FINDING THE CORRECT TREATMENT BALANCEUNDER MEDICATING/OVER MEDICATING OR CAPASSION OFMEETING IN THE MIDDLE WITH DIGNITY

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FINDING THE CORRECT TREATMENT BALANCE

UNDER MEDICATING/OVER MEDICATING OR CAPASSION OFMEETING IN THE MIDDLE WITH DIGNITY

Many medical studies confirm that far too many patients die in pain in our hospitals, and that too many patients who are not terminally ill suffer unnecessarily from painful diseases, conditions, and medical treatments. In the past, courts have dealt with over prescribing and administering lethal doses of pain medication, but now courts are also addressing the issue of under medicating failures by care providers to manage a patient's pain. Although medical and nursing boards have disciplined physicians and nurses for giving too much medicine, the new trend is being reversed as inadequate pain management is investigated and physicians and nurses are being held responsible and disciplined for under managing pain. Liabilities for under medicating include negligence (medical malpractice) for failure to medicate or failure to refer pain to a pain management specialist.

The Joint Commission on Accreditation of Healthcare Organizations has set pain management standards. JCAHO states that healthcare professionals need to recognize the right of patients to appropriate assessment and management. Assess the existence and, if so, the nature and intensity of pain in all patients. Record the results of the assessment in a way that facilitates regular reasoning and follow-up. Determine and assure staff competency in pain assessment and management. Establish policies and procedures that support the appropriate prescription ordering of effective pain mediations. Educate patients and their families about effective pain management. Address patient needs for symptom management in the discharge planning. ()

The Oregon board of medical examiners took disciplinary action against Dr. Paul A. Bilder, for improperly managing the treatment of pain in six of his patients between the dates of 1 and 1. These cases include; A 5 year old woman with pulmonary disease, on a mechanical ventilator in which he stopped giving sedatives and pain medication. The woman later became restless and pulled out her ventilator tube. Dr. Bidler did not return to reinsert the endotracheal tube and an emergency room physician performed the task. Refused to give a -year-old pneumonia patient with hypoxemia pain medicine and anxiety medications while inserting a breathing tube. The staff ended up restraining the patient to complete the procedure. An 8-year-old patient with congestive heart failure complained of not being able to breathe and was getting tired from his respiratory efforts. Dr. Bilder ordered Lasix, the symptoms continued and refused nurses request for morphine. Another physician medicated and stabilized the patient. A 6-year-old woman with pulmonary disease on a ventilator remained anxious despite paralytic agents. Dr. Bilder refused to order morphine for anxiety and pain control. Dr. Bilder refused to give a dying man of cancer adequate amounts of pain medications despite the nurse's plea. The man died three weeks later from his lung cancer. The last instance involved a man dying from cancer. The nurse requested stronger pain medicine and he ordered Roxanol .5 mg every four hours and Tylenol for a high fever over 10 degrees. This patient died that night. (1) Dr. Bilder refused to comment on this case and signed a statement acknowledging that his treatment showed unprofessional, dishonorable conduct and negligence. (1)

In addition, I would like to mention two other similar cases that went to trial. A jury awarded $1.5 million to the family (Bergman) of an 85-year-old man who's family accused his doctor of not prescribing enough pain medication during his final days. The other case was regarding Mr. Crawford who was transferred to the ICU from the cancer center. Mrs. Crawford stated, [My husband] screamed in pain the rest of his life. Very few had any sensitivity to the pain or their responsibility in managing that pain. Mr. Crawford's final words to his wife were, If I knew this is the way I would die, I would have died years ago of my lung or liver cancer, because I would have died an easier death. (10, 11)

The dilemma at hand is, why are we under medicating patients? Legal briefs states, When 7,74 nurses were asked which area ethical issues existed, pain relief and management was ranked first by 8%. Nurses often find themselves considering clinical actions that may may be ethically appropriate but raise legal concerns.()

Option # 1. Under medicating patients is not an intentional act. Under medicating principle of ethics can be considered as avoiding risks in order to insure that no harm is done. Pain happens, so patients must grin and bear it. To avoid pain is a sign of weakness. Many patients have multiple medical problems that perplex pain assessment. Pain medication also increases the likelihood of cognitive/sensory impairment and prevalence of depression. An over medicated patient may become confused and fall out of bed resulting in injury. If the patient is terminal and pain medication is given, the nurse may hasten their death or cause respiratory depression that could quicken their death. If you over medicate, this can be seen as euthanasia.

Option # . Many healthcare workers under medicate due to misconceptions about pain in the elderly. Another important factor is an unwarranted fear of addiction of the patient to the medication. Even when pain is detected and assessed, widespread and unjustified fear of addiction may preclude adequate treatment. Pain is not something that we can just put a Band-Aid on for relief. Nurses need to break the barrier to effective pain control and take pain as a high priority in patient care. We need to take on the important role in patient advocacy and education about pain management. Assessment of each patient's pain cannot be overemphasized. We play an important role in patient advocacy and education on pain management. Nurses need to promptly convey inadequate pain control to the pain management team and be an advocate for the patient.

No one needs to suffer intolerably till his or her death, from painful conditions or diseases. For around the clock pain, constant dosing is the key. Pain is a major stressor and the patient's worst memory of the intensive care unit. The first step is to recognize pain. Assume that all critically ill patients are in pain or at high risk for pain. Pain can be triggered by medical conditions such as ischemia, inflammation, infection, edema, diseases, and surgery. We need to also consider the invasive procedures and monitoring devices we use such as drains, catheters, endotracheal tubes, dressing changes and suctioning just to name a few, that can cause the patient to have more pain and discomfort. Some patients are at higher risk for poor pain management, especially those who are unable to verbally communicate because of intubation, chemically paralyzed, and those with altered mental status. (7,8)

Pain should be treated as the fifth vital sign. Every time a nurse takes the patients vital signs, the patient should be asked to rate their pain intensity from 0 to 10 on the Wong Baker scale. Patients deal with pain very differently and it is hard sometimes to know if you should give pain medicine or not. Pain is subjective and therefore we need to always believe the patient. Prevention of pain is the key. If the patient's pain is not controlled, it is the nurse's duty to report it. Nurses need to be aware of nonverbal indicators that the patient is in pain such as irritability, anxiousness, restlessness, moaning, crying, grimacing, change in vital signs, painful conditions, painful procedures, and reports from the family acting on the patients behalf. (6,8)

In conclusion, pain management is filled with ethical dilemmas. Ethical Standard E-.0 states, Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care.() There must be accountability for physicians and nurses who ignore pain, allow their patients to needlessly suffer and they must face the consequences. We have the moral, legal, and an ethical duty to provide appropriate care to our patients. These cases have alerted physicians and nurses as they become increasingly aware of the importance of statutes and regulations addressing appropriate pain care, including JCAHO standards and federal and state legislation related to adequate pain control. Nurses need to implement JCAHO pain standards to improve pain management as the ultimate goal rather than simply meeting the new standards. The most important aspect of all pain control is to communicate with your patient. Be aware of those in pain (even when they cannot tell you about it) and address the pain aggressively. Keep the patient informed and reassured. We need to keep an ongoing pain assessment, titrate analgesics effectively, manage adverse effects and complications, use non-pharmacological interventions, educate the patient and family, document pain management effectively and be aware of liability issues. One of the most important things that a nurse can do is familiarize themselves with issues that affect their practice, including state and federal laws and establish lines of authority and accountability for pain management. Adverting liability is to promptly report under treatment of pain.(4)

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