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