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Patient awareness, physician education could work in your favor
All your ethics committee needs right now is another set of standards, right? Actually, this set might give your committee the extra muscle it needs to help your facility focus on pain assessment and management. The new standards were released in August by the Joint Commission on Accreditation of Healthcare Organizations.
They couldn’t have arrived at a better time to help your committee educate staff on the need for increased awareness for pain manage ment. Fear of unrelieved pain at death has always been a major concern among patients. Physicians, however, have been hesitant to prescribe higher doses of med ications for fear of prosecution from authorities or, worse yet, hastening a patient’s death.
Ethics committees could serve as harbingers of change as hospitals start focusing on meeting the new standards. "Undertreatment of pain is clearly an ethical issue. I recommend that frustrated caregivers in the hospital turn to the ethics committee for help in bringing about change," says June L. Dahl, PhD, professor of pharmacology at the University of Wisconsin-Madison Medical School. Dahl also serves as executive director of the Wisconsin Cancer Pain Initiative, which helped develop the standards for the Joint Commission.
"Pain is the primary reason patients seek medical attention. But when pain goes unrelieved, it has no redeeming virtue — it is soul-destroying," Dahl says. Clearly, ethics committees can be involved in helping prepare a mission statement that addresses pain management in the facility. They also can develop a patient rights or patient responsibilities handbook, she adds.
There’s no doubt the tide is turning in terms of how legislators view pain management. The calls for effective pain management have reached Capitol Hill. Sen. Don Nickles (R-OK) and Rep. Henry Hyde (R-IL) are co-sponsoring the Pain Relief Promo tion Act of 1999, which would amend the federal Controlled Substances Act in two areas. First, it would affirm that pain control is a legitimate medical treatment, even if the use of controlled substances increases the risk of death. Second, it would clarify that the use of controlled substances for assisted suicide and euthanasia is not allowed.
The medical community is recognizing the need for better pain management as well. Medi cal schools are teaching effective pain assessment and management techniques. (For suggestions on institutional steps toward better pain management, see box, p. 103, top.)
"The Joint Commission represents a new and critical participant in the area of assessing and managing pain. The accreditation and oversight community’s involvement is another part of the corral that we are building around the management of pain," adds Ira M. Byock, MD, research professor at the University of Montana and principal investigator of the Missoula Demonstration Project. Byock also is author of the book Dying Well.
"It becomes evermore clear to any clinician or teacher or for a student in medical training that the assessment and management of pain is essential. It’s no longer an embellishment or ancillary to the clinical encounter," he explains.
Although the standards are applicable to pro viders throughout the continuum of care, the standards for hospitals fall under the Patient Rights and Organization Ethics chapter of the Comprehen sive Accreditation Manual for Hospitals.
"Unrelieved pain has enormous physiological and psychological effects on patients. The Joint Commission believes the effective management of pain is a crucial component of good care," says Dennis S. O’Leary, MD, president of the Joint Commission.
Introduction of the standards is the result of a two-year joint effort between the Oakbrook Terrace, IL-based Joint Commission and the Uni versity of Wisconsin-Madison Medical School. The project was funded by the Robert Wood Johnson Foundation in Princeton, NJ. (See Medical Ethics Advisor, October 1997, p. 113.)
"The new Joint Commission standards will serve as a great stimulus among providers. I’ve seen a great deal of interest among providers in various settings in making pain management a priority. We just completed a pilot program with home care agencies in Wisconsin and a very high percentage of patients report experiencing pain," says Dahl. (For more suggestions on how the ethics committee can get involved in pain management, see p. 104.)
The standards have been endorsed by the American Pain Society in Glenview, IL. Hospi tals, as well as long-term care facilities, outpatient clinics, and home health agencies, will be expected to:
• recognize the right of patients to appropriate assessment and management of pain;
• assess the existence, nature, and intensity of pain in all patients;
• record the results of the assessment in a way that facilitates regular reassessment and follow-up;
• determine and ensure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff;
• establish policies and procedures that support the appropriate prescription or ordering of effective pain medications;
• educate patients and their families about effective pain management;
• include patients’ needs for symptom management in the discharge planning process;
• collect data to monitor the appropriateness and effectiveness of pain management.
Putting the problem center stage
"These standards are putting the importance of pain management at center stage, ensuring that health care providers and professionals will take pain management in a serious way," says Russ Portenoy, MD, president of the American Pain Society.
The standards acknowledge that pain coexists with a number of diseases and injuries, requiring explicit attention. A breast cancer patient, for example, should be treated not only for the actual illness, but also for any associated pain under the new standards.
The new pain management standards — along with examples of compliance — are being included in 2000-2001 manuals. The standards will first be scored for compliance in 2001. Copies were sent earlier this year to accredited health care organizations, a variety of professional groups and associations, consumer groups, and purchasers. The standards received an average approval rating of 92%.
Pain experts suggest that patients themselves could help shift the focus of providers toward more effective pain management. "It is our great hope that patients and families will demand that health care providers pay attention to pain. That’s one of the reasons we proposed language in the patient education chapters in the Joint Commis sion manual and also in the Rights and Ethics chapter," notes Dahl. Patients and families need to understand that pain management is an important part of their treatment, she adds.
"It won’t be long until it seems unnatural, and we’ll remember with bemused embarrassment that we once made rounds and left the patient’s bedside without asking about their discomfort. I hope that day is not long in the future," notes Byock.
1. June L. Dahl, PhD, professor of pharmacology at the University of Wisconsin-Madison Medical School, says undertreatment of pain is clearly an ethical issue. She recommends:
A. Frustrated care providers turn to the ethics committee for help in bringing about change.
B. Teaching patients about their disease and what kind of pain they should expect throughout the course of the disease.
C. Teaching staff the importance of not overmedicating patients with opioids.
D. All of the above.
2. The Joint Commission on Accreditation of Healthcare Organizations’ new pain management standards, according to Ira M. Byock, MD, research professor at the University of Montana and principal investigator of the Missoula Dem onstration Project, are necessary because:
A. Staff don’t see the importance of measuring pain.
B. An oversight agency’s involvement emphasizes the importance of effective pain management.
C. Long-term care facilities need strict enforcement in the area of pain management.
D. All of the above.
3. One of the reasons the Medical College of Wisconsin placed resources available through the Center for the Study of Bioethics on the Internet, according to Mark Kuczewski, PhD, associate professor of bioethics, was:
A. Students wanted more resources available on an instantaneous basis.
B. The school’s network consisted of ethics committees at hospitals, medical centers, and teaching institutions in a four-state area.
C. It serves as an advertisement for the center.
D. All of the above.
4. One of the advantages to the new Richmond, VA-based United Network for Organ Sharing’s (UNOS) liver allocation policy, according to Jeremiah G. Turcotte, MD, director of the Ann Arbor-based University of Michigan Medical Center’s liver transplant program and immediate past chairman of the UNOS liver and intestinal organ transplantation committee, is:
A. A heightened awareness among staff that livers are in high demand.
B. A larger population base to match potential donors and recipients.
C. A coordinated transportation system for allocated organs.
D. All of the above.