suffering have relieved your pain? Which took longer to deal with – the pain or the suffering? Which was harder for you to deal with the pain or the suffering?
Definition: “a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action “ Merriam-Webster Dictionary
Why do we care? Accounts for 20% of outpatient visits, 12% of all rx’s 76.2 million Americans suffer from chronic pain Most common cause of long term disability
Take a good thorough history Pain score Location, radiation, quality Temporal aspects: duration, onset, changes since onset Constancy or intermittency Characteristics of any breakthrough pain Exacerbating/triggering factors Palliative/relieving factors Associated symptoms Impact of pain
Assessment of pain’s impact on overall QOL Social functioning Mood, affect, anxiety Relationships Work Sleep Exercise Activities of daily living
Every patient is different Treatment is constantly changing Options for treatment NSAIDs, acetaminophen, regular dosing vs. prn, relaxation, bodywork (chiropractic manipulation, massage, acupuncture), narcotics What works for the patient Pain is constantly changing Acute on chronic pain Worsening chronic pain Effective pain management involves TRUST
Establish a pain contract Gives clear rules/boundaries Protects your medical license NC Controlled Substance database https://nccsrsph.hidinc.com https://nccsrsph.hidinc.com Referral to pain specialist They’ll advise, you manage Can offer additional pain management modalities Address co-morbid conditions Psychiatric, chronic medical conditions Bring awareness to attitudes/perceptions towards pain Help them to be realistic
Patients suffer when there is: A crisis of meaning and identity Fear Vulnerability A scary, bleak, unpredictable future Their sense of wholeness, intactness, integrity is threatened
Feel helpless Too uncomfortable to ask these questions Feel vulnerable – so they numb: drink, smoke, withdraw, get angry, bring certainty to uncertainty Doctors invalidate – don’t worry, that’s no reason to get upset, etc.
Invalidation can lead to less adherence, withdrawal, and or anger Patients may feel invalidated when a clinician trivializes discounts, Dismisses finds easy solutions to complicated problems focusses solely on change and motivation
Encompasses and surpasses empathy Clinician communicates: Patient’s responses make sense Acceptance – it is what it is – the patient thinks, senses and feels the way she does Takes patients experiences seriously To validate clinician must: Search Recognize Reflect There is truth inherent in the patient’s responses
Making something valid that isn’t It is not scientific Controlled, replicable It does not need agreement or approval You as the clinician may see it differently – acceptance of the patient’s experience
1) Stay awake and pay attention Eye contact, nod Ask questions Language for suffering different than language of pain Ask: Are you suffering/ struggling? What about this illness is scary for you? What does this mean to you? What has this illness done to your life, work, family, friendships? What are you worried it will do to your life, work, family friendships? What has happened to your spirit?
2) Accurate reflection Use the NURSE model - Paraphrase (don’t parrot) what patient shared Be non-judgmental – matter of fact You don’t have to agree or like what you hear 3) State what hasn’t been said Educated guess – based on reading patient’s behavior and imagine what they are not saying clinician risks being wrong -
4) Use past history or biology More holistic view - how mind and body are connected “Of course you feel fatigue now that you are dealing with knee pain – and you can’t run with your son.” Clinician demonstrates understanding of the patient’s circumstances
Normalizing Clinician communicates the feeling, or thought is normal Anyone is your situation may feel that way We all have those moments Don’t validate the invalid – that can lead to lack of trust Look for grain of truth
Radical Genuineness Treat patient as equal in status and respect Don’t fragilize Recognize strengths and limits Admit the truth of your feelings in a way that shows respect
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