Pain after amputation is a distressing and difficult problem to treat. Patients may experience significant surgical wound pain and/or the challenging phenomenon of phantom limb pain (PLP). Individuals in this patient group often have preoperative ischaemic pain, require repeated revascularisation surgeries and display catastrophic behaviours regarding the change in their life and body image following amputation. These biopsychosocial factors predispose individuals to the risk of poorly controlled postoperative pain. Uncontrolled, acute pain following surgery further compounds the situation, with studies linking a higher postoperative pain score for stump pain with an increased presentation of PLP (Dijkstra et al, 2002).
Contemporary studies have highlighted the importance of acute pain management in the prevention of ongoing post-surgical pain, and this is especially relevant after amputation (Karanikolas et al, 2011; Lavand'homme, 2011; Schug et al, 2016).
It is estimated that between 50% and 85% of people who have had an amputation experience PLP; many develop a relentless and persistent form of this neuropathic pain (Nikolajsen et al, 2000; Schley et al, 2007). This variation in reported prevalence is likely to be associated with multiple factors. Difficulty in distinguishing between stump (residual limb) pain and PLP, confusion between phantom pain and phantom sensation, and presence of associated diffuse pain may lead to under-reporting of PLP (Dijkstra et al, 2002).
Pathophysiological processes in the central and peripheral nervous system have been implicated in causing PLP. Surgery and trauma may damage peripheral nerves, thereby causing spontaneous activity at the site of injury, which leads to repetitive depolarisation and transmission of pain signals (Weeks et al, 2010). Associated central sensitisation and pain wind-up lead to distressing evoked pain associated with allodynia, hyperalgesia, hyperpathia and dysaesthesia (Steeds, 2013). In addition, somatosensory pain memory may also be triggered following amputation.
Affected patients report a range of neuropathic pain characteristics in the absent limb, including burning, cramps, tingling, electric shocks, itching, and pins and needles (Weeks et al, 2010). Such intractable pain may affect every aspect of the life of sufferers, including sleep patterns, spousal relationships, and family and professional roles (Closs et al, 2009). In addition, the concept of pain in a limb that has been removed is difficult to comprehend, thus leading patients to question their sanity. This may further compound low mood resulting from fundamental changes in body image, leading to depression, anxiety and a deleterious or even catastrophic outlook (Vase et al, 2011).
Given the relatively high prevalence and distressing nature of this painful condition, the authors aimed to provide excellent post-amputation pain management, with the secondary aims of improving postoperative rehabilitation and reducing the possibility of chronicity. Particular emphasis was placed, therefore, on preventing uncontrolled acute pain following surgery by adopting a systematic approach to pain management and ensuring collaboration with the multidisciplinary team.
High-quality pain management
Good quality pain management will result in reduced pain severity, adequate pain relief, low functional interference, few adverse effects from pain or its treatment, and patient satisfaction with their pain management plan (Zoega et al, 2015). In order to provide a systematic pain management approach, the authors have developed a framework to guide not only assessment but also the evaluation of treatments while ensuring patient safety (Figure 1).
This framework is called PAINGO, with the initials standing for:
The PAINGO framework combines the tenets of the pain management process and the nursing process. The nursing process (Yura and Walsh, 1967) is a cyclical model of care planning that consists of four concepts: assessment, planning, implementation and evaluation. Each step of the framework is also supported by evidence from a number of pain management publications (NHS Quality Improvement Scotland, 2003; 2004; 2009; 2011; Royal College of Anaesthetists (RCoA) and Association of Anaesthetists of Great Britain and Ireland, 2006; Vickers et al, 2009; RCoA Faculty of Pain Medicine, 2015; Schug et al, 2016), but its use has not been previously validated.
Quality improvement in health care involves the analysis of performance and the use of systematic efforts to improve safety, the reliability of health care and reduce avoidable harm (The Health Foundation, 2013). ‘PAINGO once per shift’ has been introduced in the authors' organisation as an unvalidated tool to ensure that all aspects of the pain management process have been considered (NHS Tayside, 2018).
Pain assessment as fifth vital sign: identify the problem
Historically, pain assessment is a task undertaken along with other vital signs by nurses. Campaigns during the 1990s by professional bodies to declare pain as the fifth vital sign (Royal College of Surgeons of England and College of Anaesthetists Great Britain and Ireland, 1990) helped raise awareness that uncontrolled, acute pain is harmful and that it is important to give patients the opportunity to report pain. The pain assessment tool used in the authors' institution (NHS Tayside) has been validated for assessment of acute pain in the hospital setting (Jensen et al, 2002; Closs et al, 2004). It is a practical verbal rating scale that captures patient self-reporting of pain intensity at rest and on movement, which is vital for the post-surgical/trauma patient owing to the risk of complications. Patient reports of severe or uncontrolled pain should always be investigated to rule out pathological complications (Schug et al, 2016) (Box 1).
| 0 | No pain at rest or on movement |
| 1 | No pain at rest, slight on movement |
| 2 | Intermittent pain at rest, moderate on movement |
| 3 | Continuous pain at rest, severe on movement |
Patient factors that impact on pain assessment include communication difficulties, impaired consciousness, cognitive impairment, language barriers or learning difficulties. Postoperative delirium is relatively common following amputation in older adults (aged ≥65 years). Verbal or numerical rating scales can still be used to rate pain intensity in patients with mild or moderate cognitive impairment (Closs et al, 2004). In the presence of severe cognitive and communication impairment, appropriate observation scales should be used, as guided by the British Geriatrics Society (Schofield, 2018). The authors' institution uses the Abbey Pain Scale (Abbey et al, 2004) (Table 1), one of the most widely used observational assessment tools in the UK (Schofield, 2018). This tool does have limitations—it provides a measure that is based on the behaviours exhibited, which could be indicative of a number of factors, of which pain is one possible explanation. Pain behaviours differ between individuals, so assessment should include discussion with family members or carers who know the patient well (Schofield, 2018).
|
|
Accurate assessment
A simple inquiry into the presence of pain during this routine clinical assessment, which is generally taken out of context for the remainder of the pain management process, has not brought about better pain treatment or patient outcomes. Indeed, where treatment has been guided solely by numerical score, problematic analgesic side-effects have been reported (Gordon, 2015). In the authors' clinical experience, the administration of oral morphine to patients experiencing PLP has led to excessive drowsiness and increased risk of falls. Clinical experience has shown the authors the importance of investigation into both the nature and the impact of a patient's pain.
Taking the time to let the patient explore their pain experience (eg what they think, how they feel), while offering empathy, reassurance and explanations, can achieve measurable reductions in pain (Falch et al, 2014).
Nurses should document the location, type and intensity of pain in the patient's own words, to reflect their experience. A more accurate pain assessment within the context of a conversation helps nurses distinguish between nociceptive and neuropathic pain. This is vital because different types of pain respond to different pharmacological and non-pharmacological treatments (Dunn, 2000; Vickers et al, 2009; NHS Quality Improvement Scotland, 2011). Pain in the residual limb (stump pain) is nociceptive pain, eg surgical wound pain, muscle ache or muscle spasm, presence of a boney prominence or wound infection. Phantom sensation and phantom pain are types of neuropathic pain. Phantom sensation may be reported as a painless feeling that the limb is still there. Some patients experience itching, prickling or tingling sensations that are more irritating than painful, but still distressing. Patients may not report these sensations unless directly asked. Phantom pain can resemble the pain felt in the limb before surgery, burning, tingling, cramping or resembling an electric shock. Phantom pain can be mild, moderate or severe.
Simple neuropathic pain assessment tools such as the Self-completed Leeds Assessment of Neuropathic Symptoms and Signs (SLANSS) and Douleur Neuropathique 4 (DN4) (Gudala et al, 2017) include similar self-reporting of the nature of pain but not its impact, while also relying on physical examination, which is difficult in an absent limb.
The authors introduced, with permission of the original developer, a previously unvalidated ‘bothersome tool’ (Table 2) adapted from the Keele University (2007) STarT Back Screening Tool. This is a validated prognostic questionnaire that helps identify modifiable risk factors and aids the stratification of treatment packages, resulting in reduced back pain disability. The adapted questionnaire has helped nurses explore the presence of wound pain, phantom sensation or phantom pain. The screening tool is used to assess the impact, rather than the magnitude of the pain. Questions are asked about the patient's ability to sleep and participate in rehabilitation at the gym, in addition to how ‘bothersome’ their pain is on a Likert scale. The questionnaire has also helped to guide pain management treatments, although it should be noted that the tool has not been validated for use in phantom limb pain.
|
|
Prescribing for this group of patients can be challenging. Given the documented side-effects of many treatments for neuropathic pain, it is imperative to consider the balance between effect and side-effects. Although phantom sensation may not be painful, if it is moderately or severely bothersome, and interfering with sleep or rehabilitation goals, then changes to drug treatments or doses will be discussed with the patient.
Work within the authors' institution aimed to make pain assessment the role of all members of the multidisciplinary team. Pain assessment can be carried out as the opportunity arises by all team members: for example, while providing personal care (healthcare assistants, nursing students and registered nurses), while engaging in rehabilitative input (physiotherapy, occupational therapy, prosthetics team), and on routine ward rounds (medical staff, pharmacists). ‘PAINGO once per shift’ has been introduced in the authors' organisation as an unvalidated tool to ensure that all aspects of the pain management process have been considered (NHS Tayside, 2018). An important part of the pain management process is to assess or evaluate the pain management plan regularly. Key questions to ask include: ‘Is it helping?’, ‘Is it causing any side effects?’, ‘Are activity/function goals being achieved?’ The authors also recommend taking a ‘pain pause’ on every ward round. The clinical pharmacists have played a vital role here in optimising pharmaceutical care, using the 5 As of opioid analgesia review (activity, analgesia, adverse effects, aberrant behaviours, affect) (Pain Management Network, 2015), which also involved patients in discussion about their pain and pain management.
It is imperative that health professionals feel confident and competent to assess the pain that patients experience. This is particularly pertinent to those with PLP because of the complex nature of the experienced phantom pain and sensation. Rolling programmes of education are therefore essential to supporting health professionals' knowledge and engagement. Patients must also be empowered to feel part of the pain management process.
Treatment options
When pain is assessed effectively, treatment options can be appropriately selected, taking cognisance of the available evidence base. PLP can be treated with pharmacological and non-pharmacological interventions as discussed in the next two sections.
Pharmacological treatment
Although surgical wound pain is frequently treated with standard analgesic options, PLP may be more difficult to treat. Having considered the work by the Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine (Schug et al, 2016), and the Cochrane Collaboration, the authors found no definitive published guidelines for optimal treatment of PLP. They therefore undertook an extended literature review with the aim of informing clinical practice.
Relevant databases (MEDLINE, MEDLINE In-Process, Embase, AMED, CINAHL, Scopus, Cochrane Library and British Nursing Index) were used to identify appropriate studies and supportive literature. English-language research pertaining to adult human subjects was specified. Backward chaining of reference lists was used. The search was initially limited to studies completed from 2006 onwards; however, owing to the paucity of literature retrieved, all searches were extended back to 2000. In addition, the search limits pertaining to calcitonin were further extended back to 1990 to include seminal work.
Research was appraised and critically evaluated using the methodology checklist for qualitative research provided in the National Institute for Health and Care Excellence (2012) guidelines manual. Levels of evidence were assigned through the use of the Scottish Intercollegiate Guidelines Network guidelines (SIGN, 2019).
Perineural blocks
Clinically, the insertion of perineural local anaesthetic blocks is already well established at the authors' institution, with a low rate of side-effects and complications. Clinically, this provides an effective and aggressive method of perioperative pain management, thus reducing the incidence of chronic post-surgical pain (Karanikolas et al, 2011; Schug et al, 2016). Ropivacaine is the local anaesthetic of choice owing to its preferential safety profile and its provision of a more differential block. At Ninewells Hospital, the aim is to prolong the duration of perineural blockade to prevent acute wound pain, reduce the incidence of problematic PLP and remove the need for opioids. This approach is supported by a number of studies (Madabhushi et al, 2007; Grant and Wood, 2008; Borghi et al, 2010). Lambert et al (2001) suggested that there are possible benefits in preoperative and prolonged postoperative central neuraxial blockade, but this was not considered by the authors to be a viable option in managing post-amputation pain owing to patient choice, limited resources and service delivery factors (Lambert et al, 2001).
Opioids
Opioids often remain the mainstay of surgical wound pain management. Side-effects from these drugs and other analgesics may cause harm, particularly in adults aged 65 years or older (RCoA Faculty of Pain Medicine, 2015). In acute hospital settings, pain management plans require regular review (RCoA Faculty of Pain Medicine, 2015). This not only guides titration of doses according to individual patient response, but also helps to ensure safety because hospital patients are likely to experience frequent changes in their general condition (Scottish Government Polypharmacy Model of Care Group, 2018).
The need for opioids can be largely avoided using perineural blocks. Effective blocks result in negligible levels of postoperative pain and reduce the need for opioid and other breakthrough medication (Madabhushi et al, 2007; Grant and Wood, 2008). If patients are prescribed opioids preoperatively, they must be closely monitored in the postoperative period because the authors have observed that the lack of pain sensation may increase the risk of opioid toxicity. Concerns remain regarding an additive effect of high-dose opioids on neuropathic pain via opioid-induced hyperalgesia (Rakic and Golembiewski, 2009). These concerns are relevant to patients with PLP owing to the neuropathic nature of the condition.
Caution should also be exercised when considering further titration of strong opioids in the postoperative period and beyond. It is important to emphasise that the prescription of opioids within the acute postoperative period should aim not only to reduce pain but also to be part of a treatment plan aimed at improving the activity and functional rehabilitation of patients (British Pain Society, 2012). The long-term effects of opioid therapy, including increased risk of fracture and endocrine suppression, are becoming more apparent and should be considered (Schofield et al, 2014). There is evidence that about 3% of patients who started on opioids following surgery will remain on these medications for a long period of time, with the associated risks described (Clarke et al, 2014).
NMDA antagonists
N-methyl-D-aspartate (NMDA) receptors are widely distributed in the central nervous system (CNS), and are important mediators in the process of neural plasticity and neuropathic pain (Schug et al, 2016). NMDA receptors are thus an appropriate target for the treatment of PLP, but the evidence for use of NMDA antagonists is equivocal.
Several small studies and case reports, which have examined the perioperative administration of ketamine via different routes and at different doses, have not found any statistically significant difference in the incidence of PLP, but have reported a decrease in the severity of the phantom pain (Dertwinkel et al, 2002; Hayes et al, 2004; Shanthanna et al, 2010). Studies investigating ketamine, including randomised controlled trials (RCTs) (Hayes et al, 2004), prospective observational studies (Dertwinkel et al, 2002) and case reports (Shanthanna et al, 2010), have frequently reported psychotropic side-effects that limit the use of ketamine in the treatment of PLP. However, these side-effects are usually dose related and self limiting. The doses used in the authors' institution (most commonly 5–15 mg per hour intravenous infusion) rarely cause problematic side-effects and have been observed to enhance analgesia in a range of surgical specialties, including post-amputation surgery.
In practice, the use of an infusion beyond 48–72 hours may hinder early rehabilitation, such as mobilisation and gym visits. Oral ketamine does not provide favourable pharmacokinetic and pharmacodynamic properties (Neil et al, 2010), and so an alternative NMDA antagonist—memantine—is used in the authors' clinical practice. One relatively small prospective RCT (Schley et al, 2007) and two case studies (Hackworth et al, 2008; Neil et al, 2010) support the use of memantine, but concurrent pharmacological treatment is a significant confounding factor in these reports and this, along with the small study size in each of the 3 reports and concerns around rigorous methodology, reduces the ability to determine direct causality (Schley et al, 2007; Hackworth et al, 2008, Neil et al, 2010).
Gabapentinoids
There is mounting evidence to suggest that the use of perioperative gabapentinoids can have both short- and long-term benefits (Schug et al, 2016). In recognition of this, and for their opioid-sparing effects, this group of medicines has been incorporated in the authors' clinical approach. Patients undergoing amputation are often already prescribed gabapentin for pre-existing ischaemic limb pain. For these patients, the doses are optimised, including possible upwards titration, if they have already been administered a low dose for several weeks. For patients who had not been prescribed gabapentin, the commencement of pregabalin would be promoted because the clinical experience of the authors indicates that it reaches a therapeutic level more quickly than gabapentin.
Calcitonin
Calcitonin is a polypeptide hormone produced by the parafollicular cells of the thyroid gland in mammals, birds and fish (Visser, 2005). Calcitonin binds to G-protein-coupled receptors, which are structurally similar to opioid receptors, and are most prevalent in bone cells (osteoclasts), kidney cells (renal tubular cells), the CNS and the gastrointestinal tract (Visser and Kwei, 2006). Calcitonin is involved in a range of endogenous activities, including its primary role of calcium homeostasis via the inhibition of bone reabsorption, and the promotion of renal excretion (Lyritis and Trovas, 2002; Humble, 2011).
The antinociceptive effect of calcitonin was first investigated in animal studies almost 40 years ago (Wall and Heyneman, 1999). A number of mechanisms of action have been suggested, including an associated rise in plasma levels of β-endorphins, an anti-inflammatory effect linked to the inhibition of prostaglandin E2, and the movement of ionic calcium in the neuronal membranes (Appelboom, 2002; Azria; 2002; Lyritis and Trovas, 2002; Visser and Kwei, 2006; Qin et al, 2008). Contemporary theories propose the modulation of serotonergic neuronal activity in pain pathways in the CNS (Visser and Kwei, 2006). These theories are supported by the reduction in analgesic effect of calcitonin with the concomitant use of 5HT3 antagonists, such as ondansetron, and the presence of serotonergic-related side-effects (eg sedation, nausea, skin flushing and diarrhoea) (Visser, 2005; Humble, 2011).
The level of evidence is low for the inclusion of calcitonin in guidelines, and there is a current lack of well-designed prospective trials. However, the reported study findings and clinical experience are encouraging. Jaeger and Maier (1992) carried out an RCT to compare the efficacy of intravenous calcitonin versus placebo. Although the methodology of the study had several flaws, including lack of detail around randomisation, blinding methods and the omission of a power calculation, the results upheld the hypothesis that intravenous calcitonin administration following amputation for a range of pathologies provided a statistically significant reduction (P<0.05) in PLP compared with placebo (Jaeger and Maier, 1992). Long-term recurrence rates of PLP at 12 months were also lower in the treatment group compared with placebo, with 62% reporting a 75% reduction in PLP from baseline. Associated side-effects were mild but widespread among patients. Further supportive evidence for the use of calcitonin is provided by case reports (Fiddler and Hindman, 1991; Bharwani et al, 2003; Neil et al, 2012), which showed a reduction of PLP with minimal side effects, following treatment with calcitonin. It is difficult to attribute actual treatment effect within these reports owing to the co-administration of several additional anti-neuropathics, but this may support a multimodal adjunct approach, especially in view of the favourable side effect profile of calcitonin.
Having critically evaluated and synthesised the available evidence for the pharmacological treatment of PLP, a best practice guideline for the treatment of acute PLP was devised and implemented within the institution of a large university teaching hospital (Ninewells Hospital) (Table 3) (Colquhoun et al, 2014, Neil et al, 2014). This was supported by the multidisciplinary team and complemented by the adoption of non-pharmacological strategies.
| The following recommendations are evidence based. This guideline does not preclude individual, patient-centred, treatment options and clinician choice. |
|
High risk patients
|
| Standard perioperative regime |
| Perineural local anaesthetic infusion |
|
Gabapentanoids * (also refer to NHS Tayside Neuropathic Pain Guidelines) |
| If acute phantom limb pain (PLP) uncontrolled consider adding |
|
Salmon calcitonin
|
|
NMDA receptor antagonists
|
| * Dose reduction should be considered in the frail, elderly and renal or hepatic insufficiency |
Non-pharmacological treatment
It is well-known that anxiety and distress may exacerbate pain (Ballantyne and Sullivan, 2015). Psychological processes, such as lack of cognitive flexibility on pain, inactivity with behavioural fear avoidance and cognitive fusion, are associated with a suboptimal postoperative recovery and a heightened predisposition to chronic post-surgical pain (Weinrib et al, 2017). The nature of amputation surgery further compounds these issues owing to the prolonged recovery period, major changes in body image and practical implications on day-to-day life (Vase et al, 2011). The temptation to address distress by prescribing medication is usually ineffective and may produce problematic side-effects (Ballantyne and Sullivan, 2015).
A more appropriate approach is for all members of the multidisciplinary team (nursing students and registered nurses, medical staff and allied health professionals) to take biopsychosocial factors into account, by providing medication where appropriate, and by supporting the patient emotionally through this time of flux and distress. Emotional support can help patients accept the changes they are going through. Nursing students and registered nurses are in a privileged position to be able to provide regular one-to-one support. The use of relaxation exercises and smartphone apps for relaxation, meditation and mindfulness can reduce the stress response in relation to anxiety and distress, reduce catastrophic pain behaviours and improve sleep (SIGN, 2013).
In addition, early rehabilitation through physiotherapy, including techniques such as mirror therapy can be very beneficial. Mirror therapy aims to reverse maladaptive changes in cortical organisation through visualising the lost limb using a mirror. By moving the unaffected limb in front of a mirror a visual representation of the lost limb is produced (Foell et al, 2013). Developments in virtual reality have also aimed to mimic this response to, in effect, trick the brain. In addition, early input from prosthetics can reassure patients with PLP in their onward journey and in their ability to lead a fulfilling life. Providing more appropriate movement and proprioception can clinically reduce the incidence of PLP by providing more normalised body perception. The use of specialised designed limbs can allow patients to regain independence and involvement in previous hobbies such as sport.
Discussion
Pain management following amputation surgery is a complex and challenging problem. Patients undergoing amputation have a predisposition to difficult pain control. This group of patients are also likely to present with multiple comorbidities and have polypharmacy, which increases their risk of drug-on-drug interactions (Scottish Government Polypharmacy Model of Care Group, 2018). Older adults (aged ≥65 years) are vulnerable to problems associated with the existence of comorbidities, polypharmacy and physiological changes (Vickers et al, 2009; Schug et al, 2016). Changes in physical health for example, result in reduced gastric motility, a decrease in muscle mass, acute kidney injury, chronic kidney disease or liver impairment, and may affect pharmacokinetics (what the body does to the medicine) and pharmacodynamics (what the medicine does to the body).
When prescribing pharmacological treatments, it is important to consider the level of evidence that supports the use of a medication. As described previously, levels of evidence for the treatment of post-amputation pain are relatively weak. This is not unusual in pain medicine, where the subjective nature of pain experience and ethical and humanitarian issues regarding the denial of treatment are substantial. Researchers may calculate P values to determine statistical significance of data, but does a lack of statistical significance imply a lack of clinical significance? For example, reduction of two points on a visual analogue scale may not be deemed statistically significant, but it may indicate enough of a reduction to allow the patient to sleep or to attend physiotherapy for prosthesis fitting, resulting in a distinct biopsychosocial advantage for the patient and a minimal clinically important difference.
No individual pharmaceutical treatment option provides a universal panacea. Various drugs, acting through different physiological pathways, may exert some effect on the pathological processes underlying pain post amputation. This mirrors the concept of classical multimodal balanced analgesia and supports the concept of a balanced multimodal adjunct approach.
The ethical concepts of beneficence and non-maleficence should inform prescribing practice to ensure safety and a reduction in the risk of adverse effects, while improving the pain management of patients (Lovatt, 2010). Clinically, these concerns must be considered in conjunction with patient requirements, and a pragmatic approach needs to be adopted.
Pain management is a complex process involving effective communication with the patient, interpretation of assessment data and a broad knowledge of pharmacology in order to determine the most appropriate treatment. Experienced nurses do this so subtly that the patient or a junior nurse may not even be aware that they are doing it because assessment and evaluation takes place while the nurse is carrying out nursing activities. Accurate, timely assessment and appropriate evaluation of treatment options are imperative to the success of any pain management plan, particularly for patients with PLP.
Conclusion
Excellent therapeutic relationships and rapport between nurses and the patients in their care provides patients with the space to explore their pain experience, even when they feel vulnerable. Regular education of all members of the multidisciplinary team to clarify their roles, and to enhance and support their skills in order to provide excellent care has been shown to be beneficial (Cole, 2014). Future validation of the PAINGO framework and the ‘bothersome tool’, in conjunction with the evolution of a best practice guideline for the management of PLP, therefore, could potentially show a marked improvement in the incidence of problematic post-amputation pain, and that a multidisciplinary, collaborative pain management process is adopted in the future.
In conclusion, accurate pain assessment during every shift and providing patients with the opportunity to tell their pain story prompt changes to pain management treatments, thus preventing delay in providing optimal pain relief. Early recognition of patients who have difficulty communicating pain, adverse effects of treatments or uncontrolled pain will result in improved patient safety. Nursing documentation reflects the patients' experience of pain, their involvement in discussions and the decision-making process, plus their overall satisfaction with pain management while in hospital.