Chronic Pain : Nurse Transforms Pain Management in Terminally Ill

Prue Salasky

"She has changed the way we think about pain."

Hospice practitioners, physicians, compounding pharmacists, nurses and medical students all attest to the influence of Maureen Carling in their approach to pain management.

An English-born nurse and hospice worker, Carling, 73, worked at Riverside in the 1990s before "retiring" in Williamsburg. In retirement she developed the "Carling Pain Assessment Algorithm," developed tapes and CDs and conducted workshops around the country on pain management.

This year, the Virginia Association for Hospices & Palliative Care recognized her work with a Lifetime Achievement Award.

While at Riverside, her supervisors noted that Carling's patients lived longer because she managed their pain better. As a newcomer and a nurse, Carling was reluctant to tell physicians how to do their jobs, but she soon became in demand for her skill in assessing pain and her ability to ease it through the use of targeted drugs administered topically.

"This is not nuclear physics. It's applied pharmacology and good nursing," Carling says, in a phone interview from Houston, where she is staying with her daughter Debbie. In October 2011, the midwife/home health visitor/registered nurse received a devastating diagnosis of advanced pancreatic cancer. Her ensuing treatment has put on hold her collaborative work in a pending clinical trial through the Pain Management Education and Research Foundation.

"On a scale of one to 10 (unbearable), how do you rate your pain?"

That's the question every medical practitioner traditionally asks. Carling explodes over the phone, "It doesn't assess pain.... Do you find it helpful? No. All you are asking is 'how bad is it?'"

She learned early in her career from an English doctor that most patients suffer from more than one type of pain and almost one-third from as many as four.

In order to zone in on her patients' suffering, Carling broke pain into eight types: bone, muscle, pleuritic, soft tissue, neuropathic, etc. To that she added questions about duration -- was it continuous, variable or intermittent. As an example, visceral pain "just aches all the time," she says, while pleuritic is worse with breathing and bone pain with movement. She asked her patients to describe their pain. Was it burning, shooting or stabbing. She asked them which drugs relieved their pain, to what extent and for how long.

"She came with a whole new look for pain management. It opened up a new area for us," says her former supervisor Sharron Nichols, nurse manager for Riverside Hospice. "She brought a different way to look at pain. She introduced more of a spiritual, personal element." She credits Carling with improving terminal patients' quality of life, which in turn led them to live longer.

Impressed by the skill of Carling's pain assessment, Brenda Clarkson, a fellow UK native and executive director of the Virginia Hospice Association, hired her to teach nurses at the hospice she ran in the Richmond area. "She's one of life's rare people, she's really made a difference," says Clarkson.

An avid talker, Carling found that other professionals were starting to listen to her. A professor at the University of Virginia in Charlottesville and Virginia Commonwealth University in Richmond asked her to publish her findings. She started getting letters from doctors all over the country.

"There's no one more astonished than me," she says.

Abbot Laboratories in Illinois asked her to write more extensively. She joined a national speakers' bureau. She instructed the military at Fort Eustis and then at Fort Carson in Colorado, where she was awarded the Commander's Coin for Excellence.

She developed audiotapes, CDs and a workbook to pass on her findings and her assessment methods. She committed her algorithm, the Carling Pain Assessment Algorithm, to a single laminated card that nurses could carry bedside. She developed a body map for patients to pinpoint their pain along with its description and appropriate treatment.

"Opiates and narcotics don't relieve all pain," she says. "They relieve it in soft tissue, but bone pain isn't responsive."

"Pain is what the patient says it is."

Some may dismiss a patient's pain as psychosomatic, others as a drug-seeking ploy. "When you're in pain, you can do without that," says Carling with indignation. She emphasizes how documenting every detail helped her to gain buy-in from other medics. "I never stop marveling at her clinical evaluation skills," says compounding pharmacist David Creecy, owner of the Poquoson Pharmacy and current president of the Virginia Pharmacists Association. "She has a very good bedside manner and a very effective interview technique. She listens to her patients. She re-taught me to listen. The challenge is that it may take an hour."

By targeting the specific pain, Carling found that lower-dose drugs often worked better than more powerful medications and with fewer side effects. "Medical professionals are trained to treat the diagnosis, but chronic pain is completely different. The brain continues to send out pain signals even after wounds are healed. It creates changes in the nervous system," says Carling. She revels in "seeing the light go on" when doctors and nurses get an answer to something they didn't understand.

"When I first heard Maureen speak, she completely turned my understanding of pain management upside down. She is spellbinding," says Creecy, noting that medical professionals all have studied pain in the abstract, but her approach is revolutionary. "The number of people she has helped can't be counted."

When topical pain creams became available in 1996, Carling worked with Creecy and other compounding pharmacists to develop customized gels for her patients. "They're designed to permeate the skin and reach the receptors without getting into the system, the liver and kidneys," she says.

Carling maps out the dermatomes, where the nerves exit the spine, and applies the appropriate gel an inch on either side of the spine as well as where the pain is felt. "That way you're blocking it at the site as well as stopping the message that runs along the nerves to the cortex of the brain," says Clarkson, a disciple. "It's very effective."

Creecy estimates that Carling's methods double the efficacy of pain relief. For example, the hand dermatomes are C6, 7 and 8, near the top of the spine. If pain gel is applied only to the hand and not to the associated area of the spine, half of patients don't feel better, he says.

He wants her approach to be given more currency. He and his fellow compounding pharmacists are trying to persuade Carling to do a video recording so her teachings can continue.

"I am the pain doctor. I know I'm not alone," Carling says, expressing optimism that she'll beat her diagnosis. "I feel like I've been on a journey, a journey I didn't plan. I was going to retire in Florida. Now I just accept it. It has been a ride."

Lifetime Achievement Award

At the 32nd Annual conference of the Virginia Association for Hospices & Palliative Care in Richmond in May, pain nurse specialist Maureen A. Carling received a Lifetime Achievement Award "for her clinical expertise, her teaching prowess and her abiding commitment to patients facing life-threatening illnesses." Her signature achievement was the development of the Carling Pain Assessment Algorithm and the "Pain Management Workshop -- A Step by Step Approach" (Chatsworth Pain & Symptom Management, 2000).

For information about the Virginia Association for Hospices & Palliative Care, go to, or call 804-740-1344.

(c)2012 the Daily Press (Newport News, Va.)

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