ORIGINAL ARTICLE /ARTICLE ORIGINAL DOSSIER
Oncologists Facing Pain: A Qualitative Study
Les oncologues face à la douleur : une étude qualitative
L. Peyla · L. Dany · E. Dudoit · F. Duffaud · S. Salas
Received: 12 February 2014; Accepted: 9 November 2014
© Lavoisier SAS 2014
AbstractAims: To understand the medical team’s represen- tation of pain in oncology. Our goal is also to understand how these professionals perceive the support of pain. What psychosocial issues come into play in a therapeutic situation when using an opioid analgesic treatment?
Procedure: In a qualitative approach, we conducted fourteen individual semi-structured researches through interviews with doctors and residents in the department of Medical Oncology. Our study consists of an analysis of thematic con- tents.
Results: The analysis of thematic contents revealed that doc- tors believe pain in oncology is multidimensional. The imple- mentation of an opioid analgesic treatment is not as easy as one may think. Patients’ and doctors’ representations and beliefs about morphine hamper the therapeutic situation.
The medical team must implement various strategies to achieve their goal of relieving pain in patients with cancer.
The doctor may need to educate and reassure the patient about taking these treatments. You will note that a negotiation then takes place between the doctor and the patient. Usually present between the two actors, we notice a decrease of the asymmetry of the relationship in the management of pain.
Conclusion: It’s important to draw attention to the psychoso- cial issues in the therapeutic situation in the context of the management of pain within oncology.
KeywordsPain · Opioid analgesic treatment · Representations · Therapeutic situation · Negotiation
Résumé Objectifs : Comprendre les représentations de la douleur en service d’oncologie par l’équipe médicale.
Nous souhaitons comprendre comment est perçue la prise en charge de la douleur par ces professionnels, quels sont les enjeux psychosociaux mis en œuvre dans la situation thérapeutique lors de la mise en place d’un traitement antal- gique morphinique.
Matériel et méthodes: Dans une approche qualitative, nous avons réalisé 14 entretiens de recherche semi-directifs indi- viduels auprès des médecins et des internes dans un service d’oncologie médicale. Notre étude consiste en une analyse de contenu thématique.
Résultats: L’analyse de contenu thématique révèle que, dans le discours des médecins, la douleur en oncologie est plur- idimensionnelle. La mise en place d’un traitement antalgique morphinique ne se déroule pas aussi facilement qu’on pour- rait le penser. Les représentations et les croyances des patients, mais aussi des médecins envers la morphine vien- nent entraver la situation thérapeutique. L’équipe médicale doit donc mettre enœuvre diverses stratégies pour atteindre son objectif : soulager la douleur des patients atteints de can- cer. Le médecin peut être amené à éduquer ou à rassurer le patient concernant la prise de ces traitements. On remarque qu’un travail de négociation se met alors en place entre le médecin et le patient. Habituellement présente entre les deux acteurs, on observe une diminution de l’asymétrie de la rela- tion dans la prise en charge de la douleur.
Conclusion : Il est important de prendre en compte les enjeux psychosociaux de la situation thérapeutique dans le contexte de la prise en charge de la douleur en oncologie.
Mots clésDouleur · Traitement antalgique morphinique · Représentations · Situation thérapeutique · Négociation
Introduction
Pain is a very common symptom in cancer patients. It is estimated that pain symptom is present in 30 to 45% of indi- viduals with early cancer, and in 60 to 90% of patients with
L. Peyla (*) · L. Dany (*) · E. Dudoit (*) · F. Duffaud (*) · S. Salas (*)
Service d’oncologie médicale, AP–HM, Timone, F-13385 Marseille, France
e-mail : Laura.Peyla@mail.ap-hm.fr, Lionel.Dany@univ-amu.fr, Eric.Dudoit@mail.ap-hm.fr, Florence.Duffaud@mail.ap-hm.fr, Sebastien.Salas@mail.ap-hm.fr
L. Dany · E. Dudoit
Aix-Marseille université, LPS EA 849, F-13621 Aix-en-Provence, France DOI 10.1007/s11839-014-0487-x
locally advanced or metastatic cancer [1]. More recent stud- ies concerning the prevalence of pain in cancer patients showed that 24 to 60% of patients receiving active cancer treatment suffer pain [2,3] and so do 62 to 86% of patients with advanced cancer [4,5].
Despite increased knowledge about the pathophysiology of pain and the important dissemination of scales or assess- ment tools [6] it is clear that pain is often undervalued. In addition, the management of pain is not always appropriate inspite of the fact that the patients report high levels of pain [6–8]. The EPIC study (European Pain In Cancer) [9] con- ducted among thousands of European and Israeli patients is illustrative of this phenomenon. In the French data sample, we note that 76% of patients have pain that they attribute to their cancer, 62% suffer every day and 31% of patients who have moderate to severe pain receive no treatment for their pain. In addition, 28% of patients felt that their doctor didn’t know how to control their pain and 26% reported that the healthcare professional that managed their pain had never or rarely asked them about their pain. Finally, only 27% of patients with pain treatment were taking a strong opioid to control their pain, 38% reported that their pain was“intoler- able”, and 26% that their pain was sometimes so intense that they felt the desire to die.
The healthcare professionals play a main role in the
“fight”against pain in cancer [10]. This fight is represented in the doctors’practices by a systematic examination of the patients pain (intensity, localization, acute or chronic pain, evaluation of mechanisms of action) and by the introduction of the most efficient treatment. A low assessment of pain levels is a significant cause for lesser pain treatment [11,12]. Beyond the professional skills, various processes can be initiated in order to guide the professional practices of caregivers. Some research has pointed that the level of pain declared by patients and the level of pain reported by caregivers are different [13,14]. Other studies have highlighted the role of the lack of knowledge and the role of beliefs and attitudes related to pain [11,12], further inves- tigations evidenced the role of representations and attitudes associated with treatment (e.g., fear associated with the risk of addiction, toxicity, poor practices) [15]. These sources of influence act on care practices and we can observe them in all healthcare professionals, regardless of their status [16].
Moreover, only one doctor in two believes that his pain man- agement is good [12].
This brief review shows that pain management in oncology is influenced by some psychosocial factors (i.e. communica- tion skills, knowledge, identity and professional stakes, social norms, representations, attitudes, beliefs) that influence eval- uation and treatment of cancer pain. The modalities of care fit in a space of communication and interaction marked by the presence of a set of actors who are able to influence (through their practices and their thought) the course of pain manage-
ment and its efficacy. This space of communication and inter- action has been conceptualized as a “therapeutic situation” [17]. The concept of“therapeutic situation”is an integrative model for analyzing the doctor-patient relationship, which takes into account a number of psychosocial prebuilt. This model suggests that social inclusion and social participation of individuals and groups (e.g., health care workers, patients, family) in the physical, psychological and social environment constitute the initial matrix that permits to analyze the relation with the object of the representation, and the contribution of this object (pain and its management in our study) [18]. The model emphasizes the role of the representations developed and communicated by people and linked to societal influence.
These representations can be seen as a form of knowledge related to the individual behavior, to the social relations, and to the social context [19]. The representations are guides for action, they constitute a system of anticipation, and they per- mit communication between individuals [20]. In the context of care and management of disease, the representations can be understood as a “practical knowledge” that guides profes- sional practices and the lived experience of illness [17,18,21,22].
The research we conducted was to examine, in a compre- hensive and contextual perspective, the representations (meanings and images) that doctors develop with regard to pain and its management in the context of therapeutic inter- action/situation. In addition, we want to provide some reflec- tions concerning the stakes associated with the representa- tional dimensions of doctors and their potential influence on the course of the management of pain.
Method Participants
This qualitative research by interviews was conducted with 14 doctors1and interns of the Medical Oncology Unit of the University Hospital La Timone (Marseille), from February to April 2013. The sample consists of six doctors (three men and three women) and eight interns (six men and two women).
Mean age is 29 years (from 24 to 41 years). The oncology experience ranges from three months to thirteen years (mean
= 4 years). Only three people have additional training in pain (i.e. University Diploma in Palliative Care and Pain).
Procedure and analysis
The interviews were conducted to explore the doctors’repre- sentations of pain and its management. The interviews were
1To facilitate reading we will use the term « doctor » for each subsample.
led by a health psychologist using a semi-structured inter- view schedule. The set of questions included: representa- tions of pain (in general and in oncology); representations and attitudes towards the treatments; pain assessment; com- munication with patients concerning analgesics and opioids;
difficulties concerning the management of pain and treat- ments, and the relation with patients.
The interviews were fully transcribed and we conducted a thematic content analysis [23]. This analysis was performed at a vertical level (in each interview) and at a horizontal level (across all interviews). Following an immersion and famil- iarization phase, we performed the tracking and the selection of units of meaning in connection with our research problem to allow inference of knowledge. The interviews were car- ried out within an ethical framework based on several key points: guarantee of anonymity for the interviewees, willing acceptance for each interviewee, the possibility for each interviewee to consult the data.
Results
The content analysis of interviews with the medical team has given rise to different themes: the experience of pain and its
representations, analgesics and their implementation (The treatments), the conditions associated with the prescription of painkillers (Prescribe under « constraints ») and the chal- lenge of negotiation between doctor and patient in the man- agement of pain (The management of pain), (see Table 1 for a summary of the thematic analysis).
The experience and representation of pain
The first theme relates to the subjective experience of pain as a complex phenomenon. The medical definition of pain pro- posed by the International Association for the Study of Pain (IASP) does not come spontaneously in the speech of doctors.
Only a minority of them (n = 4) attempted to describe pain using this definition. It seems to reduce pain to its biological component, not taking into account the psychological and social dimensions. Doctors most often represented pain through plural components (physical, moral and social). In fact, pain is evoked through a bio-psycho-social approach by nearly three-quarters of the medical team (n = 11). Its vari- ous components and forms are widely discussed (e.g., neuro- pathic and nociceptive pain, moral, physical, psychological, as well as social pain), and three-quarters (n = 11) of intervie- wees evoked the complexity and the mixed nature of pain.
Table 1 Summary of thematic analysis.
Themes Subthemes explored n %
Experience and representations of pain Physical, moral and social pain 11 79
Mixed and complex pain 11 79
Pain caused by treatments 8 57
Subjective experience of pain 8 57
Chronicity of pain due to cancer 6 43
Pain as an indicator of disease 6 43
Medical definition of pain (IASP) 4 29
Analgesics and their implementation (The treatments)
Evocation of the three-step ladder 14 100
Use of the term morphine 14 100
Inform to reassure the patient concerning treatment 13 93
Speaking about side effects 12 86
Difficulties in the dosage of opioid analgesic treatment 10 71
Use of « derivative of morphine » 10 71
Conditions associated with the prescription of painkillers (Prescribe under « constraints »)
Refusal of treatment 10 71
Morphine equated with addiction or death 10 71 Negociation dosages, seek alternative treatment 7 50
Unnecessary treatments 6 43
Feelings of failure 4 29
Patients’wrong scientific knowledge 3 21
The challenge of negotiation between doctor and patient (The management of pain)
Convincing the patient 10 71
Educate the patient 10 71
Autonomy, patient monitoring 8 57
Do not leave the choice to the patient 3 21
”For me, schematically pain is that I try a little bit to differentiate it, what I mean is, physical pain, emo- tional pain, social pain with the isolation, the job, everything... And then, decide to really support these three axes in fact.”(Male, intern)
”It will be a pain as when somebody hits you, you will feel that nociceptive pain, is a pain more dull, more a background pain. Neuropathic pain, it will be all that is burning, swarming, electric shocks, tingling... this is a neuropathic pain.”(Male, intern)
We can also note that pain is perceived as an experience associated with the disease and/or its management. For example, pain might be indicative of pathology, it is an indi- cator (n = 6). Similarly, treatments related to cancer (n = 8) might cause pain in patients (e.g., chemotherapy, radiother- apy, surgery). Finally, cancer (n = 6) can also cause chronic pains which are difficult to alleviate.
”Chemotherapy with all undesirable effects it entails, it is not nice so it can be interpreted as a pain too.” (Male, intern)
”There is still a lot of cancer pain now, actually cancer pain equates chronic pains.”(Female, doctor)
The subjective component of pain is also mentioned (n = 8). It is part of the difficulties of pain management because the personal or singular experience of pain is not directly accessible to the observer-doctor.
”There is the definition that we all have, purely medi- cal, as the unpleasant sensation that the patient has.
And then on our side, I think it is... Well, I think it is always difficult for us to understand exactly what patients feel. I think as we have not experienced the painful thing they tell us, it is hard to fully appreciate what they tell us.”(Female, intern)
The treatments
When doctors suggest opioid analgesic treatments, the first element is the World Health Organization pain relief ladder.
The three-step ladder can represent the regulatory frame- work to be followed in the implementation of such treatment and was evocated by all the interviewees.
”We have a patient who is in pain, the first treatments we have for him is the first step of the ladder. When that step becomes insufficient, we proceed to second step of the ladder; it is all low opioid, codeine efferalgan, tra- madol. And similar, when it becomes insufficient, we proceed to the third step of the ladder. This step is morphine.”(Female, doctor)
In case of high-dose opioid analgesic treatment (step 3), all the interviewees (n = 14) say that they inform the patient
that it is morphine, directly employing this term. To discuss low-dose opioid analgesic treatment (step 2), the doctors (n = 10) most often use the term“derivative of morphine.”
”If they trust you, they will walk in the treatment, even telling them that itis morphine or a derivative of mor- phine sometimes. First ladder step: morphine, deriva- tive of morphine, it also involves a derivative of mor- phine. It is pretty good, we use a lot anyway (...) so you present it as a derivative of morphine. Because? A derivative of morphine, they hear derivative so they think it is okay, it’s not necessarily morphine, for those who are afraid.”(Male, intern)
Only two doctors (n = 2) didn’t evoke side effects (e.g., constipation, somnolence, etc.) or overdose (e.g., hallucina- tions, respiratory distress, etc.) in the context of opioid anal- gesic treatment. Almost all doctors (n = 13) reported they communicate, inform, explain this type of treatment in order to“reassure”the patient.
Prescribe under « constraints »
A relatively large proportion of doctors (n = 10) was faced with patient refusal of opioid analgesic treatment.
”He [the patient] refuses to take analgesic treatments because it will not work, he refuses anti-inflammatory because it will not work, he refuses infiltration because it will not work anyway, so actually he walks through gritted teeth, and then he comes to the consultation, and you ask him, how are you? I’m aching all over.
It is unbearable doctor, but anyway it does not matter, I do not want anything.”(Male, doctor)
”Five percent of patients, I am thinking of my consul- tation, refuse derivative of morphine because they heard about it, saying yes I will get addicted, I am afraid of being dependent. Explaining them, no, when you suffer cancer pain, it is really morphine treatments that will relieve you. Explaining them, they accept. But the majority of patients, on the contrary, they prefer not to feel pain than having... So they accept drugs.” (Male, doctor)
A less “categorical” form of patient intervention in the prescription of painkillers consists in negotiating the dosage of the treatment and /or seek alternative treatments (n = 7).
The doctors express the patients’opinions that contribute, to them / in their opinion, to the difficulties associated with the implementation of antalgics and in particular opioids: unnec- essary treatments (n = 6), feelings of failure (n = 4), wrong scientific knowledge (n = 3).
One important consequence is that doctors need to accompany the prescription of analgesic treatment. Too
“directive” a prescription without explanation does not
seem possible. This supporting effort aims to induce the patient’s approval of opioid analgesic treatment. Reassuring the patient is a key criterion in supporting the implementa- tion of the treatment. This support and reassurance are sup- posed to strengthen the compliance of the patient by remov- ing the negative representations (e.g., addiction, death) associated with morphine.
”In general, to communicate on morphine can reas- sure them [patients] in order to accept the treatment quickly.”(Male, intern)
”For one or the other it will block, but otherwise, if we start to explain them that there is still a rather low risk of dependence, especially as this is clearly indicated in the context of their pain, they agree quite well to take the treatment. (...) Otherwise I try to explain it is better if they can try the treatment and anyway risks are min- imal ... of ... addiction.”(Male, intern)
The management of pain
A significant proportion of doctors (n = 10) says to have difficulties in the dosage of opioid analgesic treatment. It needs to be both suitable for pain and in accordance with the patient’s wishes. Indeed, it often happens that the patient wishes to negotiate the dosages of his/her opioid analgesic treatment (for master effects), or that he/she requests an alter- native to the establishment of the treatment.
”When you put morphine, after it is negotiated dosages because they will tell you but then I am too sleepy, then I have nightmares... For pca [morphine pumps], they will tell you yes I want this continuous flow, boluses [doses]
I want to do that.”(Female, intern)
The management of pain constitutes a space of negotia- tion. The patient negotiates the establishment of the treat- ment that requires the doctor’s work of explanation, which in turn aims to provide explicit information and clarification (i.e., more information than if they prescribed a more“clas- sic”treatment) so that the patient can understand and accept the doctor’s option.
”I struggled to get agreement from patients to replace their ancient treatment, with unnecessary side effects, to use another treatment (morphine). It is not always easy to implement new treatment as morphine.” (Female, doctor)
The work of explanation is based on two strategies (1) convince the patient (n = 13) and (2) educate the patient (n
= 10). Both strategies might seem close (they are designed to allow each patient to make a choice and to be reassured) but remain different in their forms. The strategy which aims to convince is based on an active approach to the presentation
of options explicitly guiding an initial choice defined by the doctor.
”(...) And if it is really severe pain, requiring urgent care, like yesterday I managed to convince him to come to hospital. (...) I think it is good to convince him to be hospitalized for a few days in order to adapt the treat- ment well.”(Male, doctor)
”In general, communicate on morphine can reassure them and make them accept the treatment quickly.” (Male, intern)
The “educational” strategy is designed to provide an expert knowledge on the treatment that should lead to informed decision-making by the patient. In this sense, the doctor aims a kind of education of the patient by providing information and the patient is expected to take a decision with a certain “freedom” based on this information. In other words, the doctor shares his knowledge about opioid analgesic treatments. Thereafter, the patient is in a position to choose this type of treatment and to legitimize his/her choice on the grounds of the doctor’s presentation of positive and negative elements.
”Always information. This is the basic information, education of patients.”(Male, intern)
”It is also reassuring to explain why it is painful in fact. Why it hurts, it is also something important. “ (Male, doctor)
”(...) Here we explain to people the mechanism of action of morphine in simple words. (...) And when we explain it clearly to patients in general after that the problem is solved.”(Female, intern)
These two sub-themes we clearly distinguished are actu- ally two interrelated strategies used by doctors. This leads us to conclude that we are in presence of an overall strategy to convince and to educate the patient about opioid analgesic treatment. The challenge is always the same: the patient accepts the prescription of opioid analgesic treatment gov- erned by the doctor. In practice, doctors apply one or the other strategy depending on the circumstances and the degree of the patient’s intervention in the course of his man- agement. The search for autonomy and patient monitoring are also strategies for managing pain (n = 8). These strategies are opposed to the one that consists in not leaving the choice to the patient (n = 3).
Discussion
This research was conducted to examine the representations that doctors develop with regard to pain and its management in the context of therapeutic interaction/situation in oncol- ogy. Analysis of the interviews permitted to evidence
different themes that constitute the basic elements which explain the professional practices of oncologists facing pain and stress the importance of the negotiation processes in the therapeutic situation [24–26].
Doctor-patient exchanges as they are envisaged and described by doctors, suggest a form of negotiation when prescribing an opioid analgesic treatment. Negotiation seems socially“admitted”between the patient and the doc- tor. A significant number of professionals are faced with the patients’refusal of opioid analgesic treatment. So prescrib- ing morphine does not only consist in (im)posing an act, but is a process which needs support and where the main objec- tive is to reassure the patient. Taking into account the patient’s representations of the treatment, the doctor imple- ments the act of“negotiated prescription”. He incorporates the patient’s potential reluctance to morphine when commu- nicating, discussing and explaining his management of pain (e.g., the thematics of addiction or death). Doctors are lucid regarding issues associated with representations induced by morphine; they adapt their discourses and practices. It is in this sense that the therapeutic relationship refers not only to an exchange of information but also to an exchange of meanings [22].
More specifically, in the therapeutic situation, the doctor provides information to the patient about taking treatment and guidelines to follow its potential side effects. During this exchange, which we can describe as asymmetric, in the sense that the doctor passes on his knowledge to the patient, representations and beliefs of the two parties come together in speech [18]. In the case of the establishment of an opioid analgesic treatment, the issues are more salient. Indeed, mor- phine is a substance far from neutral. It comprises a whole range of symbolic and social issues. In this context, the doc- tor’s expert knowledge is, somehow,“secondary”in relation to the patient’s social representations (partly shared by the doctor). In the management of pain, the presence of a partic- ular substance such as morphine causes beliefs and represen- tations to pass in the foreground and to interfere with the therapeutic project. In this sense we can say that the repre- sentations are elaborated in the dialogue between the actors of the therapeutic situation. At the same time, this dialogue is part of a given medical and social context [17].
As we see, the therapeutic situation is influenced by vari- ous social representations of pain and opioid analgesic treat- ment. The management of pain by doctors is a professional practice that combines their scientific and medical knowl- edge regarding pain relief, but also their own beliefs about morphine. The latter can somehow be associated with the patients’social representations the doctors need to under- stand and decipher. To say it with Le Breton:“medical prac- tice requires taking into account the culture brought into play by the layman to express his sufferings or surprises his body tells him”[27]. This consideration becomes particularly rel-
evant through the implementation of experiential knowledge in addition to“basic”professional knowledge [28].
As indicated by the results of this research, opioid anal- gesic prescriptions take place in a space of negotiation, which shows a number of“constraints”. Earlier on, we men- tioned the need for the doctor’s apprehension of the patient’s representational world of the treatment. The strategies (i.e.
convince and educate the patient) that doctors implement also help us to draw the contours of this negotiation work.
Management of patients in oncology can be considered as a composite object consisting in a large amount of events. The concept of trajectories [26] allows organizing analytically.
The approach in terms of trajectory makes a distinction between “course of care”and“trajectory of care”. The tra- jectory includes both the development of care (its course), but also the organization and impact of the effort that goes with it. Patients can react and affect this work of care through their participation. There is an influence of patients on the negotiated order:“it can also happen they seek to influence the type of treatment that is given to them and its develop- ment”[26]. It is therefore necessary for doctors to ensure patients’adherence to a therapeutic option prone to negotia- tion in the trajectory of management.
So the concept of negotiation [26] reflects processes and exchanges described by doctors. The patient’s potential refusal concerning the establishment of an opioid analgesic treatment results in a set of negotiations between the doctor and the patient. It is conceivable that the implementation of an opioid analgesic treatment could be a“prototypical”situ- ation of the activation of a negotiation process in the context of oncology. This prototype character is based on (1) the specificity of the treated disease (i.e. cancer), (2) symbolic and practical issues associated with morphine, (3) specific relationship issues between patients and doctors in the con- text of cancer disease and opioid analgesic treatment.
Conclusion
This research provides an exploratory look at the operation of the doctor-patient relationship in the context of pain man- agement in oncology. It documents the negotiation process established in the therapeutic situation regarding the specific psychosocial issues associated with the use of opioid analge- sic treatments. Expert knowledge of the medical team coex- ists with representations and beliefs that influence the pre- scribing (meaning and modalities) of opioid analgesic treatment. The study of the representations of caregivers and patients is a relevant way of analyzing and evidencing the content and processes inherent in care practices.
Conflict of interest:The authors don’t have any conflict of interest to declare.
References
1. Larue F, Colleau SM, Brasseur CS, et al (1995) Multicenter study of cancer pain and its treatment in France. BMJ 310:1034–7 2. Pignon T, Fernandez L, Ayasso S, et al (2004) Impact of radiation
oncology practice on pain: a cross-sectional survey. Int J Radiat Oncol Biol Phys 60:1204–10
3. Rietman J, Dijkstra P, Debreczeni, R, et al (2004) Impairments, disabilities and health related quality of life after treatment for breast cancer: a follow-up study 2.7 years after surgery. Disab Rehab 26:78–84
4. Hwang SS, Chang VT, Cogswell J, et al (2004) Study of unmet needs in symptomatic veterans with advanced cancer: incidence, independent predictors and unmet needs outcome model. J Pain Symptom Manage 28:421–32
5. Stromgren AS, Groenvold M, Petersen MA, et al (2004) Pain characteristics and treatment outcome for advanced cancer patients during the first week of specialized palliative care.
J Pain Symptom Manage 27:104–13
6. Von Roenn JH, Cleeland CS, Gonin R, et al (1993) Physician atti- tudes and practice in cancer pain management: a survey from the Eastern Cooperative Oncology Group. Ann Int Med 119:121–6 7. Cleeland CS, Gonin R, Hatfield AK, et al (1994) Pain and its
treatment in outpatients with metastatic cancer. N Engl J Med 330:592–6
8. Cleeland CS, Ryan KM (1994) Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med 23:129–38
9. Breivik H, Cherny N, Collett B, et al (2009) Cancer-related pain:
a pan-European survey of prevalence, treatment, and patient atti- tudes. Ann Oncol 20:1420–33
10. Pérol D, Toutenu P, Lefranc A, et al (2007) L’éducation thérapeu- tique en cancérologie : vers une reconnaissance des compétences du patient. Bull Cancer 94:267–74
11. Ger LP, Ho ST, Wang JJ, et al (2000) Physicians’knowledge and attitudes toward the use of analgesics for cancer pain manage- ment: a survey of two medical centers in Taiwan. J Pain Symp- tom Manage 20:335–44
12. Wang XS, Cleeland CS, Mendoza TR, et al (1999) The effects of pain severity on health-related quality of life: a study of Chinese cancer patients. Cancer 86:1848–55
13. Dalton JA (1989) Nurses’ perceptions of their pain assessment skills, pain management practices, and attitudes toward pain.
Oncol Nurs Forum 16:225–31
14. Sullivan LM (1994) Factors influencing pain management: a nurs- ing perspective. J post Anaesthesia Nurs 9:83–90
15. Elliott TE, Elliott BA (1992) Physician attitudes and beliefs about use of morphine for cancer pain. J Pain Symptom Manage 7:141–8 16. Weissman DE (1996) Cancer pain education for physicians in practice: establishing a new paradigm. J Pain Symptom Manage 12:364–71
17. Marie D, Dany L, Cannone P, et al (2010) Représentations sociales du cancer et de la chimiothérapie : enjeux pour la défini- tion de la situation thérapeutique. Bull Cancer 95:577–87 18. Dany L, Dudoit E, Salas S, Duffaud F (2014) Les représentations
des soins palliatifs. In: Saint-Jean M, Bastiani, F (eds) L’épreuve de la fin de vie. Seli Arslan, Paris, pp 143–64
19. Abric JC (1994) Les représentations sociales : aspects théoriques.
In: Abric JC (ed) Pratiques sociales et représentations. Presses Universitaires de France, Paris, pp 11–35
20. Moscovici S (1988) Notes towards a description of social repre- sentations. Eur J Soc Psychol 18:211–50
21. Jeannin N, Pelletti C, Dany L (2012) La profession infirmière en cancérologie : place et enjeux de la dimension psychologique.
Prat Org Soins 43:177–85
22. Morin M (2004) Parcours de santé. Armand Colin, Paris 23. Bardin L (1977) L’analyse de contenu. Presses Universitaires de
France, Paris
24. Adam P, Herzlich C (1994) Sociologie de la maladie et de la médecine. Nathan, Paris
25. Carricaburu D, Ménoret, M (2004) Sociologie de la santé. Insti- tutions, profession et maladies. Armand-Colin, Paris
26. Strauss A (1992) La trame de la négociation. L’Harmattan, Paris 27. Le Breton D (1995) Anthropologie de la douleur. Métaillé, Paris 28. Dany L, Dormieux A, Futo F, et al (2006) La souffrance : repré-
sentations et enjeux. Rech Soins Infirm 84:91–104
