Procedure-Related Cancer Pain In Children

223 Pages·2002·3.688 MB·English

by  Christina Liossi

Procedure-related Cancer

Pain in Children

Christina Liossi

With a contribution from

Richard Hain

Forewords by

Martin Ward Platt and Patricia

McGrath
CRC Press
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© 2002 Christina Liossi
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Contents
Forewords v
Preface ix
Abouttheauthors xi
1 Thenatureofpaediatricprocedure-relatedcancerpain 1
ChristinaLiossi
2 Paediatricprocedure-relatedcancerpainassessment 35
ChristinaLiossi
3 Thepharmacologicalmanagementofpaediatric
procedure-relatedcancerpain 75
RichardHain
4 Thepsychologicalmanagementofprocedure-related
cancerpain.Part1 103
ChristinaLiossi
5 Thepsychologicalmanagementofprocedure-related
cancerpain.Part2 141
ChristinaLiossi
6 Integratedcare 173
ChristinaLiossi
Index 203

Foreword
Children still undergo unnecessary pain, distress, discomfort and su¡er-
ing during the diagnosis and treatment of malignant disease. Although
professional awareness of these issues is now much better, this book is
in part a response to the fact that there is still some way to go. It is less
often recognised that children treated for malignancy often su¡er a
heavy loss over and above their pain and distress: loss of belief in them-
selves as having control over their lives, loss of their sense of empower-
ment and loss of personal e⁄cacy. Yet this too can be countered and
managed, once it is acknowledged and understood. Children need not
experience these losses, but if they do, the long-term consequences may
beprofound.
The strength of Christina Liossi’s approach is its recognition of the
inextricable link between the poor management of adverse experiences
in childhood, and the subsequent ability of adults to cope adequately
withadversity.Thuswhenchildrendealwiththehugeproblemofmalig-
nancy and its treatment, the resilient ones may emerge unscathed, but
others may be signi¢cantly harmed. So it is not enough merely to mini-
misepainanddiscomfort during thediseaseepisode:wemustlook criti-
callyathowbothpainanditsmanagementmayhelporharmchildrenin
thelongterm.
Thatitisnotenoughmerelytojudgeproceduralpainmanagementon
a unidimensional scale is illustrated through the story of the girl who
preferredtobeabletohandleproceduraldiscomfortthroughpsychologi-
caltechniques,ratherthanhaveaseriesofanaesthetics,becauseitgave
her the control over the situation. As the passive recipient of anaesthe-
sia,shewasjustthat:apassiverecipient.Assomeonewhohadlearneda
new technique to control her discomfort for herself, she had emerged
from the experience with more than she had before. She illustrates that
psychological management is not a bolt-on luxury for procedural pain
management,itiscentraltoanintegratedandholisticapproachtochil-
dren’sneeds.
Readingthisbookyouwillbestruckbythenumberofissuesonwhich
further research is needed, yet will see that much is known which can
inform the practice of today and tomorrow. I have no doubt that you
will reconsider the approaches and procedures in your own depart-
ments, and may be inspired to introduce new ones, underpinned by the
broad range of evidence brought together here. You will be challenged
vi Foreword
by some pivotal ideas: I particularly liked the perspective of considering
what a child actually knows, rather than starting from assumptions
about what that child doesn’t know. You will read the case histories
and ¢nd that these stories give concrete expressions for some of the
moreabstractideas.
But you may also be depressed by some details. So often in the case
histories you will read about cases being referred for psychological eva-
luation, when things had clearly gone badly wrong for the child. Many
of us will think, how come things were allowed to get that bad? This
story is terrible, but we know it happens all too often ^ how can we get
it right for every child? For there are never going to be enough psychol-
ogiststogoround.
Thechallengeis,therefore,notoneof¢ndingmorepsychologists,nor
one of educating professionals about when to refer. It is about embed-
dingnewwaysofthinking,andnewwaysofworking,inthemultidisci-
plinary team. It is about the use of psychological techniques in parallel
withpharmacologyasaroutine,notasanextra.Itisaboutawarenessof
the child as an active participant, not a passive recipient. It is about
arming key professionals ^ perhaps oncology nurses ^ with the right
techniques so that they can evaluate the children themselves and help
themdirectly.Preciousresourcessuchasapsychologist’stimecanthen
be used more e⁄ciently in training and empowering others to prevent
problems,ratherthansalvagingchildrenwhomayalreadybepsycholo-
gicallyharmed.
Thegauntletisthrowndown.ChristinaLiossishowsusthatweknow
whatweneedtodo.Wenowhaveto¢ndthemeanstodoit.
DrMartinWardPlattMD,FRCPCH
ConsultantPaediatricianandSeniorLecturerinChildHealth
RoyalVictoriaIn¢rmary
Newcastle-upon-Tyne
October2001
Foreword
Inthelasttwodecades,unprecedentedscienti¢candclinicalattentionhas
focused on the special pain problems of children. Extensive research
has created better insights into how children perceive pain and how
clinicianscanalleviatetheirsu¡ering.However,under-treatedpaincon-
tinuestobeamajorproblemformanyinfants,childrenandadolescents.
A large gap still exists between what we know about controlling chil-
dren’spainandhowwepractiseclinically,andthecontrolofpost-opera-
tive pain, cancer pain, painful sickling crises, and chronic pain remains
problematicforchildreninmanycenters.
Thecontrolofcancerpain,bothpainfrommetastaticdiseaseandpain
from necessary cancer treatments, remains a serious health concern.
Optimal pain control for children with cancer begins with the recogni-
tion that children’s pain is not simply and directly related to the extent
oftheirphysicalinjuriesortheseverityoftheirdisease.Manyfactorscan
modify the neural signals for pain and increase a child’s pain and dis-
tress. As for adults, children’s pain perception depends upon complex
neural interactions, where impulses generated by tissue damage are
modi¢ed both by ascending systems activated by innocuous stimuli and
bydescendingpain-suppressingsystemsactivatedbyvarioussituational
andpsychologicalfactors.
Our increasing appreciation of the plasticity and complexity of chil-
dren’s pain has profound implications for pain management. Since a
child’s pain is not wholly determined by the level of tissue damage, we
cannot completely control pain by gearing our interventions solely to
the putative source of tissue damage. Instead, we must also identify the
situational and psychological factors that can cause or exacerbate a
child’s pain and target our interventions accordingly. Controlling chil-
dren’s pain requires a dual emphasis on administering appropriate
analgesics or anaesthetics, and on selectively modifying the factors that
exacerbatetheirpain.Ourtreatmentemphasisthusshouldshiftfroman
exclusive disease- or procedure-centered focus to a more child-centered
focus. The challenge for the future is to integrate this child-centered
approachmoree⁄cientlyintoclinicalpractice.
Christina Liossi is helping us to meet this challenge. This comprehen-
sive text provides a clear framework for understanding how children
perceive pain, how we can assess their pain, and how we can better
select drug and non-drug therapies to alleviate pain caused by medical
viii Foreword
procedures.Informationonthefactorsuniquetocancerpain,aswellas
those common to many types of acute procedure-related pain, enables
healthcareproviderstobetterunderstandtheirprofoundroleinmediat-
ing a child’s pain and distress. Emphasis in clinical care has often been
placed more on helping children to cope with or endure painful treat-
ments than on alleviating the pain evoked by treatments. Perhaps
healthcareprovidershaveacceptedtoothoroughlytheassumptionthat
painisinevitableduringnoxiousprocedures.
However, as described throughout this text, we have e¡ective drug
and non-drug therapies for procedure-related pain, child-centered pro-
grammes, and innovative ideas for implementing treatment guidelines
in clinical practice. Thus, healthcare providers can develop a diverse
repertoire of practical non-drug methods to complement ‘state of the
art’ drug management. They can adopt evidence-based guidelines for
selecting the most appropriate drugs to control pain caused by the var-
ied procedures children receive during their cancer treatment. More-
over, healthcare providers can integrate many versatile, inexpensive,
and e¡ective pain-reducing methods into routine clinical practice so as
to target all the causative and contributing factors for children’s pain.
Inthismanner,wecantrulyprovideoptimalpaincontroltothechildren
entrustedtoourcare.
ProfessorPatriciaAMcGrath
ProfessorofPediatrics
FacultyofMedicine
UniversityofWesternOntario
October2001
Preface
Pain in general and procedure-related pain in particular are important
considerationsinthecareofchildrenwithcancer.Althoughtherehave
been improvements in pain treatment over the last few decades, there
are numerous studies documenting the fact that unrelieved procedure-
related pain is still prevalent in paediatric oncology. Indeed, procedure-
related pain management continues to be an extremely challenging
problem for the young su¡erers, their families and healthcare profes-
sionals alike. Research has demonstrated that children with cancer and
their parents regard invasive procedures as one of the most di⁄cult
aspectsofhavingcancer,andtheirdistressandrecollectionsofthesetrau-
maticeventspersistyearsafterthecompletionofanti-cancertreatment.
This book provides a concise overview of essential theory and techni-
ques for the assessment and management of procedure-related pain in
children and adolescents with cancer, clearly illustrated with case his-
tories. The book provides the theoretical knowledge required to under-
stand the speci¢c nature and assessment strategies of procedure-related
cancer pain, and itdescribes anddiscusses in depth both pharmacologi-
calandpsychologicalmethodsofpainrelief,togetherwiththedi⁄culties
thatmaybeencounteredintheirimplementation.Clinicalandresearch
materialgatheredoverthelast10yearsfrommyclinicalworkinpaedia-
triconcologyandpalliativecarecanbefoundthroughoutthebook.
Two themes underlie this book. The ¢rst is that psychological and
pharmacological interventions should be better combined and form a
comprehensive,integratedapproachtotheclinicalmanagementofpae-
diatric procedure-related cancer pain. My goals include raising aware-
ness and educating where necessary that psychological techniques as
implementedbyhealthcareprofessionalsareapowerfuladjuncttophar-
macological intervention, and encouraging their more frequent and
consistentuseinpaediatriccancersettings.
The second theme is that there should be closer integration between
research work and clinical practice. It is my intention that this book
will bridgethe gapbetween research and clinicalpracticeandwillhave
direct application to the clinical environment. The aim was to write a
book for practitioners who desire information about the most e¡ective,
empirically documented methods of procedure-related pain assessment
andmanagementthatcan be appliedintheclinicalarea. Moreover,the
detailspresentedshouldinformclinicalinvestigatorsabout a number of