Pain & Symptom Management: A Multidimensional Perspective

Terry Altilio, LCSW

Social Work Coordinator

Beth Israel Medical Center

“Harm occurs when the amount of hurt or suffering is greater than necessary to achieve the intended benefit.  Here lies the basic ethical challenge to caregivers; since pain seems harmful to patients and caregivers are categorically committed to preventing harm...not using all the available means of relieving pain must be justified.”          Walco, Cassity, Schechter, (1994)

Pain and symptom management whether along the continuum of illness or at end of life is a shared responsibility of the health care team. The ethical mandate to relieve suffering emanates from the principles of justice, beneficence and nonmaleficence; principles that inform the work of all of us who interface with patients and families.

Pain is undertreated in the most vulnerable of our populations such as the elderly, children and minority populations, and this tragic reality invites participation as both advocates and clinicians. 

Of particular concern is the prevalence of pain in older adults which ranges from 25-83 percent in the community and from 45-83 percent in long term care facilities.  The undertreatment of pain in long term care has been clearly established by the work of Joan Teno and her team and others. For example, a review of data from 50 states revealed that 15 percent of residents were in daily pain, 41 percent of the residents in pain were still in pain 60 – 180 days later, 3.7 % were assessed to have excruciating pain and 42 percent continued to have unrelieved pain (Teno et al., 2001; Teno et al., 2004). This is the tragedy that is at the basis of an ethical and moral mandate to manage pain with competence and vigilance.     

Pain when viewed as a multidimensional construct includes the physical nature of pain and extends beyond to culture, spirituality, cognitive, emotional, financial, social and family impacts and response. Multidimensional exploration of pain is not a denial of physical pain but rather an expression of interest, caring and concern for the total person. Medical management is accompanied by efforts to understand beliefs, thoughts, behaviors and feelings that may contribute to pain, suffering and distress. 

The International Association for the Study of Pain has defined pain as unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage. As a subjective experience, the person’s report of pain becomes central to the beginning assessment.  This process becomes more complex and requires learnable skills in settings where patients are cognitively impaired, demented, and psychiatrically ill or speak a primary language that is different than the health care provider.

Assessment and treatment of pain assumes knowledge of symptoms, etiology and potential treatments and explores the individual experience of the patient and the family. While pain is a universal experience, the presence of pain in life threatening illness invites an assessment that considers impact on mood, function and quality of life. Pain can be infused with cultural and spiritual beliefs. Some have been taught by their family and culture to bear with pain stoically while others are raised to express pain with dramatic, emotional behaviors. Some believe that pain is a punishment from God, while others may view the presence of pain as redemptive and therefore may initially be reluctant to accept treatments that are offered.

The response of family members to the pain experience is important to explore as patients and their families are intertwined and the suffering that ensues from unmanaged pain extends beyond the life of the patient to the family and ultimately infuses bereavement and the legacy that evolves around the death of the patient. The consequences of pain, whether in life-threatening illness or chronic conditions such as arthritis, ripples outward as a person’s mood, function and quality of life impacts the lives of family members as roles and responsibilities shift and relationships are affected. This reciprocal relationship is often observed in the assessment of pain by family and caregivers who may overestimate or underestimate the level of pain because their perceptions are filtered through their own emotions, fears and suffering. This is a part of the multidimensional understanding of pain that is essential to quality care at end of life and appropriate care planning. 

Medical management of pain is a primary focus as ameliorating overwhelming pain is a prerequisite to any multidimensional assessment.  Pain assessment may include clinical interviews, tools and scales that can both partialize the experience and inform and prioritize interventions. The language and metaphors chosen to explain and describe pain can provide a narrative through which the meaning and significance of pain is expressed.  The patient’s perception and information is validated, and input from family and health care professions may be sought to complement and enrich the clinical understanding of the pain and its impact.

Comprehensive management of pain and other symptoms combines expert medical management with interventions that focus on reducing anxiety and distress and, when indicated, treating depression. If left untreated, these psychological aspects can exacerbate the patient and families’ experience of pain and the quality of their time together. Understanding the impact of pain on mood, function, sleep, appetite and family relationships creates opportunities for focused interventions that extend beyond medical management to a holistic approach that respects the unique person and family. 

Teno, J., Weitzen, S., Wetle, T. & Mor. V. (2001). Persistent pain in nursing home residents. Journal of the American Medical Association, 285(16), 2081.

Teno, J., Kabunoto, G., Wetle, T., Roy, J. & Mor, V. (2004). Daily pain that was excruciating at some time in the previous week: Prevalence, characteristics, and outcomes in nursing home residents. Journal of the American Geriatric Society, 52(5), 762-767.