Psychological impact of pain in palliative care: Between death anxiety and meaning of existence, a complex psychological impact

This is a theorical and clinical reflection of psychologists and doctors, grounded in palliative care caregivers practice where interdisciplinary is at the heart of ethical reflection. A better understanding of pain in its psychological aspects will help to improve the care of patients in end of life and will help interdisciplinary thinking. The management of pain in palliative care is a priority. For the patient, the experience of pain causes a significant impact physically and psychologically. Impacts of pain on the psychic sphere include an increase death anxiety and impede the ability to think. However, although pain disrupts the patient's existential foundation, it can sometimes present positive functions for the psychological dynamics. This article aims to question and understand the psychological repercussions of pain in palliative care : What functions may have pain in patients psychological process? These reflexive approach about pain management will lead us to raise ethical questions and to brighlight the necessity of interdisciplinary discussion. In palliative care, the disease puts the patient's psycho dynamics under strain. The disease deteriorates the body as the support of narcissistic foundations, which will then be altered. These disruptions disturb the identity of the individual as they alter the perception of self. In this context, pain will have a significant impact. While the presence of the disease requires a defensive reorganization to adapt to a difficult reality, the pain tends to restrict the adaptive faculties of the subject. The feeling of pain reminds to the patients, at every moment, the existence of pathology. Pain causes a divestment of external reality and ``freezes'' the ability to think. Futhermore the experience of pain may suggest a worsening of the general condition, meaning the imminent end of life: Pain has the function of an alarm, indicating a risk of injury tend to increase death anxiety already caused by the existence of an incurable disease. Paradoxically, although the pain disrupts the existential psychic construction, the pain may have positive functions in the psychological dynamics. Pain, by its impact, tends to reduce anxiety by concentrating on one body area. Feeling the pain can also participate in maintaining the sens of existence: All bodily perceptions, even painful, attest of the fact of being alive and give an access to the feeling of being alive. The pain may be, for some patients, the only ``purpose'' because when the disease has completely destabilized the foundations of identity, feeling pain is continuing to be. The management of pain can become the primary objective for the patient, the center of its concerns. Through a displacement mechanism being centered on the treatment may allow the patients to focus on a manageable element. The pain is also involved in the representations of the body. The feeling of pain generates a work on subjectivity and leads to a perception of the body as personal and intimate. To conclude, pain is a true disruptive experience for a person. It breaks the already precarious balance caused by the existence of disease and end of life situation. But whether the pain disturbs the individual in its internal dynamics, it also can be a carrier of the psychic organization. The pain management in a palliative context requires to integrate in the caregiver's patient's care the reflection on the psychic impact of pain. Is allows to query the care process beyond of the symptoms treatment and to adapt the care closer to the patient's need. Our reflection promotes the recognition of the subject in his singularity, in his personal and subjective construction. By giving its place to the recognition of human being in its psychological dimension, the interdisciplinary then becomes the keystone of our reflection: by bridging a plurality of views, this approach offers to build different frames of thinking and encourages comprehensive patient care. (C) 2017 Elsevier Masson SAS. All rights reserved.