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Pain remains poorly controlled, sometimes even in hospice patients. To discover the constraints to comforting in hospice settings, 28 hospice nurses were asked to describe experiences that made it difficult to control pain in their patients. Their stories were transcribed and scrutinized applying constant comparative analysis with a grounded theory search for basic psychosocial processes. Constraints were categorized as occurring with the patient, physician, family, nurse, and health system. Further exploration clearly revealed that underlying dynamics were fear and avoidance with an emphasis on opiophobia. Because fear is so influential in decisions to keep pain under control, palliative educational approaches must go beyond providing information to fill deficits in palliative knowledge. To be effective, education about comfort must directly confront the fears and deliberately apply strategies from cognitive therapy such as identifying distorted thinking, role playing, and role modeling.
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