A 36-year-old woman was admitted for I.V. antibiotic therapy to treat cellulitis and an abscess on her right thigh. She consistently reports the pain in her thigh as 10 on a pain intensity rating scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable (10/0 to 10). She describes her pain as "the worst in my life." She receives oxycodone orally every 4 hours p.r.n. as prescribed, and she always requests it 30 minutes before the next dose can be given.
During hourly rounds at 9:00 A.M., the nurse observed the patient talking on the phone. At 11:00 A.M., she was reading a magazine and requested something stronger than the oral opioid, saying, "I can't stand the pain anymore. I need something stronger-I want an I.V. pain medication."
Nurses caring for the patient think she wants I.V. opioids because she has a history of substance abuse. She also uses hydrocodone for chronic back pain.
The patient's case raises several ethical issues involving pain management. This article explores ethical issues that are involved with making ethically sound pain management decisions and proposes a plan for overcoming barriers and providing ethical care for patients experiencing pain.
FOUNDATIONS OF ETHICAL CAREGIVING
Ethics involves morals, tenets, rules, and practices of society.1 Giordano and Schatman tell us that functioning from an ethical basis involves seeking to do what is good.2 When the goal is to relieve pain and suffering, many ethical challenges can arise, including the following:
* access to care
* assessment
* treatment
* education
* pain management.
These challenges can be more intense when they involve children, older adults, minorities, noncommunicative patients, and those with comorbidities-particularly mental health or substance abuse issues. Four ethical principles (or standards) are most commonly involved in providing optimal pain control.
Beneficence and nonmaleficence. Beneficence is the duty to do what is good for the individual patient with consideration for what the person values and desires.3 Simultaneously, it encompasses duties to do no harm, to remove and prevent harm, and to support and encourage the patient. This often involves balancing risks with benefits and is closely aligned with the principle of nonmaleficence, which is the duty not to harm patients.4
When working with patients in pain, these principles form the basis for balancing patient goals for comfort with patient safety. Since many adverse reactions to medications are dose related, achieving ideal pain control while ensuring patient safety can be a challenge. Exceeding the dose limit for acetaminophen can cause liver damage. Nonsteroidal anti-inflammatory drugs can also cause adverse reactions that may limit the dose or duration of treatment. Opioids can cause adverse reactions that may require dose limitations in some patients as well. Interventions and surgeries are never free from risk. The goal should focus on helping patients control pain as well as possible while keeping them as safe as possible.
Patients will at times report that their pain is not controlled. Healthcare providers (HCPs) must assess patients' clinical status and determine if what they are requesting is reasonable, appropriate, and safe for them. The ethical principle of beneficence also requires nurses to decide how to advocate for them.
Justice. The principle of justice can be considered from various frameworks. The most appropriate in this case is this: Patients with similar diagnoses should be treated in a similar way, and those with different diagnoses should be treated differently.4 For instance, when following this principle, all patients who complain of leg pain would be assessed and subsequently treated in a similar manner, regardless of race, ethnicity, gender, or ability to pay. Those diagnosed with a fractured femur would all be treated in a similar manner while considering their individual assessment and pain control needs. Those with a sprained ankle would all be treated similarly considering their individual assessment and pain control needs; however, their treatment would be different from those with a fractured femur and different than each other depending on their particular situation.
This principle is also important in pain control because opioid-tolerant patients will need to receive their home medications or equivalent doses as well as additional medication to address acute pain. In that sense, opioid-tolerant patients can be considered to be different than opioid-naive patients who may be sensitive to opioids and require less medication.
The principle of justice can be particularly challenging when addressing pain. The definition that "pain is whatever the experiencing person says it is" conveys that pain is unique to every individual.5 Nurses see this when two or more patients with the same diagnosis, injury, or surgery have very different reports of pain, with differing responses to and expectations for pain control.
Because pain cannot be measured objectively, self-report is the most reliable way to assess it. This can be perplexing for HCPs when a patient's self-report is severe pain, but the patient's behavior is not what they expect to observe when a person is in severe pain.
Similar to patients, HCPs have cultural backgrounds and experiences with pain that influences their concept of how a person in severe pain usually looks and behaves. This quandary develops because approximately 55% of communication is nonverbal, and many people trust nonverbal cues more than verbal communication.6,7
Understanding another person's severe pain is more difficult for an HCP who has had a similar surgery or injury and experienced little pain. HCPs raised in a culture that encourages emotional expression of pain may not understand how a patient raised in a stoic culture can remain quiet despite being in severe pain.
Each patient experience with pain is unique, requiring individualized assessment, intervention, and care. The Platinum Rule encourages people not to treat others as you would have them treat you, as with the Golden Rule, but rather to treat others as they would have you treat them.8
Autonomy. The principle of autonomy calls for HCPs to respect, support, and advocate for patients to make decisions about their own healthcare.4,9 To exercise autonomy, patients must be able to understand pertinent information regarding the choices and be free from external pressures, controlling influences, or impingements.10
In some instances, patient autonomy can conflict with what HCPs consider optimal pain management (nonmaleficence). Patients may sometimes specifically request an opioid that was not prescribed for them and ask for it to be given via a particular route. Patients may also insist on receiving a particular medication or undergo a certain procedure when the HCP does not consider such treatments appropriate, desirable, or even safe when evaluating factors such as diagnosis, history, and comorbidities. On the other hand, the patient may know better than anyone else concerning what has been effective in the past. It is important to ask the patient why he or she is requesting a particular medication or treatment. This can open a dialogue and improve patient care, education, and satisfaction.
LOOKING FOR A MEANING
Pain may be complicated by fears about what the pain means. Acute pain is a symptom that relays a message. Many patients, realizing this, become concerned when pain is greater than they expected. Patients may be worried about postsurgical pain if they were not well educated before surgery. After trauma or a cancer diagnosis, patients may interpret pain as an indication of the gravity of their condition. Understanding what pain means to the patient can provide HCPs with information they need to intervene appropriately (beneficence, nonmaleficence, autonomy, justice).
BARRIERS TO OPTIMAL PAIN CONTROL
By definition, pain is a subjective experience that cannot be objectively seen, felt, or measured in another person. In technologically dependent healthcare settings, this makes pain an anomaly among the signs that are assessed and measured. Because only the person experiencing pain knows how it feels, that person is the expert, and the HCP must accept the patient's self-report as fact.
Pain is a multifaceted experience. Besides physical sensations, it has emotional, cognitive, and spiritual aspects. Pain is influenced by each individual's culture, experiences, and coping mechanisms. Patients may have difficulty explaining characteristics of the pain they are feeling.
Time constraints often interfere with HCPs' ability to actively listen to patients. Many HCPs lack adequate education in pain assessment and management. Personal experiences, beliefs, and emotional responses to pain can affect how the HCP responds to a patient's behavior or self-report of pain.
Societal factors, such as limited access to providers or therapies, can cause inadequate or inappropriate treatment of pain. Patients may lack adequate insurance coverage for pain management specialists as well as pharmacologic and nonpharmaco-logic interventions. Insurance coverage is often limited or completely lacking for interventions, such as physical therapy, cognitive behavioral therapy, or biofeedback, and few people have insurance that covers complementary modalities, such as acupuncture or massage therapy.
TAKING AN ETHICAL APPROACH TO PAIN
An important first step in providing ethical care (beneficence, nonmaleficence) for patients with pain is for HCPs to assess their own beliefs, experiences, and possible biases about pain, patients experiencing pain, and pain behaviors. Besides HCPs' attitudes about pain based on culture and personal experience, personal beliefs about opioids and substance misuse or abuse can affect their interactions with patients requiring or requesting opioids.
Sometimes, past experiences provide lessons that can affect an HCP's approach to subsequent patients. For example, a patient may seem like another patient, friend, or family member who had severe pain that was diffi cult to relieve, or a patient may seem like someone the HCP knows who abuses opioids or other substances. When problematic connections occur, it is important for HCPs to remind themselves that this patient is unique. Every patient needs to be understood as an individual.
Impressions relayed by other HCPs can influence assessments and opinions about a patient. When one HCP labels a patient as "drug seeking," this can negatively influence the perceptions of those who hear it even before they meet the patient. Each patient deserves to have each HCP become acquainted with him or her on an individual basis. HCPs can only begin to understand the pain being experienced by actively listening to the patient without preconceptions and bias to what the patient self-reports and trying to understand what the patient is saying (beneficence, nonmaleficence, autonomy, justice).
Working with patients who continue to report high levels of pain, despite HCPs' best efforts, can be frustrating. HCPs cannot erase their own culture or experiences, but they can and should acknowledge and understand them.
Assessing pain in a patient with no meaningful communication5
Regardless of what tool is used to assess pain in a patient who cannot communicate in a meaningful way, some basic concepts apply. It is important to consider the following:
* HCPs should attempt to obtain a self-report of pain: It is essential to remember that someone with dementia may be able to accurately report pain.
* Does the patient have chronic pain? If so, what medications does the patient take on a regular basis?
* Is the pathology underlying the acute condition known to cause pain? If so, HCPs should advocate to begin a trial of analgesic medication, which is followed by assessing the patient's response to the analgesic trial.
* HCPs should ascertain how the patient generally exhibits pain.
* HCPs should also assess the patient's behavior.
* HCPs need to be mindful of the fact that patients may experience discomfort with prolonged immobilization.
* The most accurate assessment of pain is through patient self-report.
* Pain behavior scores do not reflect pain intensity.
Self-awareness regarding pain behavior is an important starting point. Developing a habit of assessing personal reactions to patients with pain, particularly if pain is difficult to control, is essential.
To capture the distinctive qualities and experience of pain, it is essential to assess each patient with no expectations or preconceived notions. HCPs should listen to what the patient says while observing behavior and then try to understand any behavior that seems contradictory. It helps to ask about what seems inconsistent: "Please help me to understand how you can seem so relaxed when your pain score is so high. How do you do that?"
The character, intensity, and impact of pain are unique for each individual (beneficence, autonomy, justice). It is impossible to understand the pain being experienced simply by knowing the etiology, even though some diagnoses have some common pain characteristics (for example, neuropathic pain with herpes zoster and aching pain with arthritis). Pain can be appreciated only by listening to the patient who is experiencing it. When patients cannot communicate what their pain is like, it is important to consider if they have had chronic pain previously, what analgesic medications they were taking, if their illness or injury generally causes pain, and how they normally respond to pain.5 (See Assessing pain in a patient with no meaningful communication.)
To prevent harm (nonmaleficence), HCPs should assess for medication adverse reactions, contraindications, and interactions with other medications.
SETTING GOALS FOR PAIN CONTROL
When patients are asked what level of pain would be satisfactory to them, they frequently respond with "no pain," which is understandable- nobody wants to be in pain; however, HCPs must help patients understand the need to balance safety with comfort and work toward realistic goals (beneficence, nonmaleficence, autonomy, justice).
HCPs should differentiate between pain elimination and pain control. Some pain control is always possible, but eliminating pain while keeping the patient safe may not be possible.11 It is crucial to inform patients that while their comfort is important, their safety is also valued (beneficence, nonmaleficence).
Realistic goals may be easier for patients to understand and identify from a functional perspective. Since most facilities or agencies require pain management goals to be recorded numerically, HCPs need to help patients put functional goals into numeric form. If the patient requesting more pain medication has the goal of walking around the unit four times per day, HCPs should assist the patient to identify what number the pain needs to be to accomplish that goal.
MULTIMODAL PLAN FOR ANALGESIA
Optimal pain management is like making customized vegetable soup. Among the many options that can be included, some may not be appropriate for the individual, and others may not be safe for the individual. In some situations, the patient may not want to receive a particular medication (autonomy, justice). Medication selection depends on various factors, such as the etiology of pain, previous experiences, allergies, comorbidities, and contraindications.11,12 HCPs need to help patients control pain by finding the recipe that works best for them.
Considering nonpharmacologic and complementary modalities.13
The following interventions for pain should be considered:
Environmental control
* Lighting and temperature adjusted for patient comfort
* Patient positioning for comfort using pillows, blankets, and/or towels
Distraction techniques
* Music the patient chooses
* Puzzles (word find, crossword, jigsaw)
* Games
* Guided imagery
Relaxation techniques
* Breathing (relaxation breathing, square breathing)
* Progressive muscle relaxation
Advanced complementary modalities
* Touch therapies (Therapeutic Touch)
* Cognitive behavioral therapy
* Physical therapy
* Acupuncture
* Massage therapy including reflexology
* Biofeedback
Patients should be asked what pain management regimens have worked for them in the past as well as what has not worked (beneficence, nonmaleficence, autonomy, justice). Knowing what has worked to control pain in the past is critical to respecting ethical principles and requires HCPs to put aside preconceived notions. Ironically, patients with diabetes who know dietary precautions and their type and dose of insulin are considered well educated, but patients with chronic pain who know medication names and doses that relieve their pain may be erroneously labeled drug seeking.
Analgesic medications are only one component in multimodal pain management. Depending on the type of pain, patient preferences and beliefs, and available resources, adding various nonpharmacologic interventions can help control pain and foster patient autonomy and justice.11 HCPs can improve available options for patients (justice) by identifying available nonpharmacologic and complementary modalities. (See Considering nonpharmacologic and complementary modalities.)
NEED FOR EDUCATION
Knowledge is power. HCPs should self-educate in pain assessment and multimodal pain management, keeping in mind that pain is multidimensional. Assistance from other professionals should be sought from pain management experts, physical and occupational therapists, clergy, and members of the ethics committees.
Self-knowledge is imperative. It is important to understanding personal biases and limitations (beneficence, nonmaleficence). Patients and families should be educated in regards to:
* the etiology and meaning of pain
* reasonable expectations and goals for pain control
* medication prescriptions and adverse reactions
* nonpharmacologic options.
CASE STUDY FOLLOW UP
When the nurse caring for the patient puts aside any preconceived notions and others' opinions and accepts the patient's self-report of pain, a trusting therapeutic relationship develops. With the patient's respect and trust, the nurse can work with the patient to establish reasonable goals for pain control.11
The patient tells the nurse that she will be able to rest if her pain level is a 6/0-10. The patient explains that because she used large doses of opioids after an accident last year, she seems to need more medication to relieve pain. Using data from pain assessment and concepts of multimodal analgesia, the nurse advocates with the HCP for the patient to receive analgesia that includes adequate scheduled (around-theclock) and p.r.n. opioids for breakthrough pain, acetaminophen, distraction, Therapeutic Touch, and animal-assisted therapy. When her pain is 6/0-10, the patient reports being more comfortable and better able to concentrate and sleep. By putting aside personal biases and listening to the patient, the nurse successfully developed a pain control plan that was safe, effective, and ethically sound.
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