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 May/June 2008 93 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 inter- disciplinary 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 94 Dimensions of Critical Care Nursing Vol. 27 / No. 3 Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Pain Treatment Rights 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.