PAIN MANAGEMENT AND PALLIATIVE CARE

Chapter 22Handbook of Health Social Work, 2nd Edition

Define palliative care, including domains and guidelines and the preferred practices.

Define and distinguish pain and symptom management.

Confirm the unique opportunity and historical framework of palliative care that invites social work participation and leadership in this area of practice and explore the obstacles to realizing the opportunity.

CHAPTER OBJECTIVES

• Describe aspects of a bio-psychosocial-spiritual assessment that informs a place of care.

• Define interventions and illustrate their usefulness through patient narratives.

• Discuss ethical principles that relate to palliative care and the management of pain.

• Explore various models of team collaboration, sources of professional gratification, work related stress, and opportunities' for enhancing self care.

CHAPTER OBJECTIVES CONT.

Palliate means to “alleviate without cure.” The basic definition of palliative care is to improve

the quality of life of patients and families who are facing life-threatening illness through prevention and relief of suffering.

Palliative interventions affirm life and treat dying as a natural process.

Pain and symptom management are essential components of palliative care.

PALLIATIVE CARE

A key characteristic of chronic pain from the patient’s perspective is that it becomes like any other chronic illness.

Comprehensive assessment and interventions extend beyond the physical to psychological, social, cultural, and spiritual aspects of the patient’s experience.

Collaborative goals might include minimizing suffering and the negative impact of chronic pain and enhancing functioning and quality of life.

PAIN MANAGEMENT

Principles and values underlying palliative care and pain treatment have much in common with those of social work.

Consideration of patient and family values, needs, beliefs, and goals is implicit in the principle of respect for the dignity and worth of the person.

Palliative care programs are increasing, and expanding into settings such as extended care facilities and home care.

Standards for Social Work Practice in Palliative and End-of-Life care which includes 11 standards.

CHALLENGES AND OPPORTUNITIES

Principles and behaviors that inform the work of palliative care and the treatment of pain have their roots in human antiquity and serve a vital social function.

Until recently, limited interventions were available to influence the course of illness, so the alleviation of pain and suffering frequently was the most one could hope for.

There is a need for social work leadership in palliative care across all aspects of care: policy, research, education, and clinical practice.

HISTORICAL PERSPECTIVE

In 2004, the National Consensus Project for Quality Palliative Care describes palliative care as consisting of interventions that may accompany life-prolonging treatments and can be practiced at both the generalist and specialist levels.

The integration of palliative care into generalist practice has great potential to impact care for patients and families in various settings through the course of illness to the end of life.

In 2009, the Consensus document added justifications, supporting and clarifying statements, references, case examples, and suggest criteria for assessing outcomes, creating rich and comprehensive tool for guiding generalist or palliative care.

NATIONAL CONSENSUS PROJECT

The assessment of an individual with chronic pain or a life-limiting illness involves gathering in-depth information about the physiological aspects of the symptoms and illness, addresses treatment, and complements competent medical management.

Numerous challenges and needs arise when pain or life-limiting illness arises in the ongoing life of a family.

Such needs and challenges may include understanding the diseases, its treatment, and potential prognosis; developing strategies to manage the impact of pain or illness; coping with and learning the language of professional caregivers and institutions; maintaining stability to meet the changing individual needs and many others.

BIOPSYCHOSOCIAL-SPIRITUAL ASSESSMENT

Persons with chronic pain or chronic progressive diseases and the members of social support networks experience grief as they come to terms with the myriad losses associated with pain and illness.

Specialized spiritual assessment tools also are available for exploring patients’ spiritual and cultural coping strategies and gathering insights into how they interpret their pain or illness experiences.

Chronically ill people may experience sadness and some symptoms of depression and anxiety.

GRIEF

Individual and family attitudes and behaviors related to pain, illness, and death are infused with and enriched by cultural influences.

Societal attitudes toward health, illness, and death have been influenced by a variety of ethical, political, religious, and philosophical beliefs in addition to changing medical practices through the past century.

The assessment recognizes that cultural values and nuances inform patient and family understanding and adaption to pain and symptoms, illness, and death and that care can be adapted accordingly.

ATTITUDES

Advocacy is an ongoing task; needs change, distress varies, and skills of self-advocacy may fade as the patient and family deal with protracted illness, symptoms such as pain and fatigue, and associated feelings of exhaustion, helplessness, and hopelessness.

Supportive counseling interventions include techniques of clarifying, exploring, partial zing, validating, and problem solving.

These interventions, along with extensive medical management of symptoms, establish a basis for trust while they explore immediate needs and concerns.

ADVOCACY AND SUPPORTIVE COUNSELING

These techniques recognize that the biological, cognitive, behavioral, and emotional aspects of experience are related and that interventions focused on any one aspect have the potential to modify the entire experience.

These may be the adjuncts to the medical management of symptoms.

They can be helpful to patients during procedures and diagnostic tests that often create distress and feelings of lack of control.

COGNITIVE BEHAVIORAL INTERVENTIONS

Coping statements are internal or spoken statements designed to distract, enhance coping, self-sooth, or diminish the threatening aspect of a situation or experience.

Distraction involves refocusing attention to stimuli other than pain and to other aspects of self that might include mental activity such as prayer, reading, doing crosswords puzzles, or physical activity such as breathing, rhythm, or engaging in conversation.

COPING AND DISTRACTION

Assisting patients with life review by focusing on generativity offers a foundation for positive reflection at this vulnerable stage of life.

Social workers can assist by normalizing concerns, sharing time for review, and offering resources to assist in the life review process.

With chronic pain, life review may happen as a natural part of integrating the impact of chronic pain as patients and families reflect on changes in their present lives as well as their future hopes.

LIFE REVIEW AND LEGACY BUILDING

The expressive arts offers the social worker enormous opportunities for culturally sensitive interactions with those they serve.

Health social workers are well positioned to recommend and coordinate integrative programs.

EXPRESSIVE ARTS

Providing children with age appropriate information, and allowing them to participate as appropriate, can enhance their adjustment to a changed family experience and to the losses and adoptions that accompany chronic pain, progressive illness, and death.

Adolescents need to be aligned with peers, to regulate uncertainty and anxiety and the desire to achieve some degree of emancipation and independence may become more difficult when medical issues arise.

A number of interventions can be taken place to help the family and adolescent.

CHILD/ADOLESCENT SPECIFIC INTERVENTIONS

Meetings can be used as therapeutic tools for providing family-orientated clinical, palliative, and end-of-life care.

Effective communication with families is challenging because family members are often the “hidden patients” in palliative care, both providing and needing care.

Family conferences have shown to improve communication in palliative care.

Conferences provide opportunities for collective patient, family, and healthcare provider discussions that promote the inclusion of patients and families, invite family members to be active participants in care.

FAMILY MEETING

• The four principles that underlie and guide ethical decision making are autonomy, beneficence, nonmaleficence, and justice. • Cultural beliefs, values, and family dynamics often

require thoughtful clinicians to adapt and negotiate in order to balance the principle of individual autonomy with unique patient and family circumstances. • Justice is an important ethical principle that

involves provision of health care as relate to the availability and distribution of goods and services.

ETHICAL CONCEPTS

In 2003, a national survey of 1004 adults revealed that 57% of respondents to have reported chronic or recurring pain during the past year.

Pain is necessary to survival and generally, but not always, signals physical injury or disease and alerts one to take some kind of action.

Pain is also unique as a symptom in that it is a subjective experience and unlike other somatic experiences, cannot be measured objectively.

PAIN MANAGEMENT

The risk of under treatment increases when assessment of pain becomes more of a challenge for example those who have language or cultural differences and for infants, children, and older persons, and the cognitively impaired and mentally ill.

Many of the barriers to pain management are psychosocial, political, spiritual, or cultural in nature and thus become appropriate foci for social work assessment and intervention.

VULNERABLE POPULATIONS

Geriatric social work clinicians share responsibly for highlighting and solving the problem of unnecessary suffering in older persons caused by recognized and uncontrolled symptoms, including pain and depression.

They may experience multiple chronic illnesses over time that impact their quality of life.

The focus of assessment often extends beyond physical pain to existential issues such as the mortality of self and friends and the meaning and purpose of life.

GERIATRICS

Men and women experience pain differently, research suggest that women are more likely to be inadequately treated both in chronic pain settings and in the case of illnesses such as cancer and Aids.

The complex differences are: Biological factors Psychological factorsBehavioral responses such as coping mechanismsCultural and socialization factors

GENDER ISSUES

It is estimated that between 6 and 15% of the population have a substance use disorder that may involve the abuse of illicit drugs or misuse of prescription medications.

Addiction, physical dependence, tolerance, and pseudo addiction may all be things that abusers face.

Many persons with the disease of addiction have multiple medical problems and consequently can be quite symptomatic.

SUBSTANCE ABUSE

The transdisciplinary team is characterized by substantial overlap in functions such that members share roles in addition to providing their disciple-specific contributions to the team.

The team approach requires professionals to act both as unique contributors and as team members.

TRANSDISCIPLINARY TEAM