Dor total de pessoas com câncer de pulmão avançado - estudo com método misto / Total pain in people with advanced lung cancer - mixed method study

Introdução: São múltiplas as causas de dor de pessoas com câncer, relacionadas tanto ao adoecimento quanto ao tratamento. De acordo com o conceito de Dor Total preconizado por Cicely Saunders, além da dimensão física da dor, há componentes emocionais, sociais e espirituais que influenciam na gênese da dor e do sofrimento, nos modos de enfrentamento ao longo do tratamento e diante da morte. A identificação da Dor Total permite o oferecimento de melhor assistência e promoção de bem-estar e qualidade de vida no processo de morte e morrer. Objetivos: Investigar o conceito multidimensional da Dor Total, sua complexidade na sua avaliação em pessoas com câncer de pulmão avançado e analisar, do ponto de vista multidimensional, como os participantes do estudo compreendem seu processo doloroso, compreendido como Dor Total. Método: Estudo de método misto, sequencial explanatório, realizado com pessoas diagnosticadas com câncer de pulmão avançado. Foi realizado em duas etapas: na primeira, quantitativa, com 81 pessoas, foram descritas as características sociodemográficas e clínicas dos participantes e foram aplicados instrumentos de avaliação multidimensional de dor e sintomas. Na segunda fase, com metodologia qualitativa, foi explorada a perspectiva dos participantes sobre a experiência da dor total, por meio de entrevistas semiestruturadas com 8 participantes previamente selecionados. Para análise dos dados quantitativos, foi realizada análise descritiva simples e utilizado a classe de modelos aditivos generalizados GAMLSS. Para os dados qualitativos, foi utilizado o método de análise temática reflexiva. Resultados: Na etapa quantitativa, houve a prevalência de participantes do sexo masculino (55,6%) e a associação com a variável sexo mostrou um aumento relativo de 49,22% no escore médio de dor para participantes do sexo feminino em relação aos do sexo masculino. Em relação à escolaridade, houve um aumento relativo de 74,53% no nível médio de dor entre os participantes com ensino fundamental. Pacientes de baixa renda apresentaram aumento relativo de 9,99% na pontuação média de sintomas e dor, tristeza e ansiedade, em relação aos participantes com maior escolaridade. Na etapa qualitativa houve prevalência de mulheres (n=7) e foram analisadas e contextualizadas as percepções sobre o diagnóstico, tratamento e interferência da dor na vida dos participantes. Os dados foram organizados em três categorias temáticas, com seus respectivos subtemas: Unidade de sentido 1, referente ao modo como os participantes compreendem e vivenciam o diagnóstico e tratamento; Unidade de sentido 2- referente as dimensões da dor total; Unidade de sentido 3- referente as vivências dos participantes em relação à finitude da vida. Os resultados indicaram que problemas relacionados à dor influenciaram no cotidiano, acarretaram preocupações e afetaram a qualidade de vida dos participantes. Níveis mais elevados de ansiedade e depressão foram observados naqueles que tinham dores e preocupações sociais e emocionais. Religiosidade e espiritualidade apareceram nas entrevistas como recursos no enfrentamento da Dor Total em sua forma multifacetada, de acordo com suas dimensões emocionais, sociais e espirituais/existenciais. Por fim, a análise das duas etapas ocorreu por meio da narração, transformação e exibição conjunta dos dados através de joint displays para cada participante, retratando as citações relacionadas ao marco teórico referencial da dor total e a interface com os escores quantitativos dos instrumentos aplicados. Conclusão: A integração dos dados permitiu inferir que os sentidos das falas dos participantes da etapa qualitativa, deu suporte e conferiu validade aos resultados da etapa quantitativa. A abordagem conjugada ou integrada, de acordo com o método misto, permitiu compreender a dor em sua multidimensionalidade e complexidade, o pode favorecer uma abordagem do cuidado integral. A identificação e avaliação da Dor Total em suas múltiplas dimensões, em cada fase do tratamento, permite melhorar a assistência oncológica, principalmente em cuidados paliativos

Introduction: There are multiple causes of pain in people with cancer, related to both illness and treatment. According to the concept of Total Pain advocated by Cicely Saunders, in addition to the physical dimension of pain, there are emotional, social and spiritual components that influence the genesis of pain and suffering, in the ways of coping during treatment and in the face of death. The identification of Total Pain allows the provision of better assistance and promotion of well-being and quality of life in the process of death and dying. Objectives: To investigate the multidimensional concept of Total Pain, its complexity in its assessment in people with advanced lung cancer and to analyze, from a multidimensional point of view, how the study participants understand their painful process, understood as Total Pain. Method: A mixed-method, sequential, explanatory study conducted with people diagnosed with advanced lung cancer. It was carried out in two stages: in the first, quantitative, with 81 people, the sociodemographic and clinical characteristics of the participants were described and instruments for the multidimensional assessment of pain and symptoms were applied. In the second phase, with a qualitative methodology, the participants' perspective on the experience of total pain was explored through semi-structured interviews with 8 previously selected participants. For the analysis of quantitative data, a simple descriptive analysis was performed and the GAMLSS generalized additive model class was used. For qualitative data, the reflective thematic analysis method was used. Results: In the quantitative stage, there was a prevalence of male participants (55.6%) and the association with the gender variable showed a relative increase of 49.22% in the mean pain score for female participants in relation to to the males. Regarding education, there was a relative increase of 74.53% in the average level of pain among participants with elementary education. Low-income patients showed a relative increase of 9.99% in the average score of symptoms and pain, sadness and anxiety, in relation to participants with higher education. In the qualitative stage, there was a prevalence of women (n=7) and perceptions about the diagnosis, treatment and interference of pain in the participants' lives were analyzed and contextualized. Data were organized into three thematic categories, with their respective subthemes: Unit of meaning 1, referring to the way participants understand and experience the diagnosis and treatment; Unit of meaning 2- referring to the dimensions of total pain; Unit of meaning 3- referring to the participants' experiences in relation to the finitude of life. The results indicated that pain-related problems influenced daily life, caused concerns and affected the participants' quality of life. Higher levels of anxiety and depression were seen in those who had social and emotional pain and concerns. Religiosity and spirituality appeared in the interviews as resources for coping with Total Pain in its multifaceted form, according to its emotional, social and spiritual/existential dimensions. Finally, the analysis of the two stages took place through the narration, transformation and joint display of data through joint displays for each participant, portraying the citations related to the theoretical framework of total pain and the interface with the quantitative scores of the applied instruments. Conclusion: The integration of data allowed us to infer that the meanings of the speeches of the participants in the qualitative stage supported and validated the results of the quantitative stage. The combined or integrated approach, according to the mixed method, made it possible to understand pain in its multidimensionality and complexity, which can favor a comprehensive care approach. The identification and evaluation of Total Pain in its multiple dimensions, in each phase of treatment, allows improving cancer care, especially in palliative care

Importance of Extracting Intergroup Differences by Treatment Purpose and Content of Free-Response Answers That Should Be Considered when Screening for Pain by Administering the “Ease of Living Questionnaire” to Patients Undergoing Initial Radiotherapy

Background: We began conducting pain screenings using an in-house version of the “Ease of Living Questionnaire” for patients undergoing initial radiotherapy. Purpose: The purpose of this study was to classify patients undergoing radiotherapy for different medical purposes and to verify the differences in the responses between the groups identified. Methods: The “Ease of Living Questionnaire” was administered to all adult patients with cancer undergoing initial radiotherapy , and the responses were analyzed together with data concerning the patients’ background characteristics that were extracted from medical records. Results: A total of 543 responses to the questionnaire were collected, and the patients were divided into a palliative group (177), curative group (189), preoperative group (19), and postoperative group (158); statistical differences were observed with respect to patient gender, age, and target disease. Mental and physical distresses were more pronounced in the palliative group compared to the other three groups. Although psychosocial need was high with respect to the questionnaire items concerning symptoms and treatments/activities of daily living, the independent sensitivity values of the check fields were 0.29-0.65 and 0.08-0.38, respectively. Intergroup differences were observed with respect to symptoms and treatment/economic need as well as social security/occupational need. Conclusion: In order to gain an understanding of patient needs, we believe that it is necessary to take sufficient action in consideration of the content of free-response answers based on differences in background by treatment purpose.

De la subjetividad del dolor a una evaluación multidimensional de enfermería / From the subjectivity of pain to a multidimensional nursing assessment

Parte del rol de enfermería en cuidados paliativos es cuidar, identificando las necesidades de la unidad de tratamiento (el paciente y la familia). Es decir, evaluar exhaustivamente, explorando no solo aspectos físicos sino también las esferas culturales, sociales y emocionales que muchas veces interfieren en el componente físico, de tal manera que la sensación subjetiva de dolor es mayor que lo meramente biológico. Para lograr el alivio del dolor de la sra. C.V., fue de vital importancia planificar los cuidados de manera interdisciplinaria, apoyar al equipo básico de atención, crear un vínculo de empatía y escucha activa, teniendo en cuenta la barrera cultural; y ser muy claro, preciso, cercano y persistente.

Part of the role of nursery in palliative care is caring identifying the needs of the patients and their families, making a deep evaluation to explore not only the physical aspects but also the cultural, social and emotional spheres. These components, many times, interact with the physical one and make the subjective sensation of pain, more severe than the purely biological mechanism. The pain relief of miss C.V. was achieved by an interdisciplinary care, the support of the basic care team, the creation of an emphatetic bond, an active listening and the consideration of the cultural barriers.

Discussion about patients' QOL from a viewpoint of rehabilitation for advanced/terminal cancer patients: analysis of the patients' narratives during the rehabilitation sessions

<b>Background:</b> Rehabilitation and palliative care for advanced/terminal cancer patients share a same goal of enhancing patients' quality of life (QOL). <b>Aim:</b> The aim of this study was to identify the patients' narratives during the rehabilitation session, by analyzing words reflecting their ideas and hopes. <b>Method:</b> Out of forty-seven advanced/terminal patients' narratives during the rehabilitation session from April through September in 2011, the rehabilitation therapists recollected the impressive words. Then, the words were grouped into four categories of "total pain" concept by their meanings. <b>Result:</b> Out of a total of 215 words identified, 60% was grouped into physical aspect, 14% into psychological, 10% into social, 7% into spiritual and 9% into mixed aspects. <b>Discussion:</b> If rehabilitation therapists only deal with physical aspects of enhancing their QOL, 40% of patients' wishes will be ignored. <b>Conclusion:</b> Rehabilitation for advanced/terminal cancer patients might need multidimensional interventions with a concept of "total pain".

Acupuncture and moxibustion for palliative care / 全日本鍼灸学会雑誌

Cancer is the leading cause of death in Japan, which boasts one of the longest life expectancies in the world. Some types of cancer cause excruciating pain. Measures are actively being taken to establish palliative care units as specialized facilities to mitigate pain and set up palliative care teams in core hospitals for cancer care. In accordance with the guidelines of the WHO, a method using narcotic drugs as a means of pain relief has been established in Japan, but for patients at the middle to late stages of cancer, sufficient pain control cannot be ensured for many cases. Although various alternative therapies, including acupuncture, moxibustion, and haut care (hand and foot massages) are used to alleviate pain, the effectiveness of these methods is still unclear. Accordingly, we examined the actual conditions of palliative care together with evidence of acupuncture and moxibustion therapies and haut care as a means of pain relief.

Successful treatment of painful internal hemorrhoids using aluminum potassium sulfate and tannic acid (ALTA) injection therapy in a terminal-stage patient

A 75-year-old man with end-stage colon cancer began to experience increased pain and distress and significantly deteriorated quality of life (QOL) due to internal hemorrhoids. In order to maintain the patient's QOL, the hemorrhoids were successfully treated with aluminum potassium sulfate and tannic acid (ALTA) injection, which involves minimal patient burden and pain. The outcome of this case suggests that ALTA might be useful and effective for the treatment of internal hemorrhoids in terminally ill cancer patients.

Valoración de dolor total en el policlínico alivio del dolor y cuidados paliativos del complejo hospitalario San José / Valuation of total pain at pain relief and palliative care clinic at complejo hospitalario San José

La valoración del sufrimiento humano al final de la vida resulta relevante para la Psicología del Dolor y Paliativa, en la medida que permite determinar qué factores emocionales, sociales y espirituales agravan el dolor y el sufrimiento; y cuáles lo alivian, orientando de este modo la intervención. Asimismo, contar con un instrumento simple, de fácil aplicación y comprensión enriquece la comunicación y el trabajo de equipo. El estudio tuvo por objetivo valorar el sufrimiento humano a causa del dolor y la enfermedad oncológica avanzada en el Policlínico Alivio del Dolor y Cuidados Paliativos del Complejo Hospitalario San José. Se utilizó el modelo de Dolor Total, acuñado por Saunders y piedra angular del Programa Nacional Alivio del Dolor por Cáncer Avanzado y Cuidados Paliativos de nuestro país. Fueron entrevistados 211 pacientes entre enero y diciembre de 2010 en el contexto de su ingreso al Policlínico con diagnóstico de cáncer avanzado y derivados a la Unidad para el manejo de Dolor y Cuidados Paliativos. Las entrevistas realizadas por Psicología utilizaron el instrumento Valoración de Dolor Total (VDT), diseñado y ajustado a la ficha clínica de ingreso, tuvieron una duración promedio de 45 minutos y a las cuales asistieron también los cuidadores principales. El instrumento permitió el registro y análisis de variables sociodemográficas, clínicas, de apoyo psicosocial y de Dolor Total pertinentes a este estudio. Los datos fueron analizados a nivel descriptivo con el programa Stata 10.0, mediante medidas de tendencia central y de dispersión. Los resultados más importantes permiten concluir que el sufrimiento humano a causa del dolor y la enfermedad oncológica avanzada se caracteriza en este grupo de pacientes por la angustia de separación (85,1 por ciento), el cansancio (78,75 por ciento),la tristeza (71,71 por ciento) y por los sentimientos de inutilidad (63,59 por ciento).Se discuten las limitaciones y proyecciones del estudio.

For Pain and Palliative Psychology, evaluating human suffering at the end of Life is a most relevant matter as it allows determining the emotional, social and spiritual elements that intensify pain and suffering and those that relieve both, orienting specialists towards intervention. Likewise, having a simple, easy to use and understand instrument enriches team communication and work. The object of this study was to valuate human suffering caused by pain and advanced stage cancer at the Pain Relief and Palliative Care Clinic at Complejo Hospitalario San José. We used Sanuders’ Total Pain model, which is the cornerstone of the Advanced Cancer Pain Relief and Palliative Care National Program.A total of 211 advanced cancer diagnosed patients were interviewed from January through December 2010 when first admitted to the Clinic and were transferred to the Pain Management and Palliative Care Unit. The interviews of the Psychology department used a Total Pain Valuation (TPV) tool that was designed and adjusted to the admittance clinical chart. Interviews lasted 45 minutes in average and were witnessed by main caretakers. This instrument allowed for recording and analyzing sociodemographic, clinical, psychosocial, and Total Pain variables. Data was analyzed at descriptive level using Stata 10.0 program with central and dispersion trend measurements. Based on the most relevant results we may conclude that for this group of patients, pain and advanced stage cancer caused human suffering mostly expressed as separation anxiety feelings (85.1 per cent), tiredness (78.75 per cent), sadness (71.71 per cent), and feelings of uselessness (63.59 per cent).There have been discussions about the limitations and projections of this study and the TPV has been proposed as a useful and efficient tool to valuate and accompany relief of Total Pain caused by advanced stage cancer.

A Trial of Moxibustion with Warming Acupuncture Based on Evidence of Oriental Medicine in a Palliative Care Unit / 全日本鍼灸学会雑誌

[Introduction] We consider that the missions of acupuncture medicine are : 1) cooperation with other departments, 2) treatments of subclinical diseases, and 3) palliative care, and we have been actively persuing all of the above. We conducted an acupuncture trial in the Palliative Care Unit (PCU) in Kawasaki General Care Center.<BR>[Subjects] We studied 74 cancer patients who were hospitalized in PCU between June 1999 and March 2001. There were 36 male patients and 38 female patients, and their average age was 63.9 ± 11.8 years old.<BR>[Methods] We treated the patients using appliance moxibustion with warming acupuncture (CS-2000). Nurses in charge treated the patients according to an association of points chosen with differentiation of syndromes.<BR>[Results] Of 74 cases, 51.4% received effective palliation. Among 58 cases who complained of pains, 55.2% received effective palliation. Treatments were most effective for patients who complained of “dull persistent pain”, “severe dull pain”, “heavy throbbing pain”, “bulging pain” and “penetrating pain” in order of effectiveness.<BR>[Discussion] Appliance Moxibustion with warming acupuncture is expected to relieve 1) pain not controllable with painkiller, 2) cancer pain (pain originating from cancer) or pain from combatting the disease, and 3) pain unrelated to cancer. Such pain is considered to be dull pain (indescribable pain).<BR>This is not based on data, but we were also able to play the following roles. One is spiritual care resulting from sharing common time and space with patients, and the other is providing nurses and doctors with meaningful information obtained from close communication with patients. (This is a part in teamwork medicine.) : <BR>[Conclusion] By participating in palliative care, we found out that we were able to contribute to caring to remove physical pain (and other symptoms) which is part of holistic pain. Especially, we found out that our care is meaningfully effective in removing pain.