Total pain is the sum of four components: physical (pain), emotional discomfort, interpersonal conflicts, and nonacceptance of one’s own dying. These four components may individually or in combination affect a patient’s perception of their total pain. Lack of understanding of the influence of each of these four components may result in less-than-optimal pain management at the end of life.
The “gold standard” of pain management is constant pain assessment. Pain is whatever the patient
Physical pain is not universal with every death, but some discomfort is usually present.
1. TOTAL PAIN – PHYSICAL PAIN Physical pain is the most familiar component of the total pain concept for physicians. Pain assessment includes eliciting a history of presenting symptom(s) as well as conducting the appropriate physical examination of the patient. Laboratory and imaging studies may be used to further understand the patient’s pain.
Physical pain can be categorized in terms of its temporal nature (ie, acute or chronic) and delineated as to three types based on neurophysiologic mechanisms (ie, somatic, visceral, and neuropathic). Regardless of mechanism, breakthrough and incident pain may occur.
Acute pain results from nociceptor stimulation, usually is time-limited, and often responds to
Somatic pain results from stimulation of nociceptors (receptors for pain in the skin and deep
Neuropathic pain results from damage to the peripheral nervous system or the central nervous system
Central pain may be the result of a cerebral vascular accident and is
Breakthrough Pain and Incident Pain
Breakthrough pain is characterized as a temporary increase in pain from the basal, acute, or chronic pain level. It is frequently described as worsening pain at the latter part of the regularly scheduled analgesic-dose interval. Incident pain can occur during daily routine activities as when passing flatus. Patients should have the appropriate comprehensive pain management in place for each type of pain.
Pain scales are universally used for patients to convey the intensity of their pain throughout treatment.. Using a particular pain scale is not as important in the care of patients as the consistent use of the same pain scale. Patients’ perception of an acceptable pain level should be the endpoint of the therapy. The endpoint of therapy should be the patient’s perception of an acceptable pain level.
2. TOTAL PAIN – ANXIETY : The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM IV-TR) defines anxiety as the apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension.(Pg. 820) The focus of anticipated danger may be internal or external.
Anxiety may be due to many organic causes and may occur in the course of pain management if patients are not receiving adequate pain control.Anxiety may also be preexisting and should be managed as any other comorbid medical condition.
Even when patients are adequately treated, the thought that pain relief will not be available at the end of life causes some to have great anxiety. Abandonment by their physicians, families, or friends, as well as fear of dying alone, is another source of symptomatic anxiety at the end of life.
3. TOTAL PAIN – INTERPERSONAL INTERACTIONS:
An interpersonal conflict influences the development of pain as much as any other aspect of total pain. Families and individuals who coped well before end of life may require little additional support, but patients in families with marital discord or other conflicted relationships may experience total pain. Mounting financial stress along with family discord may cause additional disharmony. The loss of status within the workplace or in the family can intensify pain symptoms. Whereas analgesic medication and anxiolytics cannot quell the pain of interpersonal conflict, counseling often can be of assistance. Patients at the end of life can achieve comfort and a sense of completion in personal relationships by addressing Dr. Ira Byock’s five key points:
“I forgive you.”
“I love you.”
4. TOTAL PAIN – NON-ACCEPTANCE : Acceptance at the end of life is the self-acknowledgment of the imminence of death. Buckman’s Three-Stage Model of the Process of Dying offers a guide for physicians to anticipate how patients accept their finality in terms of personal spirituality. In the initial stage, the patient has awareness of the definitive reality that the disease process will possibly result in death. Reactions to such awareness are characteristic of the individual’s basic personality and may include fear, shock, anger, guilt, and vacillation between hope and despair. In the middle stage, most patients resolve their anger and denial. Depression is common in this stage as individuals are aware they will indeed die, but they do not view death as immediate. Supportive family and friends are helpful if the dying persons do not have negative interpersonal conflicts. Others in this intermediate stage have an intensified positive emotional resolve.
The third stage is defined by dying individuals’ acceptance of the imminence of their death. Nonacceptance is evidenced by intense distress with the proximity of death and is a source for increased total pain. This model is helpful for those who may anticipate the need for support of patients at the end of life
Spirituality is a function of personal values, not specific religious tenets. Hay provides a spiritual model that is compatible with medical constructs for good end-of-life care. There are four versions of individual spirituality according to Hay:
Spiritual suffering is the presence of interpersonal or intra-psychic pain.
Inner resource deficiency is defined as having diminished spiritual capacity.
Belief system problem is a lack of conscious awareness within a personal-meaning system.
Specific religious requests that are made by some individuals at the end of life assist them in obtaining a sense of spiritual well-being. Effective pain management at the end of life applies the concept of total pain. An assessment is required to determine the nature of the pain. They must treat patients for reversible physical causes and address interpersonal and spiritual pain. Analgesics will be most effective if all components of total pain have been explored. Opioids are often the medication of choice for end-of-life pain. They are safe and effective for the treatment of patients with moderate to severe pain, and they have side effects that can be managed effectively.
*Added by Vaishnavas CARE Editor