AANP News Brief

Multicultural Pain Management

Health care professionals can benefit from understanding the diverse
cultural attitudes patients have toward pain and tolerance.

By Maureen Sullivan-Tevault, RN, CEN

Despite significant advances in many areas of medicine, many studies, including a landmark investigation of elderly cancer patients and pain management published in JAMA in 1998, indicate pain remains poorly managed and under-treated for many patients.1 Unrelieved pain has been associated with undesirable outcomes, such as delays in postoperative recovery. Thus, health care providers must improve their understanding of pain management.

One of the most challenging aspects of pain management is understanding a patient's culture and how it affects their response to pain. Religious beliefs, cultural influences and diverse personal attitudes toward pain and suffering impact a person's response to pain, and health careproviders have a responsibility to honor their choices, offer them culturally competent care and maximize their pain relief options.

Patients need to be educated about the importance of adequate pain relief, be it delivered via traditional pain medications or, if the patient prefers, through alternative options, such as acupuncture, massage, imagery, meditation, music therapy, relaxation therapy, yoga or herbs.

JCAHO established standards related to pain management in 1999.2 These standards advocate the patient's right to appropriate management of pain and the provider's responsibility to educate patients and their families about the importance of pain management. Also noted in the standards is the need to ensure staff competency in both pain assessment and management to achieve optimal results for patients.

Demographics of Pain

Pediatric patients often are under-treated for pain because they cannot effectively communicate the level of pain they are experiencing. By age 4, however, most children can point to the part of their body causing them pain or identify it on a drawing.

While children's coping skills and developmental levels vary widely, their body language can provide clues to pain they are experiencing. For example, a child lying on his side in bed, with his knees pulled up toward his chest, might have abdominal pain.3

Elderly patients face unique issues regarding pain management, as well. For example, the desire to be a "good patient" often makes them hesitant to mention their pain. They also may fear the addiction potential and other side effects of narcotics. They may decline any pain medication, preferring to "tough it out."

Pain management for the elderly should focus on the different types of pain they suffer, including arthritis, osteoporosis, diabetes-related neuropathy and angina, to name a few examples. And these types of pain all may need to be addressed by different interventions. In addition, pain from different conditions, such as arthritis, may vary throughout the day and depend on activity levels, and can require multiple medications.

Meanwhile, cancer-related pain is another specialized area of pain management. These patients may fear increasing medication amounts can cause side effects worse than the pain, prolong hospitalization and hasten death. Education of staff and patients and their families about cancer pain management is paramount, to not only reduce suffering, but also promote healing.4

Cultural Influences

The influence of cultural upbringing impacts the response to pain, as
well as acceptance of pain medication.

While health care providers cannot know everything about a person's culture, they should be aware of external influences to one's pain experience, including the effects of religious beliefs. They should acknowledge and respect the patient's choices in pain management. In some cultures, pain may be interpreted as a test of one's faith, and the foregoing of pain medication may be viewed as a sign of personal strength and fortitude.

To maintain open, accepting lines of communication, the health care provider should acknowledge and respect a patient's choice to decline pain medication. The provider may enlist chaplain services and educate the patient of various other treatment options that may reduce pain, such as massage, relaxation and even biofeedback. The provider also may offer to pray with the patient, further developing a sense of trust and acceptance.

Life Experience

Pain is a complex phenomenon. A person's response is shaped by his individual life experiences. The health care provider first must understand the patient's pain is unique, and also be aware no two people will respond to pain in precisely the same manner.

Patient education is important to ensure patients receive sufficient pain control to optimize recovery and enhance their quality of life. Patients' family members also should be educated regarding adequate pain management in regard to its positive influence in the healing process.
Many patients, hesitant to ask for "as needed" medications for fear of appearing weak, may respond better to scheduled analgesic administration.

The effective management of pain is multifaceted at best. To maximize patient comfort and trust and to minimize poor outcomes, the health care provider must take into account not only the patient's complaints of pain, but factors influencing the patient's response to it. A willingness to understand the uniqueness of the patient's pain and to respect the patient's pain management choices will greatly improve the success of any interventions.

References

1. Bernabei, R., et al. (1998). Management of pain in elderly patients
with cancer. JAMA, 279(23), 1877-1882.

2. JCAHO. (1999, August 3). Joint Commission focuses on pain
management. Retrieved Feb. 12, 2005 from the World Wide Web:
http://www.jcaho.org/

3. Wong, D.L., & Hockenberry-Eaton, M. (2001). Wong's essentials of
pediatric nursing (6th ed.). St. Louis: Mosby.

4. National Coalition for Cancer Survivorship. (2004). Pain and the
elderly. Retrieved June 13, 2005 from the World Wide Web:
http://www.canceradvocacy.org/resources/essential/pain/elderly_test.aspx

Maureen Sullivan-Tevault works in the pain management department at the VA Medical Center, Bay Pines, FL.