PAIN
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New concept
Generally agreed upon that it exists
Definition variable
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You are born alone and you die alone the rest
doesn’t matter.
Steve Jobs
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Mahar 1955 began to develop the concept of
pain as being both somatic and physical.
This became more expansive to differentiate
between acute and chronic
Acute serves as physiologic warning
Chronic pain is “associated with endless
meaningless suffering”
Mahar Lancet 268 (1955)
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Mental distress may be the most intractable
pain of all.
C. Saunders “Treatment of Intractable Pain in
terminal cancer”
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Spiritual Pain
Bitter anger at the unfairness of what is
happening and above all a desolate feeling of
meaninglessness.
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Suffering is experienced by persons not merely
bodies.
NEJM 306 (1982) The nature of suffering and
the goals of medicine.
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Meaning is essential for life and people are
looking for or creating meaning, as
meaninglessness is impossible to endure.
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Distinction between fear, for something and
diffuse unfocused anxiety (dread)
Focused on death anxiety and the dread for
annihilation.
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Concept of man’s freedom
Man is doomed to freedom, meaning that man
must always chose and choices creating anxiety
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Freedom which means that man must always
choose ( unethical choices)
The question of meaning and meaninglessness
Existential isolation
Death
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Current definitions are as varied as the
disciplines and biases of those defining the
concept of existential pain
Journal of pain and symptom management,
Strang and Strang, illustrated this concept
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Stressed guilt issues as well as various religious
questions
Stressed existential pain as related to annihilation
and impending separation
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Emphasized living is painful
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Patient dignity inventory (PDI) Chochinov et al
Patient reports on the factor of their existential
distress such as,
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Not feeling worth while
Not being able to carry out important roles
Life no longer has meaning
Feeling a burden
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Primary goal to improve quality of life
Development of sensitivity and trust relations
and awareness of the patient’s existential
concerns
Spiritual/religious counseling
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Meaning-centered therapy
Cognitive behavioral interventions
Psychoeducational counseling
Hypnotically facilitated therapy
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Life tape project
Family counseling
Corticosteroid treatment
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Rousseau notes that existential suffering can be
as refractory and agonizing as physical
symptoms
1) Patients must have a terminal illness
 2) A DNR order must be in place
 3) All palliative treatments must be exhausted
 4) A psychological assessment must be completed
 5) An assessment of spiritual issues should be
completed
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Is it palliative or is it physician assisted
suicide?
Removal of life sustaining measures after PS
initiated
Slippery Slope: Palliative sedation as an
alternative versus an encouraged option
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Jack Kevorkian
William Osler “Given the uselessness of men
above 60 years of age and incalculable benefits
might arise from such a scheme” Statement
made in relation to Trollope’s The Fixed
Period.
Derek Humphry, Founder of the Hemlock
Society
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2002 National Health Survey: 40% of patients
affirmed use of CAM Therapy
Most common spiritual and religious: 22%
Music and Pet Therapy: 16% and 14%
Followed by other varieties of intervention
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Used in multiple medical conditions for pain
Hospital beneficial effects; sedation/euphoria,
appetite stimulation
Major Criteria
 A. Depressed mood
 B. Loss of interest in pleasurable activity
Other criteria must have at least 4 of these in
addition to one of the major criteria
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A. Weight change
B. Sleep disturbance
C. Psychomotor agitation or retardation
D. Fatigue
E. Guilt, worthlessness
F. Diminished ability to think or concentrate
G. Recurrent thoughts of death (suicide)
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Excessive worry or anxiety more days than not
over a 6 month period.
Difficult to control worry’
At least 3 of the following 6 symptoms
A. Restlessness
B. Fatigue
C. Decreased concentration
D. irritability
E. muscle tension
F. Sleep Distubance
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If we have time