Abstract and Introduction
Abstract
Refractory pain is an elusive and often misunderstood symptom in palliative care. Often, persistent pain, labeled as refractory, requires more complex assessments and interventions than the physical symptom of pain. Proper assessment of the "whole person" can reveal psychological, social, spiritual, or existential concerns that contribute to the experience of pain. The purpose of this article is to review and present evidence, guidelines, and recommendations for treating older adults with suspected refractory pain. This case-based illustration of pain is specifically focused on the older adult who is suspected of having refractory pain and has undergone care setting transitions between the hospital and nursing home and provides strategies for clinicians in both settings to best assess and meet patient needs. Recognition, assessment, treatment, and goal-directed nursing implications are presented.
Introduction
Refractory pain is defined as "pain that is resistant to ordinary treatment" and persists regardless of medication use, therapeutic interventions, and other attempts to relieve suffering. However, there is confusion about when a clinician can label pain refractory, as opposed to pain that is undertreated or underrecognized, or most importantly when other psychosocial issues may be contributing to physical pain and suffering. It has been reported that older adults with cancer are at higher risk for uncontrolled pain than other populations with cancer. There are many contributing factors to inadequate pain relief that must be recognized before pain is labeled refractory. Other factors that affect pain and increase suffering are psychosocial, existential, and spiritual concerns. Any one or all of these factors can worsen, exacerbate, or cause unrelieved pain. Dame Cecily Saunders, educated as a nurse, physician, and social worker, was the first to apply a broad definition to pain, suggesting that pain is much more than the physical experience. She expanded the pain syndrome to include multiple dimensions, especially the spiritual and psychological domains. Saunders related physical pain and mental suffering and the "total pain" concept of physical, psychological, spiritual, and social factors that contribute to pain and suffering. Later, Cassel and Ferrell and Coyle elaborated on the complexity of pain and suffering as well as the influence of medicine and nursing in recognition and treatment. The concept of "total pain" is important when considering all pain, but especially the pain of an older adult with progressive cancer before it is labeled as refractory.
The purpose of this article is to discuss the complex phenomenon of suspected refractory pain in an older adult with cancer who, in addition to experiencing unassessed psychosocial and spiritual issues, has moved through different care settings and, as a result, is at risk for complicated or "total pain."