Gerri Frager

Psychological barriers to optimal pain management in infants and children.

OBJECTIVE To discuss the numerous psychological barriers to optimum pain relief in infants, children, and adolescents. DATA SOURCES The professional and scientific literature on pediatric pain was accessed by means of Psychlit and Medline searches. Our clinical experience with patients was also used. DATA SYNTHESES The potential barriers to optimum management were discussed in terms of cognitive and emotional developmental barriers, perceived lack of control, childrens knowledge and attitudes, and characteristics of children. CONCLUSIONS The psychological barriers to optimum pain relief are significant and attention to these barriers could lead to better pain management.

Tipping the iceberg? The state of arts and health in Canada

The field of arts and health is rapidly gaining momentum in Canada despite the challenges of integration across a vast geography, two official languages and multiple interdisciplinary cultures. Although the field is young, there is a solid foundation of innovative work and great enthusiasm on the part of diverse practitioners about the fields salience and impact. This article provides an overview of the arts and health in Canada and considers work that spans health policy, healthcare practice, individual and community health promotion, health professional education and arts-based health research. A final section offers reflections and recommendations on arts and health in Canada. We provide an online appendix through the journals website that refers the interested reader to Canadian programs, resources, networks and other materials on the arts and health.

Frequency and self-management of pain, dyspnea, and cough in cystic fibrosis.

Cystic fibrosis (CF) has been transformed from a fatal diagnosis in infancy to a chronic disease of children and young adults. Symptom patterns and disease burden in CF may be shifting to reflect the relatively healthier, older population with the disease. Self-management of symptoms is a hallmark of chronic illness, and yet we do not have a good understanding of how CF patients monitor or manage their symptoms. Children and adults were recruited through clinics in three Canadian provinces. Questionnaires with open-ended and close-ended questions in English and French, designed to assess the frequency, severity, and self-management of pain, breathlessness, and cough, were mailed to all the eligible participants. One hundred twenty-three respondents completed the survey, for a response rate of 64%. Eighty-four percent (103 of 123) of participants reported having pain. They reported an average of 2.1 locations of pain, with headache and abdominal pain most frequently described. Sixty-four percent (76 of 123) of participants reported having breathlessness, and 83% (99 of 123) of participants reported experiencing cough. Sixty-three percent (62 of 99) of participants with cough reported that cough always or sometimes interfered with their sleep. A variety of pharmacological and nonpharmacological treatments were used to manage symptoms. Pain and dyspnea are more common than suspected and a wide variety of pharmacological and nonpharmacological measures are used to treat symptoms. Cough is difficult to assess, but disturbed sleep may be an indicator of cough severity and an important symptom to consider when evaluating the overall burden of illness in those with CF.

Ensuring Pain Relief for Children at the End of Life

Pain management in the context of pediatric palliative care can be challenging. The present article reviews, through a case-based presentation, the nonpharmacological and pharmacological methods used to ensure adequate pain control in children facing end of life. Details on the impressive range of opioid dosages required and routes of administration are highlighted from published literature and clinical experience. Where available, evidence-based recommendations are provided. Potential side effects of pain medication and barriers to good pain control are discussed. Novel analgesics and innovative delivery methods are presented as future tools enhancing pain relief at the end of life. Some challenges to ethically grounded research in this important context of care are reviewed.

Pain and Pain Relief in Pediatric End-of-Life Care

The pain experienced at the end of a child’s life is a complexity of physical, psychological, social, spiritual, and other factors. All factors in this matrix must be considered and treated to effect a successful system of care for a dying child. It is only in recent years that the special needs of the dying child and the child’s family have been recognized and specialized pediatric palliative care services developed. There is a small but evolving collective expertise that is developing clinical services to care for dying children. The knowledge base also is small but evolving. The collective knowledge base will grow more quickly with time if this endeavor becomes an international collaborative effort.

Theatre: An innovative teaching tool integrated into core undergraduate medical curriculum

Background: Eds Story: The Dragon Chronicles is a verbatim play based on the journal of a 16-year-old with advanced cancer and transcripts from 25 interviews conducted after his death with his family, friends and health care team. After cross-country performances directed at health professionals and the general public, a viewing was incorporated into core undergraduate medical curriculum at our institution. We collected and compared responses of trainees who viewed the play voluntarily in extra-curricular settings and those who viewed a mandatory curriculum performance. Methods: Trainees completed confidential, online surveys within one year of viewing. A total of 46 trainees from five Canadian medical schools completed surveys after voluntary extra-curricular viewings (60.9% female, 39.1% male, mean age 26.2 ± 3.2 years). Of 84 eligible second-year medical students, 60 students completed surveys after mandatory curricular viewing (68.3% female, 31.7% male, mean age 26.0 ± 2.9 years, response rate 71.4%). Results: In both cohorts, a majority of trainees agreed that the play was a good learning experience (84.8%, 93.3%), should be experienced by all medical students (75.5%, 84.5%) and taught lessons they will use in their careers (71.1%, 84.7%). Trainees highlighted the plays realism, the insight gained into patient experiences and that they preferred the play to other teaching modalities. A greater percentage of trainees in the mandatory curriculum cohort agreed that a viewing should be incorporated into medical curriculum (86.7% vs. 45.3%, χ2 = 20.3, p < 0.001). Conclusions: Medical trainees responded positively to this verbatim play in both extra-curricular and curricular settings.

Reducing procedural pain.

We were most dismayed to read of the use of a placebo in a study of analgesia and the success rate of cannulation when a topical anesthetic was used on children requiring venipuncture.[1][1] It would seem unethical to expose any patient to unnecessary procedural pain when the efficacy of available

Improving End-of-Life Care: Listening to Voices from the Trenches

ing a difference in her comfort and survival. It was, and is, unbearable to me that I could not save her, could not protect her. At least, I could ensure that her medical care was carried out as she wished. My medical training made this easier for me than it might be for others. I would do just about anything to have my daughter alive. Nothing can change the relentless reality that she died. However, I am comforted, knowing that she died the death she wanted. I see that as wholly the outcome of mobilizing together to deal openly and honestly with what Liza was facing, of not leaving her alone with her dying. Not all of us will be that lucky.