Ethical Considerations in Pain Management

Chronic pain is among the top complaints of patients who visit a primary care physician. In fact, the Institute of Medicine of the National Academies reports there are approximately 100 million Americans affected with chronic pain. That’s more than diabetes, cancer, and heart disease combined.

At the same time, more than 115 people in America die every day from overdosing on opioids. Years of misuse and addiction to opioids – which include prescription pain relievers, synthetic opioids like fentanyl, and street drugs like heroin – has created a national opioid crisis.

Working in palliative and hospice care, we see patients every day who are experiencing serious, life-limiting illnesses and need to find a balance between managing patient pain and ensuring pain medication is not misused or falling into the wrong hands. This creates a major challenge for healthcare professionals as the media and mismanaged cases have created negative views of pain management.

Ethical Considerations in Pain Management 

As the issues with overuse and misuse of pain medication have become better understood, healthcare providers, communities, and government regulators have worked toward better management. This has helped many people but has also created barriers or, what we will call, ethical considerations in pain management for many others.

Healthcare providers have a moral obligation to do everything within their limits to help their patients be free of pain. These refer to the biomedical principles of nonmaleficence and beneficence.

Nonmaleficence: Do no harm

Beneficence: Help prevent or remove harm

Not ensuring that the patient’s pain and symptoms are managed are in violation of healthcare professionals’ Code of Ethics. There is an obligation to safeguard patients from incompetent, unethical, illegal practices. This can include undertreated or mismanaged pain.

It seems like every healthcare professional – doctors, nurse practitioners, nurses, etc. – would have the same ability to assist individuals with their pain management, but this is not always true. Each healthcare professional has their own personal views and experiences with pain management. Is it ethical that:

• Patients become labeled as drug seeking so their pain may be undertreated?
• Nurses at facilities may make the decision when patient is in pain or not; nurses will withhold the patient’s medication based on their views?
• Nurses may not report to the physician the patient’s concerns with their symptoms or pain?

This is sometimes at no fault of their own, but a lack of understanding in positive pain management. It can also be a result of the media creating a negative view on medications needed for proper pain management. The media doesn’t often show how a terminally ill individual can go from being withdrawn and bedridden in pain to leaving their home and working in the garden due to proper pain management. It takes experienced, trained pain management providers in hospice and palliative care to make these successful transactions.

Ethics of Pain Management in the Home

Family members and loved ones may also have trouble adjusting to positive pain management routines with the same ethical considerations. It is very common for individuals to need time for their bodies to adjust to new medications. One main side effect is an increase in sleep. Sometimes families do not allow their loved ones to be medicated properly as they “do not want them to sleep all day.” 

The family also will then say, “I do not want them to have any pain.” This creates a dilemma between healthcare providers and families. It can be very difficult to control an individual’s pain and keep them at their current level of function. 

This ethical dilemma may arise when the healthcare professional feels the patient may be suffering due to family not wanting the patient to receive either the dose or type of medication. This could be because there are side effects, but it also could be a result of the negative stigma associated with certain pain medications.

Methadone, for example, is becoming a much more commonly used medication, but carries a strong stigma. I have had patients prescribed methadone, to which they have said: “I don’t use heroin.”  

While addiction is not a concern with hospice patients who only have a short time remaining, having medication in the home can be a cause for concern with other family members or visitors. Steps taken to ensure medication is being used properly include limiting the length of prescriptions, counts at each visit, and weekly medication reviews. For patients residing in private homes, medication is counted and in some cases a lockbox for medication storage may be provided. If a patient cannot be safely treated in their own home, it may be necessary to move them to a place where care can be provided.

Finally, having pain medication alone is not enough to treat many different kinds of pain. One must also consider the psychosocial aspects of pain. Pain is more than physical. Pain can be psychological, spiritual, financial, and social. A team approach with a physician and a social worker is one of the strongest ways to assist with pain management. Cognitive behavioral therapy and assistance with resources is essential for successful pain management.

To learn more about how Crossroads Hospice & Palliative Care addresses ethics in pain management and the benefits of palliative care, please call us at 1-888-564-3405.

Kristin Kitzmiller
Support Services Director
Crossroads Hospice & Palliative Care

If you found this information helpful, please share it with your network and community.
Copyright © 2018 Crossroads Hospice & Palliative Care. All rights reserved.