Pain Assessment & Communication

Attribution: Ferris, FD. Pain Assessment and Communication. 2022. ISBN: 978-1-64207-016-3. In Ferris FD, Gustin J, Humphrey L
(eds). Palliative Care Interdisciplinary Curriculum. Copyright © 2022 Frank D Ferris. PCIC ISBN: 978-0-9884318-1-2.

Permission to Use, Reproduce or Adapt any presentations and other content within the Palliative Care Interdisciplinary Curriculum
(PCIC) is granted for non-commercial educational purposes only, provided that the above attribution statement and copyright are
displayed. Commercial entities presenting not-for-profit educational programs based on the PCIC Curriculum must not use the PCIC
materials with products, images or logos from the commercial entity. Commercial entities presenting for-profit educational
programs using any part of the PCIC Curriculum, must only do so with written permission from Drs. Frank D. Ferris, Jillian Gustin or
Lisa Humphrey, Principals of PCIC. They can be reached through info@PallMed.us
Acknowledgements: The Principals of the Palliative Care Interdisciplinary Curriculum gratefully acknowledge the support of Award
Number R25CA134309 from the National Cancer Institute, the Host Institutions and Private Donors. The content is solely the
responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute, the National
Institutes of Health, the Host Institutions, or the Donors. Acknowledgment and appreciation are extended to faculty and staff of
OhioHealth, The Ohio State University Wexner Medical Center, Nationwide Children’s Hospital, the OhioHealth Research &
Innovation Institute, the Institute for Palliative Medicine at San Diego Hospice and the consultants who provided the inspiration and
assisted in the development of this curriculum.

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 Pain Assessment & Communication
Hi, I'm Frank Ferris. Let's talk about a very important topic, how do we effectively assess and
communicate pain? This is absolutely crucial if you and I are going to effectively manage pain.
We need to know not only what type of pain the patient has, but we also need to know how
it's affecting their life experience.
And as I've said before, it's all about life, isn't it? Our task is not only to manage the patient's
underlying illness, and try to slow the progress or stop it; our goal is to help the patient have
the best possible experience. Of course, you and I know pain not only affects the patient, but it
affects their whole family, anybody close in knowledge, care, and affection. So let's begin.

As we think about the goal, it's to

actually find out what type of pain the
patient has, what's the cause, and
establish the severity, and look at the
impact of that pain.

I'd like you to think about yourself.

Imagine that you've not been feeling well
for a few weeks. You're not able to move
the way you were; you're increasingly
weak and fatigued. Over the last three or
four weeks you've had a lot of pain. Like
most good healthcare workers you
avoided going to see the doctor. Finally
you did. You had a few tests, and in the
last five or so days, you and your family learned you have quite an advancing illness. You've
also had a lot of pain. It's now up to eight out of ten.
My question for you is: how long do you want to enjoy that eight out of ten pain for? A month
okay, while we treat your disease? I suspect not for most of you. Most of you would probably
say, "Please get rid of it in the next hour or so." Well, are you going to do that for your patients

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as well? I've heard many healthcare workers say, "Well, I'm not sure I should trust this
patient." Well, should I trust you? Are you trustworthy? Are you somebody who confabulates,
acts out? Or are you in fact somebody who's actually reliable? You actually just want to get
your pain managed, and you want to get on with your life.
Most people don't even like taking medications. They're real resistors. What you and I need to
understand is as we look at the population, and in America, about 88 to 90% of folks are
completely reliable; 10 to 12% of folks are actually using substances. We should trust what
people say until they prove to us that they're not trustworthy, that they are confabulating.

The other question is, do I ask you not

only about your pain, but all your
concerns about how it's impacting you
and your life? If I don't ask, how are you
going to feel? Are you going to trust me?
I suspect you won't. You really want me
to understand your personal experience.

The real question becomes how much do

we actually listen, and for how long do
we listen when we ask people questions?
Several studies show us and you can see
it, certainly in my colleagues, they ask a
question, they let the patient answer for
five or seven seconds and they are ready
with another question. The problem is
they're not listening to understand,
they're listening to ask the next question.
Now, if I've got a story to tell, and I'm going down this path, and suddenly you take me this
way, are you going to hear this part of the story ever? You may never know what I wanted to
tell you. I'd like you to really use, even Buckman's six steps, ask the question and stop, even
shut up, and listen. Wait for the patient to stop talking and then ask the next question.
Important that we really learn to listen.

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 Why do we focus on pain assessment?
Well, it's actually a fabulous model for
how you and I might assess any
symptom. We could assess nausea the
same way. We could assess constipation;
we can assess anxiety, depression, all
using the same technique. So let's begin.

When we think about pain and doing an

assessment, we need to understand the
two major types of pain, nociceptive and
neuropathic. The nociceptive pain comes
from normal function. A stimulus causes
a signal in our somatosensory system,
and we perceive pain, typically
describing it as sharp, aching, dull,
throbbing.

Neuropathic pain comes from damage to

the neurological system itself actually
leading to dysfunction, either
hyperactivity in the somatosensory
system or reduced function. There's a
variety of different causes, often
described as burning, electrical,
shooting, stabbing, throbbing. It's often
also associated with numbness, and
frequently the pain experienced is much
greater than any kind of injury that you and I can see. This is actually a disease in the
neurological somatosensory system.

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To best think about assessment, let's use a
real case. We're going to talk about
Hector, a patient that we videoed for the
EPEC curriculum back in 1999, when we
created it through the American Medical
Association.
Hector is a 67-year-old gentleman. He has
cancer that started in his colon and now
metastases in his bones. As you listen to
Hector, I want you to listen to the important elements of the pain assessment.

(Physician) Hello, Mr. Gonzalez, how are

you doing?
(Hector) Well, I'd say one day at a time,
Doctor.
(Family Care Giver) He was doing quite
well until recently.
(Physician) Can you tell me more about
it?
(Hector) Yes, I got pain in my leg.
(Physician) Does it move anywhere?
(Family Care Giver)) No, it stays right there in the same spot.
(Physician) Is it sharp or dull?
(Hector) Well, right now it's dull.
(Physician) Burning, tingling?
(Hector) I don't know.
(Physician) I want to ask you-- I want to give you a scale so that I can understand how severe
the pain is. In this scale, zero is no pain at all, and 10 is the worst pain you could imagine. I'm
going to ask you, in the past 24 hours on the average how has your pain been? Can you give it
a number?
(Hector) Well, I think it's about three.
(Physician) Over the past 24 hours, what's the worst it's been?
(Hector) Like four.

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(Physician) What's the best it's been in the past 24 hours?
(Hector) When I take the medication it's O, zero.
(Physician) Okay, good. So there are times when you have no pain?
(Hector) No pain.
(Physician) Besides the over-the-counter medicine that you've been taking for your pain, are
you taking anything else?
(Hector) Yes, Doctor. My wife went to the botanica, and she bought me some cream, and
when she put it on my leg, she rubs it on my leg, and that helps. Also, my wife's sister, she got
me some pills, and she say it's good for the cancer.
(Physician) Maybe the next time you come you could bring them so I could see what they are.
(Hector) Yes, Doctor.
(Physician) Tell me, Mr. Gonzalez, what do you think is causing the pain you're having?
(Hector) I think this pain is coming from my sickness.
(Family Care Giver) It's the cancer, right?
(Physician) Remember the last time you were here we looked at your bone scan, and there is
cancer in your leg in that spot. That's probably what's causing your pain. Tell me more about
your appetite.

As you listen to Hector's story, did you

hear these key elements of a pain
assessment? Where was it located? In his
upper leg. How did he describe it? Would
you say it's nociceptive or neuropathic
pain? In his case, probably nociceptive,
coming from his bone metastases. Was it
continuous? Or continuous with
breakthrough when he moved? Or was it
just acute intermittent pain? How did it
change over time? What was the severity? Did he use a scale from zero to 10? What was the
effective medications and other therapies? What was the specific story for Hector?

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 We've provided you with reference
cards. This is our severity assessment
scale tool that we can actually use for
pain and other symptoms. You could
choose depending on the patient's
understanding of language and concepts,
to use the visual analogue scale, a line
that goes from zero over to 10 where
zero represents no pain, 10 represents
the worst possible pain.
I really want you to say the worst possible pain, not worst imaginable, 'cause many patients
will say, "It's much worse than I ever imagined." You could use words like the ones you see
here on the card, or you could use the Wong-Baker Faces Scale, a beautifully validated tool for
use in pediatrics or with adults. We use any of these.
Or you could choose to use this as your tool right here. We have the 0, 1, 2, 3, 4, 5, worst
possible pain right here.

Also important is for us to assess the

impact of the pain. It's direct impact for
Hector, is it changing his ability to move
around? Is it changing his ability to do the
thinking he likes? Is he actually totally
focused on the pain and his concentration
is markedly decreased? Has he got some
anorexia, he's not eating very much?
Insomnia, he's not sleeping well? What
about his mood? Is it actually causing him
depression or even to withdraw?
For many patients, these impacts completely get in their way. I'm going to advocate you and I
need to chart these five impacts every time we see the patient. While their pain severity score
might not change, I've had many patients never drop below a 6 out of 10 on a visual analogue
scale. They would say to me, "Well, I used to not be able to get up and move around, but I'm
up, I'm moving, I'm thinking, I'm doing the things I like to be able to do. I'm eating better, I'm
sleeping better, I'm laughing." They clearly had a change in the direct impact of the pain.
That's what it's really all about, because it's all about life, isn't it? We need to recognize not
only do those impacts impact the day-to-day experience of the patient, but they mean like
they're not going to be able to work well. They're not going to have anything that's
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pleasurable. They may not have the same experience in their relationships. They may be quite
tense, angry, stressed. They may even become dependent or does the whole process shorten
their life?
It's really important that you and I think about managing pain quickly. We're trying to help
people live longer and better. This is crucial.

We've given you this tool as one of our

reference cards, how to effectively
assess pain and other symptoms. You
can see on the left, we've given you a
short pictorial version of the five key
features for an assessment, as well as on
the right the behavioral changes that
patients experience. We've also added
the psychological, social, and spiritual
factors that can actually be affected by
pain. Or may contribute to the pain if it happens to be “total pain”.
Now never forget the opportunity to do a physical exam, especially a focused exam. It's an
opportunity for us to actually look more effectively for the cause, and sometimes our findings
will point us towards appropriate physical therapies that might be helpful for these patients.
Let's do an effective assessment and understand our patients. Let's listen carefully, and we will
do a much better job.

Communicating Pain Assessment Effectively

Now that you've done an effective
assessment, the next step, particularly if
you're out in the community and you
want to speak with somebody else on
your team, is how do I communicate that
assessment effectively? You've probably
been out in a situation where you were
receiving the report from a colleague,
and you really couldn't understand what
they were saying at all. Let's illustrate.

Imagine I'm out in the community, and I'm trying to call the report in to you about our patient
Hector. You say to me, "Please describe the pain." My response is, "Well, I'm not sure, I
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haven't asked. Well, so, Hector, how is your pain?" And Hector says, "Well, it's not bad." Now I
tell you, "Well, it's not bad." What's your response? “Come on Ferris, what are you saying? I'm
not getting any information from you.” This can go on, and I've even seen this kind of report
take up to 45 minutes to drag it out of somebody as opposed to the right way, if I've been and
I've assessed the patient would be able to give the report in 45 seconds to a minute.

If I simply use this protocol: Hector, he's

a 67-year-old gentleman; he's out in the
community; he has cancer that started in
his colon. He's got metastases to bone,
and he's having pain in his right upper
hip. He describes it as continuous,
occasionally with extra pain on
movement, so it's pretty constant. He
would say it's 6 to 7 out of 10 in severity.
It goes up to an 8 or 9 out of 10 when he
moves. The medications we have him on are, let's say, long acting, or extended release
morphine, 60 milligrams, twice a day with 15 milligram breakthroughs every one hour, and
he's been using six of those breakthroughs in the last 24 hours.
Is that enough? You understand it's nociceptive pain. You understand it's much more severe
than he would hope for. Probably he's hoping it would be a 1, or a 2, or maybe even a zero out
of 10. It's affecting his ability to move, maybe even his sleep if we ask him. The medication has
been helping; he's using breakthroughs. We can write a new prescription.
It's very important to make it very simple. Can you hear, I can actually do this report in 45 to
60 seconds? You, the listener, can get on with your part of the team-based activities to
manage Hector's pain. It's really easy. We don't need to make it more complex. Let's learn to
do it right. The important thing is if I follow these steps one at a time in sequence, and if you're
listening to me expecting these concepts in sequence, you'll receive it quickly and you'll be
able to act. This is the way to communicate pain assessment easily and effectively. Let's all try
it.

Pain Assessment in Cognitively Impaired Adults…

It's all well and good if we're able to assess pain in a patient whose able to effectively
communicate with us, and really has capacity to share what they're experiencing. But of
course, there are many of our patients who are cognitively impaired. It could be the patient
with Alzheimer's disease; it could be the patient with delirium, and they're not actually able to
share their experience with us effectively.
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To assess patients who are cognitively
impaired, colleagues of ours developed a
tool particularly for Alzheimer's disease.
It's been partially validated in this study
group. The disadvantage is it's about us
observing what the patient's experience
is as opposed to them being able to
report it.
Of course, you and I know that pain is
really about perception. We can't really
rely on the behaviors, but in this case, it's the best we have, and it's been shown to be
relatively reliable.
We rate each of these five factors, breathing independent of vocalization, negative
vocalization, facial expression, body language, and our ability to console the patient whether
they have a zero, for each of these parameters, a 1, or a 2. We calculate a total score and that
becomes the PAINAD score anywhere from zero to 10.

What would you say is the score for this

particular patient? An 82-year-old
woman who has Alzheimer's dementia
for the last four years, is not able to
communicate. She requires total care.
During bathing you note that she's noisy
and labored breathing. She moans when
rolled, frowning and frightened
appearance, pushes you away, and not
able to reassure with your voice or
touch. Is it a 7? Is it an 8? It's quite significant, isn't it? What we see in these folks is as we
actually move to manage their pain, these factors typically improve.
Now this tool was developed for folks with Alzheimer's disease. We actually apply it in other
patients who are cognitively impaired because we don't have another tool. It becomes
important for at least to do some sort of assessment. Although it's not actually self report or
perception, I think with this tool we frequently see that as we manage the patient's pain these
factors improve.

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1 Key Take-Home Message
So, as you think about pain assessment, it becomes absolutely crucial, doesn't it?

As Epictetus said, "We have two ears and

one mouth so that we can listen twice as
much as we speak." I hope you're going
to apply those principles, because, of
course, what we get to see in terms of
the patient's pain experiences, like an
iceberg, it's just the tip of what is a huge
impact on their lives. You and I are all
about managing the experience in order
to help improve their life. Let's find out
what's under the water. Great success with pain management.

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