Nurses and Pain Management Pain management has always been a critical goal of health care workers. Strategies for improved pain management guidelines have been in place since the early 1990s, with the aim of allowing clinicians to improve pain management. However, research shows that patients in all age groups continue to experience needless pain, despite the guidelines and treatment availabilities.

This paper examines the pain management strategies that could be employed by nurses towards alleviating pain in a variety of patients.

The first part of this paper examines the background and reviews the current literature regarding pain management. The next part then examines the key pain management issues, including the concern regarding addiction, a clinician's ethical responsibilities towards patients and legal culpability.

The next section examines the pros and cons of establishing pain management standards.

The paper then examines these proposed guidelines from a nursing viewpoint, in line with the 2001 Code of Ethics as well as the ANA's "Nursing's agenda for the future." The paper then addresses how a proposed set of pain management guidelines affects nursing practices. This section also discusses how the inclusion of pain management strategies could effect changes on the practice of health care in general.

In the last section, the paper makes further recommendations on how pain management strategies could be tailored to facilitate the practice of nursing. This paper argues that an effective pain management program should be a cornerstone of a patient's treatment.

Background

In a landmark study, the SUPPORT Principal Investigators (1995) surveyed 9,000 sick adult patients who had a prognosis of 50% or less. Among other findings, the study showed that more than half of the patients surveyed experienced moderate to severe pain during the last three days before they died.

Pain management takes a backseat in a variety of medical specialties. Tanabe and Buschmann (1999), for example, found that 78% of patients experience severe pain in the emergency room. Furthermore, clinicians often followed a standard pain treatment program that did not take into account the severity of an individual patient's pain. As a result, many patients did not receive adequate pain medication, despite the availability of pharmacologic solutions.

A follow-up SUPPORT study (1997) further showed that majority of the hospitalized patients who were 80 years or older were distrustful of many life-prolonging treatments. The distrust stemmed from fears that such treatment would result in pain. Instead of high-tech treatments, many respondents to this follow-up study preferred on getting comfort and time with loved ones. The same study also concluded that in many cases, these patients' wishes were not honored. Many patients suffered from pain, as well as other unpleasant symptoms like hunger, confusion, depression and fatigue.

Henkelman and Dalinis (1998) wrote that the inability to control the pain and suffering of patients remains one of the "biggest failures in 20th-century Western scientific medicine" (40). Much of the growing debate regarding euthanasia and physician-assisted suicide stems from the public and the clinicians' fear of a pain-wracked existence.

A nationally instituted pain management program that recognizes the valuable contributions of nurses and nurse practitioners would therefore go a long way towards alleviating such confusions. The next sections focus on the specific issues of a pain management program, with an emphasis on the field of nursing.

Key Issues

In many instances, patients experience pain not because of the lack of pharmacologic cures. On the contrary, many cases of severe pain are left untreated in spite of a variety of pharmacologic and non-pharmacologic treatments.

In this paper, the key issue is thus not the lack of medical ways to treat pain. Rather, this paper focuses on the ethical duties of healthcare professionals towards their individual patients. T. Patrick Hill (1994) argued that health-care professionals were bound to honor "a principle on which rests the human right to be free of pain" (438). Hill further argues that the measure of medicine's success is its respect for a patient's "right to be free of pain" (439).

Towards this, bioethical principles and the concept of an ethics of care form a good framework for locating the ethical duties of a clinician regarding pain management.

The application of bioethical principles means that a clinician has to balance the potential benefits of medical treatment against any potential harm to the patient. The clinician's task thus goes beyond medical interventions to treat a person's illness or save a person's life (Henkelman and Dalinis 1998). In assessing any potential harm, clinicians should also consider a wide range of possibilities, including a patient's wishes, values and, as states in the Hill article, a patient's right to be "free from pain."

In addition to physical needs, health care professionals should also respond to their individual patient's needs (Henkelman and Dalinis 1998). If the SUPPORT studies (1995, 1997) are indications, many of the patients' self-identified needs will include measures to reduce pain levels.
In applying the ethics of care, Henkelman and Dalinis (1998) argue that many clinicians address the patient's physiological symptoms vigorously. However, many of these actions do not satisfy the self-identified needs of the patients. As an example, a patient may request a "Do Not Resuscitate" order, or may ask for pain medication that would preclude other pharmacologic treatments. In this case, ethical clinicians are required to weigh the patients' needs against the benefits of more aggressive medical measures aimed at the physical symptoms.

Both ethical frameworks thus require the clinicians to take a patient's needs into consideration, including any specified wish to be free from pain. This is particularly important for patients such as those in the SUPPORT study (1995), many of whom were dying. Withholding treatment or prescribing pain medication may present a conflict to the clinician, whose natural inclination would be to prolong a patient's life.

However, such a treatment strategy also includes the patient in the decision process. This inclusion means that in addition to their illnesses, patients are also seen as people who have personal values, as well as beliefs regarding what would constitute a meaningful life.

Consensus or controversy discussed

The current lack of equally aggressive measures to address pain stems from a fundamental conflict in medicine - that between helping a patient become more comfortable and shortening a patient's life. Many clinicians fear that stopping treatment for the disease or prescribing medication for pain would help usher a patient's death, which is still regarded not as a natural outcome of life, but as the ultimate failure.

This orientation has led many physicians to criticize the influential SUPPORT studies. Bernard Lo (1995), a physician of internal medicine, states that the opposite conclusion of the SUPPORT study is often true, that many patients want treatment that others regard as aggressive.

Rather than blaming individual physicians, others place the blame on the strict hierarchical culture in the medical world. Marshall (1995) believes that this culture places the bulk of decision-making in the hands of physicians, allowing for little contribution from nurses, the patients or their families. Most physicians do not even bother to read nursing notes on the charts or discuss steps with the patients.

Many physicians fear that aggressive measures to fight pain can result in lawsuits. Hoffman and Tarzian (2003) found that many physicians fear that treating a patient's chronic pain could lead to potential disciplinary action. This hesitation is often present when controlled substances like opiods are involved, leading many to inadequately prescribe opiod medication.

For nurses, the problem is compounded by an uncertainty regarding the proper use of morphine and other narcotics to help alleviate severe and chronic pain ("Nurses have unrealistic fears..." 2002).

In summary, the failure to address a patient's pain stems not from a lack of ethics per se, but from the inherent desire of a physician to prolong a patient's life. However, many clinicians also believe that they have the moral and ethical duty to give their patients adequate pain control, particularly patients who are terminally ill. Unfortunately, however, due to concerns over lawsuits, the side effects of drugs like morphine and opiods and concerns over a patient's conflicting needs, many clinicians continue to relegate pain management concerns to the back burner.

Pros and cons

In addition to appealing to individual clinicians' ethics, many activists have called for increased monitoring of clinicians' responses to pain, both on a federal government and state medical board level. Many activists have successfully lobbied for the passage of the Pain Relief Act in Congress in 1996. This Act covered all health care providers, from doctors and nurses to pharmacists and physician assistants. Among the Pain Relief Act's important provisions protected health care workers from possible lawsuits or disciplinary procedures or even lawsuits. This law thus helps to address the clinicians' fears that treating pain could leave them vulnerable to disciplinary action (Johnson 2003).

However, critics of such a measure argue that decisions regarding health care and pain management should be left in the hands of health care professionals.

Gilson, Joranson and Maurer (2003) believe that effective pain management is best addressed through state medical boards. These boards could create model guidelines that address their state's needs while requiring…