Pain is not simply a matter of an impulse traveling along a nerve. Because the components of total pain interact with one another, hospice and palliative medicine can be effective only when all four components are addressed.
Patients with life-limiting illness frequently harbor death-related anxieties and fears but may be reluctant to discuss them out of fear their thoughts and feelings will be considered strange or abnormal. All hospice and palliative care clinicians should ask about and listen for clues about the presence of psychological, social, and spiritual issues that may be contributing to and amplifying the pain experience. During the assessment process, estimating the severity of nonphysical pain is as important as rating the severity of physical pain.
Nonjudgmental listening, emotional support, and education can often alleviate mild nonphysical pain, but the presence of moderate-to-severe nonphysical pain requires more potent interventions, including the involvement of counselors, social workers, or chaplains and the addition of pharmacological therapies when anxiety or depression interfere with quality of life.
It is important to use open-ended questions to assess for the presence of nonphysical pain. Examples of open-ended questions that may elicit information about psychosocial and spiritual pain include the following:
When people become seriously ill, they usually find themselves wondering why it happened to them. When you wonder about this, what comes to mind?
When you think about the next few weeks or months, what are some of the concerns that first come to your mind? What things concern you more than others?
When you think back over the years, what are some of your happiest times? Saddest?
What has given you strength in the past? What gives you strength now? What do you wish could happen to give you more strength?
How has this illness affected you emotionally? What has been particularly difficult? Has anything been more (or less) difficult than you thought it might be?
How is your family coping with this illness? Can you tell me something about what is going on with them? What are some of your concerns about your family?