Feature Article
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The Ethics of Pain Management (Annals of Long Term Care 2000;8[11]:23-26)
This article was adapted from a session at the 1999 American Geriatrics Society Annual Meeting.
Introduction The focus of this article is on terminal end-of-life care, with a concentration on maintenance and comfort measures when the patient's condition is no longer responsive to curative treatment and the goal is to provide the patient with the best possible quality of life right up until a "good death."1,2 This article is based on two premises: that in this nation there is a right to the relief of pain and suffering at the end of life as well as for nonterminal conditions; and that in this nation there exists now, and continues to exist, liability for "sins of omission" in medical practice.
Along with the care of terminally ill patients comes an ethical obligation for nonabandonment—a longitudinal, continuous caring partnership between the physician and the patient.3 This partnership may begin in health but should continue through the patient's death. The promise to face an illness until its end should be an ethical responsibility of any adequate physician-to-patient relationship.
Law and Medicine The first assisted suicide in 1990 by Jack Kevorkian, a former physician and pathologist in the author's home state of Michigan, inspired various studies on the terminally ill. In November 1995, one such study was published in the Journal of the American Medical Association4 in which 4300 terminally ill patients were followed until their deaths. Researchers learned that more than 50% of the patients' physicians claimed that they had no indication of their patients' end-of-life wishes. They also learned that more than 50% of the patients' families claimed that their loved ones suffered moderate to severe pain in the last three days of life. Patients remained on a respirator or in a coma for an average of eight days.
In the second arm of that same study, 2300 terminally ill patients were assigned a registered nurse highly trained in communicative skills who intervened once a week with each patient, the patient's physician, and the patient's family. It was again found that 50% of the physicians claimed that they were unaware of the patients' wishes for end-of-life care, and that they had to proceed with whatever they deemed necessary, regardless of what the patient had said or written. Also similar to the previous study was the finding that more than 50% of the families claimed that the patients suffered moderate to severe pain in the last three days of life. However, the number of days they spent on a respirator decreased to seven on average. The call went out across the nation, "Wake up, medical profession. The problems in honoring a patient's wishes for end-of-life care are not even understood! Yet the profession has a responsibility to control pain and suffering at the end of life!"5
In 1997, the Michigan Pain Study at Chelsea Community Hospital was published that examined 1500 adults in the state of Michigan, and extrapolates to 1.2 million adults. The results revealed that one out of five adults suffers from chronic pain. Forty percent of those adults stated that they experience that pain every day and that it significantly interferes with the quality of their lives. Thirty-five percent said that their pain caused them to miss at least 20 days of work each year, and 70% alleged that it did not desist even during treatment. Finally, 10% of the patients stated that they contemplated ending their own lives because of the pain.
In 1997, Oregon voted to legalize physician-assisted suicide, and the U.S. Supreme Court ruled that even if the doses of medication required to relieve pain and suffering inadvertently or accidentally hasten or cause death, there is still an obligation to relieve the pain and suffering. The intent of the practitioner determines whether or not the health care provider is practicing good-quality medicine, committing euthanasia, or committing physician-assisted suicide ("Doctrine of Double Effect").6,7
In 1998, Michigan attempted to become the second state to legalize physician-assisted suicide, but Proposal B was resoundingly defeated at the polls. The Lethal Drug Prevention Act was introduced in Congress by several conservative members. This act proposes that any physician who prescribes strong opioid medication for the purpose of ending a patient's life would lose his or her Drug Enforcement Agency (DEA) license. The president of the American Medical Association (AMA) testified against passage of the act because it would have a detrimental effect on the AMA's progress in pain management made within the last decade.
Ethical Obligations Commission involves something a person is entrusted to and promises to do. Liability in the medical profession relies on medical negligence, which requires that:
-There is a duty between the health care provider and the patient -There is a breach of that duty -There is causation, a connection between that which is done wrong, a negligent act or an omission, and a resulting injury -The damages are measurable and detrimental
Omission in medicine is the failure to act or to do that which one is obligated to do. Here is an example: A 75-year-old female patient in a nursing home who has congestive heart failure, insulin-dependent diabetes, and atrial fibrillation develops a small ulcer on her toe. The doctor continues to care for the patient's major symptoms, but the patient develops red streaks up her leg, and the ulcer extends down to the tendons. The patient loses her leg, and the physician is sued for failure to address the ulcer. Since an ulcer on a toe is a consequence of insulin-dependent diabetes, it was previously thought that the physician was obligated only to keep the ulcer clean. Today, however, it may be thought that the physician has an obligation to use technologically advanced wound care that (arguably) might have prevented the amputation. Similarly, failure to treat intractable pain is rapidly being associated with liability.
Several years ago, recent law school graduates took nursing home patients' cases (to "sharpen their teeth on"); today senior partners take these cases.8 The American Bar Association recently encouraged all states to pass a Patient's Bill of Rights and to take seriously nursing home–dwelling senior citizens' complaints of pain and suffering.
A Fifth Vital Sign Adequate pain management is available today, unlike in the past when there were no long-acting pain medications, patients' progress was intermittent, and pain medication was administered only when patients could no longer handle the pain. In every institution, pain should be a fifth vital sign. On entering any institution, patients should be informed that the institution does not accept pain higher than a certain standard set by that institution. Patients become responsible to assist professionals in never allowing their pain to go beyond that standard. If the treatment of pain in any health care institution is decreased, the pain becomes difficult to control. There are ways to educate patients on how to help in monitoring their pain, as well as ways to adequately manage that pain. When patients' pain is constant, they should not be expected to inform the health care provider every three hours that they need pain medicine.
There are guidelines for pain management in more than 30 states because the federal and state licensing boards meet regularly with representatives from the DEA. This group is now suggesting that physicians who refuse to address patients' pain and suffering be sanctioned, just as they have been for writing too many prescriptions for chronic opioid medication.
Road Blocks Physicians have legitimate obstacles in providing adequate pain control, such as the fear of getting a patient addicted to the medication. Yet, addiction is an obsessive, overwhelming compulsion to obtain a medical substance and use it for nonmedically approved purposes, and it is extremely rare when pain medication is used for true pain.
Physicians are also afraid that their patients may become tolerant and require a larger dose of medication to provide them with the same effect. This situation is also rare when opioid medication is used for legitimate pain. If the dose has to be increased to achieve the same effect, the first step that should be taken is to consider whether the disease process is increasing or worsening.
Another fear many physicians have is that their patients might become physically dependent. Physical dependence, however, is experienced by every patient who takes substantial doses of opioid medication for more than 7-10 days. Patients should be taken off the medication slowly and gradually.
Patients may be legitimately afraid of becoming addicted to a medication, but the physician must take control of the patients' fears. Patients may also be afraid to talk about pain because it may mean that their disease is worsening or that they are weak. An example might be a 72-year-old man who had a hip replacement and used a patient-controlled analgesia (PCA) pump for the first 24 hours until it was turned off. The patient thereafter kept judging his own character and refusing his short-acting pain medication (ie, hydrocodone/acetaminophen) because he had never taken a pain pill in his life. During physical therapy, he was often in severe pain, and the orthopedic surgeon was called. The surgeon prescribing a 12-hour opioid medication for a similar patient profile might see a much more rapid rehabilitation. That patient with excellent pain management would be quicker to recommend his surgeon to others. The surgeon who takes time to make his patient a partner in pain management has strengthened his patient rapport and his reputation in the community by taking control of a situation.
Managed Care Health care systems have obstructions because, in a managed care environment, all wound patients cannot be sent to wound care centers, nor can all patients with pain be sent to pain clinics. Managed care will not tolerate the cost. Primary care physicians will be obligated to treat pain because the money will not be available for all the invasive kinds of pain control.
There are consensus statements from the American Pain Society, the American Geriatrics Society, and the American Academy of Pain Medicine not only for acute pain control, but also for chronic pain control. There are model guidelines in more than 30 states. Recent studies have revealed that less than 5% of all sanctions from licensing boards on physicians are related to opioids. Of those that do involve opioids, none of them have to do with prescribing opioids. Every one of them has to do with not documenting the treatment plan and the progress made with that patient toward improving the quality of the patient's life.
George Washington University's Center for the Care of the Dying recently uncovered the fact that there is a tremendous lack of standard textbook information about caring for patients who are near death. Center personnel also discovered that some of the books that are written for the lay audience offer more information than many of the medical textbooks with which the physicians are being trained.
Oregon, the only state that has legalized physician-assisted suicide, has actually mandated better pain care to reduce it. That state is also implementing pain care task force committees and is recommending the following:
1. An office should be created to oversee the management of chronic pain. 2. A Patient's Bill of Rights should be passed. 3. Access to pain care should be improved. 4. Managed care organizations must address patients' pain, and if pain cannot be controlled satisfactorily, patients should get a second opinion or a pain care center evaluation.
The institutional commitment to improve pain management applies to all workplaces. A hospital task force for the management of pain should have as its goal evolving into a standing committee, which has more power. Task force committees for pain management should be multidisciplinary; they should include nurses, pharmacists, surgeons, internists, and anesthesiologists. The institution must be committed to assess pain with the patient's help, and to treat pain as if it were just as important as low or high blood pressure or chest pain.
Conclusion The skillful management of pain may be the physician's most important calling and one of the most valuable services health care can provide. It requires both the art and science of medicine. The licensing boards have supported pain management, and the model guidelines exist. Therefore, pain management is clearly a necessary objective of health care.
In this nation, it has been said that people are living longer but are dying more painfully. The health care profession as a whole will be judged in the next century not by how it has been able to take technological skills and prolong life by a few more hours, days, or perhaps weeks, but rather by how it controls the pain and suffering in each life that is entrusted to its care.
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References 1. Lammers S. Making Michigan a model in palliative care. Michigan Medicine September 1998;98:18-22. 2. Improvements in end-of-life care. Michigan Medicine February 1999:26-33. 3. Kutner M. Terminal care for elderly patients. Clinical Geriatrics 1998;6(2):46-57. 4. Support study. JAMA November 1995. 5. Caplan A. Editorial. Detroit Free Press December 19, 1995. 6. Washington v Glucksberg, 521 U.S. 702 (1997). 7. Vacco v Quill, 521 U.S. 793 (1997). 8. Higgins M. Getting sued by seniors. American Bar Association Journal December 1998:28-29. 9. Epstein D. Is $5.5 million too much for an athlete's injuries? Medical Economics March 1999.
Additional Reading Dunegan LJ. The Handbook of Pain Management. Ann Arbor, MI: Dunewood Press; 2000. (For order information, contact Dunewood Press, 317 S Division, PMB #38, Ann Arbor, MI 48104.)
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Dr. Dunegan is a full-time Board-Certified General Surgeon practicing in a specialty group practice and holds a law degree. Address for correspondence: L. Jean Dunegan, MD, JD, 14400 Ames Rd, Hudson, MI 49247.
Annals of Long-Term Care - ISSN: 1524-7929 - Volume 8 - Issue 11 - November 2000 |