BY: FR. PETER A. CLARK, SJ, PhD
Fr. Clark is John McShain Chair in Ethics, St. Joseph's
University, Philadelphia.
The effective management of pain is a time-honored goal of
medicine. From the time of Hippocrates1 to the present-day
Code of Medical Ethics of the American Medical Association,2
the assessment and management of a patient's pain has been the
primary responsibility of every physician. However, the medical
profession has a history of not effectively assessing or managing
patient pain. The 1995 SUPPORT study found that 50 percent of
patients in the intensive care unit (ICU) had moderate to severe
pain during their last days of life. This study also found that
pain assessment and management was not an institutional priority
in most acute care facilities.3 Another report showed
that 40 percent of all dying patients in the United States die
in pain.4 In 1997, the Institute of Medicine found
that from 40 percent to 80 percent of patients with terminal
illness reported that treatment of their pain was inadequate
and prolonged the very agony of death.5 Finally,
a recent research study on persistent pain in nursing home residents
found that after two assessments 14.2 percent of residents were
in persistent pain and 41.2 percent of residents in pain at
the first assessment were in severe pain 60 to 180 days later.6
This high rate of persistent pain is consistent with other studies
that have shown that pain is not adequately assessed or treated
in patients in nursing homes.7 The result of this
undertreatment is impaired mobility, clinical depression, and
a diminished quality of life for these patients.8
These studies only confirm a long series of articles in the
medical literature documenting the widespread and significant
undertreatment of pain, beginning with a 1973 study of hospital
inpatients.9
As a result of these studies, the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) was prompted to issue revised
standards, intent statements, scoring guidelines, and survey
process questions so that assessment and treatment of pain is
included in all patient populations.10 The cornerstone
of the revised JCAHO standards is that all patients have the
right to appropriate assessment and management of pain and that
this will be a condition of accreditation. Despite all this
concern, the proper assessment and treatment of pain is still
lacking in most of our acute care facilities. As a result, patients
are pursuing other avenues to deal with the problem, such as
litigation and the right to actively seek physician-assisted
suicide.
Although the U.S. Supreme Court ruled in June 1997 that there
was no federal or fundamental right to commit suicide by having
assistance in effecting it,11 two concurring opinions
by Justice O'Connor and Justice Stevens appear to validate legally
the medical right to terminal sedation as an efficacious form
of palliative treatment for intractable pain.12 The
Supreme Court put the medical profession on notice that it has
a responsibility to relieve the pain and suffering of patients
to the very best of their ability. If this cannot be done, then
there is the distinct possibility that the discussion on physician-assisted
suicide could be revisited by the Supreme Court. This warning,
along with several recent court cases in which family members
successfully sued physicians for not adequately treating a patient's
pain,13 has placed the issue of pain assessment and
management as a top priority in most acute care facilities.
However, despite all this attention, some patients still do
not have their pain adequately assessed and managed. This is
not just a medical and legal issue; it is also an ethical issue.
Patients have the ethical right to have their pain managed as
part of the basic dignity and respect that is accorded to every
human person. This right has a theological underpinning based
in the doctrine of Creation; it also has deep ethical roots
in the medical profession. Some ethicists, such as Ben Rich,
associate professor of bioethics at the University of California-Davis
medical school, believe that the medical profession's failure
to recognize the ethical implications of untreated and undertreated
pain calls into question whether the majority of practitioners
recognize that health care is a moral enterprise.14
The purpose of this article is threefold: first, to examine
why pain assessment and management have been problematic; second,
to give an ethical basis for the duty of health care professionals
to assess and manage pain effectively; and third, to recommend
ways to implement proper pain assessment and management, including
a pain management policy that can serve as a paradigm for other
Catholic health care facilities.
Problems Related to Pain Assessment and Management
Pain is an unpleasant sensory
and emotional experience.15 It is recognized as a
complex phenomenon derived from sensory stimuli and modified
by individual memory, expectations, and emotions.16
Because pain does not have objective biological markers, the
most accurate evidence of pain and its intensity is based on
the patient's description and reporting. The dimensions of pain
affect every person, from the tiniest neonate to the elderly.17
Pain can be classified into three types, each of which can be
acute or chronic.
Types Nociceptive pain is generated by somatic
or visceral tissue damage. Somatic pain is generated by nociceptors
in cutaneous and deeper tissues, such as in the musculoskeletal
system, and is described as gnawing, cramping, and throbbing.
Visceral pain results from stimulation of the nociceptors in
the cardiovascular, gastrointestinal, genitourinary, and respiratory
systems. It is described as deep, aching, squeezing, or pressured.
It is poorly localized and may spread to cutaneous sites. Second,
neuropathic pain is usually described as constant, burning,
shooting, or stabbing pain (such as in diseases affecting the
nerve root). Third, incidental pain is pain caused by
associated conditions (not necessarily cancer), such as positioning
or constipation.18 Acute pain is pain that
lasts or is anticipated to last a short time, typically less
than a month. It is often associated with anxiety and with hyperactivity
of the sympathetic nervous system. Chronic pain is usually
defined broadly and arbitrarily as pain persisting more than
a month beyond the resolution of an acute tissue injury, pain
persisting or recurring for more than three months, or pain
associated with tissue injury that is expected to continue or
progress. Chronic pain has no adaptive biologic role. (Pain
may be broadly classified as somatogenic [organic]explicable
in terms of physiologic mechanismor psychogenicoccurring without
organic pathology sufficient to explain the degree of pain and
disability and thought to be related mostly to psychological
issues.)19 Unrelieved pain is one of the greatest
fears of people suffering from illnesses, especially terminal
illness. Families of the suffering patient can be in great emotional
distress as well. Undertreatment of pain and unrelieved pain
are also costly for patients, families, institutions, and society
as a whole.20 The reasons that pain has been undertreated
or untreated are varied and numerous, but certain well-defined
barriers can be identified.
Barriers Barriers to effective pain assessment and
management fall into four distinct categories. First is the
failure of health care professionals to identify pain as a priority
in patient care.21 The failure to treat pain adequately
is a result of a remnant of Cartesian dualism that dichotomizes
the physical and the mental. Pain is the body's reaction to
disease, and suffering is the person's reaction to pain. Bodies
are the site of disease, but persons undergo the experience
of illness. Suffering is a personal matter. It is as much a
function of the value of individuals as it is of its physical
causes. Suffering is broader than pain and is synonymous with
a reduced quality of life.22 This dichotomy has allowed
medical professionals to claim as their sole responsibility
the treatment of the physical and biological domain of illness
while surrendering the role of suffering to clinical psychologists,
social workers, or pastoral counselors. The result of separating
the objective dimension of disease from the subjective dimension
of the person has been that the whole person's response to the
experience of illness has suffered. 23
Pain management is a priority in the care of every patient
and has deep roots in the medical profession. Physicians have
the responsibility to treat the patient and the person, which
means they assess and manage every patient's pain and suffering;
if they fail to do so, they should be held accountable. Likewise,
patients have a responsibility to make their physicians aware
of the nature, severity, and duration of their pain to the best
of their ability. The best way to assess pain is to ask the
patient. Because pain cannot be objectively quantified, physicians
should believe their patients; patients need to be aware of
the fact that they need not suffer because their pain can be
and should be managed. This can be done on admission when patients
are informed, both orally and in writing, that effective pain
relief is an important part of their treatment, that their communication
of unrelieved pain is essential, and that health professionals
will respond quickly to their reports of pain.24
Unless patients and their physicians have an open and honest
dialogue, the covenant that binds them will be compromised because
of a lack of trust.
Second, some clinicians have insufficient knowledge regarding
the assessment and management of pain.25 A major
cause of this barrier is the lack of education in medical schools
regarding pain evaluation and management. A recent survey reported
that the average amount of time spent teaching pain management
in American medical schools is one hour; for nursing schools,
it is four hours.26 In addition, students typically
take only one course in pharmacology, which cannot properly
prepare them for what they will face once they leave the security
of medical school. Once these individuals begin their residencies
and become attending physicians, their ability to keep abreast
of the medical literature regarding pain management is almost
nil.
The need for a comprehensive pain curriculum in every medical
school is vital.27 Critics of the medical school
curriculum argue that when pain is addressed, too often it is
by a faculty whose knowledge and skills in assessment and management
are woefully outdated, resulting in misinformation being passed
from one generation of physicians to another, leaving the latter
virtually untouched by the remarkable advances of the last quarter
century.28 This becomes quite evident when one is
doing rounds with medical interns and residents. They focus
on the clinical problem, which might be a particular wound or
the disease itself, but fail to treat the entire patient. While
doing teaching rounds a resident will frequently present a case
clinically; when he or she has finished, the bioethicist will
ask: "What is being done to manage this patient's pain?" A blank
stare is often returned with the response: "I didn't think of
that." Ben Rich believes this phenomenon might fairly be described
as the "cultivation and propagation of ignorance."29
If interns and residents have not been given the essential clinical
competencies in pain management in medical school and fail to
receive these clinical competencies while in their residency
programs, when will they learn the importance of assessment
and management of pain?
One way to bring this issue to the forefront is the regular
charting of a patient's pain as the "fifth vital sign." This
concept enhances the clinical competency of physicians in pain
assessment and management and assures patients that their fear
of untreated pain will not become a reality.
Third, there is a fear of regulatory scrutiny of prescribing
practices for opioid analgesics.30 Some physicians
are quite open about the fact that they will underprescribe
opioid analgesics to avoid regulatory scrutiny. As Rich states:
While the medical literature over the last quarter century
is replete with studies demonstrating widespread and significant
underuse of opioid analgesics by physicians in their treatment
of patients with pain, there is only a single instance in which
a state board has disciplined a physician for unprofessional
practice for failure to provide adequate pain management in
the care of such patients. However, there are many cases in
which the courts have criticized the efforts of state boards
to discipline physicians on the grounds that they inappropriately
prescribe (i.e., overprescribe) opioid analgesics for patients
with pain.31
Critics contend that the medical profession has been conscripted
into the government's war on drugs. They contend that physicians
believe their primary responsibility is to help regulators prevent
drug diversion and excessive prescribing of opioid analgesics,
not to effectively manage a patient's pain.32 This
fear, which is realistic, has had the potential to coerce physicians
into failing to act in the best interest of their patients.
As a result, the covenant between physician and patient can
be fractured as basic trust dissolves. Both the state medical
licensing boards and the federal government need to reevaluate
and revise their present regulations regarding opioid analgesics.
These antiquated regulations are causing patients to suffer
needlessly, are raising anxiety levels among those nearing death
that the dying process will be cruel and full of excruciating
pain, and are leading the American public toward the slippery
slope of physician-assisted suicide. Instead of playing into
this antiquated system of regulations, medical professionals
should take the initiative to advocate comprehensive new regulations.
In addition, economic barriers to proper pain management exist.
With the advent of managed care, greater inattention to pain
assessment and management has occurred. Lower staffing levels,
with fewer nurses having responsibility for a larger number
of patients, decrease the likelihood that even a persistent
patient will succeed in securing required pain relief. The reluctance
of physicians to prescribe and the lack of an adequate staff
to monitor and evaluate patients will only lead to further barriers
to pain relief.33
Fourth, unsound beliefs and unsubstantiated fears about addiction,
tolerance, dependence, and adverse side effects of opioid analgesics
persist among health care professionals and the public.34
The major problem is the lack of knowledge concerning the difference
between addiction to narcotics and psychological dependence
on opioid analgesics for relief of severe and persistent pain.
The medical literature confirms that the majority of patients
who receive large and extended doses of opioid analgesics for
the management of their pain are not, and rarely become, addicts.35
An abundance of medical literature emphasizes the important
difference between the natural, physiological dependence on
opioid analgesics that develops and the pathological, psychological
dependence that characterizes addiction. It seems obvious that
many physicians and nurses are not being exposed to this important
medical information in their training.36
Issues of patient tolerance to opioid analgesics are also
based on myths and misinformation. The need for higher doses
is almost invariably related to a progression of the underlying
disease producing the pain. Patients whose disease is stable
do not necessarily require an increase in dosage once an effective
level of analgesia is achieved and maintained.37
Finally, the issue of side effects from the sustained use of
opioid analgesics has been greatly exaggerated, according to
pain management experts. The most common side effects of the
drugs recommended for moderate to severe pain that persists
are constipation, sedation, and respiratory depression. Prevailing
clinical practice guidelines offer a range of effective means
of managing these side effects without compromising the goal
of pain relief.38
There are clear barriers to the assessment and management
of pain that are complex and multifaceted; however, they are
not insurmountable. These barriers need to be challenged medically
and ethically. If medicine is a moral enterprise, then there
is an ethical reason, in addition to a medical reason, to challenge
these barriers.
Ethical Analysis
Failure to treat a patient's pain
has an impact on the deepest ethical roots of the medical profession.
The primary responsibility of a physician is to do what is in
the best interests of his or her patient. Not to treat the pain
and suffering of a patient is to deny the patient basic human
dignity. I believe that the failure of physicians to assess
and adequately manage pain violates the basic ethical principles
of respect for the human person, beneficence, nonmaleficence,
and justice.
Respect for persons incorporates two ethical convictions:
first, that individuals should be treated as autonomous agents;
second, that persons with diminished autonomy are entitled to
protection. The principle of respect for persons thus divides
into two separate moral requirements: the requirement to acknowledge
autonomy and the requirement to protect those with diminished
autonomy.39 The physician-patient relationship is
a covenant that is based on mutual trust. It is a fiduciary
relationship that is based on honesty. Ethicists Edmund Pellegrino
and David Thomasma, who have written extensively in this area,
argue that among the obligations that arise from the physician-patient
relationship is technical competence: "The act of the medical
professional is inauthentic and a lie unless it fulfills the
expectation of technical competence."40 This means
that patients can expect their physicians to have the technical
skills to assess and manage their pain. Unfortunately, most
patients believe that the pain medications they receive are
all the pain relief that can be safely and effectively administered.
Therefore, their continued pain and suffering can be attributed
to the inherent limitations of medical science and technology.41
This misconception directly relates to the issue of informed
consent. Patients have a right to be informed about the advantages
and disadvantages of any treatment as well as about any viable
alternatives. Patients usually cannot give informed consent
because in most cases they have not been given all the options
available to manage their pain. One of the basic aspects of
the principle of respect for persons is that a person should
never be treated simply as a means, but always as an end. To
undertreat a patient because of fear of regulatory scrutiny
in prescribing opioid analgesics or out of misguided beliefs
concerning addiction, dependence, and tolerance is to use patients
as a means rather than an end. Because of a basic lack of education,
widespread misinformation, and unnecessary fear among physicians,
patients are suffering needlessly, their autonomy is compromised,
and the basic respect they deserve as human persons is violated
because they are allowed to endure pain that can be alleviated.
Beneficence involves the obligation to prevent and
remove harm to and to promote the good of the person by minimizing
possible harm and maximizing possible benefits. Beneficence
includes nonmaleficence, which prohibits the infliction
of harm, injury, or death upon others. In medical ethics this
principle has been closely associated with the maxim Primum
non nocere: "Above all do no harm." Allowing a person to
endure pain when said pain can be managed and relieved violates
the principle of beneficence because one is not preventing pain
and therefore not acting in the best interest of the patient.
It also violates the principle of nonmaleficence because it
is causing harmand sometimes injuryto the person. Prescribing
lower doses of effective analgesics because the physician fears
regulatory scrutiny and failing to prescribe adequate doses
of opioid analgesics because of misinformation place the patient
in a situation in which his or her pain is either undertreated
or not treated at all. This comes very close to willfully inflicting
pain.
It is true that most pain technologies also have associated
side effects. Therefore, the physician must balance the pain
relief potential with the potential harm. This can be done through
dialogue with the patient and/or surrogates. The impact on the
caregivers should also be considered in terms of physical and
psychological burdens.42
Physicians have a moral obligation to do what is good for
their patients. Compromising the basic ethical foundations upon
which medicine stands is not only destructive for the patient
but for society as a whole. Patients do have different pain
levels that they can tolerate. It is also true that some people
may wish to voluntarily embrace or tolerate suffering for spiritual
reasons. For example, Christians believe that suffering can
have value and is salvific because the person can thereby experience
the love of Christ in a way that recalls Christ's own love as
demonstrated in his willing acceptance of death on the cross.
Uniting one's suffering with Christ's is perceived as redemptive.
However, this notion should never be understood as a glorification
of pain and suffering. To endure unnecessary pain and suffering
is not only useless, it is also a misrepresentation of the Christian
position.43 The United States Conference of Catholic
Bishops, as stated in the Ethical and Religious Directives
for Catholic Health Care Services, is quite clear that a
patient's pain should always be managed effectively. "Patients
should be kept as free of pain as possible so that they may
die comfortably and with dignity, and in the place where they
wish to die."44 In fact, the bishops go so far as
to state that "medicines capable of alleviating or suppressing
pain may be given to a dying person, even if this therapy may
indirectly shorten the person's life so long as the intent is
not to hasten death." 45 This is justified under
the principle of double effect.46
Physicians, as moral agents, have an ethical responsibility
to treat their patients in a way that will maximize benefits
and minimize harms. Failure to adequately assess and manage
pain, for whatever reason, is not in the best interests of the
patient. Therefore, if a physician has impediments to his or
her reason or free will because of fear or coercion, then that
physician has an ethical responsibility to transfer his or her
patient to a physician who will do what is demanded by the basic
precepts of medicinethat which is for the good of the patient.
This may mean having the courage to challenge state medical
boards and the federal government to revise their regulations
regarding opioid analgesics. Finally, the principle of justice
recognizes that each person should be treated fairly and
equitably and be given his or her due. Every patient has the
right to have his or her pain assessed and managed adequately.
Ignorance is not an excuse or a defense because physicians have
the responsibility to be adequately trained and up-to-date on
medications that will benefit their patients. If that is not
possible, then these physicians have an ethical responsibility
to consult those in the medical field who are trained to manage
pain effectively. To plead ignorance violates the very goals
of medicine and the basic duty a physician has to his or her
patients.
It has also been reported that two-thirds of pharmacies in
minority neighborhoods do not carry adequate medications to
treat persons in severe pain. This is a form of racial injustice,
according to Sean Morrison, MD, a pain specialist at Mount Sinai
School of Medicine in New York. Morrison and his colleagues
surveyed New York pharmacies and found that African Americans
and Latinos do not get adequate treatment for severe pain when
compared with white males. Not only are they less likely to
be prescribed painkillers, but when they get a prescription,
they may not be able to get it filled at a local pharmacy. In
poor neighborhoods pharmacists may decide not to stock opioids
because of the risk of being targeted by drug addicts.47
Pain is color-blind, and all people deserve to have their pain
managed. Health care professionals have an ethical obligation
to supply medications to their clientele that are needed to
manage pain. Justice dictates that similar medical conditions
should be treated in a similar manner if at all possible. If
there are pain medications that can adequately manage pain for
patients and these are prescribed for only some, then failure
to do so for all violates the basic tenet of justice.
The Need for Reform
The issues surrounding pain assessment and management are here
to stay. Much has been written about the failure of health care
professionals to address this issue, but simple rhetoric without
significant reform will accomplish nothing. Immediate changes
that will address the issues of pain assessment and management
directly and concretely are needed. If health care professionals
honestly believe that one of the major goals of medicine is
the relief of pain and suffering, then untreated and undertreated
pain and unnecessary suffering must be alleviated. In addition,
if Catholic hospitals believe that patients should be kept free
of pain so they can die with dignity and respect, then our failure
to address this issue conflicts with the basic core values of
the Christian faith. Finally, if we know that our failure to
relieve pain and suffering is causing people to seek other methods,
such as physician-assisted suicide, then we must do everything
in our power to help our brothers and sisters to deal with their
pain and suffering in a way that benefits the good of the whole
person. To accomplish this task, I submit the following recommendations.
* Each hospital should formulate a pain management policy
that will address the assessment and management of all types
of pain. I submit the Pain Management Policy that has been formulated
by the Mercy Health System in Philadelphia as a paradigm for
other health care facilities (see Appendix below). This
policy is grounded in the dignity and respect of every human
person and the duty of health care professionals to relieve
pain and suffering of patients.
* Each hospital should also form a pain management team. This
team would be interdisciplinary and would consist of a physician,
nurse, social worker, physical therapist, pharmacist, anesthesiologist,
psychiatrist/psychologist, pastoral care member, and someone
skilled in alternative therapies. This team would assist physicians
who are unable to manage a patient's pain. It would also make
health care professionals accountable for pain assessment and
management.
* More educational initiatives for health care professionals
regarding how pain should be assessed and managed are needed.
This begins with medical schools instituting pain assessment
and management curricula, residency programs that include practical
experience in pain management (hospice, etc.), and the education
of attending physicians through continuing medical education
courses. This education of medical professionals must include
instruction about pain management, pharmacologic principles,
the uses of analgesics, and nonpharmacologic methods.
* More educational initiatives for the public are needed.
The public needs to be educated to the fact that it can expect
pain to be assessed and managed properly and that they, too,
have a role to play in this process. Patients have the responsibility
to report the nature, severity, and duration of their pain to
their physicians and to expect that their pain be relieved.
This can be accomplished by the regular charting of a patient's
pain as the "fifth vital sign." It can also be accomplished
by the staff instituting a simple assessment tool of a 0 to
10 scale or a "faces" pain rating scale for children and patients
who are cognitively impaired.48
* Physicians should begin a grassroots movement to challenge
the outdated regulations by medical boards and the federal government
regarding opioid analgesics. If physicians are required to act
in the best interests of their patients, then they will challenge
the regulatory agencies that are hostile to effective pain management
as both medical professionals and ethical persons.
The issue of pain assessment and management should always
be a priority in the medical profession. Reforms are needed
from various aspects of society. Health care professionals have
the professional and ethical responsibility to see that these
reforms are initiated and carried out so that the best interests
of patients remain at the forefront of the medical profession.
Pain management can be improved if it becomes a priority for
all.
NOTES
- Hippocrates,
"The Art," reprinted in S. J. Reiser, A. J. Dyck, & W. J.
Curran, eds., Ethics In Medicine, MIT Press, Cambridge,
MA, 1977.
- American Medical
Association, Code Of Medical Ethics, Chicago, 1997, p.
20.
- The SUPPORT
Principal Investigators, "A Controlled Trial to Improve Care
for Seriously Ill Hospitalized Patients," Journal of the
American Medical Association, vol. 274, no. 3, 1995, pp.
1591-1598.
- J. Lynn, J.
M. Teno, R. S. Phillips, et al., "Perceptions by Family Members
of the Dying Experience of Older and Seriously Ill Patients,"
Annals of Internal Medicine, vol. 126, no. 2, 1997, pp.
97-106.
- Institute of
Medicine, Approaching Death: Improving Care at the End of
Life, National Academy Press, Washington, DC, 1997.
- Joan Teno,
Sherry Weitzen, Terrie Wetle, et al., "Research Letter: Persistent
Pain in Nursing Home Residents," Journal of the American
Medical Association, vol. 285, no. 16, 2001, pp. 2081.
- R. Bernabei,
G. Gambassi, K. Lapane, et al., "Management of Pain in Elderly
Patients with Cancer," SAGE Study Group: Systematic Assessment
of Geriatric Drug Use via Epidemiology, Journal of the American
Medical Association, vol. 279, no. 23, 1998, pp. 1,877-1,882.
- B. A. Ferrell,
B. R. Ferrell, and L. Rivera, "Pain in Cognitively Impaired
Nursing Home Patients," Journal of Pain Symptom Management,
vol.10, no. 8, 1995, pp. 591-598. See also E. A. Sengstaken
and S. A. King, "The Problems of Pain and Its Detection Among
Geriatric Nursing Home Residents," Journal of the American
Geriatric Society, vol. 41, no. 5, 1993, pp. 541-544.
- Ben Rich, "An
Ethical Analysis of the Barriers to Effective Pain Management,"
Cambridge Quarterly of Healthcare Ethics, vol. 9, 2000,
pp. 54-70. See also R. M. Marks and E. J. Sachar, "Undertreatment
of Medical Inpatients with Narcotic Analgesics," Annals of
Internal Medicine, vol. 78, no. 6, 1973, pp. 173-181.
- Joint Commission on Accreditation of Healthcare Organizations, Comprehensive Accreditation Manual for Hospitals: The Official
Handbook,HAugust 1999, RI.1.2.8. Available at www.jcaho.org/standard/pm_ac.html.
- Washington v. Glucksberg, 65 U. S. Law Wk. 4669
(1997), 117 S. Ct. 2258; Vacco v. Quill, 65 U. S. Law
Wk. 4695, 117 S. CT 2293 (1997).
- Justice Sandra Day O'Connor opined that those individuals
suffering from a terminal illness accompanied with great pain
may presently obtain whatever level of medication determined
professionally by a physician will "alleviate that suffering,
even to the point of causing unconsciousness and hastening death."
See note 19, Washington v. Glucksberg, at 4679; Vacco
v. Quill, at 4700. Justice John Paul Stevens concluded that
because palliative care cannot alleviate every degree of pain
and suffering for all patients, there may be situations in which
a competent person could make an informed judgment or "a rational
choice for assisted suicide." See note 19, Washington v.
Glucksberg, at 4682; Vacco v. Quill, at 4703. Also
see Marcia Angell, "The Supreme Court and Physician-Assisted
Suicidethe Ultimate Right," New England Journal of Medicine,
vol. 336, 1997, pp. 50-53.
- The most recent case was that of the family of William
Bergman, who sued his physician, Wing Chin, MD, for undertreating
Bergman's pain. The family argued that their father was denied
proper pain medication during a five-day stay at Eden Medical
Center in Castro Valley, CA, where he was admitted in February
1998 for intolerable back pain. During the course of his hospital
stay, nurses charted Mr. Bergman's pain levels ranging from
7 to 10 on a scale that awards a 10 to the worst pain imaginable.
Mr. Bergman was discharged and died of lung cancer at home three
days later under the care of a hospice program. On June 13,
2001, an Alameda County jury awarded $1.5 million to the family
of William Bergman. The jury found Chin guilty of elder abuse
and recklessness for failure to give a dying man sufficient
medication to relieve his suffering. The jury deadlocked on
whether Chin was guilty of malice, oppression, or intentional
emotional distress. The family settled its suit against the
Eden Medical Center on May 7, 2001, before that trial began.
As part of the settlement the hospital has agreed to provide
pain management classes to its staff and to physicians who admit
patients to the hospital. See Maria LaGanga and Terence Monmaney,
"Doctor Found Liable in Suit over Pain," Los Angeles Times,
June 15, 2001, pp. A-1, A-34.
There have been two previous lawsuits for the undertreatment
of pain that have resulted in large damage awards. A North Carolina
jury awarded $15 million in damages in a 1990 lawsuit against
a nursing home where a nurse failed to administer prescribed
pain medicine to a terminally ill patient. See Estate of
Henry James v. Hillhaven Corp., 89 CVS 64 (S.C. Hertford
Co., North Carolina, 1991). A judge in a 1997 case in South
Carolina awarded $200,000 in damages for pain and suffering
caused by inadequate treatment of a cancer patient's pain. See
Susan Okie, "Doctor's Duty to Ease Pain at Issue in California
Lawsuit," Washington Post, May 7, 2001, p. A-3. - Rich, p. 55.
- H. Merskey & N. Bogduk, eds., Classification of
Chronic Pain, 2nd ed., IASP Press, Seattle, 1994, p. xi.
- R. A. Sternbach, "Clinical Aspects of Pain," in R. A.
Sternbach, ed., The Psychology of Pain, Raven Press,
New York City, 1978, pp. 15-17.
- Recent research suggests that infants may be more vulnerable
to the negative effects of pain, which may later affect their
neurological development, including the reaction to pain. See
B. A. Larsson, "Pain Management in Neonates," Acta Paediatrica,
vol. 88, 1999, pp. 1,301-1,310.
- T. M. Cutson, "Management of Cancer Pain," Primary
Care, vol. 25, no. 2, 1998, pp. 407-421.
- Robert Berkow and Mark Beers, eds., The Merck Manual
of Diagnosis and Therapy, 17th ed., Merck Research Laboratories,
Whitehouse Station, NJ, 1999, p. 1363.
- Effective pain management has been shown to shorten hospital
stays and reduce costs. For a more detailed analysis, see J.
Slack and M. Faut-Callahan, "Pain Management," Clinical Nursing
in North America, vol. 26, no. 4, 1991, pp. 463-476.
- Rich, p. 54.
- Catholic Health Association Task Force on Pain Management,
"Pain Management: Theological and Ethical Principles Governing
the Use of Pain Relief for Dying Patients," Health Progress,
January-February 1993, pp. 30-39, 65.
- Rich, p. 56.
- M. I. Donovan and C. Miaskowski, "Striving for A Standard
of Pain Relief," American Journal of Nursing, vol. 92,
no. 3, 1992, pp. 106-107.
- Rich, p. 56.
- B. A. Rich, "Pain Management: Legal Risks And Ethical
Responsibilities," Journal of Pharmaceutical Care in Pain
Symptom Control, vol. 5, no. 1, 1997, p. 5-20.
- For a more detailed analysis of this topic, see R. S.
Weiner, "An Interview with John J. Bonica, M.D.," Pain Practitioner,
vol. 1, 1989, p. 2.
- C. S. Hill, "When Will Adequate Pain Treatment Be the
Norm?' Journal of the American Medical Association, vol.
274, no. 23, 1995, pp. 1,881-1,882.
- Rich, p. 59.
- Rich, p. 54.
- Rich, p. 60. The one state medical board that did discipline
a physician for not adequately managing a patient's pain was
Oregon. See "Foubister v. Oregon: Doctor Cited for Negligence
for Undertreating Pain," American Medical News, September
27, 1999, pp. 7, 9.
- Rich, p. 60.
- Rich, p. 63.
- Rich, p. 54.
- J. Porter and H. Jick, "Addiction Rare in Patients Treated
with Narcotics," New England Journal of Medicine, 1980,
vol. 320, no. 2, pp. 123.
- Rich, p. 64.
- Rich, p. 64.
- Rich, p. 65. See also Agency of Health Care Policy and
Research, Management of Cancer Pain, Washington, DC,
1994, pp. 61-65.
- National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research, The Belmont Report:
Ethical Principles and Guidelines for the Protection of Human
Subjects of Research, U. S. Government Printing Office,
Washington, DC, 1979, p. B-1.
- E. D. Pellegrino and D. C. Thomasma, A Philosophical
Basis of Medical Practice, Oxford University Press, New
York City, 1981, p. 213.
- Rich, p. 62.
- B. R. Farrell, "Cost Issues Surrounding the Treatment
of Cancer Related Pain," Journal of Pharmaceutical Care for
Pain Symptom Control vol. 1, 1993, p. 9-23.
- Illinois Bishops, "Facing the End of Life, " Origins,
June 21, 2001, pp. 106-109.
- National Conference of Catholic Bishops, Ethical and
Religious Directives for Catholic Health Care Services,
Washington, DC, 1995, Directive 61, p. 23.
- Directive 61, p. 23.
- The principle of double effect supposes that an action
produces two effects. One of these effects is something good
that may be legitimately intended; the other is an evil that
may not be intended. For such an action to be morally acceptable,
it must meet four conditions: (1) the action itself is good
or indifferent; (2) the good effect is not produced by means
of the evil effect; (3) the evil effect is not directly intended;
and (4) a proportionate reason supports causing or tolerating
the evil effect. For a more detailed analysis see, Gerald Kelly, Medico-Moral Problems, The Catholic Hospital Association
of the United States and Canada, St. Louis, 1958, pp. 12-16.
- Abigail Trafford, "No Pain Relief for Some: Study Points
out Inequality in Care," Philadelphia Inquirer, September
4, 2000, p. E-3.
- A simple 0-10 numeric scale that rates pain from "none"
to "worst imaginable" and pain relief from "none" to "total"
can be used with most patients older than 7 years of age. Patients
should be shown the scale and asked about pain intensity on
admission, after each painful procedure, and at least once per
shift. With children under 7 years of age and with the cognitively
impaired, the same type of scale can be used with representations
of human faces instead of numbers.
Appendix: Pain Management
Policy
Purpose
The
purpose of this policy is to state Mercy Health System's commitment
to provide a dignified, comprehensive, and collaborative approach
to pain management consistent with the Ethical and Religious
Directives for Catholic Health Care.
Policy
Mercy Health System believes that patients
have the right to maximal pain relief at all stages of their
acute and/or chronic disease processes. We recognize that appropriate
pain management is critical in the care of patients and believe
that all patients are entitled to a dignified, comprehensive,
and collaborative approach to pain management. While we realize
that some medicines that alleviate pain in the dying patient
may indirectly shorten the patient's life, our goal is to relieve
pain and suffering as much as possible.
Although maximal pain relief is the right
of all patients, some patients may choose to endure some aspects
of their pain as an affirmation of their religious beliefs.
The theological foundation of pain management for Christians
is rooted in the passion of Christ. "Physical suffering is certainly
an unavoidable element of the human condition. According to
Christian teaching, however, suffering, especially during the
last moments of life, has a special place in God's saving plan;
it is in fact a sharing in Christ's Passion and a union with
the redeeming sacrifice which he offered in obedience to the
father's will. Therefore one must not be surprised if some Christians
prefer to moderate their use of painkillers in order to accept
voluntarily at least part of their sufferings and thus associate
themselves in a conscious way with the sufferings of Christ
crucified (Mt 27:34)."*
Respect for the dignity of each patient
creates a responsibility for the health care team to respect
the free and informed decision by the patient to make medical
treatment decisions, including the degree of pain relief. Emphasis
of pain management should be on prevention, evaluation, and
relief. Comprehensive pain management is a multidisciplinary
and collaborative effort that must address physical, psychological,
spiritual, and social effects of unrelieved pain.
Principles for Pain Management
- The dignity of the human person creates
a responsibility for medical professionals to relieve maximally
the pain and suffering of patients.
- Pain management must be tailored to
the specific patient's needs and situation and include a comprehensive
assessment of pain and an evaluation of the effectiveness of
treatment.
- Patients who possess decision-making
capacity are the decision-makers for the course of their medical
treatment, including the degree of pain relief desired. For
patients who lack decision-making capacity, the appropriate
surrogate, acting in a compassionate and ethical manner, should
be the decision-maker.
- Consistent with our policy of informed
consent, placebos should not be used to assess or manage pain.
Complementary treatment modalities may be used.
- All patients will have pain addressed
as part of the plan of care and will be taught that pain management
is an essential part of treatment.
- Discharge instructions will include
information about pain as it pertains to the patient's individual
situation. This will include the cause(s) of pain, recognizing
precipitating and relieving factors, available methods of relief
and how to use them (including the importance of safe and effective
use of medications), and communication to the physician relating
to pain and its management.
Procedure/General Pain
Management for Patients
A. Assessment
1. Each patient will be assessed by the
nurse and the health care professional on admission for the
presence/absence of pain.
2. Each patient will be reassessed for
the presence/absence of pain prior to, during, and/or following
any intervention that may cause pain.
3. Each patient will be assessed for his/her
previous experiences with pain, beliefs about, and preferences
for pain assessment.
4. Every patient will have pain addressed
as part of the plan of care.
5. Every patient will be educated to inform
the health care professionals when he/she experiences pain,
recognizing that communication of unrelieved pain is essential
in helping to manage its relief.
Staff will utilize one of the available
pain scales in assessing a patient's pain. The scale used will
be determined by patient age and cognitive function.
Staff will educate patients with regard
to prevention of pain or reduction of pain rather than chasing
and reducing pain once pain is established.
6. The patient will be assessed and reassessed
for pain. The frequency of assessment and reassessment is based
on how well each patient's pain is controlled.
7. Documentation will reflect assessment,
reassessment, education, interventions, and patient outcomes.
B. Intervention
1. Response to a patient's complaint of
pain will be timely in an attempt to provide quick relief of
pain.
2. If initial interventions are not effective
to decrease the pain to a level acceptable to the patient, additional
methods of pain relief will be sought. These may include other
available pharmacologic methods as well as nonpharmacologic
methods.
3. If relief is suboptimal, the physician
will be notified.
4. Documentation will reflect additional
interventions, reassessments, and patient outcomes.
C. Pain Management Team Consultation*
1. For hospitalized patients, a Pain Management
Consult is recommended in the following situations:
For any patient admitted with intractable
pain
For any patient experiencing increasing
pain or decreasing relief of pain by current methods utilized
For any patient situation in which the
physician desires assistance with pain management for his/her
patient
D. Patient Education
1. Patient education is tailored to address
the patient's needs, values, abilities, and readiness to learn.
2. The goal of patient education is to
include the patient in the management of his/her pain.
3. Education on pain management includes:
A general overview of the causes, a rating
scale to communicate pain as well as effectiveness of interventions,
and the use of a diary to record occurrences, intensity, treatment,
and relief
Pharmacological management
Nonpharmacological management
Procedure/General Pain
Management
for the Geriatric Patient
1. The health care professionals caring
for the geriatric patient recognize that the geriatric patient:
May suffer from multiple, chronic, painful
illnesses and may take several medications
Is at greater risk for drug-drug and drug-disease
interactions
Presents unique problems when assessing
for painthese include physiologic, psychological, religious,
and cultural changes associated with aging
May believe that their pain cannot be
relieved and are stoic in reporting their pain, especially the
elderly and frail elderly
May have cognitive impairment, delirium,
and dementia as well as visual and hearing changes
2. Health care professionals will adjust
their assessments for the geriatric patient to include observations
for behavioral cues to pain such as restlessness, agitation,
or facial grimacing, recognizing that the absence of behaviors
does not negate the presence of pain.
3. When appropriate, caregivers or family
members will be included when assessment of pain is necessary
and will be asked about pain history, interventions, and outcomes.
Procedure/General Pain
Management
for the Pediatric Patient
1. The health care professionals caring
for the pediatric patient recognize that the pediatric patient:
Determines pain by many factors, including
medical/surgical condition, developmental level, emotional and
cognitive state, personal concerns, meaning of pain, family
issues and attitudes, religion, culture, and environment
Requires frequent assessment/reassessment
of the presence, amount, intensity, quality, and location of
pain
Requires prevention or reduction of anticipated
pain and, when prevention is not possible, needs prompt alleviation
of pain
May require the use of a different format
for measuring pain, e.g., a "faces" pain rating scale, gestures,
quality of cry, or the use of special pain scales
2. Health care professionals will adjust
their assessments for the pediatric patient to include knowledge
of the growth and development level of each individual child.
3. The assessment of the child will include
a pain history, an evaluation of diagnoses such as infection
that could cause the pain or an increase in the pain, evaluation
of the pain severity and location, as well as observation of
the child and his or her response to the environment.
4. When appropriate, patients, caregivers,
or other family members will be included when the assessment
of a child's pain is necessary.
5. All interventions are tailored to the
developmental level and personality of the child.
Procedure/General Pain
Management for the Dying Patient
1. Dying patients who possess decision-making
capacity are the decision-makers for the course of their medical
treatment, including the degree of pain relief desired.
2. It is incumbent on health care professionals
to make every effort to relieve the pain and suffering of the
dying patient even if this requires either intermittent or continued
administration of progressively larger doses of opioids. The
goal of treatment is to relieve pain and suffering to the fullest
extent possible.
3. Dying patients should be assured the
maximal possible comfort even in the face of impending death
as heralded by falling blood pressure, declining rate of respiration,
or altered level of consciousness.
4. A variety of means for pain relief,
including what the patient believes is effective, should be
used.
5. Establish a relationship of trust with
the patient so that the patient will not feel abandoned.
Continuous Quality Improvement
The process of managing pain in our patients
and its effectiveness will be monitored, evaluated, and revised
to continually improve outcomes.