Conducting holistic pain assessments in patients with cancer-related pain
Intended for healthcare professionals
CPD    

Conducting holistic pain assessments in patients with cancer-related pain

Martin Galligan Lecturer practitioner, Royal Marsden School, Royal Marsden NHS Foundation Trust, London, England

Why you should read this article:
  • To learn more about the experience of pain in patients living with and beyond cancer

  • To enhance your knowledge of tools that can assist in conducting holistic pain assessments

  • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

The incidence of cancer is increasing and people diagnosed with cancer are living longer, with and beyond cancer, and experiencing acute and long-term effects of their disease and its treatment. One such effect is pain, which may occur at any stage, from diagnosis to survivorship or end of life. The exact incidence of cancer-related pain is challenging to determine but it is estimated to affect between 39% and 66% of patients, according to the stage of their disease trajectory. Cancer-related pain is complex, multifactorial and multidimensional, and nurses need to be equipped with the knowledge and skills to assess it in a holistic way. This article explores how nurses working in cancer settings can support people in their care by conducting holistic pain assessments.

Cancer Nursing Practice. doi: 10.7748/cnp.2021.e1802

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@boywonder1989

Correspondence

martin.galligan@nhs.net

Conflict of interest

None declared

Galligan M (2021) Conducting holistic pain assessments in patients with cancer-related pain. Cancer Nursing Practice. doi: 10.7748/cnp.2021.e1802

Published online: 20 October 2021

Aim and intended learning outcomes

This article aims to explore how nurses can conduct holistic pain assessments to reduce the symptom burden of people living with and beyond cancer. After reading this article and completing the time out activities you should be able to:

  • Explain the concept of total pain.

  • Describe various types and triggers of pain in patients with cancer.

  • Feel more confident in your ability to conduct holistic pain assessments.

  • Discuss the role of pain assessment tools in holistic pain assessments.

  • Outline various types of barriers to holistic pain assessments.

Key points

  • People with cancer may experience many adverse effects of the disease and/or its treatment, with pain prominent among them

  • Nurses have a crucial role in assessing people with cancer-related pain and need to be equipped with the knowledge and skills to conduct assessments in a holistic way

  • Various tools can be used to structure an assessment of cancer-related pain, including unidimensional, multidimensional and functional pain tools

  • The use of pain assessment tools should neither replace nursing care and insight nor detract from communication with the person being assessed

Introduction

New cases of cancer worldwide are expected to rise to 27.5 million per year by 2040, compared with 17 million in 2018 (Arnold et al 2019, Cancer Research UK 2021a). In the UK there are around 367,000 new cases every year and the incidence rate is projected to rise by 2% to 742 cases per 100,000 people by 2035 (Cancer Research UK 2021b). As the incidence of cancer increases, so do survival rates, since improved screening and treatment mean people live longer with and beyond cancer (Cancer Research UK 2021c).

In the first year after a cancer diagnosis patients may experience up to 30 different symptoms of the disease and/or its treatment (Stark et al 2012), and pain features prominently among them (Bubis et al 2018). This symptom burden negatively affects people’s quality of life and is often compounded by co-morbidities. Around 70% of people diagnosed with cancer already have one or more other long-term conditions, which increases the complexity of their care needs (Macmillan Cancer Support 2015).

Cancer-related pain may occur at any stage, from diagnosis to survivorship or end of life. The exact incidence of cancer-related pain is challenging to determine but it is estimated to affect 55% of patients during active treatment, 39% of patients in remission after effective curative treatment and 66% patients with advanced disease (van den Beuken-van Everdingen et al 2016).

The studies mentioned above were conducted before the coronavirus disease 2019 (COVID-19) pandemic, and there is growing evidence that people with cancer have experienced an overall increase in pain, anxiety and depression as a direct result of the pandemic (Miaskowski et al 2020). Nurses have a crucial role in assessing people with cancer-related pain and need to be equipped with the knowledge and skills to conduct assessments in a holistic way.

TIME OUT 1

How many of your patients experience pain? Do they usually report pain on one or several sites? Is their pain mostly physical or does it have other aspects as well? Are you usually able to determine its origin? What effects does it have on them as a whole?

Pain concepts

The International Association for the Study of Pain recently updated its definition of pain to ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’ ( Raja et al 2020). This updated definition acknowledges that pain has an emotional component and is not always directly linked to tissue damage, but it does not fully describe the complex and individual nature of the pain experience.

Historically, McCaffery (1968) proposed that pain is ‘whatever the experiencing person says it is’ and that it exists ‘whenever and wherever the person says it does’. Also in the 1960s, in the context of palliative and end of life care, Dame Cicely Saunders and others introduced the concept of ‘total pain’, which gradually changed how healthcare professionals considered pain (Mehta and Chan 2008). The basis of the total pain concept is that the experience of pain is influenced not only by physical factors but also by psychological, social and spiritual ones. Considering the psychological, social and spiritual aspects of pain beyond the physical ones helps in understanding that each person experiences pain differently. The concept of total pain enables healthcare professionals to acknowledge and explore the complexity of cancer-related pain.

People living with cancer have a high symptom burden, two of the most commonly reported symptoms being pain and anxiety (Stark et al 2012). Looking at this in terms of total pain, it is unsurprising that pain and anxiety go hand in hand – if the emotional burden is heightened, the experience of pain is exacerbated (Lumley et al 2011). The link between emotion and pain has been described using the neuromatrix theory of pain, according to which the body-self neuromatrix in the brain is activated not only by sensory inputs triggered by physiological damage but also by multiple other influences, including emotions (Melzack 2001).

The experience of pain is complex, individual and multidimensional. When assessing patients with cancer-related pain, nurses should adopt a holistic view, consider all aspects of the person’s pain and assess the individual, not the symptom.

TIME OUT 2

What treatments do your patients undergo that can result in acute or chronic pain? In somatic, visceral or neuropathic pain? How do you discuss this with your patients before they start treatment?

Types and triggers of pain

Pain can be categorised in a variety of ways, notably according to duration and nociceptive pathways. In terms of duration, pain can be described as acute or chronic (persistent). Acute pain is triggered by an injury or damage to an area of the body and should resolve within three months, while chronic pain lasts for more than three months (Treede et al 2015). Chronic pain can be secondary to an underlying condition. Conversely, primary chronic pain has no clear cause or appears out of proportion to any observable injury or disease (National Institute for Health and Care Excellence (NICE) 2021).

In terms of nociceptive pathways, pain can be described, for example, as somatic, visceral or neuropathic:

  • Somatic pain is caused by the activation of the peripheral nociceptors (Chang et al 2006), which are pain-detecting nerve fibres distributed throughout the skin, muscles and subcutaneous tissue (Godfrey 2005). Nociceptors respond to phenomena including temperature changes, mechanical changes (such as pressure or stretching) and chemical changes (such as those occurring when, as a result of tissue damage and inflammation, chemicals are released to aid healing and stimulate a pain response as a way of the bodyprotecting itself from further damage) (Chang et al 2006). Somatic pain is often described as a sharp pain of sudden onset that is easy to locate (Chang et al 2006).

  • Visceral pain works along similar pathways to somatic pain but is located in the internal organs. It often results from compression or stretching and is often described as a dull sensation, aching or cramping (Urch and Suzuki 2008).

  • Neuropathic pain is triggered by damage to the nerves or to the somatosensory system (Merskey and Bogduk 1994). It is often described as burning, numbness or like pins and needles or electric shocks (Chang et al 2006).

In addition to these various types of pain there is a pain type that is unique to cancer called breakthrough pain. The onset, duration and severity of breakthrough pain are unpredictable, and breakthrough pain can occur despite pain having been adequately controlled in the past (Lister et al 2018). Breakthrough pain is generally considered to be idiopathic (with no identifiable cause) but it can be linked to certain activities such as movement (Davies et al 2009). There is a significant psychological and emotional component in breakthrough pain. The person may have experienced pain from a certain activity and therefore associate that activity with pain, expecting it to reoccur if they resume the activity.

Cancer-related pain can have many physiological triggers, some of which are shown in Table 1.

Table 1.

Physiological triggers of cancer-related pain

TypePotential triggers
Acute pain
  • Caused by diagnostic interventions

  • Tumour-related

  • Treatment-related

  • Caused by infection

  • Acute surgical pain

Chronic pain
  • Tumour-related

  • Treatment-related

  • Caused by bone metastases

  • Persistent surgical pain

Neuropathic pain
  • Caused by infection

  • Tumour-related

  • Persistent surgical pain

  • Chemotherapy-induced

  • Radiation-induced

Breakthrough pain
  • Idiopathic

  • Movement-related

  • Caused by dressing changes

(Adapted from Lister et al 2018)

TIME OUT 3

One of your female patients, who is aged 55 years, has recently undergone chemotherapy and surgery for breast cancer. She reports pins and needles in her hands and feet, but also a burning pain across her mastectomy scar that has been ongoing for the past six months. How would you conduct a holistic assessment of her pain?

Holistic pain assessment

The various pain types do not occur in isolation. An individual may experience several pain types at the same time or varying combinations of pain types at different times. A study by Schumacher et al (2021) followed a group of people undergoing outpatient cancer treatments and noted that over a ten-week period their pain states varied significantly, with participants reporting daily changes in the site, severity and duration of pain. A comprehensive and individualised pain assessment is essential to identify all the types of pain experienced by the patient. It also enables the nurse to identify the potential triggers of any breakthrough pain.

While it is important to understand the physiology behind pain transmission, it is equally important to remember that there does not have to be a physiological trigger for someone to experience pain (Mischkowski et al 2018). Syrjala et al (2014) examined the evidence for psychological factors that affect pain experienced by patients with cancer from diagnosis through to treatment and long-term survivorship or end of life. The researchers found convincing evidence that emotional distress, depression, anxiety, uncertainty and hopelessness can all heighten the pain experience and increase pain severity.

It is essential to adopt a holistic view and explore all aspects of the pain experience, since the physical aspect may have only a small role. If an assessment does not identify all of the elements of a patient’s pain experience it could result in undertreatment, suboptimal pain control and unnecessary pain and distress.

Potential adverse effects of poorly controlled pain include decreased mobility, increased risk of pressure ulcer development, reduced immunity, impaired concentration and altered sleep patterns (King and Fraser 2013). Conversely, a holistic pain assessment will lay the foundations of a management plan that addresses the multidimensional nature of pain.

Pain assessment should be tailored to the individual as well as being multidimensional and dynamic – dynamic in the sense that pain should be assessed in various situations, such as on movement and at rest. Before starting the assessment, the nurse should ensure that the environment is suitable. This involves maintaining the patient’s dignity and privacy and reducing the likelihood of interruptions so that the person feels cared for and able to share their experience (Kieft et al 2014). Optimal communication skills are essential to support a holistic pain assessment and ensure that the patient is at the centre of this assessment (Kourkouta and Papathanasiou 2014). Applying the principles of active listening can assist the nurse in establishing not only the content of what is being said but also the intent and feeling behind it (Jahromi et al 2016).

A holistic pain assessment will lead to holistic pain management, whereby the patient may receive not only analgesics but also non-pharmacological strategies for managing the physical and non-physical aspects of their pain. This support may be provided by other members of the multidisciplinary team such as chaplains, psychologists, counsellors, palliative care specialists, pain specialists, physiotherapists, occupational therapists and social workers.

TIME OUT 4

One of your male patients, who is 65 years old, has been admitted to the ward with an exacerbation of his pain. He has a history of metastatic prostate cancer with widespread bony involvement. How would you approach a pain assessment? What tools would you use? How would you ensure the assessment is holistic?

Pain assessment tools

Various tools can be used to structure an assessment of cancer-related pain, including unidimensional pain tools, multidimensional pain tools, aides-memoires and functional pain tools. Nurses should choose a tool that is fit for purpose by asking themselves the following questions:

  • Is this tool suitable for this setting?

  • Is the person experiencing pain able to understand and complete the questions in this tool?

  • Do I have the appropriate knowledge and skills to use this tool?

Unidimensional pain tools

Unidimensional tools are still the most commonly used pain assessment tools in cancer settings because they enable the clinician to quickly assess pain intensity (Lister et al 2018). They are easy to use and require minimal training (Faculty of Pain Medicine 2019) and the variety of designs means they can be suitable for people who have communication difficulties or where there may be a language barrier (Kettyle 2015). Unidimensional tools provide a quick means of assessing pain at the bedside but they should be used as part of a more holistic approach, since they do not enable healthcare professionals to explore patients’ total pain experience (Ford 2019).

Unidimensional pain assessment tools include numerical rating scales, visual analogue scales and verbal rating scales. The person will be prompted to rate their pain intensity, for example on a numerical scale from zero to ten, on a visual analogue scale using a colour scheme from green to red, or with verbal descriptors such as ‘no pain’, ‘mild pain’, ‘moderate pain’, ‘severe pain’ and so on (Faculty of Pain Medicine 2019). Figure 1 illustrates these different ways of rating pain – that is, numerical rating, visual rating and verbal descriptors.

Figure 1.

Three ways of rating pain on a unidimensional pain assessment tool: numerical rating, visual rating and verbal descriptors

cnp.2021.e1802_0001.jpg

Multidimensional pain tools

Compared with unidimensional pain tools, multidimensional pain tools provide more insight into the individual’s pain experience and can be used for a more comprehensive assessment of pain, including its severity and its effects on function, mood and daily activities. Two examples are the Brief Pain Inventory (BPI) (Cleeland 2009) and the short-form McGill Pain Questionnaire (SF-MPQ) (Melzack 1987).

The BPI is one of the multidimensional pain tools most commonly used in cancer settings. It was designed to measure not only the severity of cancer-related pain but also its location and its effects on factors such as mood, sleep, mobility and quality of life (Cleeland 2009). The BPI has been shown to have high reliability and validity for assessing both cancer-related and non-cancer-related pain (Furler 2013). There is strong evidence that the BPI gives structure to the assessment process and that it is an effective guide in decision-making regarding the use of analgesics (Andersson et al 2020).

The SF-MPQ enables the person to pinpoint the location of their pain on a body chart, rate it using 15 verbal descriptors and give an overall pain score using a verbal rating scale (Melzack 1987). The descriptors include terms such as ‘mild’, ‘moderate’ and ‘severe’, as well as ‘throbbing’, ‘sharp’ and ‘cramping’. The SF-MPQ has been widely used since the late 1970s and has been shown to have high reliability and validity to assess cancer-related pain, which it was originally designed for (Ngamkham et al 2012).

Aides-memoires

Aides-memoires such as SOCRATES (Box 1) and MOPQRSTU (Box 2) prompt healthcare professionals to ask certain questions about pain, thereby giving structure to the assessment. However, with SOCRATES there may be a temptation to focus solely on the physical aspect of pain (Swann 2021). In that sense, MOPQRSTU may be more appropriate than SOCRATES since its questions about ‘meaning’ and ‘understanding’ provide an opportunity to explore other aspects of the pain experience.

Box 1.

SOCRATES

S: site – what is (are) the location(s) of pain?

O: onset – when pain did start?

C: character – can you describe the pain in your own words?

R: radiation – does the pain radiate anywhere else?

A: associated symptoms – are there any other symptoms associated with the pain?

T: time – is there a specific time at which the pain occurs?

E: exacerbating/relieving – what makes the pain worse and what makes it better?

S: severity – please score your pain using a pain assessment tool (the tool used for this will depend on the setting)

Box 2.

MOPQRSTU

M: meaning – what does the pain mean to you?

O: onset – when did the pain start?

P: provocation or palliation – what makes the pain worse or better?

Q: quality – can you describe the pain in your own words?

R: radiation or region – where is the pain and does it go anywhere else?

S: severity – please give a score for your pain using a pain assessment tool (the tool used for this will depend on the setting)

T: time – when does the pain come on?

U: understanding – what do you understand about your pain and its management?

Functional pain assessment tools

There has recently been a shift in how healthcare professionals think about the assessment of pain, especially acute and chronic non-cancer pain, as well as a move away from unidimensional and multidimensional tools towards functional tools (Halm et al 2019). Functional pain assessment tools focus on the effects of pain on functions such as movement, breathing and physical activity (Halm et al 2019). One example is the Functional Activity Scale, which uses descriptors such as ‘no limitations’, ‘mild limitations’ and ‘significant limitations’ (Levy et al 2018). The use of functional pain assessment tools is now recommended for assessing post-operative pain (Faculty of Pain Medicine 2021, Levy et al 2021). However, their use for assessing non-post-operative pain, such as persistent pain and other types of cancer-related pain, has yet to be researched (Halm et al 2019).

TIME OUT 5

What barriers have you encountered in your practice when assessing cancer-related pain? How would you reassure a patient who is reluctant to disclose the severity of their pain? In patients who report severe pain, have you ever noticed a tendency, in yourself or your colleagues, to minimise their pain?

Important considerations

Limitations of pain assessment tools

The use of pain assessment tools should neither replace nursing care and insight nor detract from communication with the person being assessed. The tools described above do not consider all the factors that may be involved in a person’s pain experience. For example, they do not consider the person’s medical history, previous pain experiences and previous use of analgesia, the care environment, potential co-morbidities and potential communication difficulties, nor the cultural, spiritual and social factors that may influence their pain experience (Gregory 2021). Similarly, they do not consider the person’s coping mechanisms and resources, social support networks, pre-existing mental health conditions such as depression or anxiety, and their stage in the disease trajectory. Also, they do not acknowledge the importance of using optimal communication skills when exploring the pain experience (Schug et al 2015). These tools are aids and should only be used to give structure to holistic pain assessments.

Patient groups with specific needs

There are patients for whom the tools described above are unsuitable. In people with dementia or cognitive impairment, it is often more appropriate to use observational (behavioural) pain assessment tools (Gregory 2021). UK guidelines on the assessment of pain in older people (Schofield 2018) recommend to use, in older people with dementia or cognitive impairment, the Pain in Advanced Dementia (PAINAD) scale (Warden et al 2003), the Abbey Pain Scale (Abbey et al 2004) or the Doloplus-2 tool (Hølen et al 2007).

In people with learning disabilities, pain assessment often relies on careful observation and interpretation of the person’s behaviour, on clinical judgement and on the clinician’s knowledge of the person (Davies and Evans 2001). Again, in this patient group, observational tools such as the Abbey Pain Scale (Abbey et al 2004) can be useful. In younger children, another set of tools such as the Wong-Baker FACES Pain Rating Scale (Wong and Baker 1988) and the Face, Legs, Activity, Cry, Consolability (FLACC) observational scale (Merkel et al 1997) would be used. However, it must be noted that none of these tools are specific to cancer-related pain.

Barriers to holistic pain assessments

There are several potential barriers to holistic pain assessments, which can be divided into patient-related barriers, healthcare professional-related barriers and organisational barriers. Part of the nurses’ role is to be aware of these barriers and attempt to overcome them to ensure that patients are effectively assessed and consequently that their pain is appropriately managed.

Patient-related barriers can be encountered regarding the use of analgesia, for example when patients are reluctant to report pain or disclose the severity of their pain because they fear adverse effects of analgesics such as nausea, vomiting, constipation and drowsiness (Sun et al 2008). Some patients may be reluctant to report pain because they are concerned that taking opioids for pain relief will cause addiction (Page and Blanchard 2019). Patients’ willingness to report pain and to take analgesics is influenced by social and cultural factors, including the views of their family and carers (Al-Masri et al 2020). The nurse’s role includes being able to dispel misconceptions and provide reassurance about analgesia.

Two major healthcare professional-related barriers to holistic pain assessments are a lack of knowledge and a failure to credit the patient’s experience of pain (Galligan and Wilson 2020). There is a growing body of evidence suggesting that nurses tend to undervalue patients’ reports of pain (McCaffery and Ferrell 1997, Galligan and Wilson 2020). Most of this evidence comes from research in non-cancer settings, but a systematic review into nurses’ knowledge of cancer-related pain found a similar lack of knowledge – in particular about the assessment of cancer-related pain – and a similar tendency to disbelieve patients’ reports of pain (Bouya et al 2019).

Organisational barriers to holistic pain assessments in cancer settings include a lack of time and resources, heavy workloads and a workplace culture that does not acknowledge the importance of holistic pain assessments, as well as a lack of access to pain assessment tools and to training and support from specialist pain teams (Bell and Duffy 2009).

Conclusion

Cancer-related pain is complex, multifactorial and multidimensional. Adequate pain management relies on a holistic pain assessment that considers not only the patient’s physical pain but all aspects of their pain experience. Nurses working in cancer settings have a responsibility to reduce the symptom burden of people in their care and a crucial role in conducting holistic pain assessments that will ensure patients’ pain is adequately managed.

TIME OUT 6

Consider how your knowledge of the holistic assessment of cancer-related pain relates to the Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018) or, for non-UK readers, the requirements of your regulatory body

TIME OUT 7

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account. See: rcni.com/reflective-account

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