Conclusion
Mrs H. was seen by the palliative care team nurse practitioner for initial consult in the hospital. Based on conversations with the nursing staff at the nursing home and hospital, and assessment of the patient, the palliative care team recognized that her pain management regimen was not optimal. Methadone was reinitiated by the hospital attending provider in close collaboration with the palliative team pharmacist, nurse practitioner, and physician. After a goals-of-care conference where Mrs H.'s prognosis and options for treatment were reviewed with her, she decided against any additional treatment of her cancer and to focus on aggressive symptom management. She did express a desire to have "more time" to connect with and perhaps even see her sister. After involving the team nurse, chaplain, and social worker, an interdisciplinary plan was developed during hospitalization. Counseling sessions with the team's social worker resulted in Mrs H. gaining important insight into her many and recent losses, including the death of her husband, loss of her community home, recent life-limiting diagnosis, and loss of independence. The team chaplain provided spiritual support and counseling that included reconnecting her with her long-time and trusted pastor and facilitating phone calls with her sister. The team nurse spent time educating Mrs H. on energy-conserving techniques so she could complete some of her own daily care. Once the plan was in place and pain was at an acceptable level to Mrs H., she was discharged to the nursing home for continued palliative care that included a care conference with the facility's social worker, medical director, nurses, several CNAs, her sister by phone, and her pastor. This time she was admitted with goals of care focused on relief of pain and suffering and optimizing her quality of life until death. She died several weeks later without pain and in the care of the staff at the nursing home, who over time had become her extended "family."
Pain assessment and management are central to nursing and palliative care. As this case illustrates, pain that appears refractory can in fact be related to inadequately treated or incompletely assessed psychosocial, spiritual, or existential symptoms. When pain and suffering continue despite usual pain management interventions, the nurse, central in the care of complex patients, must recognize additional patient needs. This includes "whole person" assessment and involving interdisciplinary colleagues.