Download - Ethical Dilemmas and Interventions for Pain
Ethics and Interventions for Pain Management
Presented by Andrea Chatburn, DO, MAMedical Director for Ethics
9.25.2015
“Addressing the enormous burden of pain will require a cultural transformation… Effective pain management is a moral imperative, a professional responsibility, and the duty of
people in the healing professions.”
-Institute of Medicine, Relieving Pain in America, 2011
Objectives
• Acknowledge systemic & personal biases regarding pain management
• Discuss themes that arise in pain ethics in different clinical contexts:
• Acute setting• Chronic setting• Palliative setting
• Apply ethics questions specific to the 4 principles of Autonomy, Beneficence, Non-maleficence and Justice
• Explore the Principle of Double Effect and contextual limits
Reciprocity
Kalki
WHO HAS EXPERIENCED CHRONIC DEBILITATING PAIN?
Layering Empathy Exercise
ALL LIFE INVOLVES SUFFERING. WE ARE CALLED TO RELIEVE THAT SUFFERING.
TOTAL PAIN
BECAUSE THE RISE OF PRESCRIPTION DRUG ABUSE HAS OCCURRED ALONGSIDE INCREASED USE OF OPIOIDS IN LEGITIMATE PAIN RELIEF, IT IS TEMPTING TO ASSUME CAUSE AND EFFECT.
-FISHMAN, SCHOTT. RESPONSIBLE OPIOID PRESCRIBING: A PHYSICIAN’S GUIDE. FETERATION OF STATE MEDICAL BOARDS. 2007.
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice &
Nonmaleficence
The Providence Model Promotes:
• Clinical Integrity Honesty in representing right professional practices and delivery of health care
• Beneficence Dependability in delivering care that benefits patients medically
• Autonomy Fairness to patients in their contexts
• Justice Accountability to the legitimate interests of others in light of justice
Kockler, N. Seeing Ethics Consultations for the First Time: Disclosure Models, Analytic Design, and Ethical Decision-Making. ©2014 –Nicholas J. Kockler
Clinical IntegrityBeneficence
AutonomyJustice &
Nonmaleficence
Therapeutic relationship between patient and provider
Clinical Context
Acute Rescue, Fix Chronic Maintain, Manage Palliative Alleviate, Enhance QOL Futile Non-Beneficial
or harmful
Clinical Context
Acute ER, Trauma, Post-op Chronic Clinic, ICU, hospital floor Complex Mixed Pain Acute and Chronic Palliative Hospital floor, ICU, clinic,
& hospice
Case: Acute Pain Management
43 yo otherwise healthy gentleman comes to the ER with back pain, found to have a fractured L1 Vertebrae with mild spinal cord compression after a construction accident.– Emergency– Intraoperative– Postop
Case: Chronic Pain Management
43 yo otherwise healthy gentleman comes to the ER with back pain, found to have Ankylosing Spondylitis (Autoimmune).– Immediate phase– Chronic phase
Case: Complex Mixed Pain
43 yo otherwise healthy gentleman comes to the ER with back pain, found to have a fractured L1 Vertebrae after a construction accident. He also has underlying chronic back pain and Lower Extremity Neuropathy due to prior traumas and has a pain agreement with his Primary Doctor.– Immediate phase– Chronic phase
Case: Palliative Pain Management
43 yo otherwise healthy gentleman comes to the ER with back pain, found to have a fractured L1 Vertebrae due to a new diagnosis of widely metastatic cancer.
Ethical Issues in Chronic Pain Management
• Patient access to an outpatient evaluating provider, lack of medical home model– Scheduling bias
• Public misconceptions about pain management• Concerns of drug diversion• Fears about addiction• (Non-) “Compliance”• Failure to recognize Psuedoaddiction• Community lack of Pain Specialists• Fear of regulatory or law enforcement intervention
Ethical Issues in Palliative & Hospice Pain Management
• Doctrine of Double Effect and worry about “last dose”
• Lack of specialty referral to Palliative Care team/lack of primary provider comfort with high dose opioid calculations
• Recognition of Total Pain- emotional, relational, existential, functional, physical
• Trust/relationship concerns
Doctrine of Double Effect
Bad Effect
Good Effect
Cause & Effect
Cause & Effect
Action/Object
Doctrine of Double Effect
St. Augustine Thomas Aquinas Joseph Magnan (‘49)
• Act itself must be good or at least indifferent• Must intend the good effect • Good effect cannot be caused by bad effect• Proportionality
Criticisms: Principle of Double Effect
• Evidence Based Medicine shows that opioids do NOT cause significant respiratory depression that could hasten death in terminally ill patients.
• However, most physicians report the Principle of double effect was relevant (71%) and useful (68%) in “justifying optimal pain and symptom management at the end of life.”
Maccauley, Robert. The role of the principle of double effect in ethics education at US medical schools and its potential impact on pain management at the end of life. J Med Ethics 2012; 38: 174-178.
“Addressing the enormous burden of pain will require a cultural transformation… Effective pain management is a moral imperative, a professional responsibility, and the duty of
people in the healing professions.”
-Institute of Medicine, Relieving Pain in America, 2011