Suffering Knowing and Managing Suffering

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).

Theoretical Perspectives

Suffering is perceived as being on the other side, which cannot be completely shared with another person or bridged by any help resource or skill (Frank 2001 as qtd in ABCW934 2009). In a very real way and despite the best efforts, suffering is beyond help. It cannot be captured by speech or adequately revealed. In every way, it is impossible to reveal. It is clothed in darkness and clear only to the sufferer's soul. The sense of loss is both present and anticipated. The absence of what is missed is beyond recovery. Something irreparably wrong lies at the core. Suffering always defies definition because it is beyond expression. It lies on the other side of reality. It is a reality another person cannot "come to grips with," because it is known only to the sufferer (Frank 2001 as qtd in ABCW934). Suffering also has different but concurring dimensions: spiritual, emotional, psychological and physical "as a suffocating, stomach-wrenching sickness of the heart (Johnson and Scholler-Jaquish 2007 as qtd in ABCW934).

Good clinicians stay as close as possible to an objective finding and delay final interpretation until all the evidence is gathered (Cassell 1999). They must deal with the patient's subjective information in the form of symptoms, emotions, beliefs, fears and concerns. These dictate behavior. The doctor patterns medical care after the relief of suffering, something quite subjective. If he sticks entirely with objective information, he cannot relieve suffering in his patient. The doctor needs to listen to both what the patient says and does not say. He should observe his face and body expressions without being judgmental. When he does, he begins to know something about the patient. Biases and misconceptions can mislead without it. The doctor must learn sympathetic listening, emphatic communication and attentiveness. The patient will begin to see the doctor as trustworthy, caring and understanding. The doctor develops non-discursive thought, the product of intuitive thinking. This enables him to diagnose and treat suffering even when its cause cannot be cured or removed. The doctor must know the patient as a person. Relieving suffering depends on it (Cassell).

On the whole, the ability of medicine to resolve all suffering remains limited. Both patient and doctor must accept that suffering is inherent in human experience and that some of it is beyond the power of medicine. By accepting this, suffering can be transcended and meaning can be obtained from the situation. When that meaning is found, "suffering ceases to be suffering in some way (Egnew)."

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).