Patient Involvement Called Key to Successful Pain-Management Programs

SAN DIEGO—Notwithstanding the last quarter century's advances, pain management in the 21st century continues to be an area fraught with moral questions and challenges. So said presenters here at the International Association for the Study of Pain's 10th World Congress on Pain, at a symposium entitled, “Patient Involvement in Pain Management: A Necessary Nuisance or a Critical Concern for All Clinicians?” Although techniques for measuring and treating pain have improved, the importance of patients' self-reports of pain and of their involvement in the management of pain is still undervalued and underutilized, said Kate Seers, RN, PhD, Head of Research at the Royal College of Nursing at Radcliffe Infirmary in Oxford, UK. In opening remarks for the symposium, Dr. Seers remarked, “Many of the ethical and moral issues [of pain management] can be easily overlooked in the business of everyday clinical practice. Few here would disagree with the idea of a patient's right to communicate his or her concerns to clinicians, yet therapeutic communication is very complex. When this complexity goes unrecognized, or is underestimated, assumptions are made and misunderstandings are common.” The consequences of such misunderstandings are often under-recognition and under-treatment of patients' pain. The answer, said the presenters, is to encourage practitioners to actively enlist patients as partners in the therapeutic process. As they addressed the advances in and barriers to patient involvement in pain management, Dr. Seers and her co-presenter, Judith Watt-Watson, RN, PhD, Associate Professor on the Faculty of Nursing and Center for the Study of Pain at the University of Toronto, introduced several motifs: Historical changes in health professionals' attitudes toward patient involvement. Challenges inherent in assessing and managing pain. Strategies for improving patient/clinician communication about the subject of pain. Since the third presenter, Irena Madjar, RN, PhD, Professor in the School of Nursing & Midwifery at the University of Newcastle, NSW, Australia, was unable to attend, her material was presented by both Dr. Seers and Dr. Watt-Watson. Pain Measurement Inclusion of pain measurement as the fifth vital sign in the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey attests to the prominence of current thinking about patients' pain. Ironically, though, the sole use of uni-dimensional measures such as the Visual Analog Scale (VAS) may yield insufficient data for adequate pain assessment and a result that is opposite to their intended purpose. “On the surface, it might appear that pain measurement is value-free,” Dr. Seers said. “In fact, it might be seen as a deliberate attempt to get away from the subjective and value-laden aspects of the clinician/patient interaction. Unless we can understand what the pain means to the person experiencing it, what it does to him or her, and how that person endures or copes with it, we risk reducing a complex experience to nothing more than a number on a scale.” “Measurement of pain intensity is important but is only one part of pain assessment,” agreed Dr. Watt-Watson. “We need to encourage clinicians, our colleagues, and our students not to lose sight of the patient as a person.” In line with that, clinicians should also remain sensitive to the level of responsibility for decision-making that patients and families are willing to take on. Simply shifting decision-making from physician to patients is not the answer, said the presenters, who said it is preferable to encourage dialogue and negotiation about treatment planning. Practitioners must be attentive to ways in which their everyday responses limit patient involvement and thus contribute to patients' pain, she said. “There is a tendency to expect patients to endure and be cooperative.” She quoted Dr. Madjar, who emphasizes that “making pain visible requires the voice of the person with pain, but also that of the clinician, the health professional with the power to help.” In answer to the symposium's title question, Dr. Watt-Watson concluded, “Patient involvement is not a nuisance. Patient involvement is an ethical responsibility and a clinical necessity if we are ever going to make any progress in changing pain management practices.”

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