Promoting Comfort: Moving Beyond Pain Management

1. Promoting Comfort: Moving Beyond Pain Management • Tara Foote RN, BSN, OCN

2. Objectives • Identify several nonpharmacological interventions to promote patient comfort • Understand the importance of nursing presence in alleviating suffering • Learn to apply nursing theory to positively impact quality of life and comfort • Understand how to engage the interdisciplinary team to provide holistic comfort measures to patients in distress or discomfort

3. Managing pain is far more than the giving of pain medication. Nurses demonstrate compassion as they listen to the patient’s description of pain, validate its presence and importance, and offer their commitment to relieving the pain. (Ferrel & Coyle, 2008)

4. Pain Basics: A Brief Review

5. Pain Definitions • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” (Agency for Health Care Policy and Research, 1994) • “What the patient says it is, existing whenever he or she says it does.” (Institute for Clinical Systems Improvement, 2008)

6. Types of Pain • Nocioceptive Pain: nerve fibers within bodily tissues perceive noxious stimuli, usually responds to NSAID and narcotic medication and has a brief duration • Somatic pain arises from damage to bodily tissues and is usually well-localized (e.g. I cut my arm) • Visceral pain is mediated by stretch receptors and is usually poorly localized, deep, dull, and cramping (e.g. uterine cramping, gas pain, liver pain) • Musculoskelatal pain arises from the bones and associated structures, tending to be inflammatory-type pain (e.g. tendonitis, twisted ankle)

7. Types of Pain • Neuropathic pain: arises from abnormal neural activity secondary to disease, injury or dysfunction of the nervous system • Can be further subdivided into sympathetically mediated pain, peripheral neuropathic pain or central pain (arising from the CNS) • Sensory experience ranges from sharp, shooting, burning pain to numbness and tingling • Tends to respond better to anticonvulsant, antispasmodic and antidepressant medications than narcotics and NSAIDS alone

8. Acute vs. Chronic Pain • Serves as a warning that something is wrong • Response to actual bone or tissue injury • Generally viewed as a time-limited experience • Responds to traditional pain medications (NSAIDS, narcotics) • Has no apparent biological value • Persists beyond the time required for the body to heal • Worsens and intensifies over time • Requires multifaceted approach to achieve pain management

9. Pain Assessment • OLDCART • O = Onset • L = Location • D = Duration • C = Characteristics • A = Aggravating factors • R = Relieving factors • T = Treatment

10. Pain Assessment • The ABCDE acronym • A = Ask about pain regularly. Assess pain systematically. • B = Believe patients’ reports of pain and what relieves it • C = Choose pain control options appropriate for the patient, family, and setting. • D = Deliver interventions in a timely, logical, and coordinated fashion. • E = Empower patients and their families. Enable them to control their course to the greatest extent possible.

11. Sometimes Medication Just Isn’t Enough • Pain vs. Suffering

12. Suffering Defined • Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity (Cassell, 1982) • A state of anguish in one who bears pain, injury, or loss (Copp, 1974) • Suffering can be looked at in physical, personal, family, and spiritual aspects

13. Physical Suffering • Not all physical suffering is caused by pain, and not all pain is identified by the patient as physical suffering. Assess the following sources: • physical discomfort that patients don’t identify as pain (aching, pressure, spasm, cramping, numbness, tingling) • discomfort or distress from immobility • sleeplessness • chills or fever • declining functional ability and increasing dependence on others • changes in appearance • skin problems (itching, inflammation, wounds) • odors from bodily fluids or wounds

14. Personal and Family Suffering • How much are you suffering because of loss of enjoyment of life? • How much are you suffering because of your feelings for and relationships with family and friends? • How much are you suffering because of your concern for your loved ones? • How much are you suffering because of fear of the future? • How much are you suffering because of unfinished business?

15. Spiritual Suffering • Can also be viewed as existential suffering or the search for meaning, hope or connection with oneself, others or a higher power. • How much are you suffering relative to your ability to interact with your spiritual tradition? • How much are you suffering relative to your ability to find strength in your belief system? • How much are you suffering relative to your feelings about your personal sources of inner strength?

16. Ten Tenets of Suffering • It is a loss of control, creating insecurity. Suffering people often feel helpless, trapped, and unable to escape their circumstances. • Suffering is often associated with loss. It may be loss of a relationship or some aspect of self, or loss of some aspect of the physical body. The loss may only be evident in the mind of the sufferer, but leaves the person feeling diminished and broken. • Suffering is an intensely personal experience. • It encompasses a range of intense emotions including sadness, anguish, fear, abandonment, and despair. • Suffering forces one to confront their own mortality. In the face of serious illness, some may fear death while others may yearn for death.

17. Suffering often begs the question “Why?” Illness or loss may be seen as untimely or undeserved. People may seek meaning and answers for that which is unknowable. • It is often associated with separation from the world. People may express intense loneliness and desire for connection with others while also feeling intense distress about dependency on others. • Suffering can produce spiritual distress, feelings of hopelessness, self-reflection of lived experiences and what remains undone, and reevaluation of one’s relationship with a higher power. • Although not synonymous with suffering, pain can produce psychological, spiritual and social distress. Pain which persists without meaning becomes suffering. • Suffering occurs when individuals feel voiceless or unheard.

18. How Can Nursing Theory Guide Us? • Quality of Life Model • by • Betty Ferrell (1996)

19. Quality of Life Model Physical Well Being Fatigue Sleep Disruption Function Nausea Appetite Constipation Aches/Pains Social Well Being Isolation Role Adjustment Financial Burden Roles/Relationships Affection/Sexual Function Leisure Activities Burden Employment Quality of Life Psychological Well Being Anxiety Depression Helplessness Difficulty Coping Fear Uselessness Concentration Control Distress Spiritual Well Being Meaning Uncertainty Hope Religiosity Transcendence Positive Change

20. The Process of Pain Impacting Quality of Life Physical appetite function sleep fatigue Suffering Social isolation finances sexuality leisure Chemo (ImmediateCause) Physiologic Effects (Immediate Effect) PAIN(Patient Sypmtom) Spiritual meaning hopeless uncertainty Psychological anxiety depression helplessness concentration fear

21. How Can Nursing Theory Guide Us? • Comfort Theory • by • Katharine Kolcaba

22. Comfort Theory • Middle range nursing theory developed in the 1990’s for health practice, education and research drawn from nursing, medicine, psychology, psychiatry, ergonomics and English literature • Holistic comfort is defined as the immediate experience of being strengthened through having the needs for relief, ease, and transcendence met in four contexts of experience (physical, psychospiritual, social, and environmental). (Kolcaba & Fisher, 1996)

23. Types of Comfort • Relief: the state of having a discomfort mitigated or alleviated or having had a specific need met • Ease: a state of calm or contentment or the absence of a specific discomfort • Transcendence: the state in which one rises above one's problems or pain even when they cannot be eradicated or avoided

24. Contexts of Comfort • Physical: pertaining to bodily sensations and homeostatic mechanisms. • Psychospiritual: pertaining to internal awareness of self, including esteem, concept, sexuality, and meaning in one's life; one's relationship to a higher order or being. • Environmental: pertaining to external surroundings, conditions, and influences. • Sociocultural: pertaining to interpersonal, family, and societal relationships. Also to family traditions, rituals, and religious practices.

25. Types of Care Coaching (relieve anxiety, plan for recovery) -reassure -educate -provide hope -active listening -help plan for optimizing health -encourage Comforting (unexpected things) -care for and strengthen -environmental interventions -massage, touch, holding a hand -providing opportunities for life review -calm presence -creating a memorable connection Technical (maintains homeostasis) -monitor & manage pain, nausea, dyspnea, etc. -prevent complications -administer medications -observe for side effects

26. Case Study • 74 year old client in own home with 70 year old wife (Mr. & Mrs. Green). Recently, Mr. Green has had weight loss, nausea and abdominal pain. Mrs. Green is anxious when present at physical exam where Mr. Green is diagnosed with pancreatic cancer with liver metastases. Sociocultural -many treatment options, side effects -financial distress -wife’s anxiety -body image, self-esteem Physical -pain -nausea -anorexia -jaundice Psychospiritual -anger -anxiety -questioning meaning -depression Environmental -transportation issues -uncomfortable wait room -cold treatment rooms -bright lights -hallway noise

28. Intervening Variables: factors unlikely to change and over which providers have little control (prognosis, financial situation, etc) Health seeking behaviors: behaviors the patient engages in that facilitate health or a peaceful death. They can be measurable outcomes that are either internal (healing, T-cell formation, oxygenation,) or external (observable behaviors such as working in therapy, shortened length of stay) Institutional Integrity: values, financial stability and wholeness of health care organizations at local, regional, state and national levels Best Policies: protocols and procedures developed by an institution for overall use after collecting evidence

29. Putting It All Together: • Using Nursing Presence and Communication to Provide Comfort

30. NonpharmacologicalInterventions • heat/cold • deep breathing • repositioning • elevation • distraction • music therapy • prayer • massage • acupuncture • aromatherapy • physical therapy • occupational therapy

31. Cognitive-behavioral approaches: biofeedback, guided imagery, hypnosis, passive relaxation, progressive muscle relaxation • Guided imagery is a gentle but powerful technique that focuses and directs the imagination to promote healing, relaxation, and pain and anxiety relief. Going through an entire exercise may be time-intensive but nurses can develop skills to enhance their practice or direct patients and caregivers to do exercises on their own. • http://www.cancer.med.umich.edu/support/guided_imagery_podcasts_descriptions.shtml • http://www.innerhealthstudio.com/ • Jill Lematta Learning Center • CD’s and downloads available on line, at bookstores and libraries • Social Work consult (may be able to provide resources)

32. Nursing Process as Intervention • Nursing was born out of the desire to provide comfort. As technology advances, we increasingly move to a “fix-it” medical model focused on outcome more than process. • Nurses can respond to suffering by • Assessing sources of pain and suffering, such as shame, feelings of abandonment and isolation • Diagnosing sources of suffering to identify those that can be relieved, witnessed or supported • Intervening through presence, listening and communication that enables patient expression and by eliminating sources of suffering • Evaluation to allow alterations in the plan of care and recognition of new problems to meet patients’ needs

33. Presence • Benner described skill acquisition of nurses as they progress from novice to expert • “Presencing” is one of the eight competencies of the nurse’s helping role • Behaviors of expert nurses are committed and involved, contributing to the patient’s personhood, meaning and dignity • Expert nurses knew their “being” was sometimes more important than their doing

34. Presence Defined (from Schaffer &Norlander, 2009) • Being available with the wholeness of one’s being • Encountering the patient as a unique human being in a unique situation and choosing to “spend” oneself on the patient’s behalf • Intuitive knowing or sensing another’s needs for help and making self physically available to be present in a helping way • A subject-to-subject interrelationship that honors the ever-changing reality of the other

35. Key Elements of Nursing Presence • Attentiveness: being in the moment focused on the patient’s message • Accountability: doing the right thing, invested and committed • Sensitivity: knowing the patient as a unique person • Touching: massage, turning, positioning and teaching families to help • Openness: willing to enter another’s experience bringing one’s authentic self • Active Listening: hearing beneath the words to their meaning, using silence • Acknowledging: life review, seeing the patient as still having something to contribute • Honoring the Patient’s Wishes

36. Death is awful, demonic. If you think your task as comforter is to tell me that really, all things considered, it’s not so bad, you do not sit with me in my grief but place yourself off in the distance away from me. Over there, you are of no help. What I need to hear from you is that you recognize how painful it is. I need to hear from you that you are with me in my desperation. To comfort me, you have to come close. Come sit beside me on my mourning bench. (Hauerwas, 1990)

37. References • Agency for Health Care Policy and Research. (1994). Management of cancer pain, clinical practice guideline number 6. Rockville, MD: U.S. Department of Health and Human Services. • Cassell, E. (1982). From Ferrell, B. R. & Coyle, N. (2008). The Nature of Suffering and the Goals of Nursing. New York: Oxford University Press. • Copp, L. (1974). From Ferrell, B. R. & Coyle, N. (2008). The Nature of Suffering and the Goals of Nursing. New York: Oxford University Press. • Ferrell, B. R. & Coyle, N. (2008). The Nature of Suffering and the Goals of Nursing. New York: Oxford University Press. • Ferrell, B. R., & Coyle, N. (2010), Oxford Textbook of Palliative Nursing. New York: Oxford University Press. • Institute for Clinical Systems Improvement. (May, 2008). Health care guideline: Palliative care. Retrieved 14 October 2008 from http://www.icsi.org/palliative_care/palliative_care_11918.html

38. Kolcaba, K. (201o). An introduction to comfort theory. Retrieved December 2, 2012 from http://www.thecomfortline.com • Kolcaba, K. (1992). Holistic comfort: Operationalizing the construct as a nurse-sensitive outcome. Advances in Nursing Science, 15(1), 1-10. • Kolcaba, K. & Fisher, E. (1996). A holistic perspective on comfort care as an advance directive. Critical Care Nursing Quarterly, 18(4), 66-76. • Kolcaba, K., Tilton, C, & Drouin, C. (2006). Comfort theory: A unifying framework to enhance the practice environment. Journal of Nursing Administration, 36(11), 538-544. • March, A. & McCormack, D. (2009). Nursing theory-directed healthcare: Modifying Kolcaba’s Comfort Theory as an institution-wide approach. Holistic Nursing Practice, March/April, 75-80. • Norlander, L. (2008). To Comfort Always: A Nurse’s Guide to End-of-Life Care. Indianapolis: Sigma Theta Tau International. • Schaffer, M. & Norlander, L. (2009). Being Present: A Nurse’s Resource for End-of-Life Communication. Indianapolis: Sigma Theta Tau International. • Smith, H. & Aronson, M. Definition and pathogenesis of chronic pain. UpToDate last literature review version 19:1: January 2011.