Hands by Georgianne Valli, Columbia University
College of Physicians and Surgeons, New York, NY
Grahic Jump Location
Every doctor who treats patients will confront their pain and suffering.
Yet for each individual patient the experience of pain will be private and
largely unique. This creates difficulty not only for the clinician but for
anyone who tries to grasp the meaning of someone else's pain.
The sensory component of pain, the neuronal capacity to localize and
identify noxious stimuli, is largely consistent both within an individual
and between populations.1 But the meaning
of pain becomes much more than the ability simply to localize or discern it.
For the affective component of pain—the subjective sense of suffering
that accompanies its perception—is multifactorial.
Myriad factors underlie our ability to conceptualize our own pain, or
to comprehend that of another: the meaning of the pain within one's larger
life context, the intensity and location of the pain, the particular illness
associated with the pain, the rituals of medicine around pain, and the social
understanding of suffering. The pain that results from this multiplicity of
factors is uniquely defined for each individual; pain becomes framed in the
clinical encounter by the interplay between the physician's gaze into the
patient and the patient's gaze into himself or herself.
This exercise of framing is at the center of every patient-physician
encounter, but most particularly so for pain. For pain is not an objective
and visible clinical finding in the manner of a fractured femur or purulent
sputum. Rather, pain is a perception communicated through both language and
nonverbal behaviors such as tears or agitation. As such, pain is intrinsically
subjective and inaccessible, "that which cannot be denied, and that which
cannot be confirmed."2
This intangibility contributes to misunderstanding and undertreatment
of pain in the clinical setting. As discussed by Kathleen Foley in this issue,
pain remains a serious public health problem. Many patients are inadequately
palliated, especially at the end of life. This need not be so. Janet Abrahm
describes how we can make palliative care itself a goal of medicine. Even
when cure of the underlying disease is not possible, there is still much we
can do to relieve physical and psychosocial suffering. Jane Loitman recounts
that many patients seek pain relief from complementary therapies. Often they
feel that these methods offer a holistic approach that is lacking in the traditional
As we grapple for solutions to these problems within our current clinical
context, we might do well to realize that none of these experiences are entirely
new. Schuyler Henderson describes the expressions and definitions of pain
as a function of not only personal but social, cultural, and historical influences
To treat pain adequately therefore requires not just that we understand
its pathophysiology, solicit patient reporting, and follow practice guidelines,
but that we also reflect on its meanings and thoughtfully incorporate them
into our clinical interactions. We hope that this issue of MSJAMA will encourage further thought about current issues in pain
management and its significance within the clinical encounter.
In 1997, the Institute of Medicine (IOM) published a report, Approaching Death, that called for the need to improve care of patients
at the end of life.1 The IOM report identified
serious deficiencies in the current provision of palliative care in the United
States. Among its 7 recommendations, health care professionals were asked
to commit themselves to use existing knowledge to reduce pain and manage symptoms
in patients facing death. The report also recommended that medical training
programs educate practitioners in the care of dying patients.
For patients whose disease is not responsive to curative therapies,
palliative care offers pain control, symptom management, and psychological
and existential support to maximize patients' quality of life.2
Historically, cancer has served as the model disease in the development of
hospice and palliative care services, but importantly, the IOM report calls
for the expansion of such services to patients with noncancerous chronic illnesses.
Providing compassionate and competent care to dying patients and families
is an enormous challenge for the medical profession. Major attitudinal, behavioral,
educational, and institutional barriers have been described that prevent physicians
from delivering and patients from receiving the desired humane and compassionate
Pain is one of the most common complaints of patients seeking medical attention.
Among the general population surveyed in 1997, 72% feared dying in pain.4 In an earlier survey of cancer patients, 57% endorsed
the statement that a painful death can be expected with cancer; 69% reported
that they would consider suicide if their pain was not adequately treated.5 Prevalence studies reveal that one third of adult
and pediatric cancer patients in active therapy and two thirds of those with
advanced disease require analgesic drugs.6
Studies from the World Health Organization Cancer and Palliative Care Unit
show that 4.5 million patients from developing and industrialized countries
die each year in uncontrolled pain.2
In a landmark study of 1308 oncology patients, 56% reported moderate
to severe pain, and 72% of physicians expressed their lack of knowledge concerning
pain management.7 Pain is also prominent
in seriously ill patients with noncancer diagnoses; moderate to severe pain
has been identified as a major symptom in 50% of seriously ill patients who
were conscious during the last 3 days of life.8
These and other data support the concept that pain is a serious public health
Impediments to adequate pain treatment include health care providers'
fear of inducing physical or psychological addiction, misconceptions about
pain tolerance, and assessment biases. A strict drug regulatory environment
that closely monitors physicians' prescribing practices further contributes
to patients' undertreatment. Major medical and nursing textbooks devote a
few pages to current pain and symptom control guidelines.9
This inadequacy has been most evident in the care of dying patients in cases
where physicians' ignorance of the proper use of opioids has led to needless
suffering.3,10 The recent
Supreme Court decision against a constitutional right to physician-assisted
suicide endorsed the need for pain control and palliative care.11
More importantly, it supported the aggressive use of opioids to manage symptoms
as distinct from physician-assisted suicide.10,12
Advances in pain research have redefined our understanding of tolerance
and neuropathic pain, offering new therapies to maximize pain relief and minimize
side effects. Protocols, such as the WHO Three Step Analgesic Ladder,2 provide detailed methods to facilitate pain relief
These efforts, coupled with the IOM's call to action, are signs that
improving pain and palliative care is becoming a priority for medicine. Medical
students can participate in curriculum electives that incorporate didactic
and experiential learning in pain management and palliative care. Increased
attention to pain and palliative care education by each medical school is
critical if we are to reduce the barriers to patient undertreatment that education,
clinical experience, and role modeling can readily change.
When one of our patients has an incurable illness, we physicians must
expand our focus of care beyond the disease to encompass all dimensions of
the patient's distress. That is when we begin to deliver palliative care.
The World Health Organization defines palliative care as the "active, total
care of patients whose disease is not responsive to curative treatment" and
notes in a statement that "control of pain, of other symptoms, and of psychological,
social, and spiritual problems, is paramount."1
Consider the case of Mr Joseph Taylor, a 71-year-old man with non–small–cell
lung cancer who developed a spinal cord compression manifested by severe back
pain. Beyond treating this problem, the clinician interested in palliative
care will discover his goals and values, identify sources of suffering, and
work with him to find the best solutions.
The first opportunity to practice palliative care will be in telling
Mr Taylor and his family the diagnosis. No matter how sensitively you break
this news, all of you are likely to feel sad. To the degree that you will
have succeeded in establishing a valuable relationship, however, the Taylors
will look to you for information and support.
Buckman suggests 6 steps to minimize the distress of this conversation.2 First, make yourself, Mr Taylor, and his family
comfortable. Second, determine what he knows, not just what he was told. Third,
determine what he wants to know. Fourth, disclose the news, in small chunks
and in words he will understand. Fifth, listen to his reactions. If he is
angry, realize that he is not angry at you. Sixth, review the next steps.
If you know what the plan is going to be, tell him. If not, schedule another
meeting. Ask for questions (there rarely are any) and invite him to write
down questions for the next meeting.
Further staging indicates continued progression of Mr Taylor's cancer.
His physician plans no further chemotherapy but does not tell him that she
has nothing more to offer. She discusses both experimental chemotherapy and
hospice options with Mr Taylor and his family, offering him not hope of cure
but rather the possibility that he will have the time and strength to accomplish
the tasks that are important to him. Mr Taylor enrolls in hospice. Hospice
seeks neither to prolong life nor to hasten death, but to enhance the quality
of remaining life. To be appropriate for hospice care, patients must be terminally
ill with a prognosis of 6 months or less. They do not need to be homebound
or have a do-not-resuscitate order. For patients at home or in nursing homes,
hospices provide nurses, social workers, chaplains, volunteers, home health
aides, consultants, medications, equipment, supplies, oxygen, and bereavement
care. Inpatient stays and care in a nursing home, designed to provide a respite
for caregivers, are often included.
Mr Taylor's pain was well controlled in the hospital, but a month after
discharge the pain intensifies. Mr Taylor refuses the opioids suggested by
his physician. Patients like Mr Taylor harbor several concerns about opioids
that they rarely mention. Common fears include addiction, social isolation
from friends, oversedation, and the lost chance to relieve more severe pain
by taking opioids later. Through the hospice chaplain Mr Taylor discovers
that attending church is a goal strong enough to overcome his fears about
opioids. His pain diminishes, and he returns to attending Sunday services.
Regular discussions among the nurse, social worker, chaplain, and the
patient's physician are needed to address and relieve most of the sources
of physical, spiritual, psychological, and social or financial distress that
patients and caregivers experience.
Extensive information about the role of the team and the practice of
palliative and end-of-life care can be found in textbooks, handbooks, and
a case-based palliative care manual.3
Over the next 2 months, Mr Taylor's pain is well controlled with dexamethasone
and an increase in opioids and laxatives. Hospice volunteers help him put
his stamp collection in order and finish a cradle for an expected grandchild.
His physician's biweekly phone calls have offered much support, and the hospice
social worker and chaplain have helped Mr Taylor's family begin to accept
their impending loss. Four months after you first met him, Mr Taylor dies
peacefully in his sleep.
Mr Taylor relied on his physician and nurse to control the pain from
bone and spinal cord lesions, but he faced multifaceted distress during his
terminal illness. Interdisciplinary teams can address and relieve this distress
and in so doing, provide physicians with significant personal and professional
No other physical experience is as heavily imbued with meaning as pain.
The idea that pain is simply the result of an internal physical condition
is relatively recent. For many philosophers and cultures, pain has been seen
as having an external source such as "God's arrows."1
With this externalizing of pain comes the understanding of pain as meaningful
in a social and moral context. The Biblical story of Genesis depicts the introduction
of pain and suffering in the human experience as a divine punishment for transgression,
and this Judeo-Christian ethos has permeated the West's understanding of pain.
Throughout literary history, representations of pain have been based
on the doctrine of punishment. At the center of Dante's hell, the monstrous
figure of Lucifer torments the 3 men who betrayed their lords: Cassius, Brutus,
and Judas Iscariot.2
In Paradise Lost, Milton describes the "doleful
shades" of Hell, relishing the agony of the fallen angels after their violent
subordination. In lurid detail, he describes their "torture without end."3 Both Dante and Milton carefully emphasize that
the pain is permanent, because it is necessary to differentiate punitive pain
from the moral cleansing associated with transitory pain. The sacrifice of
Jesus on the cross, the ascetic starvation of Siddhartha, and the religious
sects that self-flagellate on holy days all manifest the use of pain for purification,
purging transgression through temporary painful ablutions. And yet, striving
to construct any consistent parallel between morality and pain ultimately
must be answered with Hamlet's bitter question, "Use every man after his desert,
and who shall scape whipping?"4 Despite
the ancient association of pain with a person's moral character and social
behavior, it is only in literary and theological texts that such an association
The notion that pain results from transgression is not solely relegated
to the graphic imaginations of writers. One need look no further than certain
recent vitriolic assertions that AIDS is God's way of punishing homosexuals5 to see that for many today, physical suffering
is not detached from perceived spiritual health. The consequences of such
assertions for those who suffer are significant, both in the individual's
solitary struggle to come to terms with suffering and as they might affect
those making health policy.
Because of differing moral and narrative traditions, cultures ascribe
meaning to pain in different ways. There have been numerous attempts to discern
the extent to which the experience of pain differs among ethnic and national
groups. Although some researchers have managed to produce statistically significant
data that suggest culturally affiliated influences on the perception and response
to experimental, acute, and chronic pain,6
the confounding factors, often based on differences in expressing pain, usually
make any distinctions untenable. 7 Just
as the relationship between morality and pain cannot be clearly identified,
so too the correlation between physiology and the experience of pain remains
More pertinent to immediate concerns is the way physicians respond to
people in pain based on ethnicity. In an Israeli study, Jewish doctors and
midwifes assessed the pain ("exhibited pain") of 225 Jewish and 192 Bedouin
parturients, who also assessed their own pain ("self-reported pain") during
delivery. The Jewish and Bedouin women evaluated their pain equivalently,
but the doctors and midwifes reported less pain in the Bedouin women.8 We may not be able to explain cultural differences
in pain, but we nevertheless perceive such differences.
Medical research has provided us with a rich understanding of the mechanisms
of pain, but the physiology of nerves and the anatomy of dermatomes cannot
describe the experience of being in pain. Pain is one of the very few experiences
that every person will have, and yet it is intensely private. When Virgina
Woolf writes that the "merest schoolgirl when she falls in love has Shakespeare
or Keats to speak her mind for her, but let a sufferer try to describe a pain
in his head to a doctor and language runs dry," she is pointing to that intrinsic
difficulty of conveying to another the personal experience of pain.9
In asking about pain, the physician attempts to interpret it as a message
coding a pathological process, reading the pain in its relationship to a problem
in the body's functioning that can then be addressed. Not only is this limited
by the painless nature of many pathological processes (such as the stealthy
streaking of arteries with fatty deposits), but more importantly, the physician
will never be able to empathize with his or her patient without trying to
understand how that person is experiencing pain.
While the investigation of pain as a physiologic phenomenon is important,
pain cannot be reduced to physiology any more than it can be neatly explained
by a social or moral paradigm. The difficulty in talking about and understanding
another person's pain stems from its complicated origin in both realms, as
a function of our bodies and of our identities.
Pain and its complications are common problems for physicians, clinicians,
and patients. Of the 17 million new cases of cancer reported worldwide each
year, 56% of patients indicated having moderate to severe pain 50% of the
time, 81% had greater than 2 complaints of pain, and 34% had greater than
3 complaints of pain.1 Many patients, hopeful
of a cure or palliation of their pain, turn to alternative practitioners.2 From 30% to 70% of patients use alternative or
complementary therapies, and while 57% of physicians report a willingness
to refer patients for complementary therapies, only 28% of physicians had
actually done so.3- 6
In its definition of pain, the International Association for the Study
of Pain includes actual or potential tissue damage as well as the emotional
experience of pain. Understanding the multifaceted experience of pain becomes
important in treatment. To mitigate their suffering, patients may turn to
complementary and alternative therapies to reduce feelings of stress, anxiety,
nervousness, agitation, despondency, lack of motivation, lack of enjoyment,
During medical education, physicians generally are taught that the tools
of their trade include pharmacotherapy, surgery, psychotherapy, and physical
therapy. Yet other modalities exist for alleviating pain, and physicians can
better participate in pain management by learning about the efficacy of complementary
therapies and when and where to apply
them (Table 1).
In the standard approach to disease the physician must understand the
neurophysiology and neuroanatomy of pain. A vocabulary of descriptors must
be part of the physician's armamentarium. A working knowledge of the syndromes
associated with various presentations of pain is essential when the physician
is obtaining the patient's history, collecting data, and performing the physical
examination. Additional factors help determine what, if any, complementary
treatments might help the patient in a given setting when synthesizing an
assessment. Those with acute pain need disease treatment and enough symptom
relief to tolerate the workup and therapy. Those with malignant or chronic
nonmalignant pain need symptom relief that allows optimal physical and mental
function and, if death is unavoidable, allows the patient to die relatively
free of pain.
Acupuncture, which originated in China during the Xia dynasty (2140-1711
BC), is based on the concept that the continuous flow of chi, "life energy,"
is vital to one's health. Acupuncture treatments aim to improve health by
inserting hair-thin needles into specific points on the body that are thought
to enhance the flow of chi.
In the United States acupuncture gained public attention in 1971, when
a well-known columnist, James Reston, underwent an emergency appendectomy
in Beijing and described acupuncture's effectiveness in alleviating severe
pain.7 In 1986, the NIH Consensus Development
Conference on the Integrated Approach to the Management of Pain identified
acupuncture as an effective tool for many types of pain and other symptoms.8 These days, Americans make up to 12 million visits
to acupuncturists per year.9 Allopathic
physicians perform or refer to acupuncture primarily in cases of pain and
substance abuse, and most research on acupuncture has focused on these treatments.
Stimulating particular points using needles, pressure, heat, or electric
waves causes the measurable release of endorphins into the blood.10 The activation of small myelinated nerve fibers
sends impulses into the spinal cord, midbrain, pituitary, and hypothalamus.
Various endorphins block incoming pain information through the release of
serotonin, norepinephrine, and possibly GABA.10
Studies11- 12 demonstrate
that acupuncture is especially, though not exclusively, effective with myofascial
pain and trigger points.
During acupuncture, patients should not feel pain from the therapy itself.
The frequency of treatment will vary according to the particular condition.
Treatments last from 5 to 30 minutes, and from 1 to 20 needles may be used.
Although some patients experience immediate pain improvement, others require
at least 3 treatments. Risks associated with this treatment include fainting,
bruising, pain, infection, or injury to underlying tissue, but these reactions
are rare. Acupuncture is contraindicated in the treatment of malignancy, mechanical
obstruction, fulminant infection, hemorrhagic diseases, or conditions that
require surgical repair.
Hypnosis, a therapy used in pain management since the mid-1800s,13 is based on conscious relaxation in association
with patient-designed suggestions and exercises. Hypnosis assists patients
in obtaining deep levels of relaxation, which often leads to more peaceful
sleep, increased energy, and a diminished experience of pain.
In the initial consultation, the patient discusses specific problems
and begins to develop trust and a rapport with the hypnotherapist. The prerequisites
for treatment are the capacity for a degree of concentration, imagination,
and a willingness to participate fully. The patient remains in control of
the process throughout the session, which reduces any risk for adverse reactions.
The hypnosis session can be directed toward the patient's emotional
and physical stress either separately or simultaneously. Through deep breathing
techniques, the patient is guided physically and cognitively into the relaxation
of each part of the body. In a deeply relaxed state the subconscious mind
is open to receiving the beneficial suggestions constructed by the patient
and therapist beforehand. The hypnotherapist suggests changes in the behaviors,
thoughts, and feelings of the patient. The patient, in hypnosis, will accept
only those suggestions that are relevant to his or her needs. By maintaining
awareness throughout the session, the patient is later able to reinforce the
hypnotic experience independently.
A conducive setting for hypnosis includes a quiet space, muted lights,
a comfortable chair, and uninterrupted time. Although the absence of environmental
distractions is preferable, hypnosis can provide positive results in almost
any setting. A session usually lasts between 20 and 60 minutes. Patients have
reported feelings of heightened emotional well-being, deep relaxation, and
reduction of physical pain. A greater number of sessions generally leads to
Research has not yet been able to delineate the mechanism underlying
hypnosis' effect, but it appears to be more effective than placebo.14- 15 Studies have shown that those
with the greatest capacity to relax respond best.16
Acupuncture and hypnosis can benefit some patients with pain; patients
with myofascial pain or headache respond well to acupuncture, and highly anxious
patients who want to actively participate in and control their care respond
well to hypnosis. The clinician should realize that while not every therapeutic
modality will work on everyone, there are options, including pharmacotherapy,
physical therapy, and complementary therapies. Given the multitude of complementary
therapies available and the incomplete understanding of their mechanisms and
efficacy, clinicians unfamiliar with them might want to familiarize themselves
with the services available in their communities. If the physician considers
acupuncture, hypnotherapy, and other complementary therapies as adjuvants
to nonsteroidal anti-inflammatory drugs and opioids for the treatment of pain,
he or she may find patients more grateful and the practice of medicine more
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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and
Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early
dhildhood mortality and growth failure data and their association with maternal
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