The session “Ethical and Legal Issues around Pain Management in Hospitalized Patients” shed light on issues that many hospitalists are aware of but perhaps not well versed in.
Speaker Vijay Rajput, MD, FACP, associate professor of medicine at the University of Medicine and Dentistry of New Jersey (UMDNJ), Robert Wood Johnson Medical School, and Cooper University Hospital, Camden, N.J., covered the many conflicts surrounding pain management, the law, and your conscience.
Dr. Rajput shared what he called “hard facts” on pain medication, which include:
- 90% of cancer pain can be controlled with available options;
- 70% of the time chronic, nonmalignant pain is poorly managed, especially in nursing homes;
- 11% of admissions in the emergency department seek treatment for a chronic pain condition;
- 8.2% of, or 19.5 million, Americans use an illicit drug at least once a month; and
- 31.2 million reported non-medical use of pain relievers including hydrocodone (Vicodin), acetaminophen and hydrocodone (Lortab), oxycodone (Percocet), and others.
Dr. Rajput discussed barriers that lead to undertreatment of pain in hospitalized patients.
“There may be prioritization of diagnosis over pain relief by surgical colleagues on hospitalized patients,” he said. “There are also inadequacies in assessing pain, educational deficiencies, and cultural challenges. Some physicians are ruled by regulatory and ethical concerns in prescribing for pain.”
—Vijay Rajput, MD, FACP, associate professor of medicine at University of Medicine and Dentistry of New Jersey (UMDNJ), Robert Wood Johnson Medical School, and Cooper University Hospital, Camden, N.J.
Pain Management and the Law
There are several legal concerns regarding pain management that most physicians are aware of. In addition to liability for repercussions of undermedicating or overmedicating, the failure to refer a patient to a pain management specialist, the use of opioids when caring for end-of-life patients, and failure to get informed consent related to risk of treatment can all mean malpractice suits.
“The general rule for avoiding a malpractice charge is to follow national standards of care and any applicable clinical practice guidelines,” said Dr. Rajput. “There are Web-based databases that serve as national guidelines clearinghouses that you can refer to.”
The Ethical Side of Pain
“There are few common domains of ethical and legal issues in pain relief,” stated Dr. Rajput. These include the pain issues around end-of-life and palliative care of terminally ill patients, a subordination of pain relief to diagnosis, chronic pain issues and substance abuse, pain control in a patient’s transfer to a nursing home, and the risk of discontinuity of pain control after discharge.
“The ethical duty to relieve pain is well established,” Dr. Rajput said. Despite this, it is still common to subordinate pain relief to diagnosis. In 2003, the American Journal of Surgery stated, “Analgesia should be given prior to diagnosis only with the knowledge and consent of the surgeon who assumes the responsibility for decision-making.”
This “decision-making” can affect hospitalists because 86% of ED physicians follow this literature, and 89% of surgeons still prefer to hold the pain medication prior to surgical evaluation.
“Without ongoing education, senior physicians risk providing less, not more, pain control,” Dr. Rajput pointed out. “This will become more critical as we are co-managing more and more surgical patients in hospitals.”
What about End-of-Life Care?
The legal case of Estate of Henry James v. Hilhaven Corp. established that healthcare facilities have a duty to treat pain. However, Dr. Rajput stressed, patients, families, and physicians all remain confused about the role of opioids in caring for dying patients.
Dr. Rajput reviewed two cases where physicians were sued for undertreatment or negligent treatment of pain, and 11 cases where physicians were sued for administering medications that resulted in the deaths of terminally ill patients.