December 13, 1996

Grand Rounds wrestles with differences between patients’ pain, suffering

Grand Rounds wrestles with differences between patients' pain, suffering

Is there a difference between pain and suffering?

Does pain control alleviate suffering altogether or does it free a patient to experience other kinds of suffering?

These and other questions were addressed last week at the Ethics Fall Grand Rounds, sponsored by the Vanderbilt University Medical Center Ethics Committee.

The Grand Rounds was entitled: "Responses to Suffering (From Beginning to End): The Imperative of Palliative Care."

Mark J. Bliton, Ph.D., assistant professor of Medical Ethics and chief of the Clinical Ethics Consultation Service, was the moderator of the event.

"Will controlling pain alleviate suffering or, paradoxically, free patients to begin to recognize their suffering and the kind of fate that awaits them?" Bliton asked the panel.

Participating in the discussion were Drs. Brian W. Christman, associate professor of Medicine, representing the division of Allergy, Pulmonary and Critical Care Medicine; Barbara A. Murphy, assistant professor of Medicine and medical director of Alive Hospice; and Debra Wujcik, R.N., M.S.N., A.O.C.N., clinical director of the Vanderbilt Cancer Center Affiliate Network and Clinical Trials Office.

"It is important that we help the families of patients we take care of appreciate, understand and cope with the shift from curative or therapeutic treatment to palliative care," Bliton said. "Sometimes there's a dramatic shift in emphasis for the families, as well as the patient, and we need to know how to help them work through those changes"

Bliton reminded the panel that the Latin derivative of the word patient is 'paschein,' which means 'to suffer.'

"Suffering is a fundamental dimension of human experience, one which historically has been rooted in the motivation and practice of medicine," he said.

But the emphasis on palliative care has been swept under the rug by some health care institutions and health care professionals in the past, Bliton said. In October, however, a new diagnosis code for palliative care has been added at some health care institutions. It will be added to VUMC's diagnosis code in January.

"This indicates that at least there is now some mainstream acknowledgment of palliative care," Bliton said.

It is necessary that health care professionals recognize physical as well as psychological suffering in patients, he said. Sometimes taking care of physical suffering only paves the way for a patient to think about their fate, thus bringing on psychological suffering.

"We need to be able to deal with both kinds," he said.

"Pain can be experienced by the patient on more than one level," Christman agreed. "At the physiological level, you have visual signs – increased heart rate and motion in the bed. But there is also psychological discomfort and this can't be ignored."

Murphy agreed.

"There is no doubt in my mind that there are patients with minimal physical problems who have tremendous psychological suffering."

A case study was presented to the panel, that of a 72-year-old women with metastatic lung cancer involving the liver and bones. The woman has declining mental capacity and limited activity, and suffers from a recent leg fracture.

Her physician is reluctant to prescribe a stronger pain medication, fearing a stronger narcotic will affect her breathing, perhaps resulting in a decline in her respiratory status and possibly even death.

The panel discussed what should and should not be done for the patient.

Murphy, who deals with terminal patients daily in her job as medical director of Alive Hospice, said that health care professionals are often reluctant to deal with pain control because it is difficult to measure.

"When a patient has pain or suffering we must deal with it in a compassionate and timely fashion. Palliative care exists," she said.

Health care professionals must be concerned with "dual effect," when the administration of narcotics for pain control affects a patient's respiratory status. But a health care team's primary goal should be to control the patient's suffering.

"It's incredibly important for us to understand dual effect," she said.

The panel agreed that how a health care team chooses to treat a patient's suffering is usually determined by how long the patient is expected to live.

Wujcik said that health care providers need to have a clear discussion with a patient about the amount of pain that is going to be acceptable. She believes discussing pain on a scale of 1 to 10 is a good way of measuring pain and deciding if it is being controlled by medication.

"Instead of using terms like "it's bad, it hurts, it's excruciating," you can use numbers to judge a patient's pain," she said.