- Email: [email protected]
Pain, Cancer, and Older Adults (CE)
CE Article Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page 248. On completion of this article, the reader should be able to: 1. Describe the causes of cancer pain in the elderly 2. Discuss the treatment of pain in elder patients with cancer 3. Identify the stages that patients with cancer may go through
Pain, Cancer, and Older Adults Anita C. All, RN, PhD, and LaRae I. Huycke, RN, BSN Abstract: Pain is the most common symptom associated with cancer. Despite the fact that appropriate pain management exists, cancer pain often is inadequately controlled. Sixty percent to 85% of individuals with advanced cancer have either severe or chronic pain. Issues associated with cancer pain and pain management in later life include the effect of pain on the person, friends, and family; the influence of hope; the perception that older adults are less sensitive to painful stimuli; the special problems of drug management in older adults; and the unique issues of older women affected by cancer. This article concludes with implications for nurses. Future research needs to be directed to pain management at home, the ethics of pain management, pain in the cognitively impaired person, and the specific needs of older women. (Geriatr Nurs 1999;20:241-7)
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C
ancer is a disease characterized by uncontrolled growth and the spread of abnormal cells. The American Cancer Society estimates that approximately 30% of the population will develop cancer and approximately 3 to 3.5 million Americans are living with the disease. 1,2 Sixty percent of cancer deaths occur among people age 65 or older, and cancer is the second leading cause of death in people 65 or older.3 Additionally, cancer is a leading cause of morbidity and disability in the older population.4 An estimated 90% of individuals who develop cancer could survive if their disease were detected early. In 1998 approximately 1,228,600 new cancer cases were diagnosed, and an estimated 564,800 cancer-related deaths occurred.5 In 1998 the leading cancer site for women was the breast and the prostate for men. In contrast, the cancer resulting in the most deaths for both genders was lung cancer.5 Furthermore, lung cancer is the leading cause of cancer among African Americans, Native Americans, Asian and Pacific Islander people, and Latinos. The second leading cause for all ethnic groups is colon and rectal cancer; female breast cancer is third for Native American and Latino groups.5 Invasive cancers in the United States from 1992 to 1994 affected 22% of the population of women between 60 and 70 and 37% of the population of men in the same age group. The survival rate (percentage) is reported to be higher for Caucasians than African Americans. Women primarily are affected by breast cancer. Approximately one in nine women will be diagnosed with breast cancer. Cancer in situ of the breast accounts for about 36,900 cases per year.5 Age is an additional risk factor for the development of breast cancer.6 Nearly 50% of newly diagnosed breast cancers occur Pain is the in women 65 or older.7 Given the high percentage rule rather of women affected and the increased morbidity associthan the ated with later diagnosis, special attention needs to directed to this issue. exception be Older women initially prewith more extensive and often is sent disease than their younger counterparts, and their suran everyday vival rates are much lower.8 Breast cancer in older companion. women grows slower and is differentiated, hormone responsive, and more likely to be malignant. 7 Some specific risk factors for
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breast cancer in women are advancing age, being Caucasian, being nulliparous, radiation exposure, obesity, estrogen replacement therapy, positive family history, and history of nonmalignant breast disease.3,7 Older women are less likely to undergo regular breast examinations and less likely to practice breast self-examination; their physicians, usually internists, are less likely to recommend mammography. 9 Ninety percent of women over 40 have heard of mammography, but only about half have had a mammogram.10 Because older women are seen later in the disease process, they are less likely than younger women to receive the curative benefits of treatment and consequently must deal with the issues of pain and advanced disease.
PAIN ISSUES Review of the literature suggests that social support, hope, facing one’s own mortality, and pain management are key concepts for health care professionals to understand in caring for older patients. Helme’s11 literature review suggests that the population prevalence and characteristics of pain in older people is difficult to ascertain and fraught with misconceptions. Pain, the most common symptom associated with cancer, afflicts approximately one-third of individuals with primary carcinoma. Sixty percent to 85% of the individuals with advanced cancer have either severe or chronic pain that requires some type of management.1,9,12,13 Pain is the rule rather than the exception and often is an everyday companion. Unfortunately, pain associated with cancer frequently is undertreated.14 Contrasting views exist on differences or similarities of the pain experience in young, middle-aged, or older adults. Because uncontrolled pain can cause anorexia, weight loss, weakness, nausea, pressure sores, and insomnia, the importance of treating pain cannot be ignored. 14 In addition to these myriad physiological consequences, pain can impair the lifestyle of people with cancer and serve as a constant reminder of the incurable and progressive nature of the disease.15
FAMILY, FRIENDS, AND CAREGIVERS Understanding the physiological and psychologic complexities of pain has resulted in the inclusion of friends, family members, and other significant individuals in planning cancer pain management. Palliative care of individuals with cancer or any chronic illness requires caregivers to enhance their expertise. Ferrell et al.16 reported that family perceptions critically influence pain management. Caregivers expressed extreme fears of patients becoming addicted to medications, experiencing respiratory depression, and developing drug tolerance. These fears often result in undermedication by the caregiver and feelings of helplessness in providing comfort. For example, family and friends may not understand or be unable to accept the
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severity of the illness and may pressure the patient to maintain an independence of which they are no longer capable. People who are ill seldom deal with the issue of death when they are focusing their energy on the demanding task of daily living. Fear of death exacerbates as the illness progresses and the individual perceives a loss of function. People with cancer, their family, friends, and caregivers need an opportunity to ventilate their feelings about loss and separation. Family and friends must be encouraged to maintain their own lives as they face their feelings of abandonment and anger. 17,18 Conflict and control issues within the family have been reported to increase patient distress and pain ratings.1921 Fearing the inability to cope with the symptoms and pain of an incurable illness may cause patients to have intense feelings of helplessness and hopelessness. Being actively involved in their treatment and having some control when it seems they have lost all hope of control can be reassuring.18 All,15 in her review of older women with cancer pain, reported that perhaps the best thing that professionals can offer cancer patients at this point is information. They must be allowed to become familiar with all treatment options, know the theories of stress and disease progression, be given material about healthy lifestyles that may increase their lifespan, and be given the opportunity to grieve.
HOPE AND HOPELESSNESS The central feature of hope is an expectation that something worthwhile lies ahead. Hope may affect the progression of cancer in early stages. A feeling of hope is associated with an increased sense that one can cope or be helped to cope by others. Hope also may be accompanied by actual biologic changes that enhance physical and mental well-being.18 Hope is believed to be related to many factors, including psychiatric status, endocrine function, stress and illness, and susceptibility to infection. Loss of hope is a cultural, personality, and/or biopsychosocial response that can account for such phenomena as rapid death from voodoo, “evil eye,” and belief in hexes. This phenomenon can be seen in the abrupt death of individuals after being given a fatal prognosis.22 As with depression and distress, hopelessness is experienced by individuals diagnosed with cancer. This issue speaks to the importance of early intervention to help newly diagnosed individuals deal with the stresses associated with their disease.23-24
FACING AN UNCERTAIN FUTURE The psychosocial tasks of a potentially terminal illness include maintaining a meaningful quality of life, coping with disfigurement and loss of function, confronting existential and spiritual questions, and planning
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for surviving friends and family. Individuals with cancer face the challenge of trying to function with an unknown future. Ferrell and colleagues17 reported that, with an increasing number of women surviving breast cancer, the focus of care has shifted from the effects of acute treatment to long-term effects that influence quality of life. Using content analysis, quality of life domains of psychologic and spiritual well-being were studied. Four themes of psychologic well-being were identified: concern for the future, survivorship of the affected Hope is individual, sources of psychologic distress, and emobelieved to tional responses to breast cancer. Women in this be related to study feared dying and expressed thoughts about many factors, the future by describing how they balance hope and reality. These women including discussed how their lives had been shortened by the psychiatric disease and its treatment. They also described their status, strong hopefulness that new treatments would be endocrine available in case of disease 17 recurrence. function, stress These authors 17 further identified three and illness, and themes in the domain of spiritual well-being: support of spirituality, aspects susceptibility of spirituality, and an altered life. Women in this to infection. study described uncertainty about the future as one of the most difficult aspects of breast cancer. They also discussed the alteration of their lives as a result of the disease. These changes centered around life priorities, altered life meaning, and thoughts regarding transcendence from their current life to death.
CANCER PAIN Regardless of whether they experience pain, people with cancer deal with an unknown future and worry about pain, death, and dying without pain relief. Pain often is defined in terms of being an unpleasant experience that is both sensory and emotional, and it may or may not be associated with actual or potential tissue damage.14 Cancer-related pain has been the type studied to the greatest extent in terminally ill individuals. Cancer pain is not the same as acute pain or
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chronic noncancer pain. Pain of an acute nature signals the need for specific therapy that usually is curative, making the pain ultimately reversible. The chronic pain of cancer, particularly advanced cancer, however, usually is irreversible and related to disease progression. Individuals who are insufficiently treated often are in a trajectory of pain that goes from bad to worse. They constantly are reminded of the recurrent or incurable nature of their disease. All15 described three stages of cancer pain reported in the literature. The first or early stage occurred during the diagnostic phase of the illness and usually followed surgery for the diagnosis or treatment of the primary lesion. Although pain subsided as incisional healing occurred, the stress of awaiting laboratory results Pain control reportedly increased this pain. The intermediate or must include second stage resulted most often from cancer recuran adequate rence. Further diagnostic testing and anxiety were use of narcotic described as increasing the pain that accompanied this analgesics, stage in the disease progression. Palliative treatwith radiation or deal with the ment chemotherapy frequently was reported to signifiissues of dying, cantly relieve pain. The final stage of cancer pain and address coincided with the terminal phase of the illness. the value of The continuous nature of the pain in this stage often adjunctive overwhelmed individuals and their families and treatments. ruled their lives.
PAIN MANAGEMENT Helme 11 reported that questions of differences in pain perception among different age groups have been studied both in clinical and laboratory settings. Results varied and demonstrated increased, decreased, and unchanged thresholds for pain in older people. The controversy revolved around the increasing morbidity for pain-associated diseases that may have affected sensorydiscriminative, affective-motivational, and cognitive-interpretive pathways and become less efficient in certain individuals. Helme did emphasize that, if all pain dimensions were recognized, pain could be treated effectively regardless of age. Pain connected with advanced cancer often is inadequately controlled, especially in the period immedi-
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ately before death. The time from diagnosis to treatment was reported to be the most stressful.25 Thirty percent to 45% of cancer patients reported experiencing moderate to severe pain at the time of initial diagnosis and during the intermediate stages of the disease.26 This inadequate pain control appeared to be related not to a lack of knowledge but the improper use of knowledge concerning pain. Many cancer patients reported the fear of dying in pain more than the fear of death. Rankin27 reported that cancer patients described their pain as becoming progressively more severe and frequent. Finally, pain developed into violent, relentless, and intolerable suffering that demoralized the person and prevented him or her from eating, resting, or sleeping. Pain was reported as continuous, producing mental and physical exhaustion, and thus trapping the person in a situation for which no relief was foreseeable. Cancer pain does respond to appropriate therapy. The most difficult aspect of pain control is the accurate assessment of pain intensity. Barriers include caregivers’ attitudes about pain, differences in caregivers’ and clients’ perception of pain, and myths that exist about pain, particularly in older people.28-30 Consistency in methods used to evaluate and communicate pain is essential for all individuals involved with the experience. Consistency will minimize confusion, reduce the extent of the assessor’s potential bias, and contribute to psychometrically valid and reliable data. 30 Dalton and McNaull31 recommended a 0 to 10 scale for universal use in clinical assessment of pain. Assessment, comfort measures, and therapeutic interventions must be simple enough to be followed by terminally ill individuals who may have impaired cognitive ability and inconsistent primary care. Pain control must include an adequate use of narcotic analgesics, deal with the issues of dying, and address the value of adjunctive treatments. The tendency to withhold narcotics until pain is severe must be discontinued. 32 The hospice movement in Britain has demonstrated that, with careful narcotic dosing, pain control and mental clarity can be achieved simultaneously.14,33 Improved function actually allows the pain threshold to be elevated. Research has reported that certain cancer pain syndromes are responsive to specific therapies as alternatives or adjuncts to narcotics. Pain management requires an aggressive interdisciplinary approach, the most effective of which has used the expertise of all professional staff members. 34-36 Furthermore, the patient and the family must be a part of the planning. Oncology patients are particularly vulnerable to autonomy loss when it comes to pain management, and they become desperate for relief. Ferrell et al.16 reported on contributions by Rimer, Kedziera, and Levy in 1992 that suggested that pain control education of oncology patients and their caregivers has five phases: assessment, goal-setting, selection of ed-
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ucational strategies, implementation, and reassessment. Pain education programs were reported to effectively decrease pain intensity, perception of pain severity, fear of addiction, and anxiety and increase the use of pain medications. Caregivers in this study reported improved knowledge, reduced fear of addiction, adequate medication administration, a pattern of medicating around the clock rather than as needed, and decreased fear of respiratory depression.
NONPHARMACOLOGIC TREATMENT OF PAIN Radiation and chemotherapy are important modes of therapy. Most people with cancer will respond to radiation therapy with significant pain relief. A palliative effect of radiation and chemotherapy goes beyond saving or prolonging life in that a reduction of tumor size can reduce pain.12 Recent approaches to alleviating or controlling cancer pain or teaching individuals to cope with it have focused on behavior-oriented treatment and biofeedback. Cognitive-oriented muscle relaxation is used to reduce sensory input. In this technique, the tensing and relaxing of various muscle groups combined with deep breathing and cognitive imagery help individuals develop coping skills. Visual imagery is used to make conscious control development easier.35,36 The goal has been to teach individuals to release tension and relax, a technique that often increases the pain threshold. Much of the work done with nonpharmacologic approaches to pain control have involved people with chronic pain not necessarily related to an organic cause. The complexity of the nature of pain has led to treatment programs that target both its psychologic and physical aspects. Alternative treatment models have incorporated behavior-oriented programs, multidisciplinary pain management, and pharmacologic and nonpharmacologic interventions.37 Improvement in coping strategies after treatment has been associated with reduced pain ratings and decreased psychologic disability.38-40
IMPLICATIONS FOR NURSING PRACTICE Nurses must take into account the influence of various psychosocial factors and the role religious faith and upbringing have on the outward expression of pain. Generational and cultural variations will exist in attitudes to pain and its expression. All15 reported in her literature review that responses to pain in older people may be modified by various psychosocial factors that have occurred during their lifetime. People with cancer who have unrelieved pain perceive their situation as extremely stressful, and consequently they suffer severe distress. When treatment begins, however, they may retain hope of a cure even though their body image often is threatened by radiation, surgery, chemotherapy, or disfigurement. Patients also fear death and dying in pain and must deal with
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feelings of despair, helplessness, and hopelessness. Progress has been made in cancer pain control. Comfort has become firmly established as a treatment goal for cancer patients. Research in pain assessment has been extended to include biobehavioral and environmental factors and affective states associated with cancer pain. The reliability and validity of pain Nurses need assessment tools and methods of standardizing to educate pain measurement are 31,41 evaluated continually. older people Research into pain management has led to new and their routes of drug administration and use of technology in the home as well as the families about hospital or hospice setting. Health care professionals cancer risks, are realizing their lack of knowledge in managing the role of pain, thus more information is being including in screening, professional training pro42 grams at all levels. and the Nurses need to educate older people and their warning signs families about cancer risks, the role of screening, appropriate screening tests, of cancer. and the warning signs of cancer. Nurses also need to be advocates for older people in a changing health care system, appropriately aggressive treatment of cancer, and inclusion of elders in clinical trials.43 A part of this advocacy may be centered on helping elders, their families, friends, and caregivers make decisions about such matters as the complexity of living with a chronic and potentially terminal condition, everyday issues (ie, pain management), and long-range concerns about hospice care and care of a surviving spouse or relative.44 Nurses, particularly in advanced practice roles, need to take careful histories of risk factors, conduct complete physical assessments, teach selfexaminations as screening techniques, and treat pain among elders as completely and aggressively as they do in younger clients.
FUTURE RESEARCH Physician gender and the beliefs of both patient and service provider concerning health screening and practices are two areas lacking research.45 Furthermore, research into home management of pain and the ethics and legalities of pain management in all segments of the population is a must in the future.
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Older people are a primary age group for cancer and its associated pain. As the numbers of older adults with cancer grows, pain management in this group cannot be ignored. Elders deserve the same pain management as other segments of the population. Until a cure is achieved, living with cancer pain will continue to affect all levels of society. The disease is a physically, emotionally, and spiritually devastating experience for patients, families, friends, and caregivers. REFERENCES 1. Ferrell B. Cost issues surrounding the treatment of cancer related pain. J Pharmaceutical Care Pain Symptom Control 1993;1(1):9-23. 2. Harmon M. The use of group psychotherapy with cancer patients: a review of recent literature. J Specialist Group Work 1991;16(1):86-61. 3. Clark J, McGee R, editors. Core curriculum for oncology nursing. 2nd ed. Philadelphia: WB Saunders; 1992. 4. Balducci L, Lyman GH. Cancer in the elderly: epidemiologic and clinical implication. Clin Geriatr Med 1997;13:1-14. 5. American Cancer Society. Cancer facts and figures 1998: sources. Available from: http://www.cancer.org/statistics/cff98/source.htlm. Cited 1999 Jan 26. 6. Costanza M, Annas G, Brown M, Cassel C, Champion V, Cohen H, et al. Supporting statements and rationale. J Gerontology 1992;47:7-16. 7. Kimmick G, Muss HB. Breast cancer in the older woman. Clin Geriatr Med 1997;13:265-82. 8. Clark G. The biology of breast cancer in older women. J Gerontology 1992;47:19-23. 9. Annas G. Breast cancer screening in older women: law and patient rights. J Gerontology 1992;47:121-5. 10. Mor V, Pacala J, Rakowski W. Mammography for older women: who uses, who benefits? J Gerontology 1992;47:43-50. 11. Helme RD. Pain in the elderly. Australas J Ageing 1998;17(1 Suppl):33-5. 12. Bruera E. Symptom control in patients with cancer. J Psychosoc Oncol 1990;8(2/3):47-73. 13. Portenoy R. Pharmacologic approaches to the control of cancer pain. J Psychosoc Oncol 1990;8(2/3):75-107. 14. U.S. Department of Health and Human Services. Management of cancer pain. AHCPR Publication No. 94-0592. Rockville (MD): U.S. Government Printing Office; 1994. 15. All AC. Current concepts and management of cancer pain in older women. J Women Aging 1994;6(4):59-72. 16. Ferrell BR, Rhiner M, Ferrell BA. Development and implementation of a pain education program. Cancer 1993;72(Suppl):3426-32. 17. Ferrell BR, Grant M, Funk B, Otis-Green S, Garcia N. Quality of life in breast cancer. Part II: psychological and spiritual well-being. Cancer Nurs 1998;21(1):1-9. 18. Moynihan R, Christ G, Silver L. AIDS and terminal illness. Social Casework: J Contemporary Social Work 1988;69:380-7. 19. Gil KM, Keefe FJ, Crisson JE, Van Dalfsen PJ. Social support and pain behavior. Pain 1987;29:209-17. 20. Turk DC, Okifuji A, Scharff L. Chronic pain and depression: role of perceived impact and perceived control in different age cohorts. Pain 1995;61:93-101. 21. Payne B, Norfleet MA. Chronic pain and the family: a review. Pain 1986;26:122. 22. Chuang H, Devins G, Hunsley J, Gill M. Psychosocial distress and well-being among gay and bisexual men with human immunodeficiency virus infection. Am J Psychiatry 1989;146:876-80. 23. Rabkin J, Williams J, Neugebauer R, Remien R, Goetz R. Maintenance of hope in HIV-spectrum homosexual men. Am J Psychiatry 1990;147:1322-6. 24. Papadimitriou M, Argyrou E, Paleogianni V. Emotional support of cancer patients: the nursing approach. Cancer Nurs 1998;21:246-51. 25. Odling G, Danielson E, Christensen SB, Norberg A. Living with breast cancer: caregivers’ perceptions in a surgical ward. Cancer Nurs 1998;21:187-95. 26. Bonica JJ. Cancer pain. In: Bonica JJ, editor. The management of pain. 2nd ed. Philadelphia: Lea and Febiger; 1990. p. 400-60. 27. Rankin M. Using drugs for cancer pain. In: Miller T, editor. Chronic pain. Vol. 2. Madison (CT): International Universities Press; 1990. p. 667-723. 28. Ebersole PA, Hess P. Toward healthy aging. 4th ed. St. Louis: CV Mosby; 1994. 29. Ferrell BR, Rivera LM. Pain. In: Lueckenotte AG, editor. Gerontologic nursing. St. Louis: CV Mosby; 1996. p. 303-20. 30. Chu NL. Pain assessment. In: Luggen AS, Travis SS, Meiner S, editors. NGNA core curriculum for gerontological advanced practice nurses. Thousand Oaks: Sage Publications; 1998. p. 366-9. 31. Dalton JA, NcNaull F. A call for standardizing the clinical rating of pain intensity using a 0 to 10 rating scale. Cancer Nurs 1998;21(1):46-9.
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32. Sizemore W. Assessment and treatment of cancer pain. In: Loeser JD, Egan KJ, editors. Managing the chronic pain patient. New York: Raven Press; 1989. p. 179-86. 33. Mount B, Ajemian I, Scott J. Use of Brompton mixture in testing the chronic pain of malignant disease. Can Med Assoc J 1976;113:112-29. 34. Lipman A. Pain management and pharmaceutical care. J Pharmaceutical Care Pain Symptom Control 1993;1(1):1-3. 35. Loscalzo M, Jacobsen P. Practical behavioral approaches to the effective management of pain and distress. J Psychosocial Oncology 1990;8(2/3):13967. 36. Miller T, Jay L. Pharmacologic and nonpharmacologic approaches to pain management. In: Miller T, editor. Chronic pain. Vol. 2. Madison (CT): International Universities Press; 1990. p. 525-71. 37. Tyre TE, Walworth DE, Tyre EM. The outcome status of chronic pain patients 4 years after multidisciplinary care. Wis Med J 1994 Jan:9-12. 38. Keefe FJ, Gil RM, Rose SC. Behavioral approaches in the multidisciplinary management of chronic pain: programs and issues. Clin Psychol Review 1986:6:87-113. 39. Spinhoven P, Linssen CG. Behavioral treatment of chronic low back pain. Pain 1991;45:29-34. 40. Turner JA, Clancy S. Strategies for coping with chronic low back pain: relationship to pain and disability. Pain 1986;24:355-64. 41. Dalton J, Feuerstein M. Behavioral factors in cancer pain. Pain 1988;33:15970. 42. McCaffery M, Ferrell BR, Page E, Lester M, Ferrell BA. Nurses’ knowledge of opioid analgesics and addiction. Cancer Nurs 1990;13:21-7. 43. Pratt PA. Cancer considerations in the elderly. In: Luggen AS, Travis SS, Meiner S, editors. NGNA core curriculum for gerontological advanced practice nurses. Thousand Oaks: Sage Publications; 1998. p. 447-67. 44. Lewis M, Pearson V, Corcoran-Perry S, Narayan S. Decision-making by elderly patients with cancer and their caregivers. Cancer Nurs 1997;20:38997. 45. Zapka J, Berkowitz E. A qualitative study about breast cancer screening in older women: implications for research. J Gerontology 1992;47:93-9.
ANITA C. ALL, RN, PhD, is an associate professor and LARAE I. HUYCKE, RN, BSN, is a graduate student at the University of Oklahoma College of Nursing in Oklahoma City. Copyright © 1999 by Mosby, Inc. 0197-4572/99/$8.00 + 0
34/1/102757
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CE
Test I.D. No.: G102757 Contact hours: 1.0 Processing fee: $9 Passing score: 70% (eight correct answers)
1. What was the most common cancer site for women in 1998? A. Lung B. Breast C. Colon D. Skin
7. Three themes in spiritual well-being include the following EXCEPT: A. Concern for the future B. Support of spirituality C. An altered life D. Aspects of spirituality
2. What percentage of breast cancer is found in women older than 65? A. 10% B. 20% C. 50% D. 80%
8. Changes in life as a result of their cancer included the following EXCEPT: A. Life priorities B. Altered life meaning C. Transcendence D. Disfigurement
3. What percentage of women older than 40 has had a mammogram? A. 40% B. 50% C. 80% D. 90%
9. At which of the three stages did All describe cancer pain as being “overwhelming”? A. First stage B. Second stage C. Third stage D. Both first and third stage
4. Caregivers may undermedicate cancer patients for fear of all the following reasons EXCEPT: A. Addiction B. Cost C. Respiratory depression D. Tolerance
10. What is the most difficult aspect of pain control? A. Accurate assessment of pain intensity B. Selection of pain medication C. Dosage of medication D. Frequency of medication
5. Older women with cancer pain indicated that the best thing professionals can offer is: A. Pain medications B. Visualization techniques C. Information D. Alternative medicine sources
11. The five phases of pain control education of oncology patients include the following EXCEPT: A. Assessment B. Goal setting C. Reassessment D. Resolution
6. Four themes of psychologic well-being include the following EXCEPT: A. Concern for the future B. An altered life C. Survivorship D. Emotional responses
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Pain, Cancer, and Older Adults Anita C. All, RN, PhD, and LaRae I. Huycke, RN, BSN Abstract: Pain is the most common symptom associated with cancer. Despite the fact that appropriate pain management exists, cancer pain often is inadequately controlled. Sixty percent to 85% of individuals with advanced cancer have either severe or chronic pain. Issues associated with cancer pain and pain management in later life include the effect of pain on the person, friends, and family; the influence of hope; the perception that older adults are less sensitive to painful stimuli; the special problems of drug management in older adults; and the unique issues of older women affected by cancer. This article concludes with implications for nurses. Future research needs to be directed to pain management at home, the ethics of pain management, pain in the cognitively impaired person, and the specific needs of older women. (Geriatr Nurs 1999;20:241-7)
241
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C
ancer is a disease characterized by uncontrolled growth and the spread of abnormal cells. The American Cancer Society estimates that approximately 30% of the population will develop cancer and approximately 3 to 3.5 million Americans are living with the disease. 1,2 Sixty percent of cancer deaths occur among people age 65 or older, and cancer is the second leading cause of death in people 65 or older.3 Additionally, cancer is a leading cause of morbidity and disability in the older population.4 An estimated 90% of individuals who develop cancer could survive if their disease were detected early. In 1998 approximately 1,228,600 new cancer cases were diagnosed, and an estimated 564,800 cancer-related deaths occurred.5 In 1998 the leading cancer site for women was the breast and the prostate for men. In contrast, the cancer resulting in the most deaths for both genders was lung cancer.5 Furthermore, lung cancer is the leading cause of cancer among African Americans, Native Americans, Asian and Pacific Islander people, and Latinos. The second leading cause for all ethnic groups is colon and rectal cancer; female breast cancer is third for Native American and Latino groups.5 Invasive cancers in the United States from 1992 to 1994 affected 22% of the population of women between 60 and 70 and 37% of the population of men in the same age group. The survival rate (percentage) is reported to be higher for Caucasians than African Americans. Women primarily are affected by breast cancer. Approximately one in nine women will be diagnosed with breast cancer. Cancer in situ of the breast accounts for about 36,900 cases per year.5 Age is an additional risk factor for the development of breast cancer.6 Nearly 50% of newly diagnosed breast cancers occur Pain is the in women 65 or older.7 Given the high percentage rule rather of women affected and the increased morbidity associthan the ated with later diagnosis, special attention needs to directed to this issue. exception be Older women initially prewith more extensive and often is sent disease than their younger counterparts, and their suran everyday vival rates are much lower.8 Breast cancer in older companion. women grows slower and is differentiated, hormone responsive, and more likely to be malignant. 7 Some specific risk factors for
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breast cancer in women are advancing age, being Caucasian, being nulliparous, radiation exposure, obesity, estrogen replacement therapy, positive family history, and history of nonmalignant breast disease.3,7 Older women are less likely to undergo regular breast examinations and less likely to practice breast self-examination; their physicians, usually internists, are less likely to recommend mammography. 9 Ninety percent of women over 40 have heard of mammography, but only about half have had a mammogram.10 Because older women are seen later in the disease process, they are less likely than younger women to receive the curative benefits of treatment and consequently must deal with the issues of pain and advanced disease.
PAIN ISSUES Review of the literature suggests that social support, hope, facing one’s own mortality, and pain management are key concepts for health care professionals to understand in caring for older patients. Helme’s11 literature review suggests that the population prevalence and characteristics of pain in older people is difficult to ascertain and fraught with misconceptions. Pain, the most common symptom associated with cancer, afflicts approximately one-third of individuals with primary carcinoma. Sixty percent to 85% of the individuals with advanced cancer have either severe or chronic pain that requires some type of management.1,9,12,13 Pain is the rule rather than the exception and often is an everyday companion. Unfortunately, pain associated with cancer frequently is undertreated.14 Contrasting views exist on differences or similarities of the pain experience in young, middle-aged, or older adults. Because uncontrolled pain can cause anorexia, weight loss, weakness, nausea, pressure sores, and insomnia, the importance of treating pain cannot be ignored. 14 In addition to these myriad physiological consequences, pain can impair the lifestyle of people with cancer and serve as a constant reminder of the incurable and progressive nature of the disease.15
FAMILY, FRIENDS, AND CAREGIVERS Understanding the physiological and psychologic complexities of pain has resulted in the inclusion of friends, family members, and other significant individuals in planning cancer pain management. Palliative care of individuals with cancer or any chronic illness requires caregivers to enhance their expertise. Ferrell et al.16 reported that family perceptions critically influence pain management. Caregivers expressed extreme fears of patients becoming addicted to medications, experiencing respiratory depression, and developing drug tolerance. These fears often result in undermedication by the caregiver and feelings of helplessness in providing comfort. For example, family and friends may not understand or be unable to accept the
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severity of the illness and may pressure the patient to maintain an independence of which they are no longer capable. People who are ill seldom deal with the issue of death when they are focusing their energy on the demanding task of daily living. Fear of death exacerbates as the illness progresses and the individual perceives a loss of function. People with cancer, their family, friends, and caregivers need an opportunity to ventilate their feelings about loss and separation. Family and friends must be encouraged to maintain their own lives as they face their feelings of abandonment and anger. 17,18 Conflict and control issues within the family have been reported to increase patient distress and pain ratings.1921 Fearing the inability to cope with the symptoms and pain of an incurable illness may cause patients to have intense feelings of helplessness and hopelessness. Being actively involved in their treatment and having some control when it seems they have lost all hope of control can be reassuring.18 All,15 in her review of older women with cancer pain, reported that perhaps the best thing that professionals can offer cancer patients at this point is information. They must be allowed to become familiar with all treatment options, know the theories of stress and disease progression, be given material about healthy lifestyles that may increase their lifespan, and be given the opportunity to grieve.
HOPE AND HOPELESSNESS The central feature of hope is an expectation that something worthwhile lies ahead. Hope may affect the progression of cancer in early stages. A feeling of hope is associated with an increased sense that one can cope or be helped to cope by others. Hope also may be accompanied by actual biologic changes that enhance physical and mental well-being.18 Hope is believed to be related to many factors, including psychiatric status, endocrine function, stress and illness, and susceptibility to infection. Loss of hope is a cultural, personality, and/or biopsychosocial response that can account for such phenomena as rapid death from voodoo, “evil eye,” and belief in hexes. This phenomenon can be seen in the abrupt death of individuals after being given a fatal prognosis.22 As with depression and distress, hopelessness is experienced by individuals diagnosed with cancer. This issue speaks to the importance of early intervention to help newly diagnosed individuals deal with the stresses associated with their disease.23-24
FACING AN UNCERTAIN FUTURE The psychosocial tasks of a potentially terminal illness include maintaining a meaningful quality of life, coping with disfigurement and loss of function, confronting existential and spiritual questions, and planning
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for surviving friends and family. Individuals with cancer face the challenge of trying to function with an unknown future. Ferrell and colleagues17 reported that, with an increasing number of women surviving breast cancer, the focus of care has shifted from the effects of acute treatment to long-term effects that influence quality of life. Using content analysis, quality of life domains of psychologic and spiritual well-being were studied. Four themes of psychologic well-being were identified: concern for the future, survivorship of the affected Hope is individual, sources of psychologic distress, and emobelieved to tional responses to breast cancer. Women in this be related to study feared dying and expressed thoughts about many factors, the future by describing how they balance hope and reality. These women including discussed how their lives had been shortened by the psychiatric disease and its treatment. They also described their status, strong hopefulness that new treatments would be endocrine available in case of disease 17 recurrence. function, stress These authors 17 further identified three and illness, and themes in the domain of spiritual well-being: support of spirituality, aspects susceptibility of spirituality, and an altered life. Women in this to infection. study described uncertainty about the future as one of the most difficult aspects of breast cancer. They also discussed the alteration of their lives as a result of the disease. These changes centered around life priorities, altered life meaning, and thoughts regarding transcendence from their current life to death.
CANCER PAIN Regardless of whether they experience pain, people with cancer deal with an unknown future and worry about pain, death, and dying without pain relief. Pain often is defined in terms of being an unpleasant experience that is both sensory and emotional, and it may or may not be associated with actual or potential tissue damage.14 Cancer-related pain has been the type studied to the greatest extent in terminally ill individuals. Cancer pain is not the same as acute pain or
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chronic noncancer pain. Pain of an acute nature signals the need for specific therapy that usually is curative, making the pain ultimately reversible. The chronic pain of cancer, particularly advanced cancer, however, usually is irreversible and related to disease progression. Individuals who are insufficiently treated often are in a trajectory of pain that goes from bad to worse. They constantly are reminded of the recurrent or incurable nature of their disease. All15 described three stages of cancer pain reported in the literature. The first or early stage occurred during the diagnostic phase of the illness and usually followed surgery for the diagnosis or treatment of the primary lesion. Although pain subsided as incisional healing occurred, the stress of awaiting laboratory results Pain control reportedly increased this pain. The intermediate or must include second stage resulted most often from cancer recuran adequate rence. Further diagnostic testing and anxiety were use of narcotic described as increasing the pain that accompanied this analgesics, stage in the disease progression. Palliative treatwith radiation or deal with the ment chemotherapy frequently was reported to signifiissues of dying, cantly relieve pain. The final stage of cancer pain and address coincided with the terminal phase of the illness. the value of The continuous nature of the pain in this stage often adjunctive overwhelmed individuals and their families and treatments. ruled their lives.
PAIN MANAGEMENT Helme 11 reported that questions of differences in pain perception among different age groups have been studied both in clinical and laboratory settings. Results varied and demonstrated increased, decreased, and unchanged thresholds for pain in older people. The controversy revolved around the increasing morbidity for pain-associated diseases that may have affected sensorydiscriminative, affective-motivational, and cognitive-interpretive pathways and become less efficient in certain individuals. Helme did emphasize that, if all pain dimensions were recognized, pain could be treated effectively regardless of age. Pain connected with advanced cancer often is inadequately controlled, especially in the period immedi-
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ately before death. The time from diagnosis to treatment was reported to be the most stressful.25 Thirty percent to 45% of cancer patients reported experiencing moderate to severe pain at the time of initial diagnosis and during the intermediate stages of the disease.26 This inadequate pain control appeared to be related not to a lack of knowledge but the improper use of knowledge concerning pain. Many cancer patients reported the fear of dying in pain more than the fear of death. Rankin27 reported that cancer patients described their pain as becoming progressively more severe and frequent. Finally, pain developed into violent, relentless, and intolerable suffering that demoralized the person and prevented him or her from eating, resting, or sleeping. Pain was reported as continuous, producing mental and physical exhaustion, and thus trapping the person in a situation for which no relief was foreseeable. Cancer pain does respond to appropriate therapy. The most difficult aspect of pain control is the accurate assessment of pain intensity. Barriers include caregivers’ attitudes about pain, differences in caregivers’ and clients’ perception of pain, and myths that exist about pain, particularly in older people.28-30 Consistency in methods used to evaluate and communicate pain is essential for all individuals involved with the experience. Consistency will minimize confusion, reduce the extent of the assessor’s potential bias, and contribute to psychometrically valid and reliable data. 30 Dalton and McNaull31 recommended a 0 to 10 scale for universal use in clinical assessment of pain. Assessment, comfort measures, and therapeutic interventions must be simple enough to be followed by terminally ill individuals who may have impaired cognitive ability and inconsistent primary care. Pain control must include an adequate use of narcotic analgesics, deal with the issues of dying, and address the value of adjunctive treatments. The tendency to withhold narcotics until pain is severe must be discontinued. 32 The hospice movement in Britain has demonstrated that, with careful narcotic dosing, pain control and mental clarity can be achieved simultaneously.14,33 Improved function actually allows the pain threshold to be elevated. Research has reported that certain cancer pain syndromes are responsive to specific therapies as alternatives or adjuncts to narcotics. Pain management requires an aggressive interdisciplinary approach, the most effective of which has used the expertise of all professional staff members. 34-36 Furthermore, the patient and the family must be a part of the planning. Oncology patients are particularly vulnerable to autonomy loss when it comes to pain management, and they become desperate for relief. Ferrell et al.16 reported on contributions by Rimer, Kedziera, and Levy in 1992 that suggested that pain control education of oncology patients and their caregivers has five phases: assessment, goal-setting, selection of ed-
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ucational strategies, implementation, and reassessment. Pain education programs were reported to effectively decrease pain intensity, perception of pain severity, fear of addiction, and anxiety and increase the use of pain medications. Caregivers in this study reported improved knowledge, reduced fear of addiction, adequate medication administration, a pattern of medicating around the clock rather than as needed, and decreased fear of respiratory depression.
NONPHARMACOLOGIC TREATMENT OF PAIN Radiation and chemotherapy are important modes of therapy. Most people with cancer will respond to radiation therapy with significant pain relief. A palliative effect of radiation and chemotherapy goes beyond saving or prolonging life in that a reduction of tumor size can reduce pain.12 Recent approaches to alleviating or controlling cancer pain or teaching individuals to cope with it have focused on behavior-oriented treatment and biofeedback. Cognitive-oriented muscle relaxation is used to reduce sensory input. In this technique, the tensing and relaxing of various muscle groups combined with deep breathing and cognitive imagery help individuals develop coping skills. Visual imagery is used to make conscious control development easier.35,36 The goal has been to teach individuals to release tension and relax, a technique that often increases the pain threshold. Much of the work done with nonpharmacologic approaches to pain control have involved people with chronic pain not necessarily related to an organic cause. The complexity of the nature of pain has led to treatment programs that target both its psychologic and physical aspects. Alternative treatment models have incorporated behavior-oriented programs, multidisciplinary pain management, and pharmacologic and nonpharmacologic interventions.37 Improvement in coping strategies after treatment has been associated with reduced pain ratings and decreased psychologic disability.38-40
IMPLICATIONS FOR NURSING PRACTICE Nurses must take into account the influence of various psychosocial factors and the role religious faith and upbringing have on the outward expression of pain. Generational and cultural variations will exist in attitudes to pain and its expression. All15 reported in her literature review that responses to pain in older people may be modified by various psychosocial factors that have occurred during their lifetime. People with cancer who have unrelieved pain perceive their situation as extremely stressful, and consequently they suffer severe distress. When treatment begins, however, they may retain hope of a cure even though their body image often is threatened by radiation, surgery, chemotherapy, or disfigurement. Patients also fear death and dying in pain and must deal with
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feelings of despair, helplessness, and hopelessness. Progress has been made in cancer pain control. Comfort has become firmly established as a treatment goal for cancer patients. Research in pain assessment has been extended to include biobehavioral and environmental factors and affective states associated with cancer pain. The reliability and validity of pain Nurses need assessment tools and methods of standardizing to educate pain measurement are 31,41 evaluated continually. older people Research into pain management has led to new and their routes of drug administration and use of technology in the home as well as the families about hospital or hospice setting. Health care professionals cancer risks, are realizing their lack of knowledge in managing the role of pain, thus more information is being including in screening, professional training pro42 grams at all levels. and the Nurses need to educate older people and their warning signs families about cancer risks, the role of screening, appropriate screening tests, of cancer. and the warning signs of cancer. Nurses also need to be advocates for older people in a changing health care system, appropriately aggressive treatment of cancer, and inclusion of elders in clinical trials.43 A part of this advocacy may be centered on helping elders, their families, friends, and caregivers make decisions about such matters as the complexity of living with a chronic and potentially terminal condition, everyday issues (ie, pain management), and long-range concerns about hospice care and care of a surviving spouse or relative.44 Nurses, particularly in advanced practice roles, need to take careful histories of risk factors, conduct complete physical assessments, teach selfexaminations as screening techniques, and treat pain among elders as completely and aggressively as they do in younger clients.
FUTURE RESEARCH Physician gender and the beliefs of both patient and service provider concerning health screening and practices are two areas lacking research.45 Furthermore, research into home management of pain and the ethics and legalities of pain management in all segments of the population is a must in the future.
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Older people are a primary age group for cancer and its associated pain. As the numbers of older adults with cancer grows, pain management in this group cannot be ignored. Elders deserve the same pain management as other segments of the population. Until a cure is achieved, living with cancer pain will continue to affect all levels of society. The disease is a physically, emotionally, and spiritually devastating experience for patients, families, friends, and caregivers. REFERENCES 1. Ferrell B. Cost issues surrounding the treatment of cancer related pain. J Pharmaceutical Care Pain Symptom Control 1993;1(1):9-23. 2. Harmon M. The use of group psychotherapy with cancer patients: a review of recent literature. J Specialist Group Work 1991;16(1):86-61. 3. Clark J, McGee R, editors. Core curriculum for oncology nursing. 2nd ed. Philadelphia: WB Saunders; 1992. 4. Balducci L, Lyman GH. Cancer in the elderly: epidemiologic and clinical implication. Clin Geriatr Med 1997;13:1-14. 5. American Cancer Society. Cancer facts and figures 1998: sources. Available from: http://www.cancer.org/statistics/cff98/source.htlm. Cited 1999 Jan 26. 6. Costanza M, Annas G, Brown M, Cassel C, Champion V, Cohen H, et al. Supporting statements and rationale. J Gerontology 1992;47:7-16. 7. Kimmick G, Muss HB. Breast cancer in the older woman. Clin Geriatr Med 1997;13:265-82. 8. Clark G. The biology of breast cancer in older women. J Gerontology 1992;47:19-23. 9. Annas G. Breast cancer screening in older women: law and patient rights. J Gerontology 1992;47:121-5. 10. Mor V, Pacala J, Rakowski W. Mammography for older women: who uses, who benefits? J Gerontology 1992;47:43-50. 11. Helme RD. Pain in the elderly. Australas J Ageing 1998;17(1 Suppl):33-5. 12. Bruera E. Symptom control in patients with cancer. J Psychosoc Oncol 1990;8(2/3):47-73. 13. Portenoy R. Pharmacologic approaches to the control of cancer pain. J Psychosoc Oncol 1990;8(2/3):75-107. 14. U.S. Department of Health and Human Services. Management of cancer pain. AHCPR Publication No. 94-0592. Rockville (MD): U.S. Government Printing Office; 1994. 15. All AC. Current concepts and management of cancer pain in older women. J Women Aging 1994;6(4):59-72. 16. Ferrell BR, Rhiner M, Ferrell BA. Development and implementation of a pain education program. Cancer 1993;72(Suppl):3426-32. 17. Ferrell BR, Grant M, Funk B, Otis-Green S, Garcia N. Quality of life in breast cancer. Part II: psychological and spiritual well-being. Cancer Nurs 1998;21(1):1-9. 18. Moynihan R, Christ G, Silver L. AIDS and terminal illness. Social Casework: J Contemporary Social Work 1988;69:380-7. 19. Gil KM, Keefe FJ, Crisson JE, Van Dalfsen PJ. Social support and pain behavior. Pain 1987;29:209-17. 20. Turk DC, Okifuji A, Scharff L. Chronic pain and depression: role of perceived impact and perceived control in different age cohorts. Pain 1995;61:93-101. 21. Payne B, Norfleet MA. Chronic pain and the family: a review. Pain 1986;26:122. 22. Chuang H, Devins G, Hunsley J, Gill M. Psychosocial distress and well-being among gay and bisexual men with human immunodeficiency virus infection. Am J Psychiatry 1989;146:876-80. 23. Rabkin J, Williams J, Neugebauer R, Remien R, Goetz R. Maintenance of hope in HIV-spectrum homosexual men. Am J Psychiatry 1990;147:1322-6. 24. Papadimitriou M, Argyrou E, Paleogianni V. Emotional support of cancer patients: the nursing approach. Cancer Nurs 1998;21:246-51. 25. Odling G, Danielson E, Christensen SB, Norberg A. Living with breast cancer: caregivers’ perceptions in a surgical ward. Cancer Nurs 1998;21:187-95. 26. Bonica JJ. Cancer pain. In: Bonica JJ, editor. The management of pain. 2nd ed. Philadelphia: Lea and Febiger; 1990. p. 400-60. 27. Rankin M. Using drugs for cancer pain. In: Miller T, editor. Chronic pain. Vol. 2. Madison (CT): International Universities Press; 1990. p. 667-723. 28. Ebersole PA, Hess P. Toward healthy aging. 4th ed. St. Louis: CV Mosby; 1994. 29. Ferrell BR, Rivera LM. Pain. In: Lueckenotte AG, editor. Gerontologic nursing. St. Louis: CV Mosby; 1996. p. 303-20. 30. Chu NL. Pain assessment. In: Luggen AS, Travis SS, Meiner S, editors. NGNA core curriculum for gerontological advanced practice nurses. Thousand Oaks: Sage Publications; 1998. p. 366-9. 31. Dalton JA, NcNaull F. A call for standardizing the clinical rating of pain intensity using a 0 to 10 rating scale. Cancer Nurs 1998;21(1):46-9.
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32. Sizemore W. Assessment and treatment of cancer pain. In: Loeser JD, Egan KJ, editors. Managing the chronic pain patient. New York: Raven Press; 1989. p. 179-86. 33. Mount B, Ajemian I, Scott J. Use of Brompton mixture in testing the chronic pain of malignant disease. Can Med Assoc J 1976;113:112-29. 34. Lipman A. Pain management and pharmaceutical care. J Pharmaceutical Care Pain Symptom Control 1993;1(1):1-3. 35. Loscalzo M, Jacobsen P. Practical behavioral approaches to the effective management of pain and distress. J Psychosocial Oncology 1990;8(2/3):13967. 36. Miller T, Jay L. Pharmacologic and nonpharmacologic approaches to pain management. In: Miller T, editor. Chronic pain. Vol. 2. Madison (CT): International Universities Press; 1990. p. 525-71. 37. Tyre TE, Walworth DE, Tyre EM. The outcome status of chronic pain patients 4 years after multidisciplinary care. Wis Med J 1994 Jan:9-12. 38. Keefe FJ, Gil RM, Rose SC. Behavioral approaches in the multidisciplinary management of chronic pain: programs and issues. Clin Psychol Review 1986:6:87-113. 39. Spinhoven P, Linssen CG. Behavioral treatment of chronic low back pain. Pain 1991;45:29-34. 40. Turner JA, Clancy S. Strategies for coping with chronic low back pain: relationship to pain and disability. Pain 1986;24:355-64. 41. Dalton J, Feuerstein M. Behavioral factors in cancer pain. Pain 1988;33:15970. 42. McCaffery M, Ferrell BR, Page E, Lester M, Ferrell BA. Nurses’ knowledge of opioid analgesics and addiction. Cancer Nurs 1990;13:21-7. 43. Pratt PA. Cancer considerations in the elderly. In: Luggen AS, Travis SS, Meiner S, editors. NGNA core curriculum for gerontological advanced practice nurses. Thousand Oaks: Sage Publications; 1998. p. 447-67. 44. Lewis M, Pearson V, Corcoran-Perry S, Narayan S. Decision-making by elderly patients with cancer and their caregivers. Cancer Nurs 1997;20:38997. 45. Zapka J, Berkowitz E. A qualitative study about breast cancer screening in older women: implications for research. J Gerontology 1992;47:93-9.
ANITA C. ALL, RN, PhD, is an associate professor and LARAE I. HUYCKE, RN, BSN, is a graduate student at the University of Oklahoma College of Nursing in Oklahoma City. Copyright © 1999 by Mosby, Inc. 0197-4572/99/$8.00 + 0
34/1/102757
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CE
Test I.D. No.: G102757 Contact hours: 1.0 Processing fee: $9 Passing score: 70% (eight correct answers)
1. What was the most common cancer site for women in 1998? A. Lung B. Breast C. Colon D. Skin
7. Three themes in spiritual well-being include the following EXCEPT: A. Concern for the future B. Support of spirituality C. An altered life D. Aspects of spirituality
2. What percentage of breast cancer is found in women older than 65? A. 10% B. 20% C. 50% D. 80%
8. Changes in life as a result of their cancer included the following EXCEPT: A. Life priorities B. Altered life meaning C. Transcendence D. Disfigurement
3. What percentage of women older than 40 has had a mammogram? A. 40% B. 50% C. 80% D. 90%
9. At which of the three stages did All describe cancer pain as being “overwhelming”? A. First stage B. Second stage C. Third stage D. Both first and third stage
4. Caregivers may undermedicate cancer patients for fear of all the following reasons EXCEPT: A. Addiction B. Cost C. Respiratory depression D. Tolerance
10. What is the most difficult aspect of pain control? A. Accurate assessment of pain intensity B. Selection of pain medication C. Dosage of medication D. Frequency of medication
5. Older women with cancer pain indicated that the best thing professionals can offer is: A. Pain medications B. Visualization techniques C. Information D. Alternative medicine sources
11. The five phases of pain control education of oncology patients include the following EXCEPT: A. Assessment B. Goal setting C. Reassessment D. Resolution
6. Four themes of psychologic well-being include the following EXCEPT: A. Concern for the future B. An altered life C. Survivorship D. Emotional responses
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