DE LA SALLE MEDICAL AND HEALTH SCIENCES INSTITUTE
COLLEGE OF MEDICINE
DEPARTMENT OF PHARMACOLOGY
RESEARCH PROPOSAL:
Pain Management and Palliative Care: Knowledge and attitudes of third year and fourth year medical students from De La Salle Medical and Health Sciences Institute
GROUP 12 A
ABELLAR, Carl Moises T.

ALCANTARA, Frances Jessica A.

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ASTORGA, Alyanna Renee M.

DELA ROSA, Ara Lyn G.

ENRIQUEZ, Francesca Odessa H.

ERANDIO, Jenikka Avi E.

GUZMAN, Agatha Francesca Z.

HIPOL, Bernadine Nicole L.

JABOLA, Kay T.

RIVERA, Amira Vianca M.

Pain Management and Palliative Care: Knowledge and attitudes of third year and fourth year medical students from De La Salle Medical and Health Sciences Institute
Introduction
Pain is usually a symptom of other medical conditions. The prevalence and burden of pain makes it one of the most reasons for patients to seek medical care. Pain is defined as “an unpleasant sensory and emotional experience arising from actual or potential tissue damage.” The subjective aspect of pain makes diagnostic and therapeutic management difficult. Successful pain control usually starts by assessing and identifying the etiology and severity of pain. An arising medical issue is the under-treatment of pain as it negatively and collectively affects an individual’s well-being and quality of life (increased functional impairment and disability, psychological distress, social difficulties, and economic burden).

Deficiencies in pain management include cultural, societal, religious, and political attitudes aside from poor attitudes and lack of knowledge of healthcare workers. Among the attitudinal barriers of healthcare professionals to pain relief are misconceptions, unrealistic anxieties, and ignorance about medications, especially considerable concerns involving opioids such as addiction, tolerance, and dependence. Lack of a requisite and in-depth understanding in relevant areas such as properties of opioids, equivalent dosing, side effect, tolerance, and addiction are contributory to suboptimal and inconsistent management of pain. Other barriers to pain relief include inadequate and inconsistent pain assessment, patient’s endurance and reluctance to report pain, and reluctance to take opioid as an analgesic (Brennan, Carr, and Cousins, 2007).

Several studies and surveys of medical personnel (medical students, nurses, pharmacists, and physicians) have revealed knowledge deficits and attitudinal barriers to pain management, but have not determined why such attitudes persist and how they may be addressed (Watson et al, 2009). In the study of Weissman and Dahl (1990), medical students showed some negative attitudes regarding pain management and palliative care that if remained to be unrecognized and unchanged would contribute to future deficient and inadequate pain treatment. Students greatly exaggerated the incidence of psychological dependence in patients treated with opioid analgesics, inappropriately timed maximal analgesic therapy, and believe that increasing pain was invariably related to the development of drug tolerance rather than to progression of the disease.
There is a need for a more innovative, integrative, and consistent pain education in the medical curriculum that would aid greater retention of concept and skills among the students as current knowledge and practice of pain is limited, variable, and fragmentary.
This study aims to describe the knowledge, attitudes, and practices of medical students on pain management and palliative care. Medical students are of interest as they are trained to understand the mechanisms behind pain, pain medications, and they should be familiar with the proper use of medications for pain. Early assessment of knowledge and attitudes is vital to further make appropriate management on how to clear up medical students’ misconceptions and negative attitudes. Based on conventional judgment, it is hypothesized that fourth year medical students would have greater and a more consistent knowledge and practice on pain management strategies compared to their younger counterparts as they are clinically more experienced and that they would utilize pharmacological techniques more often than non-pharmacological methods due to their scientific background and knowledge of pharmacotherapy.
Statement of Objectives
General Objectives: To describe the knowledge and attitudes regarding pain management and palliative care of third year and fourth year medical students of the De La Salle Medical and Health Sciences Institute, AY 2018- 2019
Specific Objectives:
To measure the level of knowledge of medical students regarding attention given to and assessment of pain, opioids related issues, general principles of pain management, pain management issues in children, and non-pharmacologic aspect of pain management
To measure the level of knowledge of medical students regarding palliative care
To assess the attitudes of medical students regarding palliative care
To estimate the proportion of medical students with inadequate level of knowledge (i.e. a score less than 70%) when it comes to pain management
To determine the domains of pain management with the most and least number of correct responses
To determine the domains of palliative care with the most and least number of correct responses
To determine if there is a significant difference in the mean scores across genders, age groups, year level, educational background, various health- related undergraduate courses, work experience in the hospital, pain management training, and frequency of using objective tools for pain assessment
Review of Related Literature
Pain
Pain can be defined as a sensory and emotional experience with associated actual or potential tissue damage. This is the most common reason for patients to seek medical consult, yet it remains to be poorly succeeded. One of the primary reasons that poor pain management remains is on the absence of sufficient learnings of clinicians, which comes from an apparent absence of pain instruction amid the preparation of undergrad therapeutic understudies. (Tellier et al., 2013) This phenomenon is possibly caused by poor knowledge revolving around pain administration which may be due to an absence of pain education in preparing the extent that undergrad restorative understudies are concerned. A study by Tellier et al., titled “Improving undergraduate medical education about pain assessment and management: A qualitative descriptive study of stakeholders’ perceptions” found out that there was a need for more medical education about pain assessment and management not only for participating patients, but also for students and even pain experts. They concluded that there should be improvement of the curriculum about pain content and education about pain should teach the students to gather appropriate information about pain and to acquire knowledge of therapeutic options, so that they develop a trusting relationship with patients and to become aware of their own biases towards patients suffering from pain.

Rational use of the health system and drugs is made possible with the care provision provided by the health professionals to patients suffering from pain (Dalpai et al., 2017). Their study, which is titled, “Pain and palliative care: the knowledge of medical students and the graduation gaps”, invited medical students from the Federal University of Health Science of Porto Alegre and gave them a questionnaire with 19 direct question about pain management. The results showed that the majority of the students of UFCSPA medical course reported lack of enough information during their undergraduate studies regarding the correct handling of patients with pain. This was thought to be due to the students not receiving enough information about the subject matter, and similar results were observed with a different medical institution in the State of São Paulo, thus the thought of an existing gap in the pain’s teachings within medical schools throughout the country could be possible. According to their study, majority of the medical curriculum only have a brief integration about pain issues and often is a non-existent subject when it comes to the clinical stages. A study directed at the University of Michigan showed that majority of the physicians lacked formal education during medical school and medical residency about pain and its management, thus making it difficult for physicians to correctly diagnose and manage it. The study concluded that there are gaps in the teaching of topics about pain management and it should be highly emphasized since this indicates the quality of health care that is given to the patients.

According to Tauben et al., international studies point out similar deficiencies are observed within numerous medical schools. A study, which used a questionnaire, with medical students from a Finnish medical school showed that with regards to pain definition, knowledge, and aspects of about geriatric and pediatric pain, the students were taught insufficiently and this was also thought to be due to only a minority (15%) of the students had access to in-depth studies on the subject. Additional studies by Green et al., which reviewed the education of 368 licensed physicians in Michigan showed that 30% did not report formal education on pain handling. Proper pain management is considered as a universal requirement in health care (Glowacki 2015). However, regardless of the advancements in the medical world, the adverse physiological and psychological consequences of unmanaged pain remain unanswered. Enhanced interventions regarding this problem can improve patients’ attitudes and perceptions of pain, but although research and treatment in practice protocols have a documented progress in the treatment of acute and postoperative pain, little awareness of choosing the best practices remains. The study concluded that in using interdisciplinary pain teams could possibly result to a progress regarding pain education, pain management, outcomes, and satisfaction.

Palliative Care
Palliative care is a form of care geared to provide optimum quality of life to patients with serious life limiting illnesses. The goal of palliative care is to relieve the suffering of patients and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms experienced by patients (Rome et al., 2011). Palliative care centers on assertive management of symptoms combined with psychosocial support. To add further, it also encourages the patients and their families to make medically important decisions by explaining thoroughly the nature of the illness and prognosis. Medical Schools are challenged to improve palliative care education and to find ways to introduce and nurture attitudes and behaviors such as empathy, patient-centered care and holistic care (Centeno et al., 2016). It would be of great value if medical students are taught how to be competent in palliative care. For the successful integration of palliative care in medical curriculum, both the medical educators and the students must realize the value of this skill.
In a study by Brogstrom et al., titled “Learning to care: medical students reported value and evaluation of palliative care teaching involving meeting patients and reflective writing”, through an analysis of hundreds of essays, they found out that students stated that dedicated time with patients, education about wider elements of treatment and holistic care, practicing communication skills, and learning about themselves through reflective writing components of the palliative care teaching are valuable. They concluded that it is possible for medical students to meet at least two patients receiving palliative care individually. It and was found out that the students, through these encounters, reported that it helped them in widening their understanding of palliative care.

According to Dalpai et al., in their study titled “Pain and palliative care: the knowledge of medical students and the graduation gaps”, they found out that majority of the students did not know the proper drug and dose to use to start opioid treatment, also majority did not know the equivalents for rotating opioids and does not feel confident about opioid prescription. The study showed that the students have a lack in theoretical knowledge about the subject, and since they weren’t provided with enough information about patient care in terminal situations or even about the control of general symptoms such as vomiting, constipation, or dyspnea to patients receiving palliative care. The same results were observed to the students from Alpert School of Medicine in the United States, where it showed that less than half of the medical students worked with patients receiving palliative care and over a quarter were unprepared for management of common symptoms such as nausea, dyspnea, and anxiety. A study by Hermes and Lamarca, confirmed the need to recreate the medical school’s curriculum because of the lack in disciplines about palliative care. They concluded that there should be given importance about the discussion on palliative care in medical schools as this reflects on the quality of health care given to patients.
Common Attitudes in Medical Students
Knowledge on palliative care is very essential among medical students. Every year along their course of medical education, students are taught of the drugs, services, and skills regarding care for patients near the end of life. However, gaining a positive attitude toward palliative care is a more challenging task. Many medical students find it difficult to deal with patients with terminal illness, as they need to inform the patient, answer questions regarding the illness, and comfort the patient and the family. A great deal of newly-qualified doctors feel inadequately trained on the skills necessary in dealing with patients on palliative care. Recently, there has been an increased emphasis in including palliative care in medical curriculum, both in policy and in practice. Honing the attitudes of students toward palliative care is of considerable importance because attitudes predict future behavior, and positive attitudes toward hospice care are associated with increased referrals
In a study conducted by Barclay et al. entitled An Important But Stressful Part of Their Future Work: Medical Students’ Attitudes to Palliative Care Throughout Their Course, 1027 participants from The School of Clinical Medicine at the University of Cambridge were given questionnaires (every year from 2007 to 2010) containing validated instruments on measuring their attitudes toward palliative care, death anxiety, depression, and personal accounts of bereavement. Results showed that over the entire course of their medical education, students had broadly positive attitudes on palliative care. This positive attitude increased even further during their clinical exposure towards the end of their medical education.

Issues in Palliative Care
The study, Psychosocial The Patient, Process and Issues in Palliative Care: the Family, and the Outcome of Care by Vachon et. al, addresses the psychosocial issues happening in terminally ill cancer patients. Some major symptoms that contribute to the distress of the patients are gradual decrease in energy, constant fatigue, loss of appetite, development of anxiety and depression, increased suicidal thoughts, and persistent feeling of frustration. It has also been stated that the cancer patient’s required services increases with the severity of their illness. This, in turn, affects the mental attitudes of the family as well and how they react when they encounter the cancer illness experience. Depending on the illness trajectory of the patient, the family undergoes different stresses and have varying mechanisms to cope with it. In the early stages of cancer, wherein the patient is not yet experiencing any symptoms, the knowledge of the family as well as the emotional support they need is notably absent in this stage. However, there is increased stress and anxiety when a member is diagnosed with cancer already. Usually at this stage of the disease in the patient, there is increasing concern about the comfort of the patient and family members also have the eagerness to learn about the disease. They play a more active role in decision making at this stage. In conclusion, not only that the disease takes a toll on the patient alone but as well as the family. This suggests a holistic approach should be used in administering palliative care among individuals diagnosed with terminal disease and their family.
Ethical issues regarding palliative care also exist. In the study, Ethical Issues in Palliative Care by Kinlaw, stated several factors that contribute to the issue of palliative care. These include communication and ethics, shared goals, resuscitation decisions, withholding or withdrawal of treatment, and fluids and nutrition. In communication and ethics, it is imperative to have an honest and open communication between the patient and his family members throughout the trajectory of disease. Both parties should be well informed and have complete participation in making decisions. The information regarding the disease, treatments needed to be done, and prognosis should be disclosed to the patient and family members. In shared goals, an “advance care planning” is advised to the patient. This is a procedure wherein patients are urged to consider their care or treatment inclinations if their illness makes it impossible for them to advocate for themselves. The advance care planning establishes a structure for shared decision-making between the patient, family members, and healthcare providers. In resuscitation decisions, it is presumptive that each patient would prefer to be resuscitated in any case. However, resuscitative efforts are often proven unsuccessful especially in late stages of the diseases such as renal failure, acute stroke, sepsis, and metastatic cancer. Revival choices are ought to be talked about with all involved relatives so clinicians will be supported when they decide to withhold resuscitative efforts. In withholding or withdrawal of treatment and fluids and nutrition, similar with the resuscitation decisions, additional interventions such as oxygen ventilation, administration of antibiotic treatments, and providing of artificial fluids and nutrition should also be discussed with the patient and family members. In simplicity, any treatment that would harm the patient should be stopped and procedures that would bring about effective results to the patient should be continued.

General Principles of Pain Management
Pain is a subjective, unpleasant, sensory, and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. There is no physiological, imaging, or laboratory test that can qualify nor quantify pain. Pain is what the patient says it is. Whenever a patient reports the presence of pain, the doctor must accept it accordingly. Fields et al. defined pain as an unpleasant sensation localized to a part of the body. It is often described in terms of a penetrating or tissue-destructive process (e.g.: Stabbing, burning, twisting, tearing, and squeezing) and/or of a bodily or emotional reaction (e.g.: Terrifying, nauseating, and sickening. Pain has a biologically important protective function. The sensation of pain is a normal response to any injury or disease, and is a result of normal physiological processes within the nociceptive system. There may also be other manifestations of pain related to tissue injury, including hyperalgesia, an exaggerated response to a noxious stimulus, and allodynia, the perception of pain from normally innocuous stimuli.

The goal of pain management includes relief of pain whenever possible: from nociception to the conscious experience as well as to decrease the emotional response to the unpleasant experience. Treatment should aim to decrease the intensity of acute pain in an effort to reduce or prevent permanent changes in the nervous system that may result to chronic pain. Management of pain is a process of several steps, including pain classification, assessment, screening, and planning.

Pain classification is an important step in management of pain as it aids in the assessment and planning processes. The common types of pain include nociceptive, neuropathic, and inflammatory. Nociceptive pain refers to the normal response of the body to noxious insult or injury. Examples of nociceptive pain include musculoskeletal pains (joint pain, myofascial pain) and visceral pain such as referred pain from hollow organs and smooth muscle. Neuropathic pain is initiated by a primary lesion or disease in the somatosensory nervous system. This type of pain includes numbness to hypersensitivity (hyperalgesia or allodynia), and to paresthesias such as tingling. Inflammatory pain is a result of activation and sensitization of the nociceptive pain pathway by a variety of mediators released at a site of tissue inflammation. Examples include pain felt in patients with appendicitis, rheumatoid arthritis, inflammatory bowel disease, and herpes zoster.
After classifying pain, intensity of the pain must be reported. Broadly, pain can be categorized as mild, moderate, and severe. Typically, a numeric scale to rate the pain is utilized where 0 corresponds to no pain, while 10 represents pain of the worst degree. In a study by De C et al. entitled Simple pain rating scales hide complex idiosyncratic meanings, he tested the reliability and consistency of self-report of pain by patients using visual analogue scales (VAS) and numerical rating scales (NRS). The study examined patients’ use of VASs and NRSs, by their own description, with particular attention to rating of multiple pains, of different dimensions of pain, and of interpretation and use of lower and upper endpoints and increments on the scales. Participants were given forced choice and free response questions. Results showed that there was indeed a lack of consistency between the ratings given by the participants.

The duration of pain should also be considered when classifying pain. Pain of less than three to six months’ duration is categorized as acute pain. Chronic pain is pain lasting for more than three to six months, or persisting beyond the course of the disease.

Pain management requires a multidimensional assessment to develop a multimodal treatment plan for the patient. Pain history should include location, quality, intensity, temporal characteristics, aggravating and alleviating factors, impact of pain on function and quality of life, past treatment and response, patient expectations and goals. Physical examination should include comprehensive sensory and musculoskeletal examinations, with a thorough observation of verbal and nonverbal pain behavior, posture, gait, and position. After careful consideration of the patient history, physical examination, and pain assessment, differential diagnoses must be generated. This will narrow down the treatment options for the patient, and this will provide a better avenue to address the pain felt by the patient.

Treatment planning for pain starts with establishment of goals, expectations, methods, and time course of treatment. The goals of pain treatment differ depending upon the type of pain and the nature of the individual case. Patient and family goals must be reconciled with what is possible and reasonable given the situation. In acute pain, the major goals are pain control and relief while efforts are made to identify and treat the underlying disease and to enhance healing and recovery. Adequate management of acute pain may also prevent the development of chronic pain. Analgesics are the mainstay of acute pain treatment, but non-drug methods (patient education, heat/cold, massage, distraction/relaxation, others) are essential too. In some situations, regional analgesia and anesthesia are also indicated. In most cases of chronic pain, multiple mechanisms are at play and the cause of the pain may be difficult to identify and cannot be completely eliminated. Pain relief is still primary but the goals of improvement in function and quality of life gain even greater importance. In addition to pain reduction, prevention of secondary pain problems is essential. Treatment planning takes into consideration the time course. A well-defined time frame for accomplishment of goals must be established. Reassessment of treatment is crucial to ascertain whether treatment is working or needs further modification. In the outpatient setting, reassessment may be done every few days to months; in the inpatient setting, treatment outcome is generally assessed within minutes to hours of intervention. By defining the time frame for treatment, all parties share the same set of expectations. Active treatment may end if first, treatment goals are met so treatment is no longer required; Second the treatment has not worked despite appropriate adjustments, or lastly, if the patient is unable or unwilling to participate in meeting goals.

Non-pharmacological Aspect of Pain Management
Non-pharmacological pain management is an approach that focuses on reducing pain without the use of drugs. It is believed that these non-pharmacological techniques alleviate pain by interfering with the hypersensitivity elicited by body, and by stimulating endogenous endorphin dispersal and neuropeptide system. This pain management commonly uses music, hypnosis, relaxation techniques and coping strategies. (Bellieni et al., 2001; Hebb et. al, 2005)
Using music is believed to be helpful in pain management by means of “Music Therapy”. Music therapy is an evidence-based use of musical elements to achieve positive interactions, restore impaired functions and to improve patient’s emotional and cognitive status. (World Federation of Music Therapy, 2010). In the study of Guetin et. 2011, it has been observed that there was a significant reduction in the pain score of the population exposed to the music intervention technique compared to control group. The results of their examination also revealed that there was a relative improvement of 53% in the patients with depression, and 50% in those with anxiety.

In neonates, swaddling, non-nutritive suckling, facilitated tucking are commonly the non-pharmacological techniques used for pain relief. Non-nutritive suckling, which is done by placing a pacifier in the infant’s mouth, may aid in calming a crying baby. It also caused a significant reduction of the pulse rate and it may influence the physiological pain indicators (Corbo et.al,2000). Facilitated tucking may also decrease the pulse rate and the neonate’s total crying time after a painful intervention (Corff et. al, 1995). More so, swaddling or wrapping the baby in fabric cloth is associated with reduced of pulse rate after a distressing procedure, and increased in oxygen saturation during recovery phase (Fearon et.al, 1997). However, this finding opposed the results in the study of Huang et al. (2004), wherein swaddling did not significantly affect the oxygen saturation of the neonate.

Hypnosis, imagery and relaxation training are the non-pharmacological techniques usually done to reduce the pain caused by medical procedures. In the study of Lang et al (2000), patients exposed to these non-pharmacological adjuncts have higher comfort levels than those who were not. Hypnosis was then linked with reported reduced pain and anxiety of the exposed population. Further, hypnosis group had fewer overall and severe episodes of oxygen desaturation and episodes of hemodynamic instability.

Pain Management Issues
Opioid Use
The use of opioids as analgesics is commonly encountered in patients suffering from chronic pain (Anita Gupta & Richard Rosenquist, 2018). In the past years, prescription of opioids for non-acute conditions have been increasing. Benefits of using opioids for short term therapy have been backed up by clinical trials, in contrast, studies on the benefits of long term therapy of opioids are limited. Furthermore, risks related to the chronic use of opioid therapy have a direct correlation with dosage amount (Anna Lembke, Keith Humphreys, & Jordan Newmark, 2016).

Certain risks have been attributed to chronic opioid therapy such as constipation and abdominal pain. Constipation, is a widely reported adverse effect of the use of opioids that is prevalent in 15 to 90 percent of patients. Prolonged use may lead to constipation being unmanageable by stool softeners and laxatives that may eventually progress to obstruction of bowels, perforation and even death. The occurrence of a new-onset or worsened abdominal pain may be linked to chronic use of opioids as therapy for pain. Although presence of such symptom is less common compared to constipation (Anna Lembke, Keith Humphreys, & Jordan Newmark, 2016).

Limitations on the success of chronic opioid therapy has been due to physiologic changes in the central nervous system relating to the long term use of opioid therapy. Such changes include somnolence, a common symptom among these patients that is most likely due to the anticholinergic activity of opioids. Another is cognitive impairment that develops as soon as opioid therapy is ensued and one that is also of concern is respiratory depression which some studies have found to decrease in occurrence by titration in small doses is respiratory depression (Candiotti & Gitlin, 2010).

Physiologic adaptations to prolonged opioid therapy can manifest as tolerance, dependence and addiction. Tolerance, follows the neuroadaptive changes that are in response to opioid therapy evident in diminished drug efficacy (Candiotti & Gitlin, 2010) and is often seen in patients which need the amount of the drug in increasing doses (Anna Lembke, Keith Humphreys, & Jordan Newmark, 2016). Dependence on opioids occurs when the maintenance of homeostasis relies on the continuance of intake of the drug (Anna Lembke, Keith Humphreys, & Jordan Newmark, 2016). Symptoms presents when there is an abrupt cessation on the usage opioids (Rosenblum, Marsch, Joseph, & Portenoy, 2008). A neurobiological disease that is complex adverse event of prolonged opioid therapy use that is characterized by a compulsive consumption of the drug regardless of experienced relief of pain is described as addiction (Candiotti & Gitlin, 2010).

Physical and physiologic tolls due to chronic usage of opioids as therapy following chronic pain lead to adverse events that remains controversial and still requires resolution.

In Children
Proper assessment and management of pain are both needed to care for pediatric patient. The determination of the occurrence and gravity of pain in children followed by treatment may be difficult to discern. Tools based on the cognitive ability is vital in making sure that children receive sufficient pain control (Julie Hauer & Barbara L Jones, 2018).

Issues regarding the pain management of children involves the failure of health care professionals to integrate functional and reliable assessment tools and the absence of relevant data on the pharmacokinetics and pharmacodynamics of pain-relieving medications (Christine Miaskowski, 2003). Important factors that affect the use of research in direct pain management are needed to be established through better understanding and improvement of various programs to provide appropriate care to pediatric patients (Ahmad Ismail, 2016). Moreover, children’s presentation of pain is different and unique thus techniques same of that of the previous patient may not ensure the same effectivity in a different patient. Consideration of many factors such as the child’s age, cognitive and communication skills, previous experiences with pain, level of development and beliefs is a must since, the understanding of pain in children is complex and involves many aspects of the child such as psychological, physiological, behavioral and developmental factors (Morton, 1997; Oakes, 2011). To add, the nature of the child’s illness must be taken into thought and so is the child’s ability to participate in the evaluation of pain (Ahmad Ismail, 2016).

Gaps on the Knowledge about Pain Management
In actuality, there are innumerable alternatives for relief from discomfort. However, there are several underlying issues that contribute to the lack of palliative care among patients. One problem important for discussion is the gap on the knowledge about pain management.
In the study conducted by Aziato and Adejumo 2014, the nurses’ skills gap about pain treatment in Ghana might have come about because of syllabus gaps during practicing days, insufficient supervision from superiors during clinical hours, inadequate review days, and lack of workshop period for training nurses. Moreover, funds that are supposed to be intended for the organization of periodic workshops are cut down, which is also one of the reasons why nurses have information breaks regarding pain care. Lastly, the study also disclosed that new information regarding pain management was not readily enforced in clinical practice because of the fact that some of the nurses have negative reactions when it comes to learning novel instructions.
From the study results of the research entitled, Pain and palliative care: the knowledge of medical students and the graduation gaps by Dalpai et. al, larger part of the pupils revealed that during their undergraduate courses, they have not been exposed to sufficient modules regarding the remedy algorithm of patients experiencing pain. Specifically, education about pain, updated research on pain and proper handling of pediatric and elderly patients struggling with pain were taught unsatisfactorily. Students who have theoretical knowledge on pain still have difficulty in administering analgesia to patients. Medical students in this study also admitted that they did not get plentiful theoretical knowledge on how to provide pain care for terminally ill patients and control their symptoms such as vomiting, constipation, dyspnea, and weight loss. The study also observed that medical students are afraid of prescribing opioids for patients with respiratory depression because of the possibility of chemical dependence brought about by this drug. It is imperative to establish a curriculum on pain education that assists the students to apply theoretical knowledge on real-life palliative care. Still, treatment should be patient-centered; risk assessment for opioid tolerance and dependence should be added.
Summary of Related Studies about Pain and Palliative Care
In a study conducted by Eyob et al., with a title, Knowledge and attitudes towards pain management among medical and paramedical students of an Ethiopian University, aims to assess level of knowledge and attitudes regarding pain management of the final year students of medical and paramedical students of College of Public Health and Medical Sciences of Jimma University, South-west Ethiopia due to an issue that has been demonstrated such as poor attitudes and insufficient knowledge regarding pain. The researchers used 23-item Likert Scale questionnaire which focuses on, 1) attention given to and assessment of pain, 2) opioids related issues, 3) general principles of pain management, 4) pain management issues in children and 5) non-pharmacologic aspect of pain management. The results revealed that only 52.3% of the respondents got the correct answers and only 4.2% scored above the cut-off of 70% for good knowledge about pain management. However, 73% responded that the have learned enough about pain management during their academic years. The study found out that there is a huge deficiency in the level of knowledge and attitudes which intensifies the inadequacies in pain management. This strongly demands improvement in education regarding pain in general so as to give a better quality of life to the patients.

A study entitled, Medical students’ knowledge and attitude toward cancer pain management in Saudi Arabia by Kaki in 2011, which primarily aims to assess the final year medical students’ knowledge, beliefs and attitude toward cancer pain and need for a formal pain curriculum in medical schools. The study was conducted for almost two years at King Abdulaziz University Hospital in Jeddah using a closed-answer questionnaire. The study is limited only to cancer pain and the use of English questionnaire among Arabic-speaking students. The questionnaire consisted of 18 close and open-ended questions covering four major areas regarding pain in cancer: 1) Attitude regarding the management of cancer pain as a future health care provider, 2) beliefs regarding the risk of opioids addiction and its side effects, 3) attitude toward involvement of patients, families, and health professionals in managing pain of patients and lastly, 4) personnel experiences with pain and its effect on the candidates response. At the end of the study, it was concluded that the medical students even on their final year still have inadequate knowledge and have negative attitude toward cancer pain management. This study also found out that the most important hindrance to optimal pain management were lack of guidance from pain specialists, lack of knowledge and lack of pain assessment. The result could be related to the varied beliefs of the students towards pain in cancer.
In a study conducted by Yanni et al., which was entitled as Preparation, confidence and attitudes about chronic noncancer pain in Graduate Medical Education, reports that physicians are unsatisfactorily prepared to manage chronic noncancer pain partly due to lack of training. The objective of the study was to assess resident preparation, confidence and attitudes about CNCP across graduate medical education programs and their perception of roles and responsibilities in CNCP management. The researchers used an online GME Chronic Noncancer Pain Survey wherein respondents were divided into categories: 1) Generalists, 2) nonsurgical specialties, and 3) surgical specialties. In terms of preparedness, 59% of respondents rated their preparatory years in medical school as fair or poor, 36% rated their residency training as fair or poor and the specialists were more than twice as likely to report good or excellent. In terms of confidence, only 17% reported being confident to very confident in CNCP patient assessment and 13% reported being confident to very confident in prescribing opioids for CNCP. The study also revealed that confidence in opioid prescription increases with years of training. In terms of attitudes, 25% agreed to strongly agreed that requesting for opioids is an addictive behaviour while 28.7% agreed to strongly agreed that asking for more opioids is an addictive behaviour. In the statement “working with patients with chronic pain is…”, most of the respondents reported to be challenged by it. The results of the study showed that regardless of specialty, residents lack preparation to treat chronic pain, have low confidence in assessment, treatment and prescription of opioids for patients with CNCP however, this increases with more training years. Although negative attitudes towards chronic pain increases with years of training, residents believe that chronic pain is treatable and may lead to positive outcomes. The study concluded that education in pain management should start during medical school and continue regardless of specialty chosen.

A study of Barclay et al. in 2015 which was titled as An important but stressful part of their future work: Medical students’ attitudes to Palliative Care throughout their course aims to examine medical students’ attitude towards palliative care every year in the course and to investigate changes in the attitudes over time. Palliative care (PC) education is important to prepare students especially when encountering terminally ill patients. The longitudinal cohort study was conducted at The School of Clinical Medicine at the University of Cambridge used a questionnaire by Sullivan et al. with a five-point Likert scale. More than 93% of respondents agreed that doctors are responsible to assist patients prepare for the end of life while more than 95% agreed that physical and psychological difficulties can be equally severe. Furthermore, around 40-60% were neutral about the impact of caring for the dying which can be depressive and dreadful. Generally, from the start until the end of the course students have broadly positive attitudes towards PC with increasing positivity each year and at the end of the course. The neutrality of students towards personal impact of PC may limit student learning, participation as a doctors and providing clinical care. The increasing positivity can be related to the students’ increasing exposure and interaction with patients in the clinic but it is important to note that the increase is minimal which may indicate that there might me a challenge in promoting change in attitudes.

Due to the changes in Medical Licensure Act in Germany, new curricula have been implemented with respect to medical students’ knowledge of palliative care. In line with this, a study of Weber et al. in 2011 was conducted with the title, Knowledge and attitude of final-year medical students in Germany towards palliative care – an interinstitutional questionnaire-based study. The researchers used a three-step questionnaire in which the first part focused on students’ confidence towards palliative care, the second part focused on detailed information about the knowledge level of final-year students using the Palliative Care Examination tool and the third part, inquires about the students’ experience of the new curriculum and mandatory implementation of palliative care education. The result of the study showed only 5-10% (n = 318) of students have high confidence in dealing with palliative care issues while only 33% answered more than 50% correctly. Thus, the researchers concluded that the medical students have limited knowledge and confidence in dealing with palliative care issues.

Moreover, according to the study of Eyigor (2013), palliative care has become more important in the health system today but, the lack of knowledge by health professionals interfere with the improvement of quality of care. The study was conducted in Turkey were in fifth year students were chosen to participate. The researcher used a survey questionnaire which was subdivided in philosophy, pain, dyspnea, psychiatric problems, gastrointestinal problems and communication. Of the 175 respondents, 98.9% responded that they did not receive any palliative care education but, most of them can define palliative care. The researchers concluded that there is an inadequacy of knowledge on symptom control and communication in palliative care patients.

Methodology
Research Design
Type of study employed
The study will employ a descriptive, analytic study design. This study design is appropriate in topics that are concerned in measuring the level of knowledge and attitudes in a particular topic. The respondents would first be described according to socio-demographic characteristics and the level of knowledge and attitudes regarding pain will be characterized in relation to the socio-demographic features of the sample population. In the analysis phase, appropriate test statistics such as t- test and one way ANOVA will be used to determine if there is a significant difference in the mean scores of at least two independent groups in a particular variable of interest. Owing to the nature of data collection in a cross- sectional study design, data that will be obtained in this study may only hold true during the time the data was collected. Thus, the data to be obtained may not account for deviations in the knowledge and attitudes of the respondents regarding pain management in the future.

Definition of study population/ study groups and source of subjects
The investigators chose medical students as the study population since they are one of the health professionals mostly involved in the management of pain and palliative care in the future. And so, it is a must to investigate their knowledge and prevailing attitudes regarding pain management and palliative care in order to gain a deeper understanding of the gaps in knowledge and misconceptions that medical students have which would ultimately influence the health outcomes of patients. The investigators limited the study population to third and fourth year medical students since the topic of pain and palliative care are often tackled in-depth during third year, wherein clinical subjects are introduced. In doing so, study participants are expected to have at least a basic idea of pain management and palliative care.

Sampling Design
Sample population
The sampling population of the research include third and fourth year medical students enrolled in the Doctor of Medicine program of the De La Salle Medical and Health Sciences Institute, in the second semester of AY 2018- 2019.

Inclusion and Exclusion Criteria
An eligible participant should satisfy all of the following attributes: (1) he/she should be third and fourth year in standing at the time of data collection, and (2) is currently enrolled in as a student in the DLSMHSI College of Medicine. The study will exclude any students on leave of absence (LOA) or absence without leave (AWOL).

Sampling Frame
The list of third and fourth year College of Medicine students who are enrolled in the second semester of AY 2018- 2019 will be obtained from the Office of the Vice Dean. The sampling frame is needed in order to randomly select potential respondents.

Sampling Unit and Elementary Units
Both sampling and elementary units will be chosen from the official list of third and fourth year students enrolled in the Doctor of Medicine program of DLSMHSI, for the second semester of A.Y. 2018- 2019.

Sampling Method
Study participants will be selected from the list of third and fourth year medical students of DLSMHSI for the second semester of A.Y. 2018- 2019. The procedure to be followed in sampling is listed as follows:
Sample size (n) calculation will be done by following the formula for sample size computation of a cross sectional study.

Elementary units will be chosen from the official list of third and fourth year medical students of DLSMHSI for the second semester of A.Y. 2018- 2019 through simple random sampling.

In employing a simple random sampling method, the list of sampling units will be created. Corresponding numbers will be assigned for each of the sampling units. Random selection will be done through generation of random numbers using OpenEpi. The process of randomization will identify n individuals between 1 and N (target population size)
Sample size
In order to compute for the sample size, the following formula will be used.

In order to estimate the proportion of medical students with inadequate level of knowledge (i.e. a score less than 70%), a standard normal deviate of 1.96 will be used. The amount of deviation from the true value allowed in this study is set at 5%. According to the study done by Eyob et al, 95.8% of the medical and paramedical students surveyed have an inadequate level of knowledge regarding pain management (i.e. a score of less than 70%). Using the values indicated in the literature and those set by the researchers, the sample size estimated for this study can be computed.

n = 1.962 x 0.958 (1-0.958) = 62
(0.05)2
Hence, to estimate the proportion of medical students with inadequate level of knowledge with a 5% margin of error at a 95% confidence interval assuming that the population prevalence is 95.8%, 62 medical students should be included in the study. However, the sample must also account the possibility of participant attrition into consideration since some may not give their consent to participate owing to a heavy academic workload, absenteeism, or for any other personal reasons. In addition, some of the data collected from the questionnaire may be invalidated due to incompleteness or inappropriateness of response.

Attrition rate
In order to calculate for the final sample size, the following formula for attrition rate is used.
n’= n / (1- A)
In this formula n is the initial sample size, A is the expected rate of attrition, and n’ is the final sample size. This formula is employed to account for potential dropouts that may arise in the conduct of the study which could threaten the internal validity of the results. In this study, the expected rate of attrition is set at 40%. Applying the formula above, the final sample size is 103.

n’= 62
(1- 0.4) = 103
Thus, accounting for the potential dropouts, the study should include at least 103 respondents.

C. Limitations/ Delimitations
Owing to the nature of a self- administered questionnaire, the correct responses of the participant may not reflect his/ her true knowledge in all instances such as in cases where a correct guess is made. In addition, due to the heavy academic workload that medical students have to face, some respondents may be tempted to simply guess the answers in the questionnaire to minimize the time required in answering; thus, possibly underestimating the true level of knowledge. The t-score that denotes a difference in the mean scores of two independent groups is randomly set at 2.0, a value that researchers deemed significant enough. The healthcare professionals that will be included in this study will only include third and fourth year medical students; thus, excluding those in the first two years of the Doctor of Medicine program. The rationale for focusing on the knowledge and attitudes of third and fourth year medical students regarding pain management is that they are the ones who have knowledge and/ or clinical exposure on pain management.

D. Step by step process on how to achieve the objectives
In achieving the four specific objectives, respondents will be asked to answer the questions in the 22- item questionnaire examining knowledge and attitudes regarding pain management. Randomly selected medical students will be asked to answer two self- administered questionnaires, one asking relevant socio-demographic variables (e.g. sex, age, year level, educational background and level) and another measuring the level of knowledge and attitudes regarding pain management. Details on how to achieve each of the four objectives are presented in Table 1 below.

Table 1. Process on how to achieve the specific objectives
Specific Objectives Process on how to achieve the specific objectives
1. To measure the level of knowledge of medical students regarding attention given to and assessment of pain, opioids related issues, general principles of pain management, pain management issues in children, and non-pharmacologic aspect of pain management Questions will be stratified according to the different categories of knowledge and attitudes regarding pain management; that is, attention given to and assessment of pain, opioids related issues, general principles of pain management, pain management issues in children, and non-pharmacologic aspect of pain management. Mean scores with corresponding standard deviations will be computed for each category of knowledge and attitudes regarding pain management.

2. To measure the level of knowledge of medical students regarding palliative care Domains of palliative care that are included in this study included are philosophy, pain, dyspnea, psychiatric problems, and gastrointestinal problems. Mean scores with corresponding standard deviations will be computed for each of the domains of palliative care.
3. To assess the attitudes of medical students regarding palliative care Absolute and relative frequencies expressing the agreement and disagreement to a particular statement will be computed using Microsoft Excel version 2016.
4. To estimate the proportion of medical students with inadequate level of knowledge (i.e. a score less than 70%) The proportion of medical students with a score less than 70% in the 22- item questionnaire will be computed via Microsoft Excel version 2016.
5. To determine the domains of pain management with the most and least number of correct responses
The domains of pain management with the most and least number of correct responses will be determined by calculating for the proportion of correct responses on each question via Microsoft Excel version 2016. The responses will be ranked and the percentage of those who got the correct responses for the particular question will be presented in a table. Furthermore, the number of correct responses for each of the domains of pain management will be determined. The rationale for obtaining this information is to highlight which domain of pain management is the most misunderstood; thereby, allowing educators to address misconception in these areas with appropriate educational strategies.

6. To determine the domains of palliative care with the most and least number of correct responses The domains of palliative care with the most and least number of correct responses will be determined by calculating for the proportion of correct responses on each question via Microsoft Excel version 2016. The responses will be ranked and the percentage of those who got the correct responses for the particular question will be presented in a table. Furthermore, the number of correct responses for each of the domains of palliative care will be determined.

7. To determine if there is a significant difference in the mean scores across genders, age groups, year level, educational background, various health- related undergraduate courses, work experience in the hospital, pain management training, and frequency of using objective tools for pain assessment In order to determine if there is a significant difference in the mean scores between variables that have only two independent groups (i.e. gender, age, year level, educational background, work experience in the hospital, pain management training, and frequency of using objective tools for pain assessment), T- test scores will be computed. Likewise to assess if there is a significant difference in the mean scores between a variable that has more than 2 independent groups (I.e. health- related undergraduate course) a one way analysis of variance (ANOVA) will be employed.

E. Plan for data analysis
Prior to encoding of data, the researchers will screen the data if whether they satisfy the study’s inclusion criteria. Inability to satisfy the inclusion criteria, incompleteness, and inappropriate responses are grounds for the response to be excluded in the analysis phase of the data. Data will be encoded using Microsoft Excel version 2016 using the coding scheme in the operational definition of variables. Through the software’s consistency and range check program, out of range entries and data inconsistencies will be excluded from the data analysis.
Univariate analysis
Analysis of data will be performed in two levels. Firstly, univariate analysis will be performed in order to describe the study population. The first phase of data analysis is performed to characterize the patterns of response for each variable. The variables, corresponding scale of measurement, and descriptive statistics are shown in Table 2 below.

Table 2. Study variables and corresponding scale of measurement and descriptive statistics
Study variable Scale of Measurement Descriptive Statistics
Knowledge of medical students regarding pain Ratio Mean + S.D.

Sex Nominal Absolute and relative frequencies (proportion)
Age Ratio Mean + S.D.

Year level Nominal Absolute and relative frequencies (proportion)
Educational background (Health vs Non- health related undergraduate degree) Nominal Absolute and relative frequencies (proportion)
Health- related undergraduate course* Nominal Absolute and relative frequencies (proportion)
Work experience in the hospital Nominal Absolute and relative frequencies (proportion)
Pain management training Nominal Absolute and relative frequencies (proportion)
Frequency of using objective tools for pain assessment Nominal Absolute and relative frequencies (proportion)
*This variable is not applicable to participants who do not have a health- related baccalaureate degree.

General characteristics of the sample population will be presented in a manner similar to table 3 below.

Table 3. General characteristics of the sample population (n= 103)
Variable n %
Age (Mean= X, SD= Y) Below mean Above mean Gender Male Female Year level Third year Fourth year Educational Background Health- related undergraduate course Non health- related undergraduate course Work experience in the hospital (Range= A-B) Yes No Pain management in training Yes No Frequency of using objective tools for pain assessment Yes No The items will also be ranked according to the number of correct responses, with the item with the most number of correct answers ranked first. The absolute number and percentages of the correct responses for each item will be presented as shown in table 4.

Table 4. Absolute and relative frequencies of medical students with correct answers on each of the items in the questionnaire
Description of question n %
Lack of pain expression does not mean lack of pain. Giving narcotics on a regular schedule is preferred over PRN schedule for continued pain. Likewise, the different domains of pain management and palliative care will be ranked according to the number of correct responses. Absolute and relative frequencies will be presented in a manner similar to that of table 5 below.
Table 5. Absolute and relative frequencies of medical students with correct answers on each of the different domains of pain management
Aspect of pain management n %
Attention given to and assessment of pain Opioids related issues General principles of pain management Pain management issues in children Non-pharmacologic aspect of pain management Absolute and relative frequencies of the number of students with inadequate level of knowledge (i.e. a score less than 70%) stratified according to those with a health-related undergraduate course will be presented in a manner similar in table 6 below.
Table 6. Health- related undergraduate courses and corresponding absolute and relative frequencies with inadequate level of knowledge (i.e. a score of less than 70%) among studied medical students of DLSMHSI, second semester, A.Y. 2018- 2019
Health- related Undergraduate course n (%)
Biology and related courses (Human biology Medical biology, Biochemistry) Pass Fail Medical technology Pass Fail Nursing Pass Fail Pharmacy Pass Fail Rehabilitation sciences (Physical therapy, Occupational therapy, and Speech Pathology Pass Fail Others Pass Fail Attitudes regarding palliative care will be presented in a table containing absolute and relative frequencies stratified according to those who agree and disagree to a particular statement. It will be presented in a manner similar to table 7 below.
Table 7. Attitudes regarding palliative care among studied medical students of DLSMHSI, second semester, A.Y. 2018- 2019
Statement Agree DisgreeFamilies should be involved in decision making about the terminally ill patient. n(%) n(%)
In the second level of data analysis, appropriate test statistics will be employed in order to determine if there is a significant difference in the mean scores across genders, age, year level, educational background, various health- related undergraduate courses, work experience in the hospital, pain management training, and frequency of using objective tools for pain assessment. In order to determine if there is a significant difference in the mean scores between variables that have only two independent groups, T- test scores will be computed. Likewise to assess if there is a significant difference in the mean scores between a variable that has more than 2 independent groups, a one way analysis of variance (ANOVA) will be employed.

Independent Sample T- test
The t- test will determine whether the means of two groups are significantly different from each other and is appropriate to use whenever one compares the means of two independent groups. A t-score should have a p-value < 0.05 in order to be considered statistically significant, denoting that there is only 5% chance that the t-score from the sample data is due to chance. Results of the independent sample t- test is shown in table 8 below.

Table 8. Differences in knowledge and attitudes regarding pain management scores between subcategories of socio-demographic variables and other student characteristics (n= 103)
Independent variable Mean + SD T- score P-value 95% Confidence Interval
Age Below mean Above mean Sex Male Female Year Level Third Fourth Educational Background Health related Non- health related Work experience in the hospital (Range= A-B) Yes No Pain management in training Yes No Frequency of using objective tools for pain assessment Yes No One- way analysis of variance
The one- way analysis of variance will be used to determine if there is a significant difference between the means of variables with more than 2 independent groups. It is worth noting that a one way ANOVA will allow us to determine that at least two groups have statistically significant difference between the mean of scores; however, it will not specify the particular groups that were different. There will be a statistically significant difference between groups as determined by the One- way ANOVA if the F- statistic has a p-value < 0.05. This test statistic will be employed in order to assess if there is a significant difference in the means across health- related undergraduate courses. Results of the one-way ANOVA will be presented in a tabular form as shown in Table 9 below.

Table 9. Differences in knowledge and attitudes regarding pain management scores between subcategories of health- related undergraduate course
Sum of squares Degrees of Freedom Mean Square F value P- value
Between groups Within groups F. Ethical Considerations
Request for ethical clearance will be obtained from the Board of Research Ethics of the De La Salle Medical and Health Sciences Institute. Random selection of third and fourth year medical students enrolled in the 2nd semester of AY 2017- 2018 will be done. An informed consent form will be distributed prior to administering the questionnaire. The objectives and procedure for the data collection will be explained to the respondents. Furthermore, it will be emphasized that participating in the study is voluntary and they may withdraw from the study should they desire to do so. After giving a brief overview of the study objectives, informed consent and questionnaires would be distributed. The risk on this study is minimal since neither vulnerable populations nor invasive procedures are present in this study. Each of the respondents will be assigned with a code to assure utmost privacy and confidentiality during data collection. After data collection, written outputs such as answered questionnaires will be stored in the office of the research adviser. Relevant materials relating to research will be stored in laptop computers of the investigators.
G. Questionnaire/ survey tool
The questionnaire that will be used in order to assess the knowledge and attitudes of medical students regarding pain management is adapted from the study conducted by Eyob et al. entitled, “Knowledge And Attitude Towards Pain Management Among Medical And Paramedical Students Of An Ethiopian University”. Unlike the original form which utilizes four likert scales to express agreement or disagreement to a particular statement, the questionnaire to be used in this study will only allow the respondents to either agree or disagree to a certain statement. This is because categories the four likert scales utilized in the study done by Eyob et al. were further collapsed into just two categories; thus, it would be better to limit the categories of responses to just two since the extent of agreement or disagreement would not matter since there is a definite correct answer for each statement.
The data tool utilized in this study has been validated through a review done by pain experts. The internal consistency of the 22- item knowledge and attitude assessment is established as indicated by the overall Cronbach’s Alpha or reliability of the items which is 0.89.

The 22 items in this questionnaire includes the domains that are considered important regarding pain and its management. This includes (1) attention given to and assessment of pain (items 1,4,6,11,12,13,15,16,21); opioids related issues (Items 2,5,8,10,17,18,19,20); general principles of pain management (Items 3,4,7,16,22); pain management issues in children (Items 8 and 9); and non-pharmacologic aspect of pain management (Item 14). An additional item (item 23) was added to gauge the student’s perceived adequacy of his/ her knowledge in pain management.
In interpreting the raw and average scores, the recommended cut-off suggested by the American Medical Association was used, a score of at least 70% is regarded as being satisfactory.

Knowledge regarding palliative care will be assessed using the Palliative Care Knowledge Test developed by Nakazawa, et al. The reliability and internal validity of this tool is well established. The Palliative Care Knowledge Test consist of five domains; namely, philosophy (items 24 to 25), pain (items 26 to 31), dyspnea (items 32 to 35), psychiatric problems (items 36 to 39), and gastrointestinal problems (items 40 to 43).

Attitudes regarding palliative care will be assessed using a Physical Therapy in Palliative Care- Knowledge, Attitudes, Beliefs and Experiences Scale (PTiPC- KABE scale) developed by Kumar, et al. The reliability of the tool has already been established. Selected statements measuring attitudes regarding palliative care were included in the study (items 44 to 49). Statements were appropriately reworded to make it more appropriate to the respondents.
Instruction: For each of the statement below, tick the box that corresponds to your response for each of the statement provided.

Statement Agree Disagree
1. Lack of pain expression does not mean lack of pain.
2. Giving narcotics on a regular schedule is preferred over PRN schedule for continues pain.
3. When a patient requests increasing amounts of analgesics to control pain, this usually indicates that the patient is psychologically dependent.
4. A patient should experience discomfort prior to giving the next dose of pain medication.
5. Patient receiving narcotics on a PRN basis may be likely to develop clock- watching behaviors.
6. The most accurate judge of the intensity of the patient’s pain is the patient.
7. When a patient in pain is receiving analgesic medication on a PRN basis, it is appropriate for the patient to request pain medications before the pain returns.
8. Because narcotics can cause respiratory depression, they should not be used in pediatric patients.
9. Children cry all the time; therefore, diversional activities are indicated rather than actual pain medications.
10. The most suitable dose of morphine for a patient in pain is a dose that best controls the symptoms; there is no maximum dose (i.e. a level that must not be exceeded) for morphine.
11. It may often be useful to give a placebo to a patient in pain to assess if he is genuinely in pain.
12. For effective pain treatment of cancer pain it is necessary to continuously assess the pain and the efficacy of therapy.
13. It is the patient’s right to expect total pain relief as a consequence of treatment.
14. Distraction, for example, by the use of music or relaxation, can decrease the perception of pain.
15. Estimation of pain by a health professional is a valid measure of pain as a patient’s self-report.
16. Patients having severe chronic pain often need higher dosages of pain medications than patients with acute pain.
17. Increasing analgesic requirements are signs that the patient is becoming addicted to the narcotic.
18. If a patient and/or patient family member reports that a narcotic is causing euphoria, she/he should be given a lower dose of the analgesic.
19. One fourth of patients receiving narcotics around the clock become addicted.
20. The preferred route of administration of narcotic pain relievers to patients with pain is IM.
21. Patients can be maintained in a pain free state.
22. Patients with chronic pain should receive pain medications at regular intervals with or without the presence of discomfort.
23. I have adequately learned about pain management in medical school.
24. Palliative care should only be provided for patients who have no curative treatments available. 25. Palliative care should not be provided along with anti-cancer treatments 26. One of the goals of pain management is to get a good night’s sleep. 27. When cancer pain is mild, pentazocine should be used more often than an opioid. 28. When opioids are taken on a regular basis, nonsteroidal anti-inflammatory drugs should not be used. 29. The effect of opioids should decrease when pentazocine or buprenorphine hydrochloride is used together after opioids are used. 30. Long-term use of opioids can often induce addiction. 31. Use of opioids does not influence survival time. 32. Morphine should be used to relieve dyspnea in cancer patients. 33. When opioids are taken on a regular basis, respiratory depression will be common. 34. Oxygen saturation levels are correlated with dyspnea. 35. Anticholinergic drugs or scopolamine hydrobromide are effective for alleviating bronchial secretions of dying patients. 36. During the last days of life, drowsiness associated with electrolyte imbalance should decrease patient discomfort. 37. Benzodiazepines should be effective for controlling delirium. 38. Some dying patients will require continuous sedation to alleviate suffering. 39. Morphine is often a cause of delirium in terminally ill cancer patients. 40. At terminal stages of cancer, higher calorie intake is needed compared to early stages. 41. There is no route except central venous for patients unable to maintain a peripheral intravenous route. 42. Steroids should improve appetite among patients with advanced cancer. 43. Intravenous infusion will not be effective for alleviating dry mouth in dying patients. 44. Families should be involved in decision making about the terminally ill patient. 45. Providing pain relief is a priority to me, when patients are nearing the end of life. 46. Should a patient under my care dies in the future, I should spend sufficient time with his or her family 47. When a diagnosis with a poor outcome is made, the patient and his or her family should be informed of palliative care options. 48. The staff should be asked by the family to continue life-extending care beyond what they feel is right. 49. My personal attitudes about death affect my willingness to deliver palliative care.
Bibliography:
Barclay, S., Whyte, R., Thiemann, P., Benson, J., Wood, D. F., Parker, R. A., & Quince, T. (2015). An Important But Stressful Part of Their Future Work: Medical Students Attitudes to Palliative Care Throughout Their Course. Journal of Pain and Symptom Management,49(2), 231-242. doi:10.1016/j.jpainsymman.2014.06.004
Bellieni, C. V., Buonocore, G., Nenci, A., Franci, N., Cordelli, D. M., & Bagnoli, F. (2001, July). Sensorial saturation: An effective analgesic tool for heel-prick in preterm infants: A prospective randomized trial. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11474143
Bradley E, Cramer L, Bogardus S, et al. Physicians’ ratings of their knowledge, attitudes, and end-of-life-care practices. Acad Med 2002;77:305e311.

Brennan, F., Carr, B., and Cousins, M. (2007). Pain Management: A Fundamental Human Right. Pain Medicine International Anesthesia Research Society 105 (1), pp. 205-218. doi: 10.1213/01.ane.0000268145.52345.55
Candiotti, K. A., ; Gitlin, M. C. (2010). Review of the effect of opioid-related side effects on the undertreatment of moderate to severe chronic non-cancer pain: tapentadol, a step toward a solution? Current Medical Research ; Opinion.

Corbo, M. G., Mansi, G., Stagni, A., Romano, A., Van, J., Capasso, L., Paludetto, R. (2000, March). Nonnutritive sucking during heelstick procedures decreases behavioral distress in the newborn infant. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/10729719
Corff K, Seideman R, Venkataraman S, Lutes L, Yates B. Facilitated tucking: a nonpharmacologic comfort measure for pain in preterm neonates. JOGNN 1995;24(2):143-7.

Eyigor, S. (2013). Fifth-Year Medical Students Knowledge of Palliative Care and Their Views on the Subject. Journal of Palliative Medicine,16(8), 941-946. doi:10.1089/jpm.2012.0627
Eyob, T., Mulatu, A., ; Abrha, H. (2013, December 22). Knowledge and attitude towards pain management among medical and paramedical students of an ethiopian university. Retrieved September 9, 2018, from https://www.omicsonline.org/open-access/knowledge-and-attitude-towards-pain-management-among-medical-and-paramedical-students-of-an-ethiopian-university-2167 0846.1000127.php?aid=22568#tables_figures
Fearon, I., Kisilevsky, B. S., Hains, S. M., Muir, D. W., ; Tranmer, J. (1997, August). Swaddling after heel lance: Age-specific effects on behavioral recovery in preterm infants. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/9276829
Gibbins J, McCoubrie R, Maher J, Wee B, Forbes K. Recognizing that it is part and parcel of what they do: teaching palliative care to medical students in the UK. Palliat Med 2010;24:299e305.

Guétin, S., Giniès, P., Siou, D. K., Picot, M., Pommié, C., Guldner, E., Touchon, J. (2012). The Effects of Music Intervention in the Management of Chronic Pain. The Clinical Journal OF Pain,28(4), 329-337. doi:10.1097/ajp.0b013e31822be973
Gupta, A., ; Rosenquist, R. (2018, July). Use of opioids in the management of chronic non-cancer pain. Retrieved from https://www.uptodate.com/contents/use-of-opioids-in-the-management-of-chronic-non-cancer-pain
Hauer, Julie J. M., ; Jones, Barbara L. (2018). Evaluation and management of pain in children. Retrieved from UpToDate: https://www.uptodate.com/contents/evaluation-and-management-of-pain-in-children?search=pain%20management%20issues%20children;source=search_result;selectedTitle=5~150;usage_type=default;display_rank=5
Hebb, A. L., Poulin, J., Roach, S. P., Zacharko, R. M., ; Drolet, G. (2005). Cholecystokinin and endogenous opioid peptides: Interactive influence on pain, cognition, and emotion. Progress in Neuro-Psychopharmacology and Biological Psychiatry,29(8), 1225-1238. doi:10.1016/j.pnpbp.2005.08.008
Huang, C., Tung, W., Kuo, L., ; Chang, Y. (2004). Comparison of Pain Responses of Premature Infants to the Heelstick Between Containment and Swaddling. Journal of Nursing Research,12(1), 31-35. doi:10.1097/01.jnr.0000387486.78685.c5
Ismail, A. (2016). The Challenges of Providing Effective Pain Management for Children in the Pediatric Intensive Care Unit. Pain Management Nursing,17(6), 372-383. doi:10.1016/j.pmn.2016.08.005
Kaki, A. M. (2011, June). Medical students knowledge and attitude toward cancer pain management in Saudi Arabia. Retrieved September 9, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/21666947Lang, E. V., Benotsch, E. G., Fick, L. J., Lutgendorf, S., Berbaum, M. L., Berbaum, K. S., ; Spiegel, D. (2000). Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. The Lancet, 355(9214), 1486-1490.

Lembke, A., ; Humphreys, K. (2016, June 15). Weighing the Risks and Benefits of Chronic Opioid Therapy. Retrieved from https://www.aafp.org/afp/2016/0615/p982.html
Miaskowski, C. (2003). Identifying issues in the management of pain in infants and children. Pain Management Nursing,4(1), 1-2. doi:10.1053/jpmn.2003.127780
Morton, N. (1997). Pain assessment in children. Paediatric Anaesthesia, 7(4), 267–272. Oakes, L. (2011). Compact clinical guide to infant and child pain management. New York, NY: Springer Publishing.

Rosenblum, A., Marsch, L. A., Joseph, e., ; Portenoy, R. K. (2008). Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions. Exp Clin Psychopharmaco.

Watson J., McGillion M., Hunter J., et al. (2009). A survey of pre-licensure pain curricula in health science faculties in Canadian universities. Pain Res 14(6), pp. 439-444
Weber, M., Schmiedel, S., Nauck, F., ; Alt-Epping, B. (2011). Knowledge and attitude of final – year medical students in Germany towards palliative care – an interinstitutional questionnaire-based study. BMC Palliative Care,10(1). doi:10.1186/1472-684x-10-19
Weissman D. and Dahl J. (1990). Attitudes about cancer pain: A survey of Wisconsin’s first year medical students. Journal of Pain and Symptom Management 5 (6), pp. 345-349. doi:10.1016/0885-3924(90)90028-I
Yanni, L. M., McKinney-Ketchum, J. L., Harrington, S. B., Huynh, C., Amin, BS, S., Matsuyama, R., … Garufi-Clark, L. (2010). Preparation, Confidence, and Attitudes About Chronic Noncancer Pain in Graduate Medical Education. Journal of Graduate Medical Education, 2(2), 260–268. http://doi.org/10.4300/JGME-D-10-00006.1