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antique
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I have come across some interesting articles on this subject. The links to the websites are included for your convenience. This is meant as a follow-up to previous discussions on this board relating to malpractice for undertreatment of pain and whether or not doctors can or do get in trouble for undertreatment.
A serious look at the undertreatment of pain
Inadequate pain care continues to draw regulatory scrutiny, as well-publicized legal decisions over the past several years have underscored the reluctance of some healthcare providers to adequately treat pain.
The Oregon Medical Board, for example, disciplined a doctor for failing to provide pain control to six patients, in one instance treating an elderly cancer patient with acetaminophen and refusing a nurse's request for stronger medication; in another, refusing requests for pain control in a patient in her 30s who required intubation. The doctor did not lose his license but was required to undergo pain training.
Pain issues specific to the elderly, particularly end-of-life issues, are drawing increased attention. In another closely-watched case, California attorneys asserted failure to adequately treat pain in an elderly patient with terminal lung cancer was not only malpractice but qualified as elder abuse.
A judge rejected defense motions to dismiss that claim recognizing that failure to treat pain adequately can constitute elder abuse under California law. In doing so, the authors note, the judge made the elder abuse statute available to elderly patients who receive inadequate treatment for pain.
While medical and nursing boards have, over the past decade, disciplined more physicians and nurses for overprescribing pain medications than underprescribing, that trend is clearly being reversed, as pain patients become more vocal about their needs and national attention turns toward clearly defining the responsibilities of healthcare providers in terms of adequate pain treatment and relief of suffering.
Physicians and nurses, however, remain apprehensive over the possibility over criminal prosecution for pain medications administered to dying patients; since 1990, at least 13 physicians have been investigated for their management of end-of-life patients, some of them tried on murder charges.
It has been assumed that the administration of excessive pain medications could lead to sanctions and even criminal penalties for nurses. Now nurses who administer inadequate pain medication can be investigated and disciplined as well, the authors note. As a result, nurses have become increasingly aware of the importance of statutes and regulations addressing appropriate pain care, including the JCAHO standards and federal and state legislation related to adequate pain control. (Frank-Stromberg M, Christensen A. Clinical Journal of Oncology Nursing. September/October 2001; 5(5): 235-236.)
http://www.partnersagainstpain.com/html/profed/pmc/pe_pmc4.htm?pg=7508§ion=pe_pmc4
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antique
Banned
Reged: 09/01/03
Posts: 215
Loc: east coast
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A new risk emerges: Provider accountability for inadequate treatment of pain
The emergence of new pain management guidelines and standards may facilitate establishing that pain care provided in specific cases was inadequate and warrants professional discipline.
Kathryn L. Tucker, JD, writing in Annals of Long-Term Care, notes the guidelines' emphasis on mandatory evaluation and routine charting of pain may also make civil liability possible on various grounds, including professional negligence and elder abuse.
Medical organizations establishing standards or guidelines for pain treatment include the World Health Organization, the American Pain Society, the American Medical Association, the AHCPR, the Federation of State Medical Boards, and the Joint Commission on Accreditation of Healthcare Organizations. These guidelines all indicate the importance of pain management as an element of medical treatment.
In addition to new clinical practice guidelines, there are other signs the "laissez-faire attitude regarding inadequate treatment of pain is beginning to change," Tucker says. In 1999, a state medical disciplinary board took corrective action against an Oregon physician who failed to treat his patients adequately for pain.
As these types of cases become more common, risk managers can be expected to undertake efforts to minimize risk, leading to more attentive and aggressive provision of pain care.
One state legislature introduced a measure in the 2000-2001 legislative session that would require the Medical Board to impose corrective action on a physician in the form of mandatory education in palliative care and pain management.
"By amending state law relating to pain in this way, essential steps in encouraging and motivating physicians to treat pain appropriately will be accomplished," Tucker notes. "Until physicians are aware that professional consequences and accountability attach if they fail to treat pain adequately, necessary improvement in provision of pain care will not occur." (Tucker K. Annals of Long-Term Care. 2001;9(4):52-54.)
http://www.partnersagainstpain.com/html/profed/pmc/pe_pmc4.htm?pg=7501§ion=pe_pmc4
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antique
Banned
Reged: 09/01/03
Posts: 215
Loc: east coast
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Failure to treat pain
When a California jury found an internist guilty of elder abuse and reckless negligence by not providing adequate pain care for an 85-year-old man dying of lung cancer, the decision marked only the third in U.S. history for undertreatment of pain. This particular case was the first against a doctor and the first time a jury had awarded this type of verdict under elder abuse laws, rather than under a conventional medical negligence suit.
The jury, which awarded $1.5 million to the man's family [later reduced by a judge to $250,000], was deadlocked on whether the physician's conduct was malicious and so did not award punitive damages. The family also sued the hospital where the man was treated, which settled before the trial began. As part of that settlement, the hospital agreed to conduct educational programs in pain care for its staff.
The case adds fuel to the American Bar Association's initiative to urge all state legislatures to review their laws and remove any impediments to adequately treating patients for pain. Observers say the case may spark similar lawsuits across the country.
Kathryn Tucker, director of legal affairs for Compassion in Dying Federation, the nonprofit patient advocacy group that helped the family bring the case, and Clayton Kent, who tried the case with Tucker, said the key to their case was using the physician's own testimony against him. The doctor told jurors that he was not aware of most developments related to palliative care and had no knowledge of new guidelines for pain management.
With this as a foundation, the attorneys set out to show the jury that the physician was in fact barraged by information about developments in pain care but ignored that information.
For example, the experts introduced copies of the federal guidelines on cancer pain management published in the1990s and a copy of pain guidelines that were mailed by the California Medical Board to every doctor in the state; the physician testified that he did not remember reading the information.
"Our experts testified that it was his obligation to keep current and he simply didn't bother. This is how we showed that it was not mere negligence but reckless conduct, " Tucker said.
Kent noted, "I don't think we could have won this case 10 years ago, or even a few years ago. It all comes down to timing. Since then, there have been new statutes and all this new literature about pain management. There is starting to be public awareness about it." (White N. Lawyers Weekly USA. August 6, 2001. Available at: http://www.lawyersweekly.com)
http://www.partnersagainstpain.com/html/profed/pmc/pe_pmc4.htm?pg=7453§ion=pe_pmc4
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antique
Banned
Reged: 09/01/03
Posts: 215
Loc: east coast
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Physicians challenged to deliver appropriate, effective pain management
"Given the many chronic diseases that physicians cannot do much about, it is puzzling that more physicians do not do a better job at relieving pain. Not only is it something that is generally straightforward to achieve but sometimes it's the only meaningful therapy we can offer our patients." Jay Siwek, MD, chairman of the department of family medicine, Georgetown University School of Medicine
A survey of over 7000 studies by the Agency for Healthcare Research and Quality (formerly the Agency for Healthcare Policy and Research) showed that half of all patients given conventional therapy for pain and most of the 23 million annual surgical cases do not get adequate relief. There are many barriers to effective pain management (see Table). Research has also shown that:
Use of prn pain medicine delays pain relief
Pain prevention is better than treatment as pain arises
Patients have the right to adequate pain control and pain control plans
Fears of postsurgical addiction to opioids are generally unfounded
Proper pain management is patient-centered; according to the American Pain Society (APS), patients' reports of unrelieved pain should be honored. Other APS guidelines suggest that clinicians keep analgesic information in the place where orders are written, promise patients pain control, urge patients to communicate their pain, implement policies and safeguards for modern analgesia, and assess pain management practices. By way of example, when staff at the Bay Area Medical Center in Marinette, Wisconsin, developed a comprehensive surgical pain management program, patient satisfaction ranking for pain control improved. (The Quality Indicator. September, 2000:10-12.)
Obstacles to Pain Relief
Not prescribing enough pain medication
Not using around-the-clock, scheduled dosing
Not using PCA systems when indicated
Using the wrong route of analgesia
Not using adjunctive treatment, or using it inappropriately
Increasing dose frequency instead of total dose itself
Not using analgesics preventively, in anticipation of pain
Not using additional short-acting medication for breakthrough pain
Not checking to see if pain medications are taken as ordered
Not adequately assessing pain
Adapted from the Quality Indicator. September 2000:10-12.
http://www.partnersagainstpain.com/html/profed/pmc/pe_pmc4.htm?pg=6302§ion=pe_pmc4
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antique
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Reged: 09/01/03
Posts: 215
Loc: east coast
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Health care providers' liability exposure for inappropriate pain management
Courts may become increasingly inclined to include proper pain management in the "standard of care" the standard health providers must meet to avoid malpractice. A reason for this is the development and promulgation of pain management practice guidelines, such as the AHCPR Acute Pain Management Guidelines and Cancer Pain Management Guidelines.
Extensive research has shown that pain management practices are often inadequate. In one study of 454 inpatients, 79% had pain during hospitalization, and 58% of this subgroup described their pain as horrible or excruciating. Seventy-five percent of cancer patients have reported suffering pain, with 25% dying in severe, unrelieved pain. Over two-thirds of nursing home residents have serious pain. These findings are shocking, in light of the fact that pain can be controlled for many patients.
Two recent lawsuits show that good pain management is becoming a medical standard of care. In North Carolina, a jury awarded $15 million (later settled for an undisclosed sum) in damages to the family of a patient who suffered through pain mismanagement at the end of life. The Georgia Supreme Court affirmed a patients right to receive medication to control pain, as well as the right to discontinue unwanted medical treatment. New statutes at the state level, institutional pain management guidelines, and the Pain Relief Act, developed by the Project on Legal Constraints on Access to Effective Pain Relief, a research project of the American Society of Law, Medicine & Ethics, will also broaden liability of professionals who mismanage pain. (Shapiro RS. J Law Medicine Ethics. 1996;24:360-364.)
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antique
Banned
Reged: 09/01/03
Posts: 215
Loc: east coast
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Legal and ethical barriers to pain management
A combination of patient, health system, and clinician-related barriers continues to impede access to optimal pain management in the U.S., where 46% of ambulatory cancer patients with pain do not receive treatment adequate to meet WHO standards, despite the many alternatives available. Women, minorities, and patients over 70 are at greater risk than others for inadequate pain control.
Legal and ethical barriers to pain control may be divided into patient, professional, and social factors, as summarized in the table below. Overcoming these barriers requires adherence to four principles: 1) respect for patient autonomy; 2) the willingness to do good for patients; 3) the commitment to avoiding harm to the patients; 4) justice equal treatment for all patients.
Pain that is unrelieved may create a desire for death while there is no correlation between morphine dose and death. According to Richard Payne, MD, failure to control pain that can be controlled is "a fundamental breach of human rights." It is a moral imperative that physicians work to relieve pain.
Fortunately, there are many ongoing efforts to support patients' right to pain relief:
The new standards for institutions from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
The VA initiative Pain is "the fifth vial sign"
Trend to lawsuits or loss of accreditation/license to practice for undertreatment of pain
(Society of Surgical Oncology. 2000 Annual Cancer Symposium, Symposia Highlights, p. 8.)
Types of barriers to pain management
Barrier type:
Specific barriers
Patient factors:
Patient fear of discussing pain:
Fear of being labeled a complainer
Fear that treatment will be discontinued
Fear that pain discussion will divert physician's attention from the underlying disease
Fear of taking pain medicine, especially opioids
Professional factors (physicians, nurses, etc.):
Poor pain assessment skills
Concern about drug side effects
Exaggerated fear of addiction
Fear of regulatory sanction
Health System factors:
Unavailability of some drugs for some patients
Cost of care
Inadequate physician reimbursement for pain management and palliative care
(Society of Surgical Oncology. 2000 Annual Cancer Symposium, Symposia Highlights, p 8.)
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antique
Banned
Reged: 09/01/03
Posts: 215
Loc: east coast
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Improving the practice of pain management
Inadequate pain management is "a systems issue," for which physicians should not be held solely responsible. The new pain standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will serve to stimulate an interdisciplinary approach to pain management and assessment, marked by greater sharing of responsibility for implementation of pain protocols. The administrative "rules" that emerge as institutions implement the standards may in fact restructure the physician's work environment.
Physicians have often been blamed for the undertreatment of acute and chronic pain. In addition to failing to assess patients' pain, studies have shown physicians may prescribe inappropriate drugs at inadequate doses at incorrect intervals. If opioids are required, physicians fear overtreating patients, and are often reluctant to prescribe for fear of regulatory scrutiny and adverse effects, especially tolerance, addiction and respiratory depression. Educational initiatives for physicians on pain management, including CME and clinical practice guidelines, have had limited success.
"One would hope that worries about undertreatment or overtreatment would not dominate the practice of pain management," says June Dahl, PhD, of the University of Wisconsin-Madison Medical School. "Physicians should instead base treatment decisions on the scientific and medical evidence that is available from many sources. It is time for physicians, nurses, pharmacists, other health care professionals, system administrators, and regulators to come together to ensure improved function and good quality of life for all persons in pain." (Dahl JL. JAMA. 2000;284(21):2785.)
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antique
Banned
Reged: 09/01/03
Posts: 215
Loc: east coast
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Physicians' attitudes toward pain and the use of opioid analgesics: Results of a survey from the Texas Cancer Pain Initiative
"Serious mismanagement and undermedication in treating acute and chronic pain" continue to plague both patients and the physicians who treat them. The clinical scenario seems to endure despite significant advances in knowledge of human pain mechanisms. Clinicians lack knowledge of opioid pharmacology and use; have difficulty making equianalgesic conversions among opioids; have a negative view of patients with chronic pain, and remain reluctant to prescribe opioids (some are inhibited by multicopy prescription programs and fear of regulatory reprisal). Using a 59-item survey, researchers studied the practices, beliefs, and attitudes about pain among 386 physicians in Texas. The intent of the survey was to identify barriers to adequate pain management and to assess the impact community size and medical discipline might have on those barriers.
Many physicians were, in critical clinical instances, reluctant to use opioids, i.e., often reserving them until patients' pain is severe and intractable. Ten percent would "withhold opioids from a patient with severe pain until prognosis is
Physicians in large communities feared creating addiction; physicians in small communities also feared creating addiction, knew less about pain management, and were less accepting toward treating chronic pain with opioids. Psychiatrists had the least negative attitudes toward pain and its treatment, were less reluctant to prescribe opioids, and less fearful of addiction risk than physicians in other disciplines including internal medicine and surgery/anesthesia. (Weinstein SM, Laux LF, Thornby JI, et al. South Med J. 2000;93:479-487.)
Selected responses to survey of 386 Texas physicians
Agreement shows misconception about pain management Survey Question Agree (%) Disagree (%)
Narcotics should be restricted to treatment of severe intractable pain 30.5 64.4
Using narcotics to relieve the pain of benign conditions is ill-advised 31.5 57.5
There are limits to the number of narcotics tablets a patient should be prescribed 67.1 21.7
I give patients a limited supply of pain medications to avoid being investigated 23.8 53.6
Increasing requests for analgesics indicate tolerance to the analgesic 62.4 24.7
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antique
Banned
Reged: 09/01/03
Posts: 215
Loc: east coast
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Another interesting article. Here's the abstract and a link to the article:
Abstract:
Undertreatment of pain is likely to occur among patient with active addiction, or those who have
a history of addiction. One of the factors that can contribute to the inadequate treatment of pain
in this patient population is the presence of laws and regulations that, when implemented, could
impede effective pain management. This article describes the current status of federal and state
policy governing the medical use of opioid analgesics for pain management with patients who
have an addictive disease. Three types of policy barriers are discussed: (1) those that can affect
pain management in any patient, (2) those that can lead to patients in pain being classified as
addicts, and (3) those that relate specifically to patients with a high risk of addiction. Also
presented are recent policy initiatives that can improve the use of controlled substances to treat
pain and, thus, ultimately enhance pain relief for patients with an addictive disease.
http://www.medsch.wisc.edu/painpolicy/publicat/02cjpn/Tx_addicts.pdf
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