I care for a patient with lung cancer who'd smoked heavily for years before the diagnosis. One of the nurses has an attitude that seems to say, "if you hadn't smoked all those years, you wouldn't be sick now." I think this attitude affects how she administers his p.r.n. pain medication. What do you think?-H.F., FLA.

It's unprofessional but unfortunately not unheard of for caregivers to judge certain patients "responsible" for their conditions. Intravenous drug users who develop AIDS may top the list, but many people with emphysema, diabetes, and cirrhosis also encounter this attitude.

Having said that, I'd like to propose another theory to explain how judgmental behavior influences pain management. Consider two patients with painful conditions. The first has severe sickle-cell disease. After repeated admissions for exacerbations of the disease, she acquires a reputation for "drug seeking." Nurses' notes display a suspicious tone, such as "the patient was laughing with visitors but as soon as they left she requested pain medication." Or "patient was sleeping peacefully, then awoke and asked for pain medication."

Research has shown that patients may sleep despite moderate to severe pain, and that distraction, especially laughter, is an effective way for patients to cope with severe pain for a short time.1 Yet some health care professionals continue to make value judgments based on these behaviors.

The second patient is a young woman with breast cancer who chose no follow-up and is admitted to the hospital with a fulminating, necrotic, breast tumor. Staff never questions her request for large, frequent doses of opioids, and their notes display a sympathetic tone.

What's different about our two patients? Conventional wisdom says that we might be more judgmental about the cancer patient because she deliberately neglected her health, yet her nurses recognize her pain and medicate her appropriately. My theory is simple: When we can actually see the disorder, if it "looks" painful, we feel compassion and recognize the need for opioids. But clumped, oxygen-depriving sickle cells are invisible. We can't see the problem, so we develop a questioning eye.

If you observe anyone denying or delaying a patient's analgesia, please remind her of the accepted credo: "If the patient says he has pain, he has pain." Pain isn't visible, and only the patient knows how it feels.

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