A few weeks ago my husband was in the emergency room with a broken rib, which resulted from a fall. His nurse was very attentive to his need for pain management. He had never had morphine before and after his second dose, he asked the nurse “How much of this will you give me?” Her reply was, “As much as it takes to safely control your pain.” What a great answer!

It isn’t always this easy when it comes to pain management. I’ve shared a story previously about a patient in our ICU, whose family member, who happened to be a nurse himself, wouldn’t allow us to treat his sister’s pain. It was a challenging case, and ultimately, our hospital’s ethics committee was consulted.

The position of the American Society for Pain Management Nursing (ASPMN) and the International Nurses Society on Addictions (IntNSA) is “that every patient with pain, including those with substance use disorders, has the right to be treated with dignity, respect, and high-quality pain assessment and management.” As nurses, we have a responsibility to make ethically sound decisions when it comes to pain management. But, how do we do this?

Be familiar with related ethical standards

• Beneficence is the duty to do what's good for the patient while considering his or her wishes. Nonmaleficence is the duty not to harm patients. The challenge here is to achieve pain control while ensuring patient safety.
• Justice refers to fair treatment for all. This can be tricky because pain can't be measured objectively and we must rely on a patient’s self-report.
• Autonomy requires us to respect, support, and advocate for patients, even when it goes against our own beliefs.

Be aware of barriers to effective pain management

• Sometimes patients aren’t able to communicate about their pain. Whether the patient is non-communicative, there is a language barrier, or the patient finds it difficult to describe the pain they are experiencing, use your knowledge and skills to perform a thorough history and physical assessment.
• Time constraints can get in the way of assessing and managing a patient’s pain. Do your best to actively listen to the patient, plan, and collaborate with other team members.
• Sometimes cost is an issue and certain modalities aren’t covered by a patient’s insurance. If this is not in your realm of knowledge, consult with a colleague who is familiar with the financial aspects of pain management.

Set goals and make a pain management plan

1. Assess your own beliefs and think about your past experiences.
2. Remember that every patient is unique.
3. Tailor your patient and family education appropriately.
4. Encourage patients to become active partners in controlling their pain. Remind them that pain control aids recovery.
5. Actively listen to the patient’s self-report of pain.
6. Be alert to fears related to reporting pain. For example, patients might not report pain for fear of having to undergo more procedures.
7. Consider asking about burning, aching, tightness, discomfort, or throbbing. Research shows that to minimize their pain, elders may not use the word ‘pain.’
8. Take cultural differences into account.
9. Use pain scales that are appropriate for the patient.
10. Ask the patient what level of pain would be satisfactory.
11. Explain the difference between pain elimination and pain control; completely eliminating pain while maintaining safety is not always realistic.
12. Work with the patient to set ‘functional goals’ – for example, being able to walk down the hall and back.
13. Consider non-pharmacologic methods, such as lighting, positioning, distraction techniques (music, guided imagery), relaxation techniques (breathing, progressive muscle relaxation), and advanced complementary modalities (massage, biofeedback).
14. Monitor the patient for medication adverse reactions, contraindications, and interactions.

As nurses, we are well-positioned and obligated to advocate for safe pain management. Remember to listen, collaborate, plan, and evaluate!
 

References

Diallo, B., & Kautx, D. (2014). Better Pain Management for Elders in the Intensive Care Unit. Dimensions of Critical Care Nursing, 316-319.
Oliver, J., Coggins, C., Compton, P., Hagan, S., Matteliano, D., Stanton, M., . . . Turner, H. (2012). American Society for Pain Management Nursing Position Statement: Pain Management in Patients With Substance Use Disorders. Journal of Addictions Nursing, 210-222.
Quinlan-Colwell, A. (2013). Making an Ethical Plan for Treating Patients in Pain. Nursing2013, 64-68.

Lisa Bonsall, MSN, RN, CRNP
Clinical Editor
NursingCenter.com