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The importance of communication in pain management

Intensive Care Specialist at Royal North Shore Hospital & UTS em SMACC Conference
1 de Sep de 2021
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The importance of communication in pain management

  1. The University of Sydney Non-pharmalogical approaches to pain management: The role of clinician communication Claire Ashton-James, PhD Associate Professor, Pain Management University of Sydney School of Medicine
  2. Page 2 The University of Sydney • Injury/nociception is not sufficient to cause pain • Pain is a bio-psycho-social phenomenon What is pain? Evaluation of sensations as unpleasant Feelings of distress Construal of actual or potential harm
  3. Page 3 The University of Sydney Feelings of distress? Dark Mofo Festival – Winter solstice nude swim
  4. Page 4 The University of Sydney Construal of harm?
  5. Page 5 The University of Sydney Managing pain involves managing feelings and thoughts about pain Evaluation of sensations as unpleasant Feelings of distress Construal of actual or potential harm What we say matters How we say it matters
  6. Page 6 The University of Sydney Positive expectations enhance analgesic effectiveness “I am going to give you a powerful pain medication to make you feel more comfortable” We must inform the patient that we are providing pain What we say matters: expectations shape experiences Open vs. hidden paradigm
  7. Page 7 The University of Sydney What we say matters: expectations shape experiences Amanzio, Pollo, Maggi, & Bennedetti, 2001 Analgesic dose needed to reduce pain by 50% Time course of analgesic efficacy
  8. Page 8 The University of Sydney What we say matters: expectations shape experiences “We are going to give you a strong painkiller now (morphine)” “We are going to stop giving you the strong painkiller now (morphine)” Benedetti F, Maggi, Lopiano, Lanotte, Rainero, Vighetti & Pollo. 2003.
  9. Page 9 The University of Sydney What we say matters: expectations shape experiences Bingel U, Wanigasekera V, Wiech K, Mhuircheartaigh RN, Lee MC, Ploner M, Tracey I. 2011. Remifentanil dose is constant after baseline
  10. Page 10 The University of Sydney Pre-surgery visit from anaesthetist: – Informed about pain that patients typically experience – Reassured that having pain was normal after abdominal surgery – Informed that pain is not a sign of harm – Informed that medications can be used to help them to relax What we say matters: expectations shape experiences Egbert et al 1964, NEJM
  11. Page 11 The University of Sydney How we say it matters: The role of empathy • RCT of treatment for IBS with three arms: • waitlist • placebo acupuncture (limited interaction) • placebo acupuncture (augmented interaction) • Augmented interaction included: • Warm and friendly manner • Active listening • Acknowledgement (“I can understand how difficult IBS must be for you” • Thoughtful silence • Communication of optimism and positive treatment expectations (“I have had many positive
  12. Page 12 The University of Sydney Outcomes at 3 weeks Kaptchuk, Kelley, Conboy et al. Bmj. 2008 May 1;336(7651):999-1003.
  13. Page 13 The University of Sydney Outcomes at 6 weeks Kaptchuk, Kelley, Conboy et al. Bmj. 2008 May 1;336(7651):999-1003.
  14. Page 14 The University of Sydney How we say it matters: The role of empathy Schupp, Berbaum, Berbaum, & Lang, 2005: – 236 patients undergoing vascular and renal interventions – All have access to PCA with fentanyl and midazolam – Randomized to 3 groups: – Standard care – Structured empathic attention – Self-hypnotic relaxation Structured empathic interaction: • matching patients’ verbal and nonverbal communication patterns, • attentive listening • provision of perception of control (eg, “let us know at any time what we can do for you”) • Encouragement (“you’re doing well”) • emotionally neutral descriptions (“what are you experiencing?”) • avoidance of negative suggestions (“you will feel a pinch or burning”).
  15. Page 15 The University of Sydney **significantly less pain medication requested and used by Empathy groups
  16. Page 16 The University of Sydney Managing pain involves managing feelings and thoughts about pain Evaluation of sensations as unpleasant Feelings of distress Construal of actual or potential harm What we say matters How we say it matters
  17. Page 17 The University of Sydney Claire Ashton-James, PhD Associate Professor, Pain Management University of Sydney School of Medicine CONTACT: Email: Claire.ashton-james@sydney.edu.au Twitter: @drashtonjames

Notas do Editor

  1. relapse of pain happened faster and pain intensity was greater when patients were told morphine was being stopped than when treatment interruption was hidden; this suggests that hidden interruption prolonged the analgesia. The faster relapse of pain after the open compared with the hidden interruption could be attributed to a “nocebo” effect, in which knowledge that the treatment has been stopped leads to an increase in anxiety. In other words, the fear of pain relapse (because analgesics are no longer provided) might have a hyperalgesic effect.
  2. relapse of pain happened faster and pain intensity was greater when patients were told morphine was being stopped than when treatment interruption was hidden; this suggests that hidden interruption prolonged the analgesia. The faster relapse of pain after the open compared with the hidden interruption could be attributed to a “nocebo” effect, in which knowledge that the treatment has been stopped leads to an increase in anxiety. In other words, the fear of pain relapse (because analgesics are no longer provided) might have a hyperalgesic effect.
  3. The "special-care" group consisted of 46 patients who were told about postoperative pain. They were informed where they would feel pain, how severe it would be and how long it would last and reassured that having pain was normal after abdominal operations. Finally, they were told that at first they would find it difficult to relax completely. If they could not achieve a reasonable level of comfort, they should request medication During the afternoon after operation (day zero) the anesthetist visited his patients receiving special care. He reiterated what he had taught the patients the night before and reassured them that the pain they were experiencing was normal; they were again told to request pain medication whenever they could not make themselves tolerably comfortable. The independent observer recorded that the special-care patients appeared to be more comfortable and in better physical and emotional condition than the control group. This was emphasized by the surgeons, who, although unaware of the care each patient received, sent the special-care patients home an average of two and seven-tenths days earlier than the control group (p less than 0.01)
  4. a warm, friendly manner; active listening (such as repeating patient’s words, asking for clarifications); empathy (such as saying “I can understand how difficult IBS must be for you”); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (“I have had much positive experience treating IBS and look forward to demon- strating that acupuncture is a valuable treatment in this trial”).
  5. a warm, friendly manner; active listening (such as repeating patient’s words, asking for clarifications); empathy (such as saying “I can understand how difficult IBS must be for you”); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (“I have had much positive experience treating IBS and look forward to demon- strating that acupuncture is a valuable treatment in this trial”).
  6. a warm, friendly manner; active listening (such as repeating patient’s words, asking for clarifications); empathy (such as saying “I can understand how difficult IBS must be for you”); 20 seconds of thoughtful silence while feeling the pulse or pondering the treatment plan; and communication of confidence and positive expectation (“I have had much positive experience treating IBS and look forward to demon- strating that acupuncture is a valuable treatment in this trial”).
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