Questions

Lesson 8—Pain Management and Complementary Therapies

 This lesson briefly explains basic pain management concepts of the terminally ill patient. Most hospice programs in the West use these ideals. More detailed information on this subject can be found in The Final Journey—Complete Hospice Care for Departing Vaisnavas (Torchlight Publishing).

 In this lesson we will discuss the use of allopathic pain medications as the mainstay of pain management. Often, complementary therapies are used along with pain medications to assist in comforting a terminally ill patient because they can give added comfort and may even decrease the dose and frequency of pain medicine used. However, complementary therapies, such as massage, aromatherapy, guided imagery, and others, should never be used as a substitute for pain medicines, as most terminally ill patients require both methods for relief. Caregivers should always consult with the hospice nurse or physician BEFORE the start of any complementary therapies or over-the-counter medications or supplements.

It is important to note that every patient has the right to question any medications recommended by the hospice nurse and prescribed by the hospice physician. Although some patients and caregivers may not want to use allopathic medication, your main goal as a caregiver is to keep the patient as pain-free as possible with the least amount of side effects as possible. I have seen hundreds of dying patients made comfortable with the use of allopathic medications. Side effects were managed well and their last days were comfortable. I have also seen patients with intolerable side effects to these same medications. Fortunately, the latter situation is less common although it does occur. As a caregiver, it is best to immediately report to the hospice nurse any side effects to medications, such as constipation, nausea/vomiting, headache, excessive drowsiness, etc. He or she is trained in pain management and to treat side effects promptly and effectively.

Pain management of a terminally ill patient is not an easy task. Constant reassessment and good communication with your patient and hospice nurse/physician is required in order to achieve the best results.

Part A: Basic Concepts of Pain Management

The main point in assessing a patient’s pain is to accept that the patient’s self-report is the MOST reliable indicator of the intensity of pain being experienced.

In this regard, Margo McCaffery, RN and Pain Management Specialist, states,  “Pain is whatever the experiencing person says it is, existing whenever they say it does.”

In other words, the patient MUST be believed. For example, we may observe a terminally ill patient laughing with visitors. When asked if he or she is in pain, the patient may reply, “Yes. I need to take my pain medicine now because the pain is severe.” But, the patient is laughing with friends and family! Therefore, you may say, “How can this patient be in pain? He is laughing with friends and doesn’t appear to be in pain.” But, if the patient is requesting medication and states the pain is severe, then that is what the patient is experiencing. Even though it may appear that the patient is not in pain, the patient must be believed because every person reacts differently to pain.

As stated in The Final Journey (Torchlight Publishing), “Pain is subjective and is influenced by one’s childhood, life experiences, and culture. A patient’s perception and reaction to pain is also influenced by mood, morale, and pain threshold. Therefore, observations of a patient’s behavior should never override what the patient is stating.”

Similarly, sleep should never be mistaken for pain relief. If a patient is not receiving proper pain medicine he or she may simply be exhausted from many nights of unrelieved pain, but may later awaken in agony. Once a proper pain management program is implemented, your patient will be able to finally get the rest he or she deserves. Therefore, all pain medication must be given on time. Awakening your patient to administer scheduled pain medicine is always justified. Most likely, your patient will easily fall back to sleep and will not have to awaken hours later in excruciating agony. Never skip a scheduled dose of pain medication even if your patient is asleep.

To assess a patient’s pain level, a 0-10 pain scale is often used. It looks something like the one below:

0____1____2____3____4____5____6____7____8____9____10

Draw this scale on a piece of paper or your hospice nurse may have a professionally printed one for you to use. Explain to your patient that zero refers to having no pain and 10 refers to the worst pain the patient has ever experienced. Ask the patient to rate his or her pain level on the scale.

• 1-4 is usually considered mild pain.

• 5-6 is considered moderate pain.

• 7-10 usually refers to severe pain.

This method of rating one’s pain can be very useful and helps the hospice staff to prescribe the proper type and dose of medication. Medication that is prescribed for mild pain, for example, would be different than if a patient rated his pain as 8 or 9. The pain scale is a clear way for the patient to communicate his or her pain level to a caregiver who then notifies the hospice nurse/physician when pain has increased or is simply uncontrolled.

As an example of how the pain scale is used, consider a situation where your patient has recently been given pain medicine (within two hours) and still states that her pain level is a “9” on the 0-10 pain scale. This may indicate that your patient is having a new type of pain that is not being relieved with current medication, or that the dosage of the medication needs to be adjusted, or that another type of pain medication needs to be considered. As a caregiver, always notify the hospice nurse if pain is uncontrolled or if your patient tells you about a new type of pain.

There are other pain assessment tools that also help patients describe their pain. On the numerical rating scale, the person is asked to identify how much pain they are having by choosing a number from 0 (no pain) to 10 (the worst pain imaginable).

Below you will see the Visual Analog Scale. It is a straight line with the left end of the line representing no pain and the right end of the line representing the worst pain. Patients are asked to mark on the line where they think their pain is.

Visual Analog Scale

No pain		Worst pain
	Directions: Ask the patient to indicate on the line where the pain is in relation to the two extremes. Qualification is only approximate; for example, a midpoint mark would indicate that the pain is approximately half of the worst possible pain.

The Categorical Pain Scale has four categories: none, mild, moderate, and severe. Patients are asked to select the category that best describes their pain.

Categorical Scale

The Pain Faces Scale uses six faces with different expressions on each face. Each face is a person who feels happy because he or she has no pain or feels sad because he or she has some or a lot of pain. The person is asked to choose the face that best describes how he or she is feeling. This rating scale can be used by people age 3 years and older.

 Pain Faces Scale

(Adapted with permission from Whaley L, Wong, D. Nursing Care of Infants and Children, ed 3, p. 1070. ©1987 by C.V. Mosby Company. Research reported in Wong D, Baker C. Pain in children: Comparison of assessment scales. Pediatric Nursing 14(1):9-17, 1988.)

The key to successfully managing a patient’s pain is to:

--Continually reassess his or her pain level.

--Administer medication at the very start of the pain; not when the pain gets too severe. To wait until it is severe will make it more difficult to control.

--Administer your patient’s scheduled medication on time.

--Notify the hospice nurse if your patient complains of uncontrolled pain

--Notify the hospice nurse if your patient complains of a new type of pain or pain that is in a new location.

--Notify the hospice nurse if your patient has uncontrolled side effects to the medication.

In addition to asking your patient to rate his or her pain level on the 0-10 pain scale, you may want to ask the following questions:

--Where is the pain?

--When did it start?

--What type of pain is it? Dull? Throbbing? Stabbing? Burning?

--How long does the pain last? Is it sporadic? Is it constant?

--Does the pain feel worse at a particular time of day?

--What makes the pain worse? Sitting? Standing? Walking?

--What relieves the pain? Medication? Repositioning? Massage?

--Is this a new type of pain? Have you had this pain before?

The answers to these questions will further assist the hospice nurse in managing your patient’s discomfort.

Always Relieve Physical Pain BEFORE Spiritual Pain:

As devotees of the Lord, we are anxious for our patients to reach certain spiritual realizations before passing away. Remember, though, that physical pain must be addressed before spiritual issues can be addressed. How can a patient remember God and his/her relationship with the Lord while suffering with severe pain? If someone is in pain, how can he or she be in peace? Without peace, how can one remember Krishna?

Part B: Complementary Therapies

It is VERY IMPORTANT to discuss the use of any complementary therapy with the hospice nurse BEFORE beginning treatments. A few types of complementary therapies are discussed in this lesson. Once again, more detailed information can be found in The Final Journey.

Guided Imagery as relaxation technique:

Guided imagery is used for the following reasons:

--To relieve anxiety, depression, headache, and insomnia

--To assist patients to better cope with pain

--To reduces nausea and vomiting in cancer patients

--To decrease pre-operative anxiety

--To hasten post-operative recovery

--To lower blood pressure

--To decrease heart rate

Below is an example of a guided imagery exercise that you may want to do with your patient for relaxation. Other suggestions for guided imagery for the Vaisnava patient are:

--Mentally take your patient to a favorite place of pilgrimage.

--Guide your patient to a favorite transcendental festival such as Rathayatra, Govardhana Puja, etc.

--Mentally bring your patient to a relaxing place that is a “safe zone” such as a mountain, a field of soft grass, by a river, etc.

The following exercise may help to promote relaxation for your patient. It is suggested to turn off any bright, overhead lights. You may wish to put on a tape or CD of soft bhajans sung by Srila Prabhupada. Assist your patient in a comfortable, relaxed position. Speak slowly in a soft voice to your patient and say the following:

Inhale slowly. Slowly exhale. Relax your feet, first the right foot and then the left. Slowly breathe in and out as you feel your toes and ankles relax. With each breath, breathe calmness in and anxiety out.

Now, release any tension in the back of your calves, first the right calf and then the left. As you breath in and out you will feel your feet and calves relax.

Inhale slowly. Exhale slowly while you breath out any tension and worry. Now release any tightness in your thighs. The muscles in your legs are relaxed and you are beginning to feel calm. Feel your legs melt into the floor.

Now feel the muscles release in your abdomen. Let the tightness in your stomach relax.

Slowly breathe in and out and feel your chest rise and fall with each breath.

Let go of any tension you are holding in your fingers, your hands, your wrists and your arms. Relax your shoulders. Allow your arms to sink deep into the floor.

Take a slow, deep breath and while you exhale feel all of the tension release from your neck. If your jaw is clenched, release it now. Relax the muscles in your face as you slowly exhale.

Now feel the relaxation throughout your entire body, from your toes to the top of your head. Continue to breathe slowly, in and out, as your entire body goes limp. You feel a tremendous release of stress. Your whole body is calm and peaceful for the next part of your journey.

Now think of your favorite Deities of Radha and Krsna. Picture the temple room where They reside.  You are there.

Enter the temple room. Pay your obeisances to the Lord. Hear the soft bhajan sung by Srila Prabhupada.

With folded hands, slowly walk toward Radha and Krsna. Smell the incense burning on the altar as you watch it release its sweet fragrance through delicate swirls of mist that float upward toward the Lord.  Take a deep breath and experience the satisfying scent of long-stem roses that were lovingly placed in gold and silver vases on the altar. Feel how happy you are to be with Their Lordships again. Just seeing Radha and Krsna’s smiling faces, you feel a sense of peace. You are so very loved by Their Lordships. You are warm and safe.

You are home.

Standing in front of the Lord and His merciful consort, Radharani, you look down at Krsna’s lotus feet. See His shining, moonlike toes, perfectly decorated with devotional leaves from Srimati Tulasi devi. Notice the glistening silver of Krsna’s ankle bells.

Now gaze your eyes upward and see what Krsna is wearing. See His bright, yellow dhoti made of the finest silk and decorated with tiny golden beads. See the gold trim that lines the front of Krsna’s pleats. See the delicate gold chains that wrap neatly around His waist, one chain dangling on top of the other. Krsna is so very beautiful and you feel so honored to be in His presence. How kind the Lord is to His devotees.

Slowly gaze upward to the Lord’s white, silky blouse. Notice His long, puffy sleeves and the details on the cuffs that wrap around His wrists.  Notice the white pearl necklaces that dangle from His lotus neck. See the strands of bright, ruby red gems that delicately intertwine with His pearls. See how they are reaching downward, almost in hope of touching the Lord’s soft lotus feet.

See the Lord’s garland made of white and red roses. Notice how a lovely gardenia is carefully placed between every other rose. Take a deep breath and smell the fragrance of Krsna’s garland. Notice the Lord’s long, black, shiny hair as it sweeps across His shoulders. See His golden crown decorated with red jewels, green gems, and white pearls. See Krsna’s peacock feather and the way it fans in all directions. Look at Krsna’s shiny, golden flute with tiny chains that dangle from the end, each chain grasping a small, white, pearl. See the other end of the flute as it stretches to embrace Krsna’s beautiful, lotus lips. See His reddish lips curling up on both ends. Remember that darshan sees both ways. You are happy to see the Lord, but He is even happier that his dear devotee has come to visit Him.

Now move your eyes to Srimati Radharani. See Her white, lace dress decorated ever so delicately with white beading that glows in all directions. Notice her glistening, white pearl necklace. See the golden broach that is pinned to Her collar that flowers around Her beautiful lotus neck.

See her garland made of white and red roses interspersed with fresh, white gardenias. Notice how Her garland is flowing toward Lord Krsna as if to embrace the Lord. Take a deep breath and embrace the fragrance.

Notice Radha’s long, black braid combed to one side and falling over one shoulder. Notice how it dangles to her waist. See the tiny, delicate pearls that are intricately braided into her hair. Radharani’s beauty only enhances the beauty of her jewels. See her golden crown decorated with ruby red jewels, green gems, and glistening, white pearls.

Look at her lotus face, full of compassion and love. Take a moment to relish the beauty that belongs only to Srimati Radharani.

Now look on the altar step and see a bright, silver tray piled with red, white, and yellow rose petals. Pick up a handful of petals and offer them at the lotus feet of Their Lordships.

When you are ready to leave, see yourself offering obeisances and exiting the temple. Take with you the tranquility of being in the presence of the Lord. The Deities are all pervading. They remain with us always. Their Lordships are with you through your illness. They will be with you when it is time to leave this world. They will never abandon you.

Slowly open your eyes and become aware of the environment around you. Take a deep, cleansing breath.

Music Therapy

Music therapy dates back to Pythagoras, who taught that singing and playing musical instruments could counteract negative emotions. Today, music therapy is used in hospitals, nursing homes, and hospices to reduce anxiety. It has been successfully used to communicate with confused patients afflicted with Alzheimer’s disease. It has also been useful in rehabilitating stroke patients.

As devotees, we understand the importance of sound vibration. Provide “transcendental music therapy” according to your patient’s wishes and you will be rendering an important service for this courageous Vaisnava who is facing imminent death. Provide chanting of the Hare Krishna mantra, bhajans, or kirtan, but keep in mind your patient’s wishes and his or her tolerance to loud sound. Often terminally ill patients prefer soft volume and low lighting as the disease progresses.

Additional infomation

Aromatherapy

Aromatherapy is the therapeutic use of essential oils extracted from various plants. Flowers, leaves, stems, and roots from certain plants are used to promote relaxation, temporary relief from mental/physical ailments. It is important to remember that aromatherapy should never be used as a substitute for appropriate medical care.

Some oils are contraindicated with certain medical conditions.

Please note that some oils are not appropriate for patients with:

-Epilepsy

-Heart disease

-Diabetes

-Neurological disorders

-Hypertension

-Asthma

-Some pulmonary diseases

-Kidney or liver disorders

-Patients with open wounds.

Aromatherapy can be used for:

Massage

Inhalation

Foot soak

Bath

Vaporizer

Steam inhalation

A detailed list of some oils to be used in hospice setting is in The Final Journey.

Additional information

Cutaneous Stimulation:

Simply stated, cutaneous stimulation is the application of heat and/or cold for pain management. Again, NEVER use this therapy as a substitute for medical pain management.

Heat Therapy (Thermotherapy):

External application of heat works by dilating the blood vessels so circulation to a particular area is increased. When blood circulation is increased to muscles, pain is often reduced. Heat should never be applied to skin that has been exposed to radiation treatment or to an area of skin that is open (a wound, for example).  

--Apply covered heating pad (moist or dry) to the area of pain.

--Apply hot water bottle (wrapped in cloth) to the area of pain.

--Apply warm compress

Please note that moist heat is more effective than dry heat. With any type of heat therapy, check your patient’s skin frequently for redness that can indicate the beginning of a burn. This becomes especially important  when caring for patients who are confused, nonverbal, or unconscious.

Cold Therapy (Cryotherapy):

Cryotherapy means to apply a cool compress to the area of pain. This causes blood vessels to constrict. This in turn decreases circulation to the area of treatment. Vasoconstriction helps to reduce inflammation and swelling which may decrease one’s pain. Always keep the patient warm with blankets during cold therapy so he or she does not develop a chill. Application of a cold pack should be less than 15 minutes. As with heat therapy, never apply a cold pack to skin that has been radiated. You can use:

--A reusable gel pack wrapped in cloth

--An ice pack wrapped in cloth

The application of cold therapy is not recommended to areas of poor blood supply.

Ice Massage:

--Fill a small paper cup with water and freeze until solid

--Ice will freeze slightly above the rim of cup and will provide a smooth surface for a comfortable massage.

--Place towels on both sides of the patient to catch the water from the melting ice.

--Apply “ice massager” to skin over soft tissue using small, circular motions for 5-10 minutes or as tolerated by your patient.

Contrast Therapy:

Contrast therapy is the application of alternate heat and cold every few minutes. Please note the following:

--Cold is believed to decrease pain faster and the effects to be longer lasting than heat.

--Contrast Therapy often works better than the application of either one alone.

Therapeutic Massage for the Terminally-ill Patient:

Please refer to The Final Journey (Torchlight Publishing) to learn about simple massage techniques and appropriate oils to use.

Massage therapy is NOT recommended for every patient. For example, if a patient is at risk or has been diagnosed with a blood clot, he or she should never be massaged due to a danger of the blood clot traveling to the heart or lungs. (This is a life-threatening situation).

As with any complementary therapies, we strongly advise you to consult with the hospice physician or nurse before using any type of massage therapy.

Massage therapy can:

--Promote relaxation

--Alleviate the perception of pain/anxiety in some cancer patients

--Increase superficial circulation to area of treatment

--Increase blood return to heart as muscles are massaged

--Have a sedative effect on the nervous system

--Reduce some types of swelling

--Increase peristalsis (intestinal movement) that increases digestion and decreases constipation

--Be combined with Aromatherapy oils/lotions

Additional information

Vaisnava Nectar:

--Sruta Kirti dasa, Srila Prabhupada’s personal servant, stated that Srila Prabhupada liked his daily massage with mustard seed oil on his body and sandalwood oil on his head. Sometimes, Srila Prabhupada would request mustard oil be mixed with camphor. Sometimes, His Divine Grace requested mustard oil be heated.

In conclusion, when assisting your patient with pain relief, please consider your patient’s wishes, as well as his patient rights as discussed in a previous lesson. Discuss any concerns with the hospice nurse or physician. Assess your patient’s pain and then reassess! Pain in a terminally ill patient can change within hours. Keep open communication with your patient and any family members involved. Finally, let your patient know that any complaints of pain or other uncomfortable symptoms will not be seen as a sign of weakness or as a bother to caregivers. Reassure your patient that you are there to help in any way you can. Your patient will then feel “safe” to let you know when symptoms need to be addressed.

 Back to top

Continue to Lesson Eight Questions

Back to Caregiver Course information page

Get to Know Us | Services | Donate | Volunteer
Care Homes | Medications | Therapies | Guestbook
News & Events | About Vaisnavas C.A.R.E. Inc. | Contact Us
Home

Lesson One

Lesson Two

Lesson Three

Lesson Four

Lesson Five

Lesson Six

Lesson Seven

Lesson Eight

Lesson Nine

Lesson Ten