Optimal pain care for hospitalized patients continues to remain elusive. Results of the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) show that only 63-74% of hospitalized patients nationwide reported that their pain was well controlled (Summary of HCAHPS Survey Results, 2011). Although pain research has resulted in a better understanding of pain modalities and the development of new treatments, patients report little increase in satisfaction with the management of their pain while hospitalized (Department of Health and Human Services, 2011). This column will examine how the deliberate use of ethical principles, when making pain management decisions for hospitalized patients, may provide more optimal outcomes.

Assessment and treatment of pain is often complex. The standard definition of pain is “whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1968, p.95). In practice, however, practitioners’ personal biases about the patient’s pain may interfere with the realization of this definition when doing a pain assessment. Regrettably, the intrinsic subjectivity of pain is often disregarded. Practitioners who would likely not judge the character of a patient who needs increased amounts of medication to treat hypertension; yet they may believe that a patient whose persistent pain does not respond to standard medications is ‘drug-seeking,’ a narcotic abuser, or has a current need to ‘escape reality.’ The unemotional, transparent principles of ethics may be useful in such cases to provide guidelines for better, more effective pain treatment. The ethical principles of autonomy, beneficence, nonmaleficence, and justice should guide all health professionals when they make assessment and treatment decisions.

Autonomy

Autonomy is the right of individuals to make decisions regarding their own healthcare regardless of what others think of these decisions (Evans, 2000). It is the right of self-determination (American Nurses Association, 2001). The Belmont Report clearly confers this right on all human beings as a ‘respect for persons’ regardless of age, capacity, or even imprisonment (National Institutes of Health, 1979). Individuals must be treated with respect for their personal healthcare decisions regardless of whether the healthcare provider agrees with these decisions. The principle of autonomy is violated when a practitioner dishonors patients’ rights to choose how they want their pain to be treated.

Infringement on the right to autonomy or self-determination may also be seen in the withholding of information from patients about how much and how often they can receive pain medication while in the hospital. Patients have the right to know, consider, request, and refuse any treatments that they believe will help manage their pain. They also have the right to have all medications, side effects, and other treatments clearly explained to them in order to make the right decisions.

Interestingly, when patients are fully extended their right to autonomy, their pain is often better managed, and they report better satisfaction with their care.  When patients perceive that they are understood, and can make their own decisions regarding pain control, they often do better. One example of this is the growing use of Patient Controlled Analgesia (PCA) for the treatment of acute pain in the hospital setting. When analgesics are adequately ordered and the pump is properly programmed for the individual, patients experience personal control over their pain and receive effective analgesia (Hudcova, McNicol, Quah, Lau, & Carr, 2005).

Beneficence

Beneficence is defined as doing good for an individual (National Institutes of Health, 1979). Most nurses and other clinicians easily ascribe to this tenet because they entered the healthcare profession, ostensibly, to do good for others and provide comfort and pain relief. In the modern hospital setting, it is very rare that pain must be allowed for diagnostic reasons; and it is even rarer that severe pain cannot be controlled in some fashion. Undertreated pain can lead to respiratory, cardiac, and endocrine complications as well as delay healing and potentiate the onset of chronic pain issues for an individual (Brennan, Carr, & Cousins, 2007). Although complete relief may not always be possible, the means for bringing pain under control quickly is usually available and must be done to be considered ‘good’ patient care.

Making decisions regarding pain treatment and ‘doing good,’ however, can take on a distinct complexity. Many reasons are often given for not providing pain relief expeditiously. Excuses range from nurses being too busy, to difficulties in getting medication orders from physicians and pharmacy departments. Patients sometime wait hours for pain relief. If nurses do not make the management of pain a priority for their patients, and do not do all they can to advocate to the physician for a patient’s need for increased dosages in medication so as  to properly combat pain, they are guilty of neglecting the principle of beneficence. Likewise, when adequate pain relief is withheld because the patient has a history of substance abuse, the nurse has not given ‘good’ care to the patient. The principle of beneficence is upheld when the appropriate amount of medication or other treatment is administered to the patient in a timely fashion resulting in the best pain control with acceptable side effects.

Nonmaleficence

The principle of nonmaleficence is defined as refraining from doing harm (National Institutes of Health, 1979). Herein may lie the greatest obstacle to ethical adherence in deciding the appropriate treatment for pain in the acute care setting.

Nonmaleficence is often the principle of ethics invoked by nurses and practitioners when having difficulty deciding on pain treatments: they withhold medication citing ‘safety’. There certainly can be a reasonable fear on the part of the practitioner of causing harm while treating pain since so many treatments for pain have potentially dangerous side effects. It is imperative to understand, however, that pain itself may be more harmful to the patient than the side effects of the drugs used to control it. As stated previously, untreated pain can have detrimental physical and emotional effects on a patient. For example, an opioid may be the only effective treatment for an acute pain situation in a hospitalized person, yet a nurse or physician’s general fear of opioids (usually a fear of respiratory depression) can result in inadequate pain treatment. This fear is often unsubstantiated in the hospital setting since the administration of opioids and their effects are carefully monitored. Nurses must remember that expecting a patient to remain in unacceptable pain can cause harm in many ways ranging from mild (anxiety) to severe (suicide).

Justice

The principal of justice states that all persons should be treated fairly according to their situation (National Institutes of Health, 1979; Velasquez, Andre, Shanks, & Meyer, 1990). This principle is violated when treatments are withheld or are not administered solely based on a person’s sex, age, race, or religion, unless those factors have a distinct bearing on treatment. For example, when choosing a pain medication for a person who is 80 years old, age must be considered since certain medications have been shown to be more harmful in older people. However, all safe pain treatments should be considered for a patient who is 80, just as they would be for a patient who is 40. When a demanding and wealthy socialite receives more consideration in the management of her pain than the quiet, unassuming, poor, single mother, the principle of justice is violated.

Disparities in treating pain continue. Persons in minority groups have been shown to receive less pain medication than their white counterparts in emergency rooms, post-operatively, and in labor (Ezenwa, Ameringer, Ward, & Serlin, 2006). It is important for nurses to be aware that these discrepancies still exist in modern hospitals and to examine their own biases when treatment decisions are made.

Ethical Pain Management

Due to the inherent subjectivity of pain, assessment and treatment decisions can easily be influenced by bias and emotion. Evans (2000) makes the case that adhering to the principles of ethics (principlism) provides a very practical, unemotional way of making right decisions. Decisions, such as those involving pain management, can be made with thought, regard, and transparency for all involved (Evans, 2000). In making decisions about pain management, it may be helpful for nurses to ask themselves questions similar to the following:

• Are the patient’s preferences in pain treatment (autonomy) given the highest priority?
• Does the patient benefit (experience good) from my pain treatment decisions?
• What can I do to decrease harm (nonmaleficence) when deciding on a pain treatment regimen?
• Did I do my best to protect the most vulnerable patient, treating his/her pain in the best possible way with respect and without discrimination (justice)?

Conclusion

In order for ethical principlism to become a practical and integral way of making pain management decisions, the nursing culture must embrace it as a matter of course. The conscious use of basic ethical principles can help nurses to see their own biases clearly and make evidence-based decisions that provide optimal pain treatment for every patient. Referring to ethical principles may also help the nurse advocate for the patient’s pain relief needs when talking to physicians who may also have their own biases in pain treatment.

At first it seems difficult to understand why hospitalized patients’ pain is not well controlled. After all, nurses want to relieve suffering – to do good without causing harm and to treat each individual justly without moral judgment, respecting each patient’s autonomy and ability to make his/her own decisions. But management of pain is complex and influenced by the personal values and biases of practitioners. Although consciously following the principles of ethics when deciding on pain treatment can be time consuming, applying the four basic principles to pain care in every situation is imperative if pain is to be managed at optimal levels. Making unbiased, ethical decisions in the treatment of pain for hospitalized patients instills confidence and trust in patients and may ultimately lead to greater patient satisfaction with pain management.

Letter to the Editor by Tanya Ushakof
with Reply by Author

Esther Bernhofer, BSN, RN-BC
E-mail: bernhoe@ccf.org