At Hospice of Southern Illinois, one of our primary goals is the management of pain in our patients. According to the International Association for the Study of Pain, pain is defined as “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” While this formal definition may sound complicated, we all have a general understanding of the concept and have experienced some level of pain in our lifetime. Pain is a very subjective symptom, and pain thresholds vary greatly between individuals. Thus, we cannot apply our own personal experiences with and opinions regarding pain to others.
In an ideal situation, health care providers and familial caregivers could simply ask a patient if they are having pain. However, some patients lack the ability to verbalize altogether or lack the cognitive capacity to reply to the question. This is commonly encountered in patients with an underlying neurological condition, such as dementia, Parkinson’s disease, stroke, or developmental delays. So, what do we do?
First and foremost, we should still ask the question, “Are you experiencing any pain?”
Oftentimes, we may be surprised by an individual’s ability to respond verbally. Many neurological conditions wax and wane. Therefore, we must always give our patients and loved ones the respect of conversation. If a response is not evoked, or if the response is not intelligible, we can also garner information from those caring for the patient daily. They know the patient’s mannerisms and behaviors best and can often point out clues or prior patterns that could indicate pain. Lastly, observational scales are vital to understanding and controlling pain. The American Geriatrics Society suggests observation of six behavioral areas when performing a pain assessment:
- Facial expressions
- Verbalizations and vocalizations
- Body movement
- Changes in interpersonal interactions
- Changes in activity patterns and routines
- Mental status changes
At Hospice of Southern Illinois, we employ a tool called the FLACC Pain Scale. Patients are assessed by a healthcare provider, and this tool can easily be taught to caregivers. A copy of the tool is included below.
|Face||No particular expression or smile||Occasional grimace or frown, withdrawn, disinterested||Frequent to constant quivering chin, clenched jaw|
|Legs||Normal position or relaxed||Uneasy, restless, tense||Kicking or legs drawn up|
|Activity||Lying quietly, normal position, moves easily||Squirming, shifting, back and forth, tense||Arched, rigid or jerking|
|Cry||No cry (awake or asleep)||Moans or whimpers; occasional complaint||Crying steadily, screams, sobs, frequent complaints|
|Consolability||Content, relaxed||Reassured by touching, hugging or being talked to, distractible||Difficult to console or comfort|
Patients who are awake:
- Observe for at least 2-5 minutes.
- Observe legs and body uncovered.
- Reposition patient or observe activity; assess body for tenseness and tone.
- Initiate consoling interventions if needed.
Patients who are asleep:
- Observe for at least 5 minutes or longer.
- Observe body and legs uncovered.
- If possible, reposition the patient.
- Touch the body and assess for tenseness and tone.
Each category is scored on the 0-2 scale which results in a total score of 0-10.
Assessment of Behavioral Score:
0 = Relaxed and comfortable
1-3 = Mild discomfort
4-6 = Moderate pain
7-10 = Severe discomfort/pain
In conclusion, after attempting to converse with your patient, interviewing caregivers, and employing an observational scale, you should be able to determine if pain is present. Then, the interdisciplinary team can begin developing a plan to manage the symptom. Moreover, always ensure that all basic comfort needs are met and begin searching for possible causes of the symptom. For a review of common medications used in hospice care to treat pain, please view our app. If you or your loved one is experiencing symptoms due to a terminal illness, please contact our team for an evaluation.