Author: Mr. G. Jay Westbrook
Arresting Pain Without Getting Arrested
Essentials of Pain Assessment & Pain Management
Introduction
There was a time when those who worked in healthcare experienced scrutiny and sanctions for what was perceived as the over-prescribing of opiates to control patient pain. Thankfully, those days are behind us, and today there is both an ethical and legal mandate to control patient pain and its attendant suffering.
Here in California, what we refer to as the “Elder and Dependent Adult Abuse Law” is actually a collection of sections within various codes (penal, welfare and institutions, health and safety, and insurance). Together they help assure that not only elders, but any adults who find themselves a patient in a 24-hour healthcare facility (acute care hospital, psychiatric hospital, or skilled nursing facility) are protected from abuse, including physical pain and mental suffering.
Included in the definition of abuse is “… physical harm or pain or mental suffering” (wic 15610.07). Select attorneys are now using these statutes to advocate on behalf of patients suffering with pain, and to litigate against those who fail to appropriately address that pain.
This article will present some of the human costs of failing to address a patient’s pain, the barriers to pain management, and some of the basics of pain management.
Case Study
I am a clinical gerontologist and a geriatric palliative care and hospice nurse, and Jorge Gonzalez [not his real name] was my newest referral, an 86 year old Hispanic male with untreatable organ cancer and less than six months to live. I was told that he was at home, bed-bound, bowel and bladder incontinent, a fall risk, confused, and on acetaminophen (Tylenol) for pain.
The Gonzalez residence was in East Los Angeles, a handsome home at the summit of a hill and overlooking a park that was clearly gang turf. Upon my arrival, I encountered a caring and concerned family, and a patient – Senor Gonzalez – in agonizing pain.
After performing a pain assessment, I contacted his physician to request orders for strong opiates to relieve and manage my patient's pain. The physician refused to prescribe any opiates, and justified his decision by stating, "At his age and level of confusion, he's not feeling any pain, and I'm not going to prescribe drugs – particularly in that neighborhood – that will get me in trouble with the DEA (Drug Enforcement Agency) and either send this patient into respiratory arrest or turn him into a drug addict"!
My first reaction was to ask this physician if he thought Senor Gonzalez would get out of bed and either mug him or steal his TV set to get money for drugs. But I restrained my sarcasm and simply asked if his life could be made easier by having our hospice Medical Director take over this patient's pain management. He agreed, and we had the patient on strong oral opiates before the day was over.
Within three days, Senor Gonzalez was essentially pain free, lucid, ambulatory, bowel & bladder continent, and no longer bed-bound. Within a week, he was making a daily morning walk, with his beloved dog Mona, of one quarter mile each way to purchase a La Opinion Spanish newspaper for his wife and a Los Angeles Times English newspaper for himself, and working in his garden every afternoon. He maintained these activities for the next five months, until his cancer's progression put him back in bed for the last two weeks of his life. He died at home, surrounded by family, loved, lucid, and pain free.
This case study captures the tremendous human costs of not treating pain, and the great ease with which most pain can be brought under control. It also illustrates the remarkable improvements in quality-of-life in those persons who have had their pain arrested by appropriate pain management techniques.
COSTS OF NOT MANAGING PAIN
The human and dollar costs of allowing a person to remain in pain are extraordinary, and include:
Spiritual Costs
On a spiritual level, untreated pain can lead to an increased sense of suffering. It can also lead to a separation from one's Higher Power or God, which for many older individuals has been a life-long source of comfort, strength, & sustenance. Finally, untreated pain can lead to a sense of being punished, tested, or abandoned by that Higher Power or God.
Psychological Costs
Psychologically, untreated pain can increase anxiety, fear, distress, despair, depression, hopelessness, somatic preoccupation, and suicidal ideation. It can also interfere with focus, concentration and memory, and lead to a decreased sense of autonomy, life satisfaction, and quality of life. It is worth mentioning that whenever new psychological symptoms occur in terminal cancer patients or patients with Alzheimer’s or other dementias, the possibility of either the onset of pain or the exacerbation of existing pain should always be explored.
Social Costs
Socially, untreated or under-treated pain can lead to an inability to engage and maintain one's informal social support system. Research has shown that the maintenance of an informal social support system is a primary factor in preventing premature and permanent institutionalization in the elderly. Untreated pain also leads to a decreased opportunity for participation in simple social interactions and leisure activities, and corrodes gerontological competence (the ability to fulfill the roles one was fulfilling prior to the onset of a limiting circumstance, i.e., illness or accident).
Additionally, those persons with inadequately treated pain find their universe shrinking and collapsing. At first they just stay closer to home, and next find themselves unable to leave the house. Then their world typically becomes limited to just a few rooms (bedroom, bathroom, and living room), then it shrinks to just the bedroom and bathroom, and finally just the bedroom as the pain eventually prevents their ability to ambulate.
Pain can greatly interfere with an elderly person's ability to perform the Instrumental Activities of Daily Living (IADLs). These activities include shopping, house cleaning, laundry, cooking, banking, bill paying, and accessing the postal system. An inability to perform IADLs may not lead directly to needing a congregate living facility, but certainly creates a need for in-home assistance.
Pain can also interfere with a person’s ability to perform Activities of Daily Living (ADLs). These activities include eating, toileting, dressing, hygiene, ambulating, and transferring. A pain-related inability to perform these activities necessitates either a need for in-home assistance or placement in a care facility.
Finally, pain can significantly increase caregiver burden. Imagine an elderly caregiving spouse who is able to have their partner get out of bed and sit in a chair while he/she makes the bed. Now just imagine the difference when compared with trying to change the bedding while their partner is still in the bed, unable to get out because of their pain. Obviously, the risk of injury to the caregiving spouse is much greater in the latter case.
Physiological Costs
On a physiological/functional level, pain can lead to disturbances in appetite and sleep, self-care deficits, disruption in ability to perform sexually, and an inability to participate in the rehabilitative process. Pain can also lead to fatigue and falls. The falls can be directly related to the pain, can be related to fatigue, and can even be related to pain medication, i.e., if the medication hits the pain patient all at once, it can make them unstable on their feet. Finally, if the pain is severe enough, it can lead to immobility with its associated atrophy, pneumonia, constipation, skin breakdown, and depression.
Other Costs
Untreated pain can also lead to requests for physician-assisted suicide, emergency room visits, or rehospitalization for pain out of control. Additionally, untreated pain can generate injuries to caregivers, increased Workers Compensation costs, and decreased quality-of-life.
Given these overwhelming costs of not adequately treating pain, one would assume that pain management would be an accomplished priority in most patients. However, studies have shown poor pain management in the elderly, people of color, women, the homeless, the mentally ill, and those with a history of substance abuse.
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