Albeit, the variety of assessment tools and published guidelines on pain assessment and management, for general population, mainly for low-back pain, cancer and renal patients, and postoperatively (Zech et al. 1995, McQuay & More 1998, Mehra et al. 2012, National Consensus Project for Quality Palliative Care 2013, National Comprehensive Cancer Network 2014, Chou et al. 2016), many patients in pain continue to be underdiagnosed and untreated (Cleeland et al. 1994, Andreucci et al. 2004, Weisbord et al. 2007, Williams & Manias 2007) causing harm to themselves and increase healthcare cost (McCaffery 2002, Gustavsson et al. 2012, Leadley et al. 2012, Azevedo et al. 2016).
Barriers to effective pain assessment and management have been reported in various studies conducted in a variety of clinical settings, such as emergency department, medical and surgical wards, coronary units, long-term care facilities and nursing homes (Manias et al. 2002, Pölkki et al. 2003, Whelan et al. 2004, Takai et al. 2010, Lee et al. 2015, Flaws et al.
2016, Malara et al. 2016, Roche et al. 2016). Inadequate pain information for staff and patients, difficulties in patients reporting pain, fear about addiction to analgesics, misinterpretation of pain sensations and disbelief for pain level reported by patients have been identified as barriers to effective assessment and management (Dix et al. 2004, Yorke et al. 2004, Wilson 2008, American Society for Pain Management Nursing 2011, Koncicki et al. 2015). Other obstacles to effective pain assessment and control include inadequate and not routinely assessment, and use of inappropriate assessment tools. Individuals find difficulty in comprehending some assessment tools (Coll et al. 2004), not because they lack intellectuallity or cleverness, but because the actual tool, in an effort to cover all dimensions and aspects of pain, is too detailed and complicated. The situation becomes even worse when caring for older adults. On the one hand, elders might have false beliefs that pain is present as part of aging and on the other, effective communication with cognitively impaired older adults might be problematic. Staff has to overcome these obstacles in order to provide efficient pain assessement and management (Tse & Ho 2014).
In a study by Manias et al. (2002) regarding postsurgical adult patients, interruptions in nursing clinical practice were major barriers to effective pain assessment and relief, and caused delays in analgesic administration. Nurses moved rapidly from task to task and were
“unable to sit at one task or in one place for a period of time of more than few minutes without interrupting themselves by thinking of other things to do”. As a result to that, patients avoided to communicate freely their pain concerns to nurses, but waited patiently to be asked about their health status at nursing rounds rather than to request pain relief at the actual moment they needed it. A lot of patients, while hospitalised, feel helpless and this increase their hesitation to communicate their needs. In addition, they believe that nurses are always too busy with their daily duties (Hallström et al. 2000, Manias et al. 2002), and they avoid adding to that more interventions.
Furthermore, in assessing pain in renal patients, unique obstacles have to be addressed and overcome, such as complexity of medication, co-existing medical conditions, altered pharmacokinetics and pharmacodynamics, and adverse effects due to renal failure itself (Davison 2005, Manias & Williams 2007, Salisbury et al. 2009). The time required in order to assess pain in a Chronic Kidney Disease patient is usually more, compared to a postoperative patient (Coll et al. 2004). Renal healthcare professionals can fail to document symptoms such as pain, because they focus on more life-threatening ones such as arrhythmias or
setting of care, issues of spirituality, personal meaning, hope and saying “goodbye” are more significant than biomedical ones (Brooksbank 2009, Grantham & Brown 2012). Palliative care focuses on the “person” through an holistic interdisciplinary team approach (Swidler 2010) aiming at making the final journey less painful and stressful for the individual and its family.
In conclusion, in the management of pain healthcare professionals must assess the aetiology, duration, intensity and pathophysiology of pain, and use all non-pharmacological and pharmacological therapeutic options available having in mind the special considerations and needs of chronic kidney disease patients. Health specialists have to ensure patients’
autonomy in choosing and following a care plan without forgetting that severe pain or use of analgesics (mainly narcotic agents) may impair decision making. Moreover, they have the obligation, deriving from the Hippocratic dictum, to protect the patients from intolerable side effects and to “do no harm” (principle of non-maleficence). Thirdly, they are obliged to do what is best for the patient, over and above the avoidance of harm (principle of beneficence).
Finally, healthcare providers have the obligation to deliver and maintain an equal distribution services and goods (Fainsinger et al. 2003).
7 Barrriers to effective assessment and management of pain in renal patients
7.1 BARRIERS TO PAIN ASSESSMENT AND MANAGEMENT
Albeit, the variety of assessment tools and published guidelines on pain assessment and management, for general population, mainly for low-back pain, cancer and renal patients, and postoperatively (Zech et al. 1995, McQuay & More 1998, Mehra et al. 2012, National Consensus Project for Quality Palliative Care 2013, National Comprehensive Cancer Network 2014, Chou et al. 2016), many patients in pain continue to be underdiagnosed and untreated (Cleeland et al. 1994, Andreucci et al. 2004, Weisbord et al. 2007, Williams & Manias 2007) causing harm to themselves and increase healthcare cost (McCaffery 2002, Gustavsson et al. 2012, Leadley et al. 2012, Azevedo et al. 2016).
Barriers to effective pain assessment and management have been reported in various studies conducted in a variety of clinical settings, such as emergency department, medical and surgical wards, coronary units, long-term care facilities and nursing homes (Manias et al. 2002, Pölkki et al. 2003, Whelan et al. 2004, Takai et al. 2010, Lee et al. 2015, Flaws et al.
2016, Malara et al. 2016, Roche et al. 2016). Inadequate pain information for staff and patients, difficulties in patients reporting pain, fear about addiction to analgesics, misinterpretation of pain sensations and disbelief for pain level reported by patients have been identified as barriers to effective assessment and management (Dix et al. 2004, Yorke et al. 2004, Wilson 2008, American Society for Pain Management Nursing 2011, Koncicki et al. 2015). Other obstacles to effective pain assessment and control include inadequate and not routinely assessment, and use of inappropriate assessment tools. Individuals find difficulty in comprehending some assessment tools (Coll et al. 2004), not because they lack intellectuallity or cleverness, but because the actual tool, in an effort to cover all dimensions and aspects of pain, is too detailed and complicated. The situation becomes even worse when caring for older adults. On the one hand, elders might have false beliefs that pain is present as part of aging and on the other, effective communication with cognitively impaired older adults might be problematic. Staff has to overcome these obstacles in order to provide efficient pain assessement and management (Tse & Ho 2014).
In a study by Manias et al. (2002) regarding postsurgical adult patients, interruptions in nursing clinical practice were major barriers to effective pain assessment and relief, and caused delays in analgesic administration. Nurses moved rapidly from task to task and were
“unable to sit at one task or in one place for a period of time of more than few minutes without interrupting themselves by thinking of other things to do”. As a result to that, patients avoided to communicate freely their pain concerns to nurses, but waited patiently to be asked about their health status at nursing rounds rather than to request pain relief at the actual moment they needed it. A lot of patients, while hospitalised, feel helpless and this increase their hesitation to communicate their needs. In addition, they believe that nurses are always too busy with their daily duties (Hallström et al. 2000, Manias et al. 2002), and they avoid adding to that more interventions.
Furthermore, in assessing pain in renal patients, unique obstacles have to be addressed and overcome, such as complexity of medication, co-existing medical conditions, altered pharmacokinetics and pharmacodynamics, and adverse effects due to renal failure itself (Davison 2005, Manias & Williams 2007, Salisbury et al. 2009). The time required in order to assess pain in a Chronic Kidney Disease patient is usually more, compared to a postoperative patient (Coll et al. 2004). Renal healthcare professionals can fail to document symptoms such as pain, because they focus on more life-threatening ones such as arrhythmias or
hypotension, leaving pain under-recognised and thus under-managed (Weisbord et al. 2005, Barakzoy & Moss 2006, Weisbord et al. 2007).
Patient-related factors contribute, also, to under-treatment in renal settings. Oral analgesics are proposed, by their manifucturers, to be used on an “as-needed” basis. This prevents healthcare personnel to administer them in frequent schedule unless the patient makes a request. Still, patients often fail to seek help until their pain becomes severe due to fear of addiction to painkillers or personal beliefs that “good” patients do not complain and stoically accept their pain and suffering (McCaffery 2002, Davison 2005, Tse & Ho 2014).
Furthermore, Chronic Kidney Disease patients can take up to 15 tablets of various medications per day, making polypharmacy a reason for not wanting to add more than it is absolutely necessary. High rates of co-morbidity (heart, lung and/or liver abnormalities) that affect renal patients, along with polypharmacy, increase the risk of toxicity and adverse effects making clinicians reluctant to prescribe stronger analgesics (Davison 2005).
7.2 RECENT RESEARCH DATA ON RENAL PATIENTS’ PAIN LEVELS
In the last five years, since 2010, twenty studies have been researching pain in renal patients.
The Visual Analogue Scale (VAS) was the most popular research tool to measure pain perception and experience prior to the initiation of dialysis and/or during cannulation for haemodialysis (Celik et al. 2011, Aitken et al. 2013, Gamondi et al. 2013, Bagheri-Nesami et al. 2014, Bah et al. 2014, Kaza et al. 2014). The McGill pain questionnaire was used also, to assess pain during cannulation as well as neuropathic pain experienced by haemodialysis patients (Harris et al. 2012, Aitken et al. 2013, Atalay et al. 2013). The Wong-Baker pain rating scales was the third popular research tool to assess pain both in children and in adults on haemodialysis (Alhani et al. 2010, Wu et al. 2015). Pain perception and disease burden in renal patients was assessed with the Edmonton Symptom Assessment System (ESAS) (Davison & Jhangri 2010, Gamondi et al. 2013). The Kidney Dialysis Quality of Life (KDQoL) and the Medical Outcomes Study for Assessment of Health-Related Quality of Life were used by two research teams for assessing the disease burden and neuropathic pain (Davison &
Jhangri 2010, Atalay et al. 2013). Finally, the Fatigue Assessement Scale (FAS) and the Instrument for Activities of Daily Life were used in Switzerland and Greece during pain assessement studies (Gamondi et al. 2013, Zyga et al. 2015b).
Some of the research teams presented in Table 3, used only one research tool in order to assess pain levels, whereas others used a combination of questionnaires or scales. Atalay et al. (2010), Davison & Jhangri (2010), Harris et al. (2012), Theofilou (2012), Aitken et al. (2013), Gamondi et al. (2013), Hsu et al. (2014) and Lowney et al. (2015) used two or three research tools combined to assess pain. It was common to administer the questionnaires either during or immediately after the haemodialysis session. In interventional studies pain and disease burden assessments were performed at baseline and at the end of the programmed intervention, such as distraction, aromatotherapy, administration of medications and application of local anaesthetics (Alhani et al. 2010, Celik et al. 2011, Atalay et al. 2013 &
Bagheri-Nesami et al. 2014). In other interventional studies, two groups of patients were used; controls with standard procedure, and study group following specific educational programmes (Chow et al. 2010). Finally, some researchers were only recording pain and disease burden levels at the specific time of the study (Pham et al. 2010, Neri et al. 2011, Plantinga et al. 2011, Theofilou 2012, Gamondi et al. 2013, Wu et al. 2015, Zyga et al. 2015b,), whereas others had repetitive measures (Davison & Jhangri 2010, Harris et al. 2012, Kaza et al. 2014).
Literature review showed that Chronic Kidney Disease patients have high disease burden, due to the number of symptoms and complications. Moreover, it was found that pain was prevalent in high rates among renal patients, either on dialysis or on conservative management, adding to the negative impact of the disease in daily living. Pain was mainly musculoskeletal and intervention originated. Cannulation of vascular access for
haemodialysis has been found to be the most painful procedure, adversely affecting the individuals’ Health-Related Quality of Life (HRQoL). Various interventions regarding pain management were used by researchers, either pharmacological or complementary, improving outcomes. The first approach was found to have contradictory results, mainly due to non-adherence and research methodologies. The later, evolved the use of herbs, aromatotherapy or behavioural interventions, resulting in efficient pain management and better quality of life.
In summary, it can be stated that although the mechanisms underneath pain perception and pain management techniques and/or methods in various patient groups have been thoroughly studied, there are limited information of renal patietns’ perception of pain and pain management.
hypotension, leaving pain under-recognised and thus under-managed (Weisbord et al. 2005, Barakzoy & Moss 2006, Weisbord et al. 2007).
Patient-related factors contribute, also, to under-treatment in renal settings. Oral analgesics are proposed, by their manifucturers, to be used on an “as-needed” basis. This prevents healthcare personnel to administer them in frequent schedule unless the patient makes a request. Still, patients often fail to seek help until their pain becomes severe due to fear of addiction to painkillers or personal beliefs that “good” patients do not complain and stoically accept their pain and suffering (McCaffery 2002, Davison 2005, Tse & Ho 2014).
Furthermore, Chronic Kidney Disease patients can take up to 15 tablets of various medications per day, making polypharmacy a reason for not wanting to add more than it is absolutely necessary. High rates of co-morbidity (heart, lung and/or liver abnormalities) that affect renal patients, along with polypharmacy, increase the risk of toxicity and adverse effects making clinicians reluctant to prescribe stronger analgesics (Davison 2005).
7.2 RECENT RESEARCH DATA ON RENAL PATIENTS’ PAIN LEVELS
In the last five years, since 2010, twenty studies have been researching pain in renal patients.
The Visual Analogue Scale (VAS) was the most popular research tool to measure pain perception and experience prior to the initiation of dialysis and/or during cannulation for haemodialysis (Celik et al. 2011, Aitken et al. 2013, Gamondi et al. 2013, Bagheri-Nesami et al. 2014, Bah et al. 2014, Kaza et al. 2014). The McGill pain questionnaire was used also, to assess pain during cannulation as well as neuropathic pain experienced by haemodialysis patients (Harris et al. 2012, Aitken et al. 2013, Atalay et al. 2013). The Wong-Baker pain rating scales was the third popular research tool to assess pain both in children and in adults on haemodialysis (Alhani et al. 2010, Wu et al. 2015). Pain perception and disease burden in renal patients was assessed with the Edmonton Symptom Assessment System (ESAS) (Davison & Jhangri 2010, Gamondi et al. 2013). The Kidney Dialysis Quality of Life (KDQoL) and the Medical Outcomes Study for Assessment of Health-Related Quality of Life were used by two research teams for assessing the disease burden and neuropathic pain (Davison &
Jhangri 2010, Atalay et al. 2013). Finally, the Fatigue Assessement Scale (FAS) and the Instrument for Activities of Daily Life were used in Switzerland and Greece during pain assessement studies (Gamondi et al. 2013, Zyga et al. 2015b).
Some of the research teams presented in Table 3, used only one research tool in order to assess pain levels, whereas others used a combination of questionnaires or scales. Atalay et al. (2010), Davison & Jhangri (2010), Harris et al. (2012), Theofilou (2012), Aitken et al. (2013), Gamondi et al. (2013), Hsu et al. (2014) and Lowney et al. (2015) used two or three research tools combined to assess pain. It was common to administer the questionnaires either during or immediately after the haemodialysis session. In interventional studies pain and disease burden assessments were performed at baseline and at the end of the programmed intervention, such as distraction, aromatotherapy, administration of medications and application of local anaesthetics (Alhani et al. 2010, Celik et al. 2011, Atalay et al. 2013 &
Bagheri-Nesami et al. 2014). In other interventional studies, two groups of patients were used; controls with standard procedure, and study group following specific educational programmes (Chow et al. 2010). Finally, some researchers were only recording pain and disease burden levels at the specific time of the study (Pham et al. 2010, Neri et al. 2011, Plantinga et al. 2011, Theofilou 2012, Gamondi et al. 2013, Wu et al. 2015, Zyga et al. 2015b,), whereas others had repetitive measures (Davison & Jhangri 2010, Harris et al. 2012, Kaza et al. 2014).
Literature review showed that Chronic Kidney Disease patients have high disease burden, due to the number of symptoms and complications. Moreover, it was found that pain was prevalent in high rates among renal patients, either on dialysis or on conservative management, adding to the negative impact of the disease in daily living. Pain was mainly musculoskeletal and intervention originated. Cannulation of vascular access for
haemodialysis has been found to be the most painful procedure, adversely affecting the individuals’ Health-Related Quality of Life (HRQoL). Various interventions regarding pain management were used by researchers, either pharmacological or complementary, improving outcomes. The first approach was found to have contradictory results, mainly due to non-adherence and research methodologies. The later, evolved the use of herbs, aromatotherapy or behavioural interventions, resulting in efficient pain management and better quality of life.
In summary, it can be stated that although the mechanisms underneath pain perception and pain management techniques and/or methods in various patient groups have been thoroughly studied, there are limited information of renal patietns’ perception of pain and pain management.
Table 3. Research data on pain assessment and management from 2010 to 2015.
Authors Title & publication Research methods Data 1. Aitken E,
461 HD patients in West of Scotland.
• The mean VAS on cannulation was 3 (0.5 – 4.5).
• The 24.4% had severe pain on cannulation and 3.2% experienced severe chronic pain.
• The 11.3% cut a dialysis session short due to pain.
• Of the patients with severe chronic pain, 46.7% had complications affecting their AVF.
• Following treatment, pain improved in 71.4% and resolved completely in 14.3%.
• Brachiobasilic AVF was associated with a higher incidence of severe pain than brachiocephalic or radiocephalic (50%, 23.3% and 24.4% respectively; p = 0.03).
• Pain from AVF was poorly recognized and was under-reported.
• While severe pain resulting in the avoidance of dialysis is rare, it can lead to significant difficulties and change from AVF to central venous catheter as vascular access.
• Pain is often suggestive of an underlying anatomical problem in the vascualr access.
21 patients in paediatric HD centers in Teheran and 21 controls, randomly selected.
Assessment of pain in 12 sessions in both groups (3 first sessions without
• The case and control groups matched in demographic variables and pain intensity.
• After distraction, pain intensity during venipuncture significantly decreased (p
=.003), after the 6th session.
• Distraction has been proven to be a simple, inexpensive, and quick way for decreasing pain during cannulation of vascular access.
Table 3. Research data on pain assessment and management from 2010 to 2015 (continued).
3. Atalay H, each HD session at doses of 300 and 75 mg, respectively.
40 patients randomied into two groups, after 6 weeks patients underwent a 2-week washout, crossover & 6 weeks of treatment.
• 40 patients completed the 14-week study period.
• Gabapentin and pregabalin significantly improved SF-MPQ total
• No significant difference in terms of efficacy of the medications against neuropathic pain (p = .05).
• Both gabapentin and pregabalin significantly improved HR-QoL at the end of the study compared with pretreatment scores (p = .001).
• Strong efficacy of gabapentin and pregabalin on pain intensity in the administered dosages. clinical trial of 92 HD patients, randomly divided into an experimental group (who inhaled lavender essence with a concentration of 10% for 5’ during 3 sessions) and a control group (who
• Mean VAS pain intensity score in the experimental and control groups before the intervention was 3.78 (±0.24) and 4.16 (±0.32), respectively (p=0.35).
• Mean VAS pain intensity score in the experimental and control groups after
• Mean VAS pain intensity score in the experimental and control groups after