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PAIN MANAGEMENT AND
PALLIATIVE CARE
Chapter 22
Handbook of
Health Social
Work, 2nd Edition
CHAPTER OBJECTIVES
 Define palliative care, including domains and
guidelines and the preferred practices.
 Define and distinguish pain and symptom
management.
 Confirm the unique opportunity and historical
framework of palliative care that invites social work
participation and leadership in this area of practice
and explore the obstacles to realizing the
opportunity.
CHAPTER OBJECTIVES CONT.
•
•
•
•
Describe aspects of a bio-psychosocial-spiritual
assessment that informs a place of care.
Define interventions and illustrate their usefulness
through patient narratives.
Discuss ethical principles that relate to palliative
care and the management of pain.
Explore various models of team collaboration,
sources of professional gratification, work related
stress, and opportunities' for enhancing self care.
PALLIATIVE CARE
 Palliate means to “alleviate without cure.”
 The basic definition of palliative care is to improve
the quality of life of patients and families who are
facing life-threatening illness through prevention and
relief of suffering.
 Palliative interventions affirm life and treat dying as
a natural process.
 Pain and symptom management are essential
components of palliative care.
PAIN MANAGEMENT
 A key characteristic of chronic pain from the
patient’s perspective is that it becomes like any
other chronic illness.
 Comprehensive assessment and interventions extend
beyond the physical to psychological, social, cultural,
and spiritual aspects of the patient’s experience.
 Collaborative goals might include minimizing
suffering and the negative impact of chronic pain
and enhancing functioning and quality of life.
CHALLENGES AND OPPORTUNITIES
 Principles and values underlying palliative care and
pain treatment have much in common with those of
social work.
 Consideration of patient and family values, needs,
beliefs, and goals is implicit in the principle of
respect for the dignity and worth of the person.
 Palliative care programs are increasing, and
expanding into settings such as extended care
facilities and home care.
 Standards for Social Work Practice in Palliative and
End-of-Life care which includes 11 standards.
HISTORICAL PERSPECTIVE
 Principles and behaviors that inform the work of palliative
care and the treatment of pain have their roots in human
antiquity and serve a vital social function.
 Until recently, limited interventions were available to
influence the course of illness, so the alleviation of pain and
suf fering frequently was the most one could hope for.
 There is a need for social work leadership in palliative care
across all aspects of care: policy, research, education, and
clinical practice.
NATIONAL CONSENSUS PROJECT
 In 2004, the National Consensus Project for Quality Palliative
Care describes palliative care as consisting of interventions
that may accompany life-prolonging treatments and can be
practiced at both the generalist and specialist levels.
 The integration of palliative care into generalist practice has
great potential to impact care for patients and families in
various settings through the course of illness to the end of
life.
 In 2009, the Consensus document added justifications,
supporting and clarifying statements, references, case
examples, and suggest criteria for assessing outcomes,
creating rich and comprehensive tool for guiding generalist or
palliative care.
BIOPSYCHOSOCIAL-SPIRITUAL
ASSESSMENT
 The assessment of an individual with chronic pain or a life limiting illness involves gathering in -depth information about
the physiological aspects of the symptoms and illness,
addresses treatment, and complements competent medical
management.
 Numerous challenges and needs arise when pain or life limiting illness arises in the ongoing life of a family.
 Such needs and challenges may include understanding the
diseases, its treatment, and potential prognosis; developing
strategies to manage the impact of pain or illness; coping
with and learning the language of professional caregivers and
institutions; maintaining stability to meet the changing
individual needs and many others.
GRIEF
 Persons with chronic pain or chronic progressive diseases and
the members of social support networks experience grief as
they come to terms with the myriad losses associated with
pain and illness.
 Specialized spiritual assessment tools also are available for
exploring patients’ spiritual and cultural coping strategies and
gathering insights into how they interpret their pain or illness
experiences.
 Chronically ill people may experience sadness and some
symptoms of depression and anxiety.
ATTITUDES
 Individual and family attitudes and behaviors related to pain,
illness, and death are infused with and enriched by cultural
influences.
 Societal attitudes toward health, illness, and death have been
influenced by a variety of ethical, political, religious, and
philosophical beliefs in addition to changing medical
practices through the past century.
 The assessment recognizes that cultural values and nuances
inform patient and family understanding and adaption to pain
and symptoms, illness, and death and that care can be
adapted accordingly.
ADVOCACY AND SUPPORTIVE
COUNSELING
 Advocacy is an ongoing task; needs change, distress varies,
and skills of self-advocacy may fade as the patient and family
deal with protracted illness, symptoms such as pain and
fatigue, and associated feelings of exhaustion, helplessness,
and hopelessness.
 Supportive counseling interventions include techniques of
clarifying, exploring, partial zing, validating, and problem
solving.
 These interventions, along with extensive medical
management of symptoms, establish a basis for trust while
they explore immediate needs and concerns.
COGNITIVE BEHAVIORAL INTERVENTIONS
 These techniques recognize that the biological,
cognitive, behavioral, and emotional aspects of
experience are related and that interventions
focused on any one aspect have the potential to
modify the entire experience.
 These may be the adjuncts to the medical
management of symptoms.
 They can be helpful to patients during procedures
and diagnostic tests that often create distress and
feelings of lack of control.
COPING AND DISTRACTION
 Coping statements are internal or spoken statements
designed to distract, enhance coping, self -sooth, or
diminish the threatening aspect of a situation or
experience.
 Distraction involves refocusing attention to stimuli
other than pain and to other aspects of self that
might include mental activity such as prayer,
reading, doing crosswords puzzles, or physical
activity such as breathing, rhythm, or engaging in
conversation.
LIFE REVIEW AND LEGACY BUILDING
 Assisting patients with life review by focusing on generativity
of fers a foundation for positive reflection at this vulnerable
stage of life.
 Social workers can assist by normalizing concerns, sharing
time for review, and of fering resources to assist in the life
review process.
 With chronic pain, life review may happen as a natural part of
integrating the impact of chronic pain as patients and
families reflect on changes in their present lives as well as
their future hopes.
EXPRESSIVE ARTS
The expressive arts offers the social worker
enormous opportunities for culturally sensitive
interactions with those they serve.
Health social workers are well positioned to
recommend and coordinate integrative
programs.
CHILD/ADOLESCENT SPECIFIC
INTERVENTIONS
 Providing children with age appropriate information, and
allowing them to participate as appropriate, can enhance
their adjustment to a changed family experience and to the
losses and adoptions that accompany chronic pain,
progressive illness, and death.
 Adolescents need to be aligned with peers, to regulate
uncertainty and anxiety and the desire to achieve some
degree of emancipation and independence may become more
dif ficult when medical issues arise.
 A number of interventions can be taken place to help the
family and adolescent.
FAMILY MEETING
 Meetings can be used as therapeutic tools for providing
family -orientated clinical, palliative, and end -of-life care.
 Ef fective communication with families is challenging because
family members are often the “hidden patients” in palliative
care, both providing and needing care.
 Family conferences have shown to improve communication in
palliative care.
 Conferences provide opportunities for collective patient,
family, and healthcare provider discussions that promote the
inclusion of patients and families, invite family members to
be active participants in care.
ETHICAL CONCEPTS
• The four principles that underlie and guide ethical
decision making are autonomy, beneficence,
nonmaleficence, and justice.
• Cultural beliefs, values, and family dynamics often
require thoughtful clinicians to adapt and negotiate
in order to balance the principle of individual
autonomy with unique patient and family
circumstances.
• Justice is an important ethical principle that involves
provision of health care as relate to the availability
and distribution of goods and services.
PAIN MANAGEMENT
 In 2003, a national survey of 1004 adults revealed that 57%
of respondents to have reported chronic or recurring pain
during the past year.
 Pain is necessary to survival and generally, but not always,
signals physical injury or disease and alerts one to take some
kind of action.
 Pain is also unique as a symptom in that it is a subjective
experience and unlike other somatic experiences, cannot be
measured objectively.
VULNERABLE POPULATIONS
 The risk of under treatment increases when assessment of
pain becomes more of a challenge for example those who
have language or cultural dif ferences and for infants,
children, and older persons, and the cognitively impaired and
mentally ill.
 Many of the barriers to pain management are psychosocial,
political, spiritual, or cultural in nature and thus become
appropriate foci for social work assessment and intervention.
GERIATRICS
 Geriatric social work clinicians share responsibly for
highlighting and solving the problem of unnecessary suf fering
in older persons caused by recognized and uncontrolled
symptoms, including pain and depression.
 They may experience multiple chronic illnesses over time that
impact their quality of life.
 The focus of assessment often extends beyond physical pain
to existential issues such as the mortality of self and friends
and the meaning and purpose of life.
GENDER ISSUES
 Men and women experience pain differently,
research suggest that women are more likely to be
inadequately treated both in chronic pain settings
and in the case of illnesses such as cancer and Aids.
 The complex differences are:
 Biological factors
 Psychological factors
 Behavioral responses such as coping mechanisms
 Cultural and socialization factors
SUBSTANCE ABUSE
 It is estimated that between 6 and 15% of the population
have a substance use disorder that may involve the abuse of
illicit drugs or misuse of prescription medications.
 Addiction, physical dependence, tolerance, and pseudo
addiction may all be things that abusers face.
 Many persons with the disease of addiction have multiple
medical problems and consequently can be quite
symptomatic.
TRANSDISCIPLINARY TEAM
 The transdisciplinary team is characterized by
substantial overlap in functions such that members
share roles in addition to providing their disciple specific contributions to the team.
 The team approach requires professionals to act
both as unique contributors and as team members.