Lessons Shared on How to Improve Cancer Pain Management

SAN DIEGO—Accepting an award for her national efforts to make cancer pain management a top priority, Betty R. Ferrell, PhD, RN, used her lecture opportunity to outline 10 philosophical precepts, or “lessons,” that form the basis for the development of good cancer pain management in the institutional setting.

Dr. Ferrell, research scientist, City of Hope National Medical Center, said that despite acknowledgment from the medical community that pain management is important, most cancer patients still have unnecessary pain.

A Clearinghouse for Information on Pain Management

In her talk at the ACCC meeting, Dr. Betty Ferrell urged individuals and institutions to take advantage of the City of Hope’s clearinghouse on pain management. Established in 1995, the Mayday Pain Resource Center maintains 250 different materials on such subjects as pain assessment tools, patient education, quality assurance, and research instruments used in pain research.

The center, located in Duarte, Calif, can send interested persons an index of the materials, which are available for a nominal charge to defer printing and mailing costs. The center can be reached by phone at 626-359-8111, ex 3829; by fax at 626-301-8941; or by e-mail: mayday_pain@smtplink.coh.org.

“Pain is still an invisible problem,” lamented Dr. Ferrell, who received her award at the Association of Community Cancer Centers’ 14th National Oncology Economics Conference. She observed that all too often physicians, wrapped up in vanquishing cancer, lose sight of the pain patients must endure.

She said it was fitting to share with the audience the question posed at the City of Hope gates: “What is the profit in curing the body, if in the process we destroy the soul?”

Dr. Ferrell devised her “lesson plan” for improving the management of cancer pain after observing how effective pain management has been successfully accomplished during her visits to dozens of hospitals across the country.

Lesson No. 1: Administrators and managers are included in the effort. Clinicians will fail in their efforts to improve pain management if they don’t receive administrative support, she said.

Lesson No. 2: The pain management team is inclusive and interdisciplinary. This is crucial because pain relief encompasses physical, psychological, social, and spiritual interventions, Dr. Ferrell said. In other words, well-intentioned physicians cannot make pain vanish all by themselves.

Dr. Ferrell offered the example of a 98-year-old woman with metastatic breast cancer who was living by herself. Experiencing severe pain, she refused her physician’s many urgings to take pain medications. Frustrated, he even drove to her apartment with morphine, which she poured down the drain after he left.

It was only when Dr. Ferrell visited and asked the woman about her life beyond the disease that she learned why the woman was being so stubborn. Facing death, the life-long atheist now wondered if God might exist after all. She hoped that living in pain would appease God.

Lesson No. 3: Pain is made visible and a clear priority. Dr. Ferrell shared the story of a Kansas man who grew frustrated with the lack of cohesion in the pain management of his ailing wife.

With every new nursing shift, the husband felt he had to start all over to explain the degree of pain his wife was experiencing. He finally drew a chart detailing his wife’s pain on a paper bag and taped it above her bed. The constant reminder at the bedside helped get the message across. “Once the problem of pain is made visible, it can’t be ignored.” Dr. Ferrell said.

Lesson No. 4: Pain management is “institutionalized” rather than only “specialized.” The sad fact is, Dr. Ferrell said, that only 2% to 3% of cancer patients will ever see a pain service team. “We should not be ignoring the other 98% who aren’t getting adequate pain relief.”

Lesson No. 5: Pain relief is integrated within the institution’s mission and philosophy, and is supported by the guardians of the mission.

Lesson No. 6: There are standards of acceptable and unacceptable pain, and these standards transcend clinical settings.

Lesson No. 7: There is recognition of the vulnerability of patients who are in pain and the obligation of health professionals to advocate for the vulnerable.

Lesson No. 8: Health care providers cannot practice what they do not know; successful institutions have provided extensive professional education.

Lesson No. 9: Pain is acknowledged as a critical symptom throughout the cancer trajectory, rather than existing only in terminal illness.

Lesson No. 10: Pain is the metaphor for the threat of, or certainty of, death. Avoidance of death creates neglect of pain. Recognition of death is the first step toward relief of pain.

“Cancer pain can be relieved,” she concluded, “and it is the responsibility of cancer centers to serve as models of excellence and change.”

Experience at The James

During the same forum, an oncology nurse from The James Cancer Hospital at Ohio State University attested to Dr. Ferrell’s talents at helping an institution improve its pain management program.

With Dr. Ferrell’s advice, along with materials developed by the City of Hope, the hospital decided to target registered nurses in its effort. This step was taken after it was realized that nurses all too often were not recording patients’ pain levels, said Elaine Glass, RN, OCN.

Specifically, the institution’s goals were to develop protocols for pain management, establish the use of standardized assessment guidelines and measurement scales to create a common language, and use the CQI (continuous quality improvement) process to monitor adherence to the pain protocols on an ongoing basis.

The task force’s effort paid off. CQI improved from a 20% documentation rate of patients’ pain to consistently being more than 70%.

The Next Goal

The hospital’s next goal, Ms. Glass said, is to increase CQI scores to greater than 90% and to develop a multidisciplinary admission assessment form that includes a large section on pain.

The hospital also hopes to strengthen registered nurses’ assessments of the different types of pain and improve their knowledge of how different types of pain are managed differently.