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THE CHALLENGE
I met Louis when he started radiation therapy for bony metastases to the thoracic region. When he lowered himself into the chair, his body language shouted that he was in pain. The smile he tried to give me was just tight enough at the edges to tell me it was really more of a grimace. Both hands grasped the arms of the chair. Yet when I asked how he would rate his pain on the 1 to 10 scale, he shook his head. “I’m not having pain, not really. It only hurts when I move around.”
He wasn’t lying. By his standards, it was the truth. For Louis, pain was bigger than what he was feeling. It was sharper and scarier. To call what he felt now pain was to exaggerate it. Sometimes it seems as if patients believe that by not using the word pain, they can somehow lessen the experience of it, that giving it the name of pain is too frightening, too definite. Too painful.
I did a synonym check for the word pain, and the following words came up: ache, hurt, soreness, sting, tenderness, hurting, twinge, throbbing. The response I hear most often when I ask patients about their pain is like the response from Louis: “I’m not in pain. It’s just uncomfortable.” Discomfort is a hill, while pain is a mountain. To scale that mountain takes training.
As nurses, we need to start our pain assessment by understanding the language the patient uses. Otherwise our assessment can be biased by misunderstanding. Using the language the patient uses helps us translate it for application. If a patient does not use the word pain to describe his discomfort, we might ask, “What level of discomfort makes it so you cannot sleep?” Or, “How much do you have to hurt before you think about taking medication?”
A complete assessment of pain involves more than asking what the level of pain is, yet often we act as if that is all that is necessary. We make the standard request: “Can you rate your pain on a level of 1 to 10?” The patient gives a number, we record it, and based on a one-line response, we decide whether or not to medicate. But we may not have established whether or not we are speaking the same language. A complete assessment requires verbal congruence and a context. Is the level of discomfort prohibiting sleep or movement? Is the patient able to function at a level he would hope to function at?
At a recent conference I attended, Pain Resource Nurse through the City of Hope, Chris Pasero was the keynote speaker. I took many notes and learned much that I can use in my practice. Yet one statement stands out in my memory. She said that we did not have to believe what a patient said about pain, but we did need to accept it.
There is a flip side to the patient who underrates pain or describes it in a way we don’t recognize. There is the patient who “looks” comfortable and yet continues to report high levels of pain.
When C.J. started his treatment for lung cancer, it had already spread extensively. He was young and motivated to “do everything I can to beat this.” His family came in from out of town to help so someone was always with him in the waiting room. He introduced his visitors to all of us. I’d hear him joking with the therapists and discussing with his family members where they should go for lunch that day. Although he did well, he was admitted several times for complications—everything from dehydration to shortness of breath and pain that was out of control. His pain was referred to his shoulder, and he routinely described it as “12 on a 10-point scale.” But when I walked into his hospital room, he was sitting up in bed with his computer on his lap. He looked comfortable. Yet when he was asked about his pain, he did call it pain. In fact, whenever he was asked about his pain, he went from calmly sitting with the computer to flinching and saying, “I’m having a lot of pain.”
THE SOLUTION
As a society, we place a high value on stoicism. The philosophy of Stoicism holds control of the body and mind as a moral virtue. Someone who is stoic about pain tends to be thought of as “good,” “strong,” “tough.” The patient who appears to be comfortable yet rates his pain higher than the outward perception is labeled as “weak,” “whiny,” a “crybaby.” Both viewpoints impact how we assess pain. In a hospital setting, we use measurements as an assessment tool. We measure many things: lab values, the size of a wound, temperature. Objective data. The pain scale and pain assessment are aimed at objective analysis of pain. Yet by its nature, pain is unseen and therefore difficult to assess objectively. We are forced to rely on the patient’s self-report. And yet … how often are we skeptical? Or, how often do we justify under-medicating pain? Both methods effectively let us off the hook.
Adequate pain management requires open communication. More than asking patients to rate their pain, we need to use complete assessment skills. Observe the patient. Is he moving around in bed and changing position, or is he staying still? What is the context of the assessment? Is the patient distracted by visitors, stressed by lack of sleep? What is the language the patient feels comfortable using? None of these are new techniques, nor do they represent new information to those of us who work with oncology patients. But our assessment cannot be rushed. It must be comprehensive each time. And it must be individualized.
Margo McCaffery, a pioneer in the field of pain management, defined pain as “whatever the experiencing person says it is.” And to each patient, pain is so much more than a four-letter word. ■
Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.
