Preliminary survey of the attitudes of Brazilian scientists towards pain management and assessment in animals used in science.

OBJECTIVE: To investigate the current scenario in Brazil regarding pain assessment and control in experimental animals. STUDY DESIGN: Prospective survey. METHODS: A confidential questionnaire was available online and sent by e-mail to Brazilian scientists working with animal experimentation in Brazil. Data collection was conducted from October 2016 to October 2017. The exclusion criteria included blank questionnaires or with <80% completed responses, researchers not performing experiments involving animals and foreign scientists. RESULTS: A total of 96 questionnaires from 104 respondents were analyzed. The Fisher's exact test showed a disparity between the proportions of scientists who recognized the importance of analgesia and their application of analgesic techniques in painful procedures (p < 0.0003), and also for the researchers who assumed that experiments inflicted pain and their classification of the degree of invasiveness (p < 0.0001), indicating their insufficient knowledge of these topics. Overall, 77% of institutions did not offer specific training to assess pain in experimental animals, and 24% of respondents had no training to work with animal experimentation. In total, 62% of the studies inflicted pain, 48% of respondents used pain scales, and the drugs administered most frequently for pain management were morphine (44%), meloxicam (43%) and tramadol (37%); 15% of respondents did not include analgesics even though their studies inflicted pain. Commonly used animals were rats (33%), mice (29%) and rabbits (8%). CONCLUSIONS AND CLINICAL RELEVANCE: The results of this preliminary survey indicated that in Brazil there is a gap in the knowledge and training on pain assessment and management of experimental animals. Therefore, there is a necessity for an educational program to prepare and train scientists to assess and manage pain in laboratory or experimental animals. Further studies using a psychometrically validated survey instrument are warranted.

El dolor y la enfermedad como transformación. Un análisis desde la fenomenología y la narración / Pain and disease as a transformation. Ananalysis from phenomenology and narration

El dolor y la enfermedad son fenómenos vivenciales que resultan difíciles de comprender por diversos motivos: porque permanecen dentro los límites de la subjetividad; porque el doliente se siente preso de su dolor y percibe una ruptura radical dentro sí mismo; y porque se siente solo frente a él, incapaz de comunicarse. Todo esto hace que el sufrir sea un elemento transformador en la vida. En la medicina científica moderna, el enfoque preponderante hacia el tratamiento del dolor es el fisiológico, quedando relegadas otras dimensiones intrínsecas de la persona, como la psíquica, la espiritual, la relacional o la identitaria. Las consecuencias éticas de esta reducción son una cosificación de la persona y una merma de su dignidad. Con el objetivo de contribuir a una visión más amplia del dolor y a una mejor atención al paciente, el presente artículo expone el resultado de cruzar dos discursos sobre el dolor: el relato que realiza un escritor sobre su enfermedad y los análisis fenomenológicos de Toombs y Carel. Se presentan cuatro categorías eidéticas del dolor: el carácter de otredad, la metamorfosis y la crisis de identidad, la instalación en el tiempo presente y la soledad y pérdida de relaciones. Se concluye proponiendo una definición de enfermedad que incluya estos elementos y se apuntan las vías de la narración y de la expresión como complementos al tratamiento farmacológico en orden a la curación y al cuidado

Pain and disease are life experiences difficult to be understood due to different reasons: they both fall under subjective limits; the sufferer feels imprisoned in his own pain and perceives a radical rupture within himself, and the sufferer feels he is alone to himself, unable to communicate. All these reasons explain that suffering is a transforming element in life. In modern scientific medicine, regarding the treatment of pain, the physiological approach is the preponderant one. Therefore, other intrinsic dimensions of the person, like the psychic, the spiritual, the relational or the identity are not viewed as detrimental. This is an oversimplification of the reality which implies that the person is treated as an object. This can be interpreted as an attempt to the dignity of the person. This paper is aimed to contribute to a broader understanding of pain and a better patient care. The author lays out the results of combining two different approaches of pain: the story that a writer invents about his own pain and the phenomenological analysis of Toombs and Carel. Four eidetic categories of pain are presented in this paper: the otherness, the metamorphosis and the identity crisis, the placement in the present time and the loneliness and loss of relations. As a conclusion, this paper gives a definition of disease that includes the previous four elements. Moreover, it proposes the ways of narration and expression as a complement to the pharmacological treatment in order to healing and care

The development of the DISCO-RC for measuring children's discomfort during research procedures.

BACKGROUND: There is a need for data on children's self-reported discomfort in clinical research, helping ethics committees to make their evaluation of discomfort described in study protocols evidence-based. Since there is no appropriate instrument to measure children's discomfort during medical research procedures, we aimed to develop a generic, short and child-friendly instrument: the DISCO-RC questionnaire (DISCOmfort in Research with Children). METHODS: This article describes the six steps of the development of the DISCO-RC. First, we updated a literature search on children's self-reported discomfort in clinical research to get insight in what words are used to measure discomfort (step 1). Subsequently, we interviewed 46 children (6-18 years) participating in research to get insight into important forms of discomfort for children (step 2), and asked them about their preferred response option for measuring discomfort (step 3). Next, we consulted nine paediatric research professionals from various backgrounds for input on the content and feasibility of the DISCO-RC (step 4). Based on the previous steps, we developed a draft version of the DISCO-RC, which we discussed with the professionals. The DISCO-RC was then pretested in 25 children to ensure face-validity from the child's perspective and feasibility (step 5). Finally, validity, reliability and internal consistency were tested (step 6). RESULTS: The search-update revealed several words used for measuring discomfort in research (e.g. 'worries', 'unpleasantness'). The interviews gave insight into important forms of discomfort for children in research (e.g. 'pain', 'boredom'). Children preferred a 5-point Likert scale as response option for the DISCO-RC. The experts recommended a short, digital instrument involving different forms of discomfort, and measuring discomfort of individual research procedures. Pretesting of the DISCO-RC resulted in a few layout changes, and feedback from the children confirmed the feasibility of the DISCO-RC. Convergent validity and test-retest reliability were acceptable. Internal consistency based on item-rest correlations and Cronbach's alpha were low, as expected. CONCLUSIONS: The DISCO-RC is a generic, practical and psychometrically sound instrument for measuring children's discomfort during research procedures. It contributes to make the evaluation of discomfort in paediatric research evidence-based. Therefore, we recommend including the DISCO-RC as standard component of paediatric research studies.

The ethics of postoperative pain management: Mapping nurses' views.

AIM: We explored the positions of nurses working in hospitals regarding the acceptability of refusing to give a repeat dose of painkiller to a postoperative patient who requested it. These positions were compared with that of lay people, physicians, and other health professionals. DESIGN AND METHODS: Factorial design was used to assess the impact of 6 situational factors: the patient's age, the current level of pain as assessed by the nurse, the number of requests, the level of risk associated with the administration of a repeat dose, the outcome of surgery, and the giving of alternative mild analgesics. We implemented a combination of scenario technique and of cluster analysis. Data were collected from April 2013 to December 2015. PARTICIPANTS: 138 registered nurses, 32 nurse's aides, 33 physicians, 23 psychologists, and 169 lay people participated in the study. RESULTS: We found 4 qualitatively different meaningful positions. A plurality of participants (57% of nurses) considered that refusing was not acceptable, irrespective of circumstances. A substantial minority of participants (but 52% of physicians) considered that refusing was acceptable only if the level of pain was low and the risk was high. Other participants (mostly lay people) considered that refusing was always acceptable each time a risk of side effects, either serious or simply mild, was present.

Neurotechnological assessment of consciousness disorders: five ethical imperatives.

Disorders of consciousness (DOCs) cause great human suffering and material costs for society. Understanding of these disorders has advanced remarkably in recent years, but uncertainty remains with respect to the diagnostic criteria and standards of care. One of the most serious problems concerns misdiagnoses, their impact on medical decision-making, and on patients' well-being. Recent studies use neurotechnology to assess residual consciousness in DOC patients that traditional behavioral diagnostic criteria are unable to detect. The results show an urgent need to strengthen the development of new diagnostic tools and more refined diagnostic criteria. If residual consciousness may be inferred from robust and reproducible results from neurotechnological communication with DOC patients, this also raises ethical challenges. With reference to the moral notions of beneficence and fundamental rights, five ethical imperatives are here suggested in terms of diagnosis, communication, interpretation of subjective states, adaptation of living conditions, and care.

Los trastornos de conciencia (TC) provocan grandes sufrimientos humanos y costos materiales para la sociedad. La comprensión de estos trastornos ha avanzado significativamente en los últimos años, pero persiste la incertidumbre respecto a los criterios diagnósticos y estándares de atención. Uno de los problemas más serios se refiere al diagnóstico erróneo, su impacto en la toma de decisiones médicas y en el bienestar de los pacientes. Estudios recientes emplean neurotecnología para evaluar la conciencia residual en los pacientes con TC en que los criterios diagnósticos conductuales tradicionales son incapaces de detectarlos. Los resultados muestran una necesidad urgente de fortalecer el desarrollo de nuevas herramientas diagnósticas y criterios diagnósticos más refinados. Si la conciencia residual se puede inferir de resultados sólidos y reproducibles a partir de la comunicación neurotecnológica con pacientes con TC, esto también plantea desafíos éticos.En relación con las nociones morales de beneficencia y derechos fundamentales, aquí se sugieren cinco imperativos éticos en términos del diagnóstico, comunicación, interpretación de los estados subjetivos, adaptación a las condiciones de vida y atención.

Les troubles de la conscience coûtent en souffrance humaine et en matériel pour la société. Ces dernières années, la compréhension de ces troubles a beaucoup progressé, mais les critères diagnostiques et les standards de soins restent à définir. Un des problèmes les plus importants concerne les erreurs de diagnostic, leur impact sur la prise de décision médicale et sur le bien-être des patients. Des études récentes utilisent la neurotechnologie pour évaluer la conscience résiduelle chez les patients ayant des troubles de la conscience ne pouvant être détectés par les critères de diagnostic comportemental traditionnels. Les résultats montrent un besoin urgent de renforcer le développement de nouveaux outils diagnostiques et de critères diagnostiques plus affinés. Si la conscience résiduelle peut être déduite de résultats solides et reproductibles issus de la communication neurotechnologique avec les patients ayant des troubles de la conscience, cela pose toutefois des problèmes éthiques. En référence aux notions morales de bienfaisance et de droits fondamentaux, cinq impératifs éthiques sont ici proposés en termes de diagnostic, de communication, d'interprétation d'états subjectifs, d'adaptation de condition de vie et de soins.

[Pain assessment in elderly nursing home residents: methods paper for the S3-guideline development]. / Schmerzassessment bei älteren Menschen in der vollstationären Altenhilfe : Methodenpapier zur S3-Leitlinie.

In Germany, there is currently no guideline for pain assessment in elderly people. Pain management in nursing home residents is, however, legally required. For this particular group, especially for people with dementia, suitable interdisciplinary orientations for health care are lacking in Germany. The working group "Pain and Age" of the German Pain Society ("Deutschen Schmerzgesellschaft") in conjunction with the German Centre for Neurodegenerative Diseases ("Deutschen Zentrum für Neurodegenerative Erkrankungen"), Witten, has embarked on the development of interdisciplinary S3-Guideline for "Pain Assessment in Elderly People in Nursing Homes", based on the methodology suggested by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V."), the German Agency for Quality in Medicine ("Ärztliche Zentrum für Qualität in der Medizin"), and that described in the DELBI ("Deutschen Leitlinien-Bewertungsinstrument"). Delegates of the 38 scientific societies and interest groups currently participating can contribute to the contents on three different levels. The present article outlines the methods for developing the guideline.

Pain as a fact and heuristic: how pain neuroimaging illuminates moral dimensions of law.

In legal domains ranging from tort to torture, pain and its degree do important definitional work by delimiting boundaries of lawfulness and of entitlements. Yet, for all the work done by pain as a term in legal texts and practice, it has a confounding lack of external verifiability. Now, neuroimaging is rendering pain and myriad other subjective states at least partly ascertainable. This emerging ability to ascertain and quantify subjective states is prompting a "hedonic" or a "subjectivist" turn in legal scholarship, which has sparked a vigorous debate as to whether the quantification of subjective states might affect legal theory and practice. Subjectivists contend that much values-talk in law has been a necessary but poor substitute for quantitative determinations of subjective states--determinations that will be possible in the law's "experiential future." This Article argues the converse: that pain discourse in law frequently is a heuristic for values. Drawing on interviews and laboratory visits with neuroimaging researchers, this Article shows current and in-principle limitations of pain quantification through neuroimaging. It then presents case studies on torture-murder, torture, the death penalty, and abortion to show the largely heuristic role of pain discourse in law. Introducing the theory of "embodied morality," the Article describes how moral conceptions of rights and duties are informed by human physicality and constrained by the limits of empathic identification. Pain neuroimaging helps reveal this dual factual and heuristic nature of pain in the law, and thus itself points to the translational work required for neuroimaging to influence, much less transform, legal practice and doctrine.

The cold pressor task: is it an ethically acceptable pain research method in children?

OBJECTIVES: The cold pressor task (CPT) is an experimental method of inducing pain. Ethical concerns have been raised regarding the nontherapeutic induction of pain in children. The objectives of this study were to describe the ethical challenges and acceptability of the CPT from the perspective of researchers, children and parents. METHODS: Study 1:16 researchers completed a survey regarding their experiences obtaining ethical approval and use of the CPT in pediatric research. Study 2: 175 children and 194 parents answered questions about their experiences participating in studies that used the CPT. RESULTS: Full ethics board review was generally required. Adverse events were rare and transient. The majority of researchers, children, and parents reported positive experiences with the CPT. CONCLUSIONS: The CPT is judged by researchers, children, and parents to be an acceptable research method. The CPT can be used ethically in pediatric research with appropriate study safeguards.

Unresolved pain in children: a relational ethics perspective.

It is considered the right of children to have their pain managed effectively. Yet, despite extensive research findings, policy guidelines and practice standard recommendations for the optimal management of paediatric pain, clinical practices remain inadequate. Empirical evidence definitively shows that unrelieved pain in children has only harmful consequences, with no benefits. Contributing factors identified in this undermanaged pain include the significant role of nurses. Nursing attitudes and beliefs about children's pain experiences, the relationships nurses share with children who are suffering, and knowledge deficits in pain management practices are all shown to impact unresolved pain in children. In this article, a relational ethics perspective is used to explore the need for nurses to engage in authentic relationships with children who are experiencing pain, and to use evidence-based practices to manage that pain in order for this indefensible suffering of children to end.

Pain assessment: subjectivity, objectivity, and the use of neurotechnology.

The pain clinician is confronted with the formidable task of objectifying the subjective phenomenon of pain so as to determine the right treatments for both the pain syndrome and the patient in whom the pathology is expressed. However, the experience of pain - and its expression - remains enigmatic. Can currently available evaluative tools, questionnaires, and scales actually provide adequately objective information about the experiential dimensions of pain? Can, or will, current and future iterations of biotechnology - whether used singularly or in combination (with other technologies as well as observational-behavioral methods) - afford objective validation of pain? And what of the clinical, ethical, legal and social issues that arise in and from the use - and potential misuse - of these approaches? Subsequent trajectories of clinical care depend upon the findings gained through the use of these techniques and their inappropriate employment - or misinterpretation of the results they provide - can lead to misdiagnoses and incorrect treatment. This essay is the first of a two-part series that explicates how the intellectual tasks of knowing about pain and the assessment of its experience and expression in the pain patient are constituent to the moral responsibility of pain medicine. Herein, we discuss the problem of pain and its expression, and those methods, techniques, and technologies available to bridge the gap between subjective experience and objective evaluation. We address how these assessment approaches are fundamental to apprehend both pain as an objective, neurological event, and its impact upon the subjective experience, existence, and expectations of the person in pain. In this way, we argue that the right use of technology - together with inter-subjectivity, compassion, and insight - can sustain the good of pain care as both a therapeutic and moral enterprise.

Models of knowledge in the assessment of postoperative pain.

This article illustrates a process of knowledge development and the interrelationship between knowledge and practice using Carper's fundamental patterns of knowing. It explores two kinds of knowledge, theoretical knowledge and practical knowledge, using postoperative pain assessment as an illustration. By using their theoretical knowledge and their practical experience, nurses can maintain and develop their professional knowledge and competence.