Pain and pain management in the dying patient

Pain and pain management in the dying patient For many years there has been a question as to whether or not providing pain medication to a dying patient is ethical or not. This subject practices on what is considered morally ethical as well as medically ethical. Allowing a person to sit in pain at the end of life, hits as both medically and morally unethical. Especially, when health care professionals can manage and control the pain. There are many medical ethics principles as well as the directives that apply from the Catholic religion side of it. Some of the principles that will be discussed are the principle of double effect, informed consent, veracity, beneficence, non-malfeasance, extraordinary versus ordinary means, and proportionate and disproportionate means. This paper is going to discuss the ethical implications regarding the barriers that are encountered when administering pain medications to patients that are in the last part of the dying phase. It is my position that patients that are dying should receive pain medication as desired and expressed by the patient. The pain medications should be administered and titrated accordingly to maintain the appropriate therapeutic level to allow the patient to maintain his or her dignity. There are several barriers that arise when providing pain relief in the dying patient. The barriers include failure of clinicians to identify pain relief as a priority in patient care, insufficient knowledge among clinicians about the assessment and management of pain, fear of regulatory scrutiny of prescribing practices for opioid analgesics, failure of the healthcare system to hold clinicians accountable for pain relief, the persistence of irrational beliefs and unsubstantiated fears about addiction, tolerance, dependence, and adverse effects of opioids, and the resistance of patients and/or their family members to the use of opioid analgesics in the management of pain (Rich, 2000). The most common barrier is under treatment due to fear of hastening death. Assessing pain and the administration of pain medication in the dying client is very important. This nursing assessment is vital through all aspects of life but is also very important in the end of life to try and maintain as much of a persons autonomy and dignity as possible. AS in life people who are dying must also be able to have and make choices surrounding the way in which they choose to spend that last portion of their life. Before getting down to the ethical concerns of pain and pain management, it is important to define what pain is and how it is assessed. Pain and suffering is often linked together and some even use it interchangeably. However, there is a difference between the two. Pain is considered a negative and unpleasant sensory felt by the person that is inhibitory to the comfort of the person, it is considered to be mainly physical in nature (Kelly, 2004). Suffering is considered to be roughly the same as pain but the effects are more geared towards a persons spirituality and mentality (Kelly, 2004). The way in which people experience pain and suffering is different from person to person. Pain is a subjective experience and is to be assessed on an individual basis. There are many ways in which pain can be assessed. There are many different scales that are used to assess pain and each scale has different characteristics that allow health team members to be able to assess every type of person for which they care for. Some of the most common scales used are the descriptive scales in which you circle the word that best describes you ranging from none to excruciating, the numerical scale which is the most common scale used allows a person to say or circle a number that reflects the amount of pain they are in ranging from 0 being no pain to 10 being the worst pain they have ever felt. There is a also a visual analog scale that allows a person to mark a place on a line or pick out a face on a faces scale ranging from no distress/pain to worst pain ever. The last scale mentioned is one of the least used and it is the functional interference scale which allows a person to circle a word that best describes the persons degree of impairment ranging from n one to incapacitated. In addition to these subjective scales there has been evidence that has helped with the ability of healthcare professionals to be able to approach pain from an objective point of view. This approach has been divided up into four different categories: sympathetic discharge signs, positional relief signs, sensory avoidance signs, and common pain distraction signs. Some of the sympathetic signs associated with pain are tachycardia, high blood pressure, dilated pupils and vasoconstriction (Leavitt and Tennant, 2008). There are several more approaches but this is just a few that are used in healthcare. Positional relief signs include; walking imbalanced, leaning while sitting or standing, lying on the floor, and differences in temperature between sides of the body (Leavitt and Tennant, 2008). Sensory avoidance signs include; speaking slowly, delays answering questions, avoids noise, shallow breathing, and wont brush teeth (Leavitt and Tennant, 2008). Some of the common pain distraction s igns include; grinding of teeth, clenching of feet and hands, bites lips, gouges or squeezing of skin (Leavitt and Tennant, 2008). The other aspect to consider is the type of pain medication being administered. When pertaining to the end of life the typical drug of choice are the ones that fall into the opioid family. These drugs are chosen for people that have pain that is moderate to severe in intensity and is unrelieved by non-opioid drugs. These drugs provide pain relief and can cause some adverse effects such as constipation, nausea and vomiting, respiratory depression, fatigue and sometimes light sedation is amongst the most common effects. The amount and type is determined on an individual basis and prolonged use can lead to dependence and the need for increased dosages due to an increased tolerance for the desired therapeutic effect. The way in which drugs are chosen is divided into 3 steps as developed by the World Health Organization. Step one is when the pain is assessed as mild to moderate and has had no previous treatment and so non-opioid drugs are used such as tylenol, ibuprofen, and toradol (Cla sen, Jonas and Whitecar, 2000). Step two is when the pain is measured at a moderate level and has been treated previously but has not responded to the treatments from step one, the medications used in step two are weak analgesics such as Tylenol with codeine, and tramadol (Clasen, Jonas and Whitecar, 2000). Step three is considered when the pain is described as severe pain or pain that does not respond to one and two. In this instance the patients should be treated with strong opioids such as morphine, dilaudid, and Demerol (Clasen, Jonas and Whitecar, 2000). Morphine is one of the most commonly used opioids because there is no therapeutic ceiling and extremely large doses can be used safely and effectively if the drug is titrated properly (Clasen, Jonas and Whitecar, 2000). Part of treating every person as an individual and respecting them as an individual is being sure to respect their autonomy. This principle applies here because to be able to treat a person that is in pain, they have to be assessed individually and be treated according to their individual needs. Every person feels pain differently and every person has a different threshold for pain. What is considered mildly painful to one person may be severe to excruciating to the next. As a health care member you have to be able to allow the patient to express what they are feeling and to allow them to be involved in the decisions regarding their pain management. The ability for them to be able to make decisions allows the people that are dying the ability to be able to have some form of control of how they live the last part of their lives. Allowing the dying person to make small decisions such as whether or not they receive pain medication allows the person to feel as though they still have a voice and a place within the world that they are about to leave. The fear usually involved with giving dying patients pain medication is hastening the death process. However, as the health care members the opinions that we may have about whether or not it does hasten death does not matter because the patient has the right to make his or her own decisions regarding their personal healthcare interventions. Due to the fact that pain is mostly a subjective matter healthcare members do not have the authority to decide whether or not a patient is in fact in pain or not. Withholding pain medication in the dying patient would be a violation against the patients human rights by allowing that person to die in pain. Allowing a person to die in pain does not allow the person to be able to concentrate on their spiritual needs, psychological needs, and family needs at the time of death. Violation of the ethical principle of autonomy is a violation of ones human rights. â€Å"There will be times when it easier to surrender to the determination, decisions, and goals of influential parties such as the primary physician† (Andrews, Constantino, and Zalon, 2008, Pg. 94). Furthermore the ANA Code of Ethics for Nurses requires that nurses practice â€Å"with compassion, and respect for the inherent dignity, worth, and uniqueness of every individual† (ANA, 2001). As nurses we are obligated to do everything within our power to relieve the persons pain when the person is requesting pain relief. It is also our responsibility to reassess the persons pain without prompt by the patient. Another responsibility that nurses own is providing accurate information to the patient regarding the medications ordered for pain, so as to allow the patient to make informed decisions about receiving the medications or not. The next principle is veracity, veracity is when a person tells another person the truth without any form of deception. In this case it would be the health care member speaking truthfully to the dying patient. Under this principle the nurse has the obligation to provide the patient with accurate information about his or her right to effective pain relief. The nurse also has the obligation to provide information about the pain medication being administered. The other thing to remember when this principle is applied is that nurses need to be aware that people that experience chronic pain exhibit behaviors that are vastly different than those who are experiencing acute pain. This becomes a very important principle because there have been instances in which the nurse will just bring in a medication and just tell the patient that the medication is for pain. Little does the patient know that the medication the nurse is administering is tylenol or ibuprofen. The patient trusts the nurse and assumes that their pain will be taken care of. Instead without directly having to lie to the patient, the patient is deceived. Granted the medication given is for pain but, the type of pain being referred to in the end of life is usually moderate to severe and the medications listed above are not made for intense pain. Violation of this principle is what leads patients to distrust the healthcare providers and the care that they are given. From this, patients start to feel they need second opinions and the continuity of care for the patient is then lacking. As we know to be able to properly control pain in our patients it has to be done with trust between the patient and healthcare members as well trust between the nurses and other members of the healthcare team. According to the ANA Code of Ethics for Nurses, the nurses primary responsibility is to the patient (ANA, 2001). So, if the patient is not given the proper information about the pain medications being used and it isnt being treated effectively the patient then loses part of their dignity and we as the healthcare members just robbed the patient of any value they might have felt like they had left. Before a person can make a decision about accepting or denying an intervention of any kind, that person has to be completely informed. This begins the discussion of the principle of informed consent. This principle is very important because it allows the person that is dying to be able to continue to make decisions about their lives all the way to death. When administering pain medication to a person that is dying it would be unethical to not inform that person of the affects that the pain medication may have on them. If medication was given to the patient and it either sedated them or it did hasten their death, their dignity and autonomy would have been taken away from them. That person would not have been able to decide whether or not they wanted to make preparations for the remainder of their life. The ability of a person that is approaching death to be able to maintain a sense of belonging and still feel as though they have authority over themselves allows for a sense of calm. The patient is able to make amends if wanted or needed. By informing them of the affects of the pain medications that person can feel comfortable about taking them and as that person is passing they wont be wondering â€Å"what if† when it is time for them to pass. Every person has the right to decide how they are going to die. The benefit of doing it pain free or as close to pain free as they can get is that it leaves the person in a state where they are more able to concentrate on important things. Such things include their spirituality, family, and even death preparations. â€Å"Do unto others as you would have them do unto you,† this is a very important saying that we are taught and is reinforced throughout our entire lives. This word of advice rolls into the next principle I would like to talk about and it is beneficence. Beneficence requires that the duty is to help the patient by managing the pain effectively. This principle goes as far as to say that not only will the nurse not harm the patient but is obligated to take positive actions that will benefit the patient whenever applicable. It would be a violation of this principle if the nurse was to give the patient pain medication and did not follow up with the patient to see if the pain has been reduced or if the dosage of the medication needed to be titrated. Any nurse can give their dying patient pain medication but it takes follow through and communication with the patient to ensure that the pain is being managed. The act of giving the pain medication is the part that is considered not doing harm to the patient. The follow through and reassessment of pain as well as dosage of medication is what is considered taking positive actions to benefit the patient. The ANA Code of Ethics for Nurses states that nurses are responsible for their practice and are therefore required to provide a standard of care that takes an appropriate action to manage the pain in their patients (ANA, 2001). This can be stretched even further by stating that they are expected to take action when incompetence, unethical, illegal, and impaired practices are suspected. This goes back to the age old fundamental nursing practice of advocating for your patient. Nurses are to be the advocates as well as the educators for their patients. If a nurse is caring for a dying person that person may assume that after so much pain medication that they will not be able to experience relief and as said before it is then the nurses duty to educate that patient about the ability to switch drugs or to increase dosages in cases of increased tolerance. Non-Malfeasance has a lot to do with beneficence; you wont normally see one without the other. Non-malfeasance is just the simple task of doing no harm to your patient. In the dying patient the nurse has a duty to protect the patient from pain. Suffering plays a big role in this principle. As recalled from earlier in this paper suffering is more of the emotional and mental effects that pain has on the patient. The patient is most likely to suffer if they are not properly medicated for their constant pain. The suffering is what inhibits the patient from being able to enjoy and participate in the final moments of their lives. Allowing the patient to go under medicated and allow their mental capacity to reduce to a suffering state is a violation of the principle of non-malfeasance. This impacts their dignity by not allowing them to eat, dress themselves, helping with a transfer, or walking around if they are permitted to do so. This could result in the patients last and even most precious moments of their lives to be reduced to a non-significant and traumatic experience. By withholding or under treating someone for pain it is indirectly causing harm to the patient. Another way to look at it would be that under prescribing the pain medication is the same thing as inflicting pain on the person. Looking at it from this point has made it so that I look at my own practices and every time that I think about the times that I didnt ask patients if they were in pain I was consequently inflicting pain and suffering thereby doing harm which is a direct violation of the principle of non-malfeasance. The competence of the nurse plays a large role within this principle. To properly be able to prevent doing harm to the patient the nurse must be aware and competent regarding pain and the medications or techniques that are used to manage the pain. â€Å"Further, competence in pain management entails demonstrating a basic knowledge of the nature and action of the drug, proper dosages, the length of coverage, the time it takes for the drug to take effect, the variety of routes of administration, the recognition of drug tolerance, and dealing with problems with break-through pain† (Silverman, Croker, 2001, Pg. 185). When talking about the care of dying patients, it cannot be forgotten that even though the client that is dying needs care, usually that patient is not the only person that the nurse is caring for. Time is one of the worst barriers for most nurses and although everyone that is in the hospital and needs care deserves the undivided attention of the nurse, this is just not reality. According to the principle of justice every patient has the right to be given their â€Å"dues.† This doesnt mean just fairness; it is giving something to a person to which they are entitled. Every dying person is entitled to being as pain free as possible by the healthcare members, especially when it comes to providing pain medication. This can become an issue for nurses caring for these patients because there are not enough nurses to be able to adequately staff to be able to provide the closer one on one care that may be needed. This becomes a dilemma because the nurses then have to then make decisions that result in less care being provided to one or all of the other patients. Under treating for pain in the dying patient is a violation of the principle of justice because everyone is entitled to a pain free death. The technology and advancements are available to make this happen and again this allows the patient to be able to address other needs at the time of death other than concentrating on how much pain they might be in. A good way to help in this type of situation would be a PCA pump, which allows the patient to manage their pain, but also allows the nurse to concentrate more on the other needs of the patient. Allowing the patient the extra time and energy to spend with their families or to spend relaxing is a right that all people have and should be upheld to the very last breathe that the person takes. Although administering pain medication to dying patients that are in pain produces a good effect by relieving the patients pain, it can also produce a negative affect that was unintended such as hastening death. The principle that this relates to is the principle of double effect. The true definition of this principle is that the â€Å"action that is good in itself that has two effects, an intended and otherwise not reasonably attainable good effect, and an unintended yet unforeseen evil effect† (NCBC, 2006). This principle has to be considered when there is a question or a discrepancy between doing good (beneficence) and doing no harm (non-malfeasance). The problem with this principle is that most healthcare professionals believe in it and therefore giving higher dosages of pain medication does in fact hasten death. Studies have been performed and revealed that although 89% of physicians and nurses agreed that sometimes it is appropriate to give pain medication to relieve suffering, even if it may hasten a patients death (Fohr, 2005). Out of the 89%, 41% agreed that clinicians give inadequate pain medication most often out of fear of hastening a patients death (Fohr, 2005). â€Å"Fohr has found that there is little research to support the notion that increasing the dose of opioid analgesics for terminally ill patients hastens their death† (Fohr, 2005). The belief in this principle has in fact allowed and caused unnecessary suffering in the dying patients. There are also state by state statutes that have been developed to protect health care members in instances such as this. The Indiana statute states as follows: â€Å"This statute provides that a licensed health care provider who administers, prescribes, or dispenses medications or procedures to relieve a persons pain or discomfort, even if the medication or procedure may hasten or increase the risk of death, unless such medications or procedures are intended to cause death is not liable for assisting suicide† (Sexton, 2000). There are four criteria that pertain to the double effect principle and the action has to meet these criterions to make the action morally ethical. The first criteria is that the action has to be good and that the action can be acceptable by Gods standards and must be considered good to the other person as well as yourself (NCBC, 2006). The second criterion that has to be accomplished is that the act that is to be good cannot come from or be the effect of a bad act (NCBC, 2006). So, the act of providing pain relief cannot be as a result of hastening the patients death. Hastening the patients death is in fact the unforeseen effect of the good action provide pain relief. The third criterion states that there is an equal or greater proportion that exists between the good effect of the action and the bad effect of the action (NCBC, 2006). The last criterion suggests that the person the action was used upon has to be moved more towards the good effect of the act of giving the pain medicat ion in the dying person. The untoward effect has to be just tolerated and prevented as much as possible by the healthcare members. To administer the medication to a dying patient in severe pain would be acting morally ethical according to the principle of double effect. The action which would be administering the drug is considered to be a good action because it is relieving a persons pain and suffering. The intention of using the pain medication and administering it was to just relieve the pain of that person; the intention was not to harm or hasten death. Giving the medication to the patient achieves pain relief so that relief was brought about by mean of the good act not the bad effect of early death. Lastly the pain felt by most people that are dying is so severe that treating it is completely justifiable although a side effect could in fact produce an early death. If any of these criteria is violated then it can be considered as euthanasia or physician assisted suicide. Another question to be asked in this scenario is whether or not the action of giving pain medication is proportionate to the condition. In this case the condition is the severe amount of pain that the patient is feeling. There are two principles that are brought up here and they are the principle of proportionate and disproportionate means and the principle of ordinary and extraordinary means. These two principles are usually together and one is not usually applied without the other. These two principles are very important when making end of life decisions because they are about what is considered ethically acceptable when making end of life decisions and which ones are not according to Catholic ethics. These two principles generally refer to life sustaining actions by the health care staff but it can be expanded into what is considered proportionate or disproportionate interventions when caring for a patient that is dying and is in severe pain. In a situation in which a person is dying and is in severe pain, providing them with pain medication would not be considered disproportionate or extraordinary. Giving a person pain medication is not considered making a decision of whether or not that person should undergo or forgo a type of treatment. It is not making the decision of whether or not to sustain life. Providing the person in pain who is also dying is providing that person with a better quality of life for their end of life. The fact is, is that there has not been enough evidence to prove that administration of pain medication does promote an earlier death. It cannot be concluded that the giving of the persons medication and maintaining a persons pain by increasing the medication if needed does hasten death. There is no good or easy answer when tragedies occur. But to try and understand, we must step back and look at the big picture. God made everything perfect. When man sinned, that perfection was spoiled and our entire environment was tainted. The fact is we live in a world where evil abounds. It is rampant throughout every aspect of creation. We are subject to the actions of the people around us. God can and does intervene in some events, but why not others? Only he knows that answer, but the Bible teaches that there will be a time when he will end this world as we know it. In heaven, there will be no more death, sadness, pain, sickness, or suffering of any kind. One reason many of us suffer is because we do things that cause us pain. We dont eat right, so we have heart attacks. We drive carelessly or fast, so we have accidents. We smoke, so we get lung cancer. What about innocent children who are not responsible for their suffering? Why do they get sick? Maybe its because we do not live in a perfect world. God intended for us to have perfect bodies, perfect health, and freedom from pain and suffering. The world He created was originally perfect, just as he had planned it. But evil destroyed our perfect world. When sin entered the picture, it brought with it death, pain, and suffering. Dont misunderstand me, people do not suffer because of their own personal sins, necessarily; but because the world is changed because of sin being in the world. Jesus said, In this world, you will have tribulation. Just as in the case with Job, I believe that evil forces attack us and cause much suffering in an attempt to get people to blame God and turn away f rom Him. In order for God to preserve our rights as individuals (to choose for ourselves), he had to allow us the freedom to sin. He also had to allow the consequences of our behaviors. That means that he does not normally interfere with things which happen naturally in this world, such as sickness and disease caused by toxins in the environment, accidents as a result of risky behaviors, and natural disasters. God does not cause these natural consequences, but he does allow them. However, many times, he does intervene miraculously or work even in the worst of situations to bring about something good from them. Why would God allow anyone to suffer? Maybe so that people can increase their faith in him, increases their compassion for others, or be better able to encourage and help other hurting people (2 Corinthians 1:3-5). When reading through the Ethical and Religious Directives for Catholic Health Care Services, there is one important directive that particularly applies to this situation. Directive number 61 states that all patients should be kept as free from pain as possible. This again goes to say that people that are dying need to be able to die with their dignity intact. It also states that a dying person should not be denied pain medication even if the indirect action of shortening their life occurs. There is one stipulation that applies to this directive. If the medications being used cause sedation of any kind, the health care member has an obligation of informing the patient of the effect. â€Å"The dying person has the right to be able to prepare for their death while being completely conscious† (USCCB, 2005). If for any reason that person is not able to be conscious there has to be a legitimate medical reason behind the decision. Under treating has become a large ethical dilemma in the healthcare world. More often than not there are people that are living and dying in pain. The problem with this is that with the readily available drugs that are out there to treat this problem, they are not being utilized (Miller, 2009). One of the biggest problems that arises is the lack of education amongst the health care professionals. The insufficient knowledge base surrounding the different pain medications and the research surrounding the effects on death has not been incorporated into the plan of care. As stated above the principle of double effect creates a problem for the health care professionals. The belief in this principle prevents them from properly treating the patient who is dying and has a severe amount of pain. The dignity of the patient has to remain as the top priority when approaching death. Part of maintaining a persons dignity is allowing the patient to make the informed decision of receiving pain medication. Every person has the right to a peaceful and painless death. It is essential that patients are given the proper types of medication needed for the type of pain they might be experiencing. The type of pain most commonly referred to at the end of life is moderate to severe pain. This requires due diligence on all health care professionals side of it. If the medication that is prescribed is no longer providing effective pain relief then the drug needs to be titrated accordingly. If the medication being used is at its highest dosage amount, then the drug needs to be changed. If this is the case then the patient needs to be informed of the change and educated on the new drug. This again allows the patient to be able to make decisions in their care, and allows them the sense of belonging that is still needed at the time of death. When the pain is not being managed in a person that is dying it is taking away their ability to be able to have the calm, spiritual, and family and friend oriented passing that is usually needed amongst the dying. By administering pain medication the patient is then able to concentrate on more important aspects of their life. Health care professionals have the ability to be able to control pain and suffering. To allow someone to die in pain or suffer would be not only medically immoral but it woul