Suffering in palliative care: physical, psychological, social and spiritual dimensions

Suffering

Knowing and Managing Suffering

Suffering, as it relates to palliative care and the dying process, refers to the bearing of pain, hardship or loss and to pain endured in distress or loss (Morrow 2009). It is generally understood as a state of anguish when going through pain, injury or loss (ABCW934 2009). It is a subjective experience, which only the sufferer can fully know (ABCW934).

Causes

These are mortality and health status, risk factors, disease, the health system and inadequate health service coverage (ABCW934 2009).

Suffering can be physical, psychological, social or spiritual (ABCW934 2009). Physical suffering occurs with a lack of basic necessities for physical survival, bodily injury, disease, burns or poisoning. Examples are loss of independence, role disruptions, disruption in routine activities, bodily disfigurement, lack or loss of recreation, loss of control over body functions, and restraints. Psychological suffering is mental anguish, which can result from unfamiliar or unwanted surroundings, separation from loved ones, boredom, poor knowledge or appreciation of one's health status, anxiety towards surgery and other hospital procedures, lack or loss of communication and illness. Social suffering occurs in a society in times of war, civil unrest, both natural and unnatural disasters, population movements, political oppression, severe economic crisis, and extreme poverty. Among the long-term effects of social suffering are Post-Traumatic Stress Disorder or PTSD, anxiety, depression, psychosomatic disorders and social dysfunction (ABCW934).

Signs

Rapid breathing, ulcers, insomnia, irritable bowel syndrome, headaches and asthma attacks often indicate physical suffering (ABCW934 2009). Anxiety, stress, excessive worry, restlessness, unreasonable fear and agitation can signal psychological suffering. A change of role, helplessness, withdrawal from others, inability to function normally or developmentally can mean social suffering. And doubt about the validity or usefulness of one's religious beliefs, the lack of comfort from one's God or a sense of being punished for lack of faith can produce spiritual suffering (ABCW 934).

Pain and Suffering

Pain is a feeling of distress caused by the stimulation of specialized nerve endings (ABCW934 2009). It is a protective mechanism of the body, which indicates that tissues are being injured. It tells the person to withdraw the injured body part or withdraw from the source of pain. At times, pain is a subjective and real only to the person. The feeling of pain produces suffering, the person's response to pain. Both pain and suffering are subjective. According to the Gate Control Theory of Pain, the two main pathways of pain are the small diameter nerve fibers and the large diameter nerve fibers. The small fibers create a dull pain sensation, while the large ones produce fast and sharp pain sensations (Sahler & Carr 2003 as qtd in ABCW934).

Pain may also be vicarious, or perceived from another person's pain experience (Ochsner et al. 2008). It is adaptive in that it helps one understand the distressful state of the sufferer, which induces the response to help. It also serves as a lesson and a warning on what to avoid to prevent pain and suffering (Ochsner et al.).

Management of Suffering

This includes improving the patient's personal hygiene, daily living skills, socialization skills, pre-vocational or work readiness; taking prescribed medicines; and attending appointments and follow-ups (ABCW934 2009). It also makes available various services for primary care, social, community health, counseling and specialist and a wide range of health professionals (ABCW934). The management of both pain and suffering is most crucial at the ICU environment towards the patient and his family (Mularski et al. 2009). Multiple team members must interact coordinately in alleviating the distress and effectively evaluate processes and outcomes of palliative care. Careful attention will either avoid suffering while promoting healing or accept dying with comfort (Mularski et al.).

Implications for Practice

The primary responsibility in the care and comfort of those who suffer rests in the nurse (Cassell 1999). Her care must be patient or sufferer-led to read the patient's interaction. She must be able to recognize articulate suffering-related behaviors. She must be able to differentiate between enduring and emotionally releasing. She should support a patient who is enduring by appropriate verbal statements. It also helps to be just being with the patient, even if he is unaware of it. The nurse's support must be focused. Empathy should not be used as he is not yet "emotionally available" in this state. Emphatic statements, consolation, commiseration, condolences and expressions of sympathy and pity will drive him to emotional release. And when he enters the emotional release, he should be embraced, touched and held firmly (Cassell).

A patient in the state of emotional release finds consolation in the voice of a caregiver or nurse (Cassell 1999) He needs to talk, listen and receive empathy. He must be given reassurance but it must be realistic. He may not constantly cry but he tends to cry easily. The nurse should assist him with daily task and offer comfort food and emotional warmth. These gestures are very important to him at this time (Cassell).

Although subjective in nature, suffering affects and involves the sufferer's family and the nurse (Ferrell 2005) who cares for him. Nurses follow the ethical perspective of feminist scholars, guided by the fundamental concepts of relationship, compassion and respect. Every nurse is committed to a deeper view of pain in every patient. In this way, she becomes the fullest professional and moral agent, sworn to provide relief of pain and suffering (Ferrell).

Suffering consists of two major behavioral states, namely enduring and emotional suffering (Morse 2001). Emotions are suppressed in the enduring state and released in the emotional suffering state. Sufferers move back and forth between these states, according to their needs, acceptance of the event, the context, and the needs and responses of others. Pain management experts now recognize enduring as a legitimate coping style. It has the quality of hardiness, often associated with psychosocial distresses, such as homelessness, imprisonment and disasters. Nurses now recognize suffering as a basis of a patient's needs, caring and comforting as well as of interpretation and follow-up clues in providing patient-centered care (Morse).

Other researches found that temperament is a modulating factor in the pain experience (Ranger & Campbell-Yeo 2008). It is the foundation of human behavior and a useful basis of ones bio-behavioral response to environmental stress (Boyce, Barr & Zeltzer 1992 as qtd in Ranger & Campbell-Yeo). As such, temperament interacts with pain perception and responses. Health professionals can then adjust to their patient's temperament. They should first learn more about the construct of temperament. Then they can help him recognize the basis of his reaction to suffering or pain. Nurses can frame a personalized clinical plan accordingly. The plan can empower the patient as well as his nurse. By using a family-centered model approach, the nurse can collaborate closely with the patient's family, who knows his temperament better (Ranger & Campbell-Yeo).

Clinical Case 1: Sciatica

Mrs. J. K, aged 42, has had stiffness and aching in the lumbar region when rising or sitting down for six now (Boger 1994). Her excruciating experience of throbbing, quivering, soreness, numbness and shooting pains through her right sciatic nerve confine her to be. She says she feels like lying on rocks with pain on the outside of her thigh. Her right calf hurts and her right sole burns when she stands. Her menses have become profuse. She also suffers from backache, itchy leucorrhea, disturbed sleep, easy fatigue, frequent thirst, hot flashes and lack of appetite. She is also often nervous, weepy and restless. Morning and evening, these are her sensations of pain (Boger).

Clinical Case 2: Venous Ulcers

A cross-sectional study on patients suffering from chronic venous ulcers found that pain reduced their overall quality of life (Park et al. 2008). The respondents were 40 outpatients in Sao Paulo, Brazil whose ages ranged from 39 to 69. More than half of them were women at 65%. The study used the McGill Pain Questionnaire in identifying pain characteristics of their illness. Severe pain was prevalent in 90% of them. It was described as sensory-discriminative and evaluative in quality. And it negatively and significantly affects their overall quality of life (Park et al.).

Most of the respondent experience severe pain, which they describe as sharp, tender, pricking, throbbing, sore, tugging and burning (Park et al. 2008). These words characterize neuropathic pain. The respondents then describe the nature of their pain as nagging, tiring, and annoying. The impairment of their overall physical, social and environmental quality of life was the consequence of other factors. These included monthly family income and the number and frequency of their ulcers or wounds. The study concluded that the qualities and intensity of pain in outpatients with chronic venous ulcers should be considered differently (Park et al.). #