As part of our coverage of ONS we discuss the role of oncology nurses in pain management, how pain management has become more complex in recent years, and review some of the most important things to remember when involved in a complex pain management case.
As part of our coverage of the Oncology Nursing Society (ONS) 41st Annual Congress, held April 28–May 1 in San Antonio, Texas, today we are speaking with Jeannine M. Brant, PhD, APRN, AOCN, FAAN, an oncology clinical nurse specialist, pain consultant, and nurse scientist for the Billings Clinic in Montana. At this year’s meeting, Dr. Brant will be participating in a session discussing advanced concepts in pain management.
- Interviewed by Leah Lawrence
Cancer Network: What is the role of oncology nurses in pain management? How much are they involved in this aspect of patient care?
Jeannine Brant: I always like to think about it as pain being a nurse-sensitive indicator. That means that the role that nurses play really has a direct impact on patient outcomes for pain and the quality of pain management that’s delivered. So really the nursing role is across the continuum and in every single setting-including the in-patient setting, the ambulatory setting, and even in home care. It begins with a good comprehensive pain assessment to determine what the patient is experiencing.
We also play an important role in the management in providing recommendations a part of the team, whether it be medications, or maybe it is a patient with pancreatic cancer and we recommend a celiac plexus block-so advocating for patients and recommending part of the management strategies. Also, education. Patient and family education are paramount in providing quality pain management so that patients can be a part of the pain management plan, as well as families, so that they can actively participate in the management of their pain.
Cancer Network: How has pain management become more complex in recent years?
Jeannine Brant: Interestingly, a lot of the interventions that are available have been available for the last 30 years. We have a lot of different pharmacological strategies to manage pain. For procedures, though, we are doing better. And even with some of the medications-for example, bisphosphonates for bone pain have been very effective.
One of the things about pain management that is so complex is that patients, of course, are living longer. Their advanced disease states require pretty complex pain management. I like to think that there is the science behind it-the recommendations, the guidelines from NCCN and other organizations-but it is also an art. It is really trying to get the balance between good pain control and also minimal side effects and optimal quality of life.
The other thing that we are struggling with right now is the issues surrounding addiction and balancing good pain management in the background of a society with a high incidence of addiction, whether it is to alcohol, prescription drugs, to straight opioids-heroin is on the increase as well. Trying to assess our goals becomes very difficult, and trying to balance issues creates the complexity that we see in pain management.
Cancer Network: What are some of the commonly used pain medications that oncology nurses have to administer?
Jeannine Brant: Opiates, of course, are the mainstay for cancer pain management, but we can’t forget some of the other adjuvant therapies. Of course there are the non-steroidal anti-inflammatory drugs. We use anticonvulsants, antidepressants, but there is also some other out-of-the-box strategies such as lidocaine, which is a membrane stabilizer, or ketamine. There is some mixed evidence about the use of ketamine. There are a lot of things that we have to consider especially in those tough cases.
It is not only about just administering. We have a lot of advanced practitioners in oncology, both nurse practitioners and clinical nurse specialists. Their main role is supportive care. Through their role they will actually be prescribing and really involved in detailing a good plan for patients in order to provide comprehensive pain relief. Both in administration and management is where we are using pain medications.
Cancer Network: During your session you plan to walk through several challenging cases involving pain management. Can you provide us with an example of a complex case and how a nurse might handle it?
Jeannine Brant: I have a couple of different cases, and I’m hoping that during the session we will have time for nurses to present their cases at the mic too so we can all talk about those.
One of the cases I have is with a patient with a history of addiction who has advanced cervical cancer, but when she is admitted to our oncology service she is also receiving treatment at a methadone clinic for her heroin addiction. With that she does quite well at first, but then she shows signs of relapse for her addictive disease. She starts running out of opioids. She starts refilling early. She is in the emergency department with withdrawal symptoms. We talk about: How do we balance trying to provide good pain management for her without adding to her problems of addiction? Closer surveillance, for example, is one of the things that we do. We look at different opioid choices that might tend to have less problems with addiction. We also look at the goals. Instead of always thinking about 0 to 10, we have to think of what we call the four A’s, which is how much relief they are having and how much analgesic relief. But, also, what are the adverse events that they have? What are some of their abhorrent behaviors? What are their activities of daily living? How comfortable are they? Are they functioning better? We will talk about those different outcomes that we have to use in measuring success.
Cancer Network: What, in your opinion, are the most important things to remember when involved in a complex pain management case?
Jeannine Brant: I would say the fact that it takes a team. Sometimes we might see things one way, but we have a supportive care team and we meet every week and review tough cases. We might do this in the hospital. We will bring our team together with a nurse practitioner. We will have a physician for support, myself as pain and symptom expert. We even have a dietician, a social worker, and a chaplain. What we do is look at what is causing the pain physiologically. We also try to think about what is going on emotionally with the patient. As a team we get to problem solve together and learn from each other. We provide better management for the patient because we come at it from many different angles. The bottom line is that it does take a village.
Cancer Network: Thank you so much for taking some time to talk to us about pain management and the role of the oncology nurse.
Jeannine Brant: Thanks for the opportunity.