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Suffering |
Suffering is so inextricably related to pain in the minds of practitioners and scholars that scholarly treatises of suffering are usually titled pain and suffering.1 This sense that pain and suffering are intertwined does violence to considerations of both pain and suffering. The pain of childbirth, for example, is not typically linked to suffering. Indeed the distinction is usually made between pain with meaning and meaningless pain. Pain with meaning is pain associated with injury or pain affiliated with healing. These examples are instances of pain with a positive outcome and thus, meaningful pain. Meaningless pain is so named because the pain does not protect the individual where meaningful pain does i.e., the pain of contact with a hot stove. Meaningless pain often is indicative of a degenerative process. It is no longer the alarm of a burn or the warning of cardiac problems, it is the pain of degeneration. It is this type of pain that is more likely to be associated with suffering.
In definitions of both suffering and suffer, verbs such as undergo, endure and be affected with are paired with nouns such as grief, pain, injury and loss. It is the archaic derivation of suffer that emphasizes the verb endure. Further, synonyms for the verb "permit" include suffer, tolerate, connive. Connivance in one�s own or another�s distress is an aspect of suffering. Thus do we abet another�s suffering when we fail to acknowledge or recognize it? Do we abet another�s suffering when we fail to acknowledge their pain? Do we as caregivers permit the patient�s suffering?
The Link between Pain and Suffering The individual who has pain that is unrelieved is in distress. That distress is magnified if that individual is surrounded by healthcare providers who dismiss the pain or who are less than assiduous in their efforts to relieve the pain. In the instance of the person in significant pain who is cared for by professionals who are committed to relieving the pain, the person is still in pain but is comforted by the knowledge that attempts at pain relief are being undertaken. When the person in pain perceives that such help is not forthcoming, then the pain is accompanied by the sense of desolation and suffering ensues.
The Distinction between Pain and Suffering As noted previously, pain may occur without suffering. Such pain is very often short- term. The pain associated with suffering is usually of longer duration but may occur without suffering. Suffering may also be experienced without physical precursors. Pain hurts physically whereas suffering may hurt physically but is accompanied by psychosocial and spiritual effects. Cassell2 contributes to our understanding of suffering when he discusses sickness. He describes sickness as in part, a loss of connectedness. He states furthermore that "I have begun to think that the word "hopeless" stands for disconnectedness."2 The person with or without pain is hopeless, is disconnected from the familiar self and the familiar environment and is cast into a world where he or she is no longer in control. This loss of control happens to various degrees in other situations. For example, individuals who are incarcerated are separated from what was their familiar environment. College students, travelers, those in the armed services make a choice and thus have some control over their separation. In all of these situations there is still connection to the familiar self. With serious illness that connection to the familiar self is threatened.
When Cassell describes the world of the sick, he notes there is a loss of the sense of indestructibility and a loss of the sense of omnipotence.2 This loss while known on an intellectual level has been kept at bay during times of wellness. Suffering has to do with the impermanence of self not in itself alone but impermanence associated with a lack of completion, a lack of fulfillment. Those who are ready to die are not suffering; they have made their peace with the world. Cassell3 captures this sense of the term suffering when he states "Suffering is a specific state of severe distress induced by the loss of integrity, intactness, cohesiveness, or wholeness of the person, or by a threat that the person believes will result in the desolation of his or her integrity. Suffering continues until integrity is restored or the threat is gone" (p. 1899).3 Thus, the threat may continue but with the restoration of the sense of integrity, the suffering is diminished. After and example the relief of suffering will be consideredIn the next section. Loraine Day, a thirty-year-old married mother of a four-year-old, insisted that no one speak negative thoughts in her presence. She did not want to discuss what to her hospice team was her inevitable dying. For her suffering was being coerced by her health team to discuss her status. She was putting all her energy into staying alive. This focus became clear when she said to her husband within 24 hours of her death. "I can't fight anymore." Lorraine and her husband agreed she had fought hard and valiantly to live. Lorraine's suffering diminished as she and her loved ones chose the nature of their discussion. Suffering resulted from sensing a lack of control of what was in their control.
Prior to a further consideration of suffering, it is important to emphasize that the approaches to suffering to be outlined in this section are not to be undertaken as a substitute for good pain management. There is no excuse for not relieving pain. A caveat must be added to this statement in that the previous statement does not encapsulate the momentary discomfort of a needlestick. Excellent pain relief is a necessary part of excellent healthcare. The inadequacy of medication prescription and provision by doctors and nurses contributes to the pain and suffering of patients. There is no excuse for this source of suffering. There are other sources. Cassell4 notes that "suffering is an affliction of the person, not the body" (p. 531).4 Given that suffering has to do with a threat to the integrity of the person, the approach to relief is not technological. The approach is one of listening and learning about the patient as a person; what is meaningful to him or her, what is not. It has to do with presence. Being there for the person as he or she grapples with the reality of impermanence and brings to bear resources both personal and social to contend with what is a change in status i.e., becoming disabled permanently or being diagnosed as having a fatal disease. Usually there is no quick fix but rather a process of exploration and a determination by the person of how to live one�s remaining life. The presence of a caring health care provider who listens and acknowledges the trauma for the patient confronting impermanence is very helpful. In this process and it is an elegant one, the strengths and positive aspects of the person�s life must be identified and extolled. In time, a celebration of what there is may bring succor and alleviate the suffering.
The relief of suffering brings to bear a holistic approach to patient care. This holistic approach acknowledges the patient as person and the caregiver as person. The role of the caregiver as person is to be present and accompany the patient as person through the vagaries of far-advanced and terminal illness. The cure, if it occurs, will be of the social body.
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