Whose pain is it anyway? (Margaret Hook)

Understanding the emotional elements of a patient’s “problem” is a necessary skill when deciding what to prescribe. With this insight I believe I can help to empower patients to respond to changes in their condition in a positive way. But, particularly in palliative care, it is not always easy.

I first met Mrs P briefly in reception: waiting, pale and drawn, in her wheelchair, while her son fetched her bags through the rain. The sudden change in the weather provided me with that characteristically English ice-breaker. Although she was desperate to get to her bed as soon as possible, a smile and a few words before I left the building meant our next meeting should be a lot easier.

My pharmaceutical assessment of Mrs P covered all medication before admission, allergies, reason for admission, problems with swallowing, communication issues, any support needed for adherence and her understanding of the medicines. She was taking soluble paracetamol and applying menthol in aqueous cream when needed, with pregabalin 100mg three times a day regularly — but nothing stronger before admission.  

But just 10 minutes after our chat she was heard screaming, even though she had been given a dose of oral morphine just an hour before. A nurse rushed to her aid to find she was still in pain, saying she needed another dose of oral morphine “now!”.

I was summoned to the bedside to authorise the administration of a second dose. In the calm that followed, we talked about what her feelings were. “The pain means my disease is spreading even faster,” Mrs P said. “Just give me something to make it go away.”

She could not understand why the first dose had not reduced her pain: “Why did I have to wait?” The description she gave of shooting, stabbing and burning in the feet and arms indicated nerve pain, which does not always respond to strong opioids.

I explained that as part of assessing her response to any changes to her medicines it was necessary to build the dose based on her needs. By encouraging her to ask for breakthrough pain relief as soon as the pain starts to build, this would help to prevent the “peak” and relieve the pain more quickly.

The memory of severe pain and fear of its return can be almost as bad as experiencing the pain itself; and she was clearly very afraid. Her expression changed instantly to one of relief when I explained that the next option, clonazepam, might reduce her anxiety but also might make her drowsy (since she had not been sleeping well).

As I reflected on the first day in our care for Mrs P, I thought about how things we consider routine could really unleash fear in our patients and how understanding their beliefs could play a big part in managing the emotional, as well as physiological, turmoil at a critical phase of their lives.

 

Margaret Hook is principal pharmacist for St Peter’s Hospice, Bristol