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Pain isn't always physical

Mick, JoAnn PhD, RN, AOCN, NEA-BC

doi: 10.1097/01.NURSE.0000494643.77680.e4
Feature: SHARING

True patient-centered care addresses emotional and spiritual pain as well.

JoAnn Mick is a nurse researcher in the Memorial Hermann-Texas Medical Center in Houston, Tex.

The author has disclosed no financial relationships related to this article.



WHEN I WAS a young oncology nurse on a unit for patients with cancer-related diagnoses, one of my roles was to round with the oncologists and other healthcare providers. On one occasion, I accompanied a consulting surgeon to evaluate a terminally ill patient, Mr. F, 77, who'd been diagnosed with metastatic cancer and required frequent hospitalizations for cancer-related complications.

Upon entering the room, I observed a frail-looking Hispanic male patient lying in bed on disheveled linens. He'd been admitted the prior evening with abdominal pain, shortness of breath, and early satiety secondary to recurrent malignancy-related ascites. He was surrounded by tubings and devices, and a therapeutic paracentesis was in progress via a peritoneal catheter connected to gravity drainage.

I stood on the opposite side of the bed from the surgeon, who introduced himself to the patient. The surgeon explained to Mr. F that he was there to determine if he could offer any additional comfort care options. With the patient's consent, he began assessing the patient's abdomen. During palpation of each abdominal quadrant, the surgeon asked Mr. F if he felt any discomfort. When it became clear that the patient wasn't answering, the surgeon stopped his exam and said, “Mr. F, I really need you to help me locate your pain so I can determine if I can offer anything to make you more comfortable.”

The surgeon resumed palpation, asking “Here?” and “How about here?” Mr. F remained silent, but I noticed tears forming in the corners of his eyes.

The surgeon asked more firmly, “Can you help me find where you're having pain?” The patient took a shallow breath, exhaled slowly, and answered with a weak voice, “Doc, you want to know where I'm having pain? It's in my mind. I'm worrying about how my wife and children are handling how sick I'm getting. I'm worrying if I'm doing everything I need to do to leave them in good shape when my time comes.”

Mr. F's response made me realize that because of our focus on the patient's physical discomfort, we hadn't been addressing his social and psychological needs. As he contemplated his frailty and all the tubing extending from his body, Mr. F was less concerned with his physical pain than his emotional suffering. The task-oriented care we were providing—managing medical devices and medications—wasn't true patient-centered care.

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Understanding fundamental needs

It's well established that the nurse-patient relationship forms the basis of professional nursing practice.1 The concept of quality nursing care requires an understanding of patients' fundamental needs to help them heal. An optimal healing environment is one in which the social, psychological, spiritual, physical, and behavioral components of healthcare come together to support and stimulate healing.2 Although technical skills are important, nurses must also effectively incorporate nontechnical skills, such as therapeutic communication, to address holistic aspects of care.3 Attributes of patient-centered care include a caring attitude, individualized care, and promotion of patient autonomy.4 Establishing a trusting nurse-patient relationship and identifying what the patient considers his or her care priorities are critical elements of effective nursing care.5

The experience I had that day with Mr. F. was life-changing. Without understanding each patient's unique views and circumstances, a nurse may not be providing the care a patient needs most. Some of the strategies I've since tried to incorporate in my daily nursing practice are to

  • ask patients how they're feeling, instead of commenting on how they appear to me.
  • ask patients if they're having any kind of pain or discomfort including physical, emotional, or spiritual concerns.
  • ask patients about their family and spiritual support systems.
  • make patients aware of the various support systems that are available to them, such as social services, support groups, clergy, and dietary services.

Nurses have heard for years that “pain is whatever the patient says it is.” However, we must remember that not all pain is physical pain. By understanding the true nature of Mr. F's pain, we were able to provide the support needed to achieve quality end-of-life care.

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1. American Nurses Association. Code of Ethics for Nurses. 2001.
2. Samueli Institute of Information Biology. Environmental Scan. Samueli Institute Nursing Forum on Optimal Healing Environment. 2004.—environmental-scan.pdf.
3. Zamanzadeh V, Azimzadeh R, Rahmani A, Valizadeh L. Oncology patients' and professional nurses' perceptions of important nurse caring behaviors. BMC Nurs. 2010;9:10.
4. Lusk JM, Fater K. A concept analysis of patient-centered care. Nurs Forum. 2013;48(2):89–98.
5. Komatsu H, Yagasaki K. The power of nursing: guiding patients through a journey of uncertainty. Eur J Oncol Nurs. 2014;18(4):419–424.
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