Thursday, April 16, 2009

Pall-Pourri: Pain Acceptance; Quality

has a paper about 'acceptance of pain' in cancer patients. They define 'pain acceptance' as: "the acknowledgement of pain without directing all efforts toward controlling it and refocusing efforts toward living a fulfilling life in spite of chronic pain."

The study involves ~130 patients at a single Canadian cancer center (mean age 55; ~60% saying that their worst pain during the day was moderate-to-severe) who answered a whole bunch of questions about pain, quality of life, etc.

They were also administered a pain acceptance scale which looked at activity engagement and pain willingness: "Activity Engagement measures the degree to which people with pain participate in life activities despite pain, and Pain Willingness measures willingness to experience pain without controlling it."

A shockingly-difficult-to-interpret (at least for me, and at least in part related to an exuberance of acronyms related to all the different scales used) regression analysis was then done to see what predicted more or less pain acceptance. So much so that I will just let them summarize their findings in their own words:

This is the first study to show that greater acceptance of cancer pain is related to better psychological wellbeing. ...This study is also the first to show a relationship between parental status and acceptance of cancer pain. Specifically, parents with children at home reported lower willingness to experience pain than those without children. Acceptance of cancer pain was unrelated to pain duration, severity, and qualities, subjective social and relational factors, and age and gender. This study adds to our growing understanding of biopsychosocial factors in cancer pain and its impact and suggests that acceptance may play a role in patients’ adaptation to living with ongoing disease-related pain. We found that Activity Engagement was related to lower severity of depressive symptoms, and Pain Willingness was related to less pain catastrophizing.

The finding that parents with kids at home had less 'willingness' was pretty solid and seems worth exploring. Regarding the other findings, I found myself asking why one couldn't conclude simply that people who were doing better (coping-wise) were doing better and they were simply measuring the same things (depressive symptoms as an index of activity engagement, catastrophizing as an index of willingness), as opposed to there being something unique/helpful about the idea of pain acceptance: particularly that pain acceptance didn't seem to have much to do with pain itself or function. For me, this is a good example of research which is tantalizing close to questions I grapple with as a clinician (What does it mean to be someone who copes well with their pain? Is that something 'real' and distinct from overall approaches to coping, psychiatric symptoms, or psychopathology? Is this a phenomenon which is amenable to clinical intervention separate from supportive counseling and good symptom control? etc.) but then disorients rather than clarifies....

JCO has a paper describing the development and initial validation (in a geographically restricted sample) of a tool to measure patient satisfaction with care in advanced cancer patients. The tool was developed to measure satisfaction/identify needs based on the following assumptions of what quality care means for advanced cancer patients:
[H]ealth care providers sensitively communicate with patients about their prognosis and promote shared decision making to the extent that patients want to be involved; patients are educated about what they can expect during treatment, what to monitor, and who they can turn to for help; patients are provided with their desired emotional support and symptom amelioration; patients are treated with respect; cancer treatment sessions support comfort, ensure privacy, and promote healing; and care is coordinated among health care providers.
As you can see there is a particular focus on communication - the tool asks numerous questions about how communication went - and notably the area which patients most consistently identified need for improvement (over half) was regarding communication (as opposed to, say, how things went in the chemo-room, etc.). The validation data (internal consistency, etc.) looked promising.

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