The Right to Pain Treatment a Reminder for Nurses

Clinical DIMENSION

The Right to Pain Treatment A Reminder for Nurses

Margarete L. Zalon, PhD, RN, CNS-BC; Rose E. Constantino, PhD, JD, RN, FAAN, FACFE; Kathleen L. Andrews, MSN, RN, BC

Critical care units are frequently the setting for the delivery of end-of-life care. A case study describing pain management for a terminally ill woman in an intensive care unit is used to illustrate conflicts that may be experienced by critical care nurses. The application of standards of professional organizations and regulatory bodies is described, as well as the ethical principles of autonomy, veracity, beneficence, nonmalfeasance, and double effect. Important legal and sociocultural considerations are included. Keywords: Ethics, Legal aspects, Pain, Professional standards, Terminal care

[DIMENS CRIT CARE NURS. 2008;27(3):93/101]

CASE SCENARIO real reason she wants these drugs. And I would hasten A 69-year-old terminally ill female patient cries out her death if I gave her as much pain medication as for help from her intensive care room. She tells the she wants.[ The nurse suggests he replace the placebo nurse that her pain is unbearable. She says, BI need with pain medication; he rejects her suggestion. The more pain medicine, it hurts too much, I can’t sleep, I doctor tries to reassure her that research has proven that can’t stand it any longer.[ She seems very anxious and placebos are effective in alleviating pain. He said, BThe irritable. The nurse asks the patient to rate her pain on placebo works on the psychological part of the pain.[ a scale from 0 for no pain to 10 for the worst pain, The physician’s final decision was not to order an in- and the patient says her pain is a 9. The nurse knows crease in her pain medication or replace the placebo. the physician ordered a placebo to be alternated with The nurse followed through with his orders for pain a low-dose pain medication. She approaches the phy- management. sician with her concerns about the patient’s poorly Did the nurse do the right thing by carrying out managed pain. He walked her to his desk and showed the physician’s order to give the patient the placebo, her a picture on his computer. The picture was of a without the patient’s knowledge and consent? Should man who was carrying another man, over his shoulder, she have taken further action? What ethical principles as a means to get him to the hospital. He said, BIn were violated? Was she negligent to have followed my country, one has to tolerate much more pain than through with his orders? What are the ethical issues Americans do, and no one complains. Here in America, related to diagnosing someone with an addiction in there is so little tolerance for pain.[ He also said, BShe the presence of unrelieved pain? Is it true that death has a history of being a drug addict, which is the would be hastened with administration of medication

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Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Pain Treatment Rights for pain? These are questions that a nurse would have upon examining this case. The purpose of this article The value of a team approach in is to address issues in pain management from the pain management is receiving perspective of the nurse. It is important for the nurse greater recognition. to examine the ethical, sociocultural, and legal aspects of this scenario.

INTRODUCTION Using McCaffery’s definition of pain2 as a guide for Pain is the most subjective of all human symptoms in practice, this case scenario of an older, terminally ill that only the sufferer can truly assess the intensity and woman who has been labeled as an addict and is pre- quality of pain that he or she is experiencing at any scribed a pain management regimen of alternating a given moment. The International Association for the weak analgesic with a placebo will be used to illustrate Study of Pain (IASP) provides a technical definition of the foundation for nursing actions that are derived from pain, BAn unpleasant sensory and emotional experience professional standards, ethical principles, and legal and associated with actual or potential tissue damage, or sociocultural considerations. Recommendations for pol- 1(p210) described in terms of such damage.[ However, it icy and research will be described. is Margo McCaffery’s definition of pain, developed in 1968, that has provided a practical guide for clini- PROFESSIONAL STANDARDS cians for nearly 40 years, Bwhatever the person ex- The American Nurses Association’s (ANA) position periencing the pain says it is, existing whenever the statement Pain Management and Control of Distressing person says it does.[2(p17) Patients have a right to Symptoms in Dying Patients,7 which is derived from effective management of that pain. The first clinical nurses’ social responsibility8 and nurses’ ethical obliga- guideline published by the federal government for acute tions,9 indicates that: pain states that Bthe ethical obligation to manage pain nurses must use effective doses of medications and relieve the patient’s suffering is at the core of a health- prescribed for symptom control and nurses have a 3(p4) care professional’s commitment.[ The value of a moral obligation to advocate on behalf of the patient team approach in pain management is receiving greater when prescribed medication is insufficiently managing recognition. According to an Institute of Medicine report, pain and other distressing symptoms. The increasing the complexity of healthcare increasingly requires that titration of medication to achieve adequate symptom control is ethically justified. healthcare professionals collaborate effectively in interdisciplinary teams to ensure the effectiveness and reli- Although the ANA position statement does not ability of care.4 mention that titrating medication to achieve adequate The use of placebos for pain management outside symptom relief is legally justified, most clinicians be- of a clinical trial involves not believing the patient’s lieve that it would carry weight in a legal argument. report of pain and illustrates the ineffectiveness of a This is illustrated by the growing body of legal evidence healthcare team. Recently, there has been more system- through court cases adjudicated in favor of patients and atic review of the nature of the placebo response in their families for poorly relieved pain.10 clinical trials and in practice,5 and the magnitude of In response to decades of research demonstrat- the placebo response has been called into question.6 ing poor pain management, the American Pain Society The literature does have numerous case reports of (APS) issued quality improvement guidelines to im- placebo use outside of clinical trials. Until there is prove the treatment outcomes for patients with acute more substantive knowledge and understanding of and cancer pain by giving greater visibility to the the placebo response through well-controlled studies, importance of improving pain management.11 These it is likely and it is hoped that placebo use for pain guidelines, which were updated in 2005, recommend management is an infrequent or rare occurrence. How- that all care settings used structured, multilevel systems ever, because of its rarity, it means that nurses may approaches that are sensitive to the type of pain, popu- not understand the ethical and legal ramifications of lation served and care setting, so that there is prompt placebo use. They may not have adequate knowledge recognition and treatment of pain, patient and family about placebo use nor have a repertoire of strategies involvement in the pain management plan, improved to deal with misconceptions held by healthcare pro- pain treatment patterns, regular reassessment and read- fessionals in the multidisciplinary environment that is justment of pain management, and quality improvement required for effective pain management when such an activities that include evaluation of pain management instance occurs. processes and outcomes.12

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In response to concerted efforts by June Dahl, a pro- further defined as Bpersonal rule of self, free from both fessor of pharmacology at the University of Wisconsin, controlling interferences by others and from personal and her colleagues, the Joint Commission on Accredita- limitations that prevent meaningful choice.[18(p277) tion of Health Care Organizations, now known as the With regard to healthcare, autonomy is defined as the Joint Commission, adopted a pain management stan- patient’s right to make his or her own medical decisions dard in 2001 in recognition of patients’ rights to effec- regardless of the opinions of healthcare providers.19 tive pain assessment and management.13 The standards Autonomy, as a primary ethical principle, was clearly address the patient’s right to have an assessment of pain articulated in the Belmont Report as Brespect for as well as appropriate management, reassessment, and persons.[20 This ethical principle confers the right to follow-up. Patient education about pain and its treat- self-determination on all human beings, including indi- ment is emphasized. Furthermore, to meet the standard, viduals with diminished capacity by reason of age the appropriateness and effectiveness of pain manage- (children and frail elders) or illness (mental, psycholog- ment must be measured.13 Both the APS and the Joint ical, or physical disorder; unconscious or semiconscious Commission emphasize the importance of a multidisci- state; or under the influence of a mind-altering sub- plinary approach to provide effective pain management. stance). It also includes those who are imprisoned and Furthermore, the ANA Scope and Standards of individuals who do not have the capacity for self- Practice require that the nurse attain and maintain determination. For those with little or no capacity for current knowledge and competency in nursing practice self-determination, a parent, guardian, adult child, or and that the nurse systematically evaluates the quality sibling who holds only the best interest of the dependent and effectiveness of nursing practice.14 This expectation should be vested with the dependent’s right to self- is carried through by the American Association of determination. In such cases, autonomy or respect for Critical Care Nurses in its acute and critical care nursing the dying patient’s needs is paramount. In this case standards.15 Thus, nurses are obligated to be knowl- scenario, the patient is vulnerable not only because of edgeable about pain management practice as it applies her age but also because of being hospitalized with a to their specialty. Nurses are also obligated to assess terminal illness and being in pain. the effectiveness of their practices with regard to pain Violation of the ethical principle of autonomy is a management by determining whether their interventions violation of one’s human rights. There will be times have provided relief of pain and incorporating new when it is easier to surrender to the determination, knowledge into their practice. Intensive care unit nurses decisions, and goals of influential parties such as the should also be familiar with critical care standards primary physician in this instance. The nonnegotiable related to terminally ill patients. Guidelines for analgesia ANA Code of Ethics for Nurses requires that nurses and sedation for dying patients in intensive care direct practice Bwith compassion, and respect for the inherent that opiates be used in the amounts that are necessary dignity, worth, and uniqueness of every individual.[9 to relieve pain and suffering.16 In this case scenario, Furthermore, respect for human dignity requires that the nurse is not using effective doses of medication nurses recognize a patient’s right to self-determination, for symptom control to relieve pain and suffering. She which is also known as autonomy.9 Only with a sincere has not collaborated with the patient, and may not be and deep respect for persons will the nurse fulfill the familiar with standards regarding pain management requirements of the ethical principle of autonomy. practice and the importance of evaluating the effective- Clearly, the physician interfered with the patient’s ness of one’s practices. right to self-determination with the need to control the situation according to his beliefs, as opposed to what the ETHICAL PRINCIPLES patient felt she needed. The physician failed to acknowl- The application of the ANA Code of Ethics, APS quality edge that the patient’s perception of pain is the reality improvement guidelines, Joint Commission standards, for that patient. The patient was not respected for her and the case scenario will provide a framework for decision to be treated with the appropriate amount of discussion of the ethical principles of autonomy, verac- medication to relieve her excruciating pain. The nurse’s ity, beneficence, nonmalfeasance, and double effect. obligation was to respect the patient’s autonomy and well-being. This means that the nurse is obligated to do Principle: Autonomy everything within her professional capacity to relieve the The principle of respect for patients’ autonomy can pain when the patient requests pain relief. Furthermore, guide nurses in their pain management practices. Auton- professional standards require that nurses assess pain omy is the right of all people to self-determination, and reassess pain even when the patient has not made a independence, and goal setting.17 Personal autonomy is specific request. O’Malley21(p236) reiterates McCaffery’s

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Pain Treatment Rights definition as a mechanism for facilitating patient au- clinicians be competent in working in interdisciplinary tonomy, BThe bioethical principle of personal autonomy teams, which includes cooperation, collaboration, com- used as a guide for practiceIis expressed as pain is munication, and integration of care so that care is con- whatever the patient says it is and exists whenever the tinuous and reliable.4 Expecting a team member to be patient says it does.[ Also, the nurse is responsible for deceitful in his or her relationship with a patient under- assisting the patient in making appropriate decisions by mines the interdisciplinary team in providing continuity giving the patient accurate information.22(p226) Self- and reliability of care. determination provides the foundation for informed consent.9,23 The nurse did not provide information to the patient about administering a placebo in place of Expecting a team member to be analgesics. In this case, the patient’s autonomy was not respected because of the intentional duplicity, not only deceitful in his or her relationship by the physician but also by the nurse. The patient is not with a patient undermines the a partner in her pain management plan as advocated by interdisciplinary team in the APS and Joint Commission. providing continuity and reliability of care. Principle: Veracity Veracity is defined as Btelling the truth without de- ception.[22(p227) To adhere to this ethical principle, the patient needs to be provided with accurate information about her right to effective pain relief,24 as well as The American Society for Pain Management Nurs- information about the pain medication being adminis- ing (ASPMN) adopted a position statement that prohib- tered. The Joint Commission standards25 and APS guide- its the nurse from using a placebo for the management lines12 focus not only on the assessment and management of pain in all patients.27 The only exception for placebo of pain but also on the provision of information about use considered by ASPMN is in clinical trials that have the patient’s right to effective pain management. Nurses been approved by an institutional review board where must also inform patients about best practices, for the patient has given informed consent. A source of example, that taking pain medication will help with controversy is the revised position statement of the APS retaining functional status by relieving pain so that it that allows for trials alternating between active medi- does not interfere with movement that is critical to cation and placebo treatments known as N-of-1 trials.28 recovery. The nurse misled the patient by not informing In such trials, the patient may not have been fully her about the administration of a placebo to control her informed when giving consent and it cannot be truly pain. By administering the placebo, the nurse was vio- determined whether such treatment is effective.29 Fur- lating the principle of veracity. Despite the physician’s thermore, the scientific rigor of such a trial is question- choice not to replace the placebo with pain medication, able because of the lack of random treatment order, it is the nurse’s obligation to have informed the patient failure to allow time for the active medication to be that a placebo was being alternated with her regular completely excreted (known as a washout period), and pain medication. According to the ANA Code of Ethics most importantly, the active medication might be as for Nurses, the nurse’s primary responsibility is to ineffective as the placebo.29 It has been found that small, the patient.9 medium, and large placebo responses are dependent on Veracity consists of truthfulness, trustworthiness, a variety of factors such as whether the previous and transparency, all of which are in the eye of the analgesic treatment was effective and the length of time beholder. Trust and trustworthiness are not usually part between treatment and placebo response.30 Thus, if the of a program of study, but are more likely to be part of patient obtains some relief from the analgesic, he or she informal discourse, friendships, family, and business might then exhibit a response to the placebo. Subse- relationships.26 To practice effectively as a nurse, one quently, it might be decided to lower or withdraw the must establish a nurse-patient relationship that is based analgesic dose, resulting in increased pain for the upon trust. Administering a placebo without informed patient. Thus, in our case scenario, carrying out the phy- consent is deceitful and undermines trust. To apply the sician’s order for an N-of-1 trial places the patient at risk ethical principle of veracity in practice, nurses need to be of a poor pain management outcome without really ever truthful, trustworthy, and transparent, and they must being able to assess the effectiveness of the analgesic consistently apply these qualities in their conduct. medication. In addition, it creates conflict for the nurse Furthermore, effective care for patients requires that all who is involved in being deceitful to the patient.

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Principle: Beneficence nonmalfeasance.33 Underprescribing pain medication is Beneficence refers to the duty Bto provide treatment that the equivalent of inflicting pain.21 In this scenario, the promotes the good of the individual[ not just refraining unrelieved pain resulted in physical and psychological from harmful acts.[22(p226) Beneficence is embedded in harm to the patient. The patient is placed in the position the golden rule: BDo unto others as you would have of not being believed and having to beg for medication others do unto you.[31,32 The nurse has a solemn duty in addition to having to endure intolerable pain. Thus, to provide service for the good of the patient. Benefi- the ethical principle of nonmalfeasance is violated. cence requires that the duty is to help by managing pain effectively.18 It is not sufficient to abstain from harming Principle: Double Effect the patient; under the scope of nursing practice, nurses Many healthcare professionals may believe that the are obligated to take positive actions that will benefit ethical rule of double effect applies when caring for their patient whenever possible. The ANA Code of terminally ill patients. Double effect is defined as a Ethics for Nurses indicates that nurses are accountable permitted act with more than one possible outcome, for their practice.9 Therefore, nurses must provide a Beven when one of the outcomes is morally wrong.[34 standard of care with regard to the appropriate man- For example, the appropriate amount of analgesics agement of pain. Furthermore, the Code of Ethics for to control the pain of a terminally ill patient may Nurses indicates that nurses have the obligation to take be administered even if the caregiver understands that action in cases of incompetent, unethical, illegal, or it may end the patient’s life because the intention is impaired practice by any member of the healthcare team to control the pain, not to end the patient’s life.34 or healthcare system.9 Clearly, the administration of a BSupreme court judges, ethicists and healthcare pro- placebo outside of a clinical trial is not in accordance fessionals justify the use of high doses of opioids for with nursing standards. Therefore, the nurse has the re- severe pain of dying patients, even in the amounts that sponsibility to take action in instances when placebos may hasten death.[34(p49) However, Fohr found there is are being used. The IASP, in its Ethical Standards in little research to support the notion that increasing the Pain Management and Research, indicates that Bwit- dose of opioid analgesics for terminally ill patients nesses to patients’ suffering of unnecessary pain have a hastens their death.35 Applying the ethical principle of moral responsibility to those patients, even if the wit- double effect to end-of-life issues perpetuates the myth nesses are not clinically responsible for that pain.[33(p1) that administering opioid analgesics has the double In this case scenario, the patient was in such extreme effect of providing pain relief and hastening death, pain that she was anxious and irritable and unable to which in turn leads to needless suffering.35 Belief in this eat and sleep. By carrying out the physician’s orders and principle may have actually caused healthcare profes- not advocating for an appropriate pain medication sionals to have reservations about the administration of order, the nurse did not provide the patient with the opioid analgesics at the end of life because of the fear much needed pain medication, violating the ethical that increased dosages may cause respiratory depression principle of beneficence. and therefore hasten death. The physician did not want to hasten death. His reluctance to administer a higher Principle: Nonmalfeasance analgesic dose illustrates how belief in the double effect Nonmalfeasance is encapsulated in the saying Bprimum of pain medication leads to unnecessary suffering. The non nocere[ (First, do no harm).17,32 The nurse has a nurse’s unquestioning acceptance of the physician’s solemn duty to protect the client from pain. Non- statement indicates that she is not knowledgeable about malfeasance is usually interpreted to prohibit an action common myths related to the care of the terminally ill. to avoid harm.18 Nursing practice should also be guided Unfortunately, despite the many years since Fohr’s care- by the duty to Bdo no harm.[ Suffering with pain may ful analysis of the research, belief in the double effect of be harmful to patients because their mobility is reduced. pain medication still persists, as is evident by the articles They may be unable to carry out simple activities of that address helping healthcare professionals under- daily living such as eating, dressing, transferring from a stand how to apply the double effect principle in pro- bed to a chair, or walking around. This in turn has viding appropriate levels of analgesia.36,37 serious consequences for patients’ quality of life and/or recovery depending in the circumstances of the situa- LEGAL ISSUES tion. The IASP standard is based upon the under- In addition to the ethical dilemma posed by the case standing that pain above moderate levels can be scenario, the question of whether the nurse was physically and psychologically harmful, and thus, insti- negligent while providing care for the patient is raised. tuting appropriate pain relief measures prevents harm or Negligence is the failure to meet a standard of care, as

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Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Pain Treatment Rights any reasonably prudent healthcare provider would do by following the physician’s orders to undermedicate possessing similar knowledge and skills under compa- and administer a placebo. However, it is also a standard rable circumstances.22 Negligence consists of 4 elements, of care for the nurse to assess and reassess the patient’s which must exist and be proven to claim malpractice as pain and evaluate the plan of care with regard to pain follows: duty, breach of duty, causation, and damages.17 management. It is unclear how the nurse would be able to continue to document a failure to act. Duty The element of duty is established when the nurse Damages accepts responsibility for direct care and treatment for In the element of damages, there are 3 types: special, an individual.17 Most nurses are not in private practice, general, and punitive. Special damages provide mone- so they do not choose their patients. Thus, by accept- tary compensation for expenses incurred by the plaintiff ing an assignment, the nurse in our scenario had the as a consequence of the negligence. General damages, responsibility to care for the patient. Duty was estab- under most circumstances, recompense for damages on lished when the nurse accepted the responsibility to which a monetary value cannot be placed, such as pain provide care and treatment for the patient. and suffering. Punitive damages are imposed at a speci- fied rate to punish the defendant, set a representative Breach of Duty example, and act as a deterrent for future behavior.22 The element of breach of duty occurs when nurses fail In this case, the damages do exist and fall under the type to provide an expected standard of care within their of general damages, specifically pain and suffering. specialty while providing care or treatment to a patient The actions of the nurse (and physician) in this under their care.22 The nurse in our scenario failed to scenario meet the legal standards of negligence. The take appropriate action to provide the patient with nurse had a duty to provide effective management of adequate pain relief, causing the patient significant pain. Duty was breached by not providing effective pain suffering; therefore, this qualifies as a breach of duty. relief by administering a placebo, and harm resulted be- In this instance, standards of care as established by cause of the patient’s suffering in pain. This is illustrated the ANA,7,9 ASPMN,27 IASP,33 and the Joint Commis- by the growing body of legal evidence to support this sion,25 among others, indicate that nurses must provide argument. patients with appropriate pain relief. Tucker reported There are an increasing number of court cases in that the California Board of Registered Nursing has which undertreating pain is defined as Babuse, negli- indicated that Bthe use of a placebo in a deceitful man- gence, malpractice and professional misconduct.[21(p237) ner would not fulfill informed consent parameters.[38 For example, in 1990, a jury held a nurse liable for Clearly, the prohibition against the use of a placebo for failure to treat a patient’s pain appropriately in a North pain management by multiple governmental and non- Carolina case, the Estate of Henry James v Hilhaven governmental entities indicates that this is a well- Corp.39 In this case, the nurse was held responsible for accepted standard of care. The weight given to clinical making the dying days of the patient intolerable by guidelines and other documents by the courts depends delaying or withholding the administration of analgesic on (1) the degree of acceptance and authority of the medication. Fifteen million in damages was awarded to practice parameter, (2) the fit between the clinical the family of the patient who was dying of prostate situation and the practice parameter, and (3) the validity cancer with bone metastases. However, no nurse has of the research and evidence for the practice parame- been held liable for administering too much pain ter.39 Administering a placebo for pain is a breach of medication to a suffering patient. A nurse has a legal duty, which, in this instance, is compounded by lying to obligation to act in a patient’s behalf to relieve his or a dying patient in pain. her pain.21 In another case in California State Court in 2000, a jury found the physician liable for ordering Proximate Cause an insufficient amount of analgesics for a terminally The element of proximate cause requires that the act of ill patient, causing the patient to die in agony.40 Clearly, negligence be identified as the proximate (legal) and cases like this send the message that nurses and phy- direct cause of the patient’s injury or loss.22 Although sicians are responsible for the appropriate treatment of this is by far the most difficult element to prove, it seems a terminally ill patient’s pain. In yet another California that the inaction by the nurse (not to do anything to case, a 14-year-old boy was hospitalized with severe provide adequate pain medication) was the proximate migraine headaches.38 The physician had initially pre- and direct cause of the dying patient’s suffering. The scribed morphine but then switched to saline for the nurse neglected the patient’s need for pain medication pain. Subsequently, the physician told the patient and

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Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Pain Treatment Rights his mother about the placebo. The mother filed a case of incompetent, unethical actions or when the ac- complaint with the California Board of Nursing, which tions of an individual places the rights or best interests filed formal accusations against 3 nurses. of the patient in jeopardy.9

SOCIOCULTURAL ISSUES The physician in our scenario decided to deprive the Regardless of the patient’s patient of the appropriate amount of pain medication history, the patient is indeed and described differences in his culture and his preju- entitled to have her pain managed dice toward those with a history of drug addiction. effectively. He implied that in his culture, pain is a way of life, as opposed to how easy the Americans have it. He also implied that Americans lack tolerance to discomfort. In the United States, there are multiple ethnic groups, and RECOMMENDATIONS AND STRATEGIES it is assumed that each possesses a unique view of pain The nurse’s responsibility in this case scenario is to and suffering.40 Pain is a subjective and a private ex- advocate for the patient and address the misconceptions perience, often expressed in variable ways by different that she and other healthcare professionals may have people.21 This type of situation is even further compli- related to pain management having an impact the on cated when the patient is considered to be of weak this patient’s care. Regardless of the patient’s history, character because she was a former drug user. Further- the patient is indeed entitled to have her pain managed more, physicians themselves may not be well prepared effectively. Withholding medication at the end of life in dealing with patients who are culturally different. will cause needless suffering. A survey of nurses, In a study examining non-Western physician strat- physicians, and psychologists in pain management egies in caring for patients in Canada, it was found indicated that undertreatment of pain, management of that physicians generally used 3 types of strategies: (1) pain, and undertreatment of pain in the elderly are the 45 insistence on patient adaptation to local beliefs and most commonly encountered ethical dilemmas. In a behaviors, (2) physician adaptation to what was as- survey of 2,033 nurses, it was found that 45% of nurses sumed to be wanted by patients, and (3) development thought that the fear of causing death by giving 46 of a mutually agreed-upon plan.41 However, the physi- medication is a common dilemma at the end of life. cians did not use a consistent framework for address- Given the pervasive undertreatment of pain and fears ing cultural differences. Despite cultural differences, about the administration of pain medication, the critical research has demonstrated that ethnic differences in care nurse needs to consider multiple resources and pain, pain-related sequelae such as emotional distress, strategies to address this issue to avoid the negative pain-related disability, and pain coping may be small outcome of a patient who is allowed to suffer because of when the ethnic groups are closely matched and that poor pain management. These strategies are described interventions to enhance adaptive coping might be ef- in Table 1. fective across ethnic groups.42 One of the issues in this case study is the persistence of myths or stereotyping POLICY AND RESEARCH QUESTIONS about patients’ pain that presumably are attributed to The overall goal in addressing the issues raised by the cultural differences when they are just as likely to be case scenario is to eliminate misconceptions about pain derived from a lack of knowledge about pain and its and its management, promote collaboration among management. Research has demonstrated a lack of con- healthcare team members, improve pain management cordance between physicians and patients in the end-of- practices, provide culturally sensitive care, and eliminate life care options, including pain management.43 In a the use of placebos in the clinical treatment of pain. A survey of critical care nurses, it was found that 2 of number of policy and research questions are raised in the barriers to effective end-of-life care were treatment this case scenario. These questions are related to the decisions based upon physician rather than patient strategies used to provide ongoing education for hospi- needs and behaviors that cause patient suffering or tal personnel and the extent to which written policies prolong pain.44 The nurse in this scenario needs to be should be developed regarding pain management. sensitive to the multiple factors that may influence a Because pain management is such an important focus healthcare provider’s behavior and take them into and because of the high prevalence of pain in hospi- consideration in planning an appropriate course of talized patients, should an institution have a specific action. In this instance, the ANA Code of Ethics for mandated annual training program not only for pain Nurses provides guidance directing nurses to act in the management but also for cultural diversity? Should this

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TABLE 1 Strategies for Nurses to Promote Effective Pain Management 1. Review the literature for evidence-based practices for effective pain management in the terminally ill patient. Complete continuing education programs on palliative care and pain management. 2. Check if the healthcare facility has a policy on pain management and/or the use of placebos. If there is no pain management policy, refer to the American Pain Society guide on analgesic use.48 If the facility does not have a pain management policy or a policy on the use of placebos, help develop one in collaboration with the medical staff. Consider including an automatic referral to a pain management service for unrelieved pain at a certain level. Consider including an automatic call to the medical director if a physician orders a placebo outside of a clinical research study and is unwilling to amend the order. 3. If the patient has a history of substance abuse, refer the patient to a pain management service, palliative care program, or the substance abuse treatment program in order to develop an effective pain management plan that takes into consideration the patient’s special needs. 4. Approach the physician privately regarding concerns about the ethics of placebo administration and share information on standards of care and position statements. Raise the issue of the importance of addressing the needs of patients with sensitivity to their culture. Point out that the goal of care is to provide a plan of care that provides the patient with relief of pain. 5. Inform the patient and his or her family about the right to effective pain management. The nurse can offer to accompany the physician when he or she informs the patient that he or she was taking a placebo for pain and that a new pain management plan has been developed. 6. Contact the hospital’s ethics committee about the ethical issues that are raised by the use of a placebo for pain. 7. Contact the hospital’s risk manager and point out the legal liability associated with a failure to manage pain effectively. training also be required of physicians, advanced is noted that the nurse was placed in the position of practice nurses, and others who have hospital priv- violating the ANA Code of Ethics for Nurses9 and its ileges? What are the evidence-based strategies to sustain underlying ethical principles. In addition, the nurse was evidence-based pain management? A review of system- also at risk of being considered negligent and could atic reviews of professional behavior change inter- possibly be at risk of being sued for malpractice because ventions indicates that educational outreach is effective of her negligence as a licensed professional. Further- for prescribing.47 Regardless, it is likely that no single more, the case scenario illustrated the complexities of intervention will yield a sustained behavior change. the application of standards of care to a specific situa- Furthermore, the writing of a policy is only one step tion and the challenges of dealing with conflict among of the process in behavior change. A policy on pain healthcare team members. To prevent such a situation management and a policy prohibiting the use of pla- as described in this scenario, healthcare institutions can cebos outside of a clinical research study provide guid- adopt policies for the appropriate treatment of pain, ance and support for nurses in interacting with other provide opportunities for training regarding cultural sen- healthcare team members. The situation illustrated in sitivity and pain management, and provide adminis- this case scenario of a terminally ill woman not receiv- trative support for the implementation of policies and ing pain adequate pain relief is complex. Therefore, a changes in pain management practices. multifaceted approach is required to improve pain management practices not only for this one situation but References also for all patients. 1. Merskey H, Bogduk N, eds. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2nd ed. Seattle, WA: IASP Press; 1994. 2. Pasero C, Paice JA, McCaffery M. Basic mechanisms underlying It is unlikely that no single the causes and effects of pain. In: McCaffery M, Pasero C, eds. Pain: Clinical Manual. 2nd ed. St Louis: Mosby; 1999:15-34. intervention will yield a sustained 3. Acute Pain Management Guideline Panel. Acute Pain Manage- behavior change. ment: Operative or Medical Procedures and Trauma. 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Oncol Nurs practice of patient autonomy and cancer refusals: a patient’s and Forum. 2000;27(3):445-455. physician’s perspective. Soc Sci Med. 2004;58(11):2325-2336. 47. Grimshaw JM, Shirran L, Thomas R, et al. Changing provider 24. Haddad A. Ethics in action [acute care decisions]. RN. 2001; behavior: an overview of systematic review of interventions. 64(11):25-28. Med Care. 2001;39(8 suppl 2):II2-II45. 25. Joint Commission on Accreditation of Healthcare Organiza- 48. American Pain Society. Principles of analgesic use in the tions. Comprehensive Accreditation Manual for Hospitals: treatment of acute and cancer pain. 5th ed. Glenview, IL: The Official Handbook. Chicago, IL: Joint Commission American Pain Society; 2003. Resources, Inc; 2007. 26. Gabriele E. Shifting the emphasis: protection follows from trustworthiness. Protecting human subjects. Washington, DC ABOUT THE AUTHORS US Department of Energy, Office of Biological and Environ- Margarete L. Zalon, PhD, RN, CNS-BC, is a professor at the mental Research; 2005. http://www.science.doe.gov/ober/humsubj/ Department of Nursing, University of Scranton, Pennsylvania. Summer05.pdf. Accessed August 15, 2007. 27. American Society for Pain Management Nursing. Position state- Rose E. Constantino, PhD, JD, RN, FAAN, FACFE, is an associate ment on use of placebos in pain management. Lenexa, KS: Au- professor at the School of Nursing, University of Pittsburgh, thor; 2004. http://www.aspmn.org/Organization/position_ Pennsylvania. Dr Constantino is a consultant with Dimensions of papers.htm. Accessed July 22, 2007. Critical Care Nursing. 28. American Pain Society. APS position statement on the use of placebos in pain management. J Pain. 2005;6(4):215-217. Kathleen L. Andrews, MSN, RN, BC, is a diabetic educator at Children’s 29. McCaffery M, Arnstein P. The debate over placebos in pain Hospital of Pittsburgh at UPMC, Pittsburgh, Pennsylvania. management. The ASPMN disagrees with a recent placebo position statement. Am J Nurs. 2006;106(2):62-65. Address correspondence and reprint requests to: Margarete L. Zalon, 30. Colluca L, Benedetti F. How prior experience shapes placebo PhD, RN, CNS-BC, Department of Nursing, University of Scranton, analgesia. Pain. 2006;124(1-2):126-133. Scranton, PA 18510-4595 ([email protected]).

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