Occasionally, discrepancies between behaviors and a patient's self-report of pain may occur. For example, patients may describe pain as an 8, on a scale of 0 to 10, while smiling and walking freely, or conversely, as a 2 while experiencing tachycardia, splinting, and sweating, although this is less usual. These discrepancies may result from several factors, including the effectiveness of the patient's coping skills (see Chapter 4). The patient who uses distraction and relaxation techniques may engage in diversionary activities while still experiencing severe pain; in fact, this is a goal of many behavioral pain therapies. Patients may deny severe pain for a variety of reasons, including a perception that stoicism is expected or rewarded or a fear that the pain symbolizes disease progression. Similarly, patients managed with as-needed analgesia may perceive that medication will be given only if the pain score is very high. When discussing pain assessment and control with patients, members of the health care team should emphasize the importance of a factual report, thereby avoiding both stoicism and exaggeration. If anxiety or other concerns are significant, patients should be asked to rate their emotional distress separately from their pain, using similar scales (see Pain Distress Scales in Attachment B). They also may be asked to rate their mood or the effectiveness of analgesic therapies (see the Memorial Pain Assessment Card in Attachment B). When discrepancies between behaviors and self-reports of pain occur, these differences should be discussed with the patient, and the pain management plan should then be revised. Most cancer patients are treated for pain in outpatient and home care settings. Plans should be made to ensure ongoing assessment of the pain and the effectiveness of treatments in these settings. Patients can keep a log of their pain intensity scores and report these scores during followup visits or through telephone follow up. In addition, patients should be taught to report changes in their pain or any new pain so that appropriate reassessment and changes in the treatment plan can be initiated.
Patients unable to communicate effectively with staff require special consideration (see Chapter 7). Even patients previously able to communicate may be unable to do so as their disease progresses. Aggressive efforts should be made to find a translator for the non-English speaking patient to determine a convenient way to assess pain. Many of the pain assessment tools have already been translated (Beyer and Wells, 1993; Cleeland and Syrjala, 1992).
When developing a treatment plan, members of the health care team should pay particular attention to the preferences and needs of patients whose education or cultural traditions may impede effective communication (see Chapter 7 for additional discussion). Certain cultures have strong beliefs about pain and its management, and members of these cultures may hesitate to report unrelieved pain or may have specific preferences for pain-relieving measures. When developing a treatment plan, clinicians should be aware of the unique needs and circumstances of patients from different age groups or various ethnic and cultural backgrounds.
PAIN IN SPECIAL POPULATIONS
Assessing the Adequacy of Pain Management Strategies (Children)
MONITORING THE QUALITY OF PAIN MANAGEMENT