Sandra E. Ward

Application of the American Pain Society quality assurance standards

&NA; The American Pain Societys (APS) patient outcome questionnaire was used to examine patient satisfaction with pain management in a quality assurance study of 217 adults and 31 children in a large university hospital. On a scale of 1–6, mean (S.D.) patient satisfaction with pain management provided by nurses was 5.37 (1.02) and by physicians was 5.10 (1.02). Many patients (84% of adults and 90% of children) reported that early in their hospital stay a nurse or physician had communicated the fact that treatment of pain is considered very important. The mean (S.D.) pain severity score (worst pain in the last 24 h) for adults was 6.62 (2.79) on a 0–10 scale and for children was 4.33 (0.85) on a 0–5 Faces scale. Analyses revealed little relationship between pain severity and satisfaction; even persons with high levels of pain were very satisfied with the pain management they received from nurses and physicians. Satisfaction was, however, related to whether nurses and physicians had communicated to the patient that pain management has a high priority. It appears that patients are satisfied if clinicians say they want to provide pain management regardless of whether they actually do. The data raise questions about the interpretation of patient satisfaction as an outcome variable in studies of the quality of pain management.

Patient-related barriers to cancer pain management in Taiwan

The reluctance of patients with cancer to report pain and to use analgesics hinders the management of their pain. In the United States, this reluctance is related to the patients misconceptions regarding addiction and tolerance to analgesics and the desire to be a “good patient” who does not complain. Reports in the literature suggest that patients in Taiwan may have these same concerns and misconceptions. This study was designed to explore (a) the concerns of patients in Taiwan about reporting pain and using analgesics and (b) the relationship between these concerns and the adequacy of analgesics used by the patients. Sixty-three patients with cancer completed the Barriers Questionnaire-Taiwan (BTQ) form, a self-report instrument that measures the extent to which patients have eight specific concerns about reporting pain and using analgesics. The responses indicated that patients who were less educated were more likely to have concerns and that patients in general were most worried about tolerance. Patients who were inadequately medicated, as determined by an index of “adequate pain management” constructed for the study, had significantly higher levels of concerns. Open communication between health professionals and patients and educational programs about pain and about the concerns measured in this study could help overcome these concerns and misconceptions and improve pain management.

Reducing racial disparities in pain treatment: the role of empathy and perspective-taking.

&NA; Epidemiological evidence indicates that African Americans receive lower quality pain treatment than European Americans. However, the factors causing these disparities remain unidentified, and solutions to this problem remain elusive. Across three laboratory experiments, we examined the hypotheses that empathy is not only causing pain treatment disparities but that empathy‐inducing interventions can reduce these disparities. Undergraduates (Experiments 1 and 2) and nursing professionals (Experiment 3) watched videos of real Black and White patients’ genuine facial expressions of pain, provided pain treatment decisions, and reported their feelings of empathy for each patient. The efficacy of an empathy‐inducing, perspective‐taking intervention at reducing pain treatment disparities was also examined (Experiments 2 and 3). When instructed to attempt to provide patients with the best care, participants exhibited significant pro‐White pain treatment biases. However, participants engaged in an empathy‐inducing, perspective‐taking intervention that instructed them to imagine how patients’ pain affected patients’ lives exhibited upwards of a 55% reduction in pain treatment bias in comparison to controls. Furthermore, Pro‐White empathy biases were highly predictive of pro‐White pain treatment biases. The magnitude of the empathy bias experienced predicted the magnitude of the treatment bias exhibited. These findings suggest that empathy plays a crucial role in racial pain treatment disparities in that it appears not only to be one likely cause of pain treatment disparities but also is an important means for reducing racial disparities in pain treatment. An empathy‐inducing, perspective‐taking intervention reduced racial bias in pain treatment within experimental settings. Empathy may not only cause but can also reduce pain treatment biases.

Factors women take into account when deciding upon type of surgery for breast cancer

For women with stage I or II breast cancer, randomized trials have demonstrated no significant difference in survival rates between women receiving modified radical mastectomy (MRM) and women receiving breast conserving (BC) surgery. Therefore, many women are now in a position of having a choice between these two options. Twenty-two women who met the surgical criteria for having this choice were interviewed 1 to 2 weeks postsurgery to determine factors they had considered when deciding between MRM and BC, how much they wished to participate in decision-making, and the sources of information they used. The sample was purposefully limited to women attending one clinic in order to insure control over variables such as the information to which patients are exposed. When asked why they had chosen a given surgery, two factors, concerns about radiotherapy (p = 0.003) and body integrity (p = 0.04), emerged as significantly different for women choosing BC vs. MRM. Furthermore, women reported that participation in decision-making was important to them and that they had had sufficient participation in the decision-making process. Finally, they rated “people” sources of information as more important than written or visual materials, suggesting that nurses and other care providers are important in supporting women through the decision-making process.

A randomized, controlled trial to improve advance care planning among patients undergoing cardiac surgery

Background:Although many healthcare providers and researchers consider it necessary to assist patients with end-stage chronic illnesses to plan for the end of life, they tend to avoid discussing end-of-life issues with patients before major surgery. Consequently, surgical patients and their families generally have insufficient knowledge to make plans in case of life-threatening complications. Objective:The objective of this study was to evaluate short-term effects of Patient-Centered Advance Care Planning (PC-ACP). Design and Subjects:Thirty-two dyads of patients undergoing cardiac surgery and their surrogates were randomly assigned to receive either the PC-ACP intervention (PC-ACP) or usual care. Measures:Measures studied were patient–surrogate congruence regarding goals for future medical care, patient and surrogate knowledge of advance care planning and anxiety, and patient decisional conflict. Congruence and anxiety were measured before and after the intervention. Decisional conflict and knowledge of advance care planning were measured after the intervention. Results:Compared with the control group, PC-ACP significantly improved patient–surrogate congruence (Δ = 1.27, P < 0.01) and reduced patients’ decisional conflict (Δ = −0.77, P < 0.05). Anxiety change (pre/post) did not differ between treatment and control groups. No difference in knowledge of advance care planning was found between the 2 groups. Conclusions:The PC-ACP can be an effective approach to advance care planning. Its specificity and relevance to patients’ actual medical conditions (as exemplified by its plans for potential complications related to cardiac surgery) can lead to greater patient–surrogate congruence without increasing decisional conflict and anxiety.

Patients' reactions to completion of adjuvant breast cancer therapy

Thirty-eight women with breast cancer were studied to determine the psychological distress they experienced at the completion of adjuvant treatment. Measures were completed at the start of adjuvant chemotherapy, one week after chemotherapy was completed, and following completion of radiotherapy. Approximately 30% of the women reported the termination of treatment was upsetting. For the group as a whole, depression scores decreased significantly from the first to the last measurement. Those who were most upset by termination of treatment had been more depressed since the onset of treatment, tended to view their illness as chronic rather than acute, and had more side effects during their last cycle of chemotherapy. Some women stated they were upset by the termination of treatment perse, but many other problems were reported including side effects that had continued after treatment ended.

Patient-related barriers to management of cancer pain in Puerto Rico☆

&NA; Two hundred and sixty‐three ambulatory patients older than 21 years of age who were attending clinics at an oncology hospital in San Juan, Puerto Rico, were studied. They completed a questionnaire (BQ‐PR) that measures 8 concerns about reporting pain and using analgesics, such as fears of addiction and tolerance and the belief that reporting pain can distract a physician from focusing on curing ones disease. Ninety percent of the patients had at least some concern about each of the 8 topics, and mean scores on the 8 subscales were near the midpoint on a 0–5 scale. There were significant inverse relationships between level of education, income, and BQ‐PR total score. Those persons who experienced cancer‐related pain on the day they completed the questionnaire were categorized as using adequate versus not adequate analgesic medication, a determination that was based on a comparison of their level of pain to the medication they were using. Those who were not using adequate analgesic medication had higher BQ‐PR total scores than did those who were using adequate medication.

Concerns about analgesics among patients and family caregivers in a hospice setting

Patients receiving curative treatment for cancer have concerns about reporting pain and using analgesics. These concerns are associated with underutilization of analgesics. To extend knowledge about such concerns to the context of palliative care, the concerns of hospice patients and family caregivers were compared. Within 5 days of admission to hospice, 35 patients with cancer and their caregivers each completed a measure of eight concerns such as fear of addiction, worry about tolerance, and worry about side effects. There was no correlation between caregiver and patient concerns and means for the two groups were similar, indicating that within a given dyad either the patient or the caregiver may have greater concerns. The findings highlight the need for patient and caregiver education about reporting pain and using analgesics.

Institutionalizing pain management: the post-operative pain management quality improvement project

Clinical practice and quality improvement (QI) guidelines for acute postoperative pain management have been developed to address the well-documented problem of undertreatment of postoperative pain. The Post-Operative Pain Management Quality Improvement Project (the POP Project) was initiated to determine whether an intervention designed to support hospitals in the development of QI efforts would lead to improvements in structures, processes, and outcomes consistent with recommended guidelines. A nationwide sample of 233 hospitals joined the project. The intervention consisted of written resource materials accompanied by support services that included an e-mail list server, a resource Web page, and assistance from POP Project staff via telephone. Data regarding critical structures, processes (practice patterns), and patient outcomes were collected at baseline before the intervention began and at follow-up 12 to 18 months later. Results showed a statistically significant increase from baseline (45%) to follow-up (72%) in the presence of structural elements that are critical to improving pain management. There were statistically significant improvements in practices including documented use of pain rating scales, decreased use of intramuscular opioids, and increased use of nonpharmacologic strategies. Patient survey data showed no change in pain outcomes. Evaluation data showed that 70% of hospitals were very or extremely satisfied with their participation in the POP Project and 90% of them planned to continue efforts to improve pain management after the POP Project ended. Further research is needed to determine how to translate the excellent results obtained for structure and process into meaningful outcomes for patients.

A Randomized Trial of a Representational Intervention to Decrease Cancer Pain (RIDcancerPain)

OBJECTIVE Based on theories regarding cognitive representations of illness and processes of conceptual change, a representational intervention to decrease cancer pain (RIDcancerPain) was developed and its efficacy tested. DESIGN A two-group RCT (RIDcancerPain versus control) with outcome and mediating variables assessed at baseline (T1) and 1 and 2 months later (T2 and T3). Subjects were 176 adults with pain related to metastatic cancer. MAIN OUTCOME MEASURES Outcome variables were two pain severity measures (BPI and TPQM), pain interference with life, and overall quality of life. Mediating variables were attitudinal barriers to pain management and coping (medication use). RESULTS One hundred and fifty subjects completed the study. Subjects in RIDcancerPain (T1-T2 and T1-T3) showed greater decreases in Barrier scores than those in control. Subjects in RIDcancerPain (T1-T3) showed greater decreases in pain severity than those in control. Change in Barriers scores mediated the effect of RIDcancerPain on pain severity. CONCLUSION RIDcancerPain was efficacious with respect to some outcomes. Further work is needed to strengthen it.