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Frequently Asked Pediatric Palliative Pain Questions
published in the NHPCO Pediatric Palliative Care
Newsletter, October 18, 2004 |
by David Sine and Donna Armstrong
We welcome your questions related to our newsletter theme. February’s
issue will focus on all aspects of bereavement. Submit your bereavement
questions to Dr.
David Sine or
Donna
Armstrong . We want to address your active concerns so be sure to
submit your questions and we’ll help to guide the answers.
Palliative Nurse: Is there a difference in acute and chronic pain in
children?
Are they assessed differently?
Acute pain is fairly well understood and easily identified as we have all
experienced it at some point in our life. If you think of touching a hot
stove with your hand: your autonomic system is activated.
· Respiratory rate & heart rate increase; you become diaphoretic
· It serves a purpose: “do not touch the hot stove again”
· It has a limited duration: as soon as you take your hand off the stove
the healing process begins and natural pain killers are released
· There are many tested assessment tools for acute pain, the most utilized
being the 0-5 or 0-10 scale
Chronic pain is less understood and often even experienced health-workers
do not fully believe that the pain is ‘as bad as the patient states it
is’: the autonomic system is not activated as it is with acute pain.
· Vital signs are often normal as the body has become accustomed to the
signals; but this does not mean that the patient is not experiencing
extreme pain
· It does not really serve a purpose other than to remind the patient of a
chronic or terminal illness
· It does not have a limited duration and will often continue until death
· The assessment tools used for acute pain can be used for chronic pain
but the assessor has to believe that the pain is what the patient says it
is and the tool is only a guide as to whether your treatment is effective.
For example a terminal patient who has been coping with liver carcinoma
for 2 years can have chronic pain that they assess as a 10/10 while they
are carrying on a conversation with the assessor in no apparent distress.
Parent: Can children become addicted to pain medications?
Pain medications are no more dangerous in children than adults. Medical
research shows that < 1% of patients treated for pain develop an addiction
(Foley, 1996.)
Home Care Nurse: How can you really assess pain in a severely
developmentally disabled child?
The best way to assess pain in such a child is by asking the caregivers.
Parents/caregivers may describe behavioral changes such as the child
rubbing his/her face on a pillow or a certain type of cry or movement. A
unique pain scale can be developed with the assistance of such
information.
Pediatric Resident: Is there ever a ‘use’ for narcan as a reversal
agent?
Narcan can be used when someone is determined to be “over-sedated” at a
time when this is not one of the goals of care. It should not be given in
the manner in which most health-care workers are trained (i.e. push it in
to get a deliberate fast reversal) but rather as a slow incremental
infusion to balance the sedation with pain control to get the achieved
goal of comfort.
Hospice Nurse: “I don’t want to be the one that gives the last dose!”
No one wants to ‘feel’ responsible for the death of another on any level.
However, the intent is what is important and if your intent is to provide
comfort knowing that one of the side effects may be respiratory depression
than that is an ethically sound decision and it is called the implied
intent.
Clergy: How do you know when spiritual suffering is contributing to
‘Total Pain”?
Total pain is made up of many things including physical pain (visceral and
neuropathic) as well as spiritual and psychological suffering to name a
few. When one attempts to treat only one piece of ‘total pain’ than one is
likely to fail to achieve the goal of comfort. An interdisciplinary
approach including all of the team members is necessary. Pain needs to be
frequently assessed and treatment modified to achieve comfort.
Social Worker: Is there anything I can do to help with pain?
In my experience, it was very helpful to have social workers include a
form of pain assessment into some of their visits. The most effective in
children was the color model wherein the child colored a picture of
themselves with certain colors representing different types of feelings
including types of pain or suffering.
Home Care Aide: Can I help?
Training your entire team in assessment of pain can only lead to a more
successful approach. Again, in my experience, our aides were often able to
help us get a clear picture of what was or was not effective as they were
often the team-member who had spent the most time with the child. We also
had a video camera that the aide could take with them on home visits if
the parent and child consented when there was a concern that could not be
well described verbally.
Are there pain interventions that all members of the interdisciplinary
team can use?
Yes, all members of the team can use non-pharmacological interventions.
All team members can easily learn many of the techniques, such as muscle
relaxation, distraction, and guided imagery. Other techniques, such as hot
and cold therapy and massage may require more specialized training. In
addition, caregivers should always be mindful of the age and developmental
level of the child/adolescent.
Examples:
Hot/cold therapy—The application of heat or cold to the painful area may
relieve pain. Hot and cold therapy includes the use of icepacks, cold
cloths, heating pads and hot cloths.
Relaxation techniques—Relaxation helps reduce tension and promotes
calmness. Relaxation techniques include controlled breathing, and muscle
relaxation exercises.
Distraction techniques—Distraction can be used to focus the child on
something other than the pain. Distraction techniques include blowing
bubbles, story telling, looking at books, playing music, and deep
breathing.
Imagery –The use of imagery allows the child to focus on a pleasant
activity. Imagery should transport the child to another place in his/her
mind and should engage all the senses. Imagery can be as simple as
encouraging a child to imagine he/she is in a favorite places engaging in
a favorite activity (on a playground with friends). Children should be
encouraged to engage all senses as they imagine. Imagery can be more
involved where children follow a scripted imagery exercise.
Art—Art allows children to communicate and express their feelings.
Children with pain issues may wish communicate the location of the pain by
coloring a body tracing. Children may also wish to express their feelings
about their illness through drawings or other art mediums.
Comfort Measures—The use of touch to provide comfort may be very soothing
to those in pain, especially infants. Comfort measures include rocking,
patting, holding, and changing positions.
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