The failure of healthcare institutions to hold clinicians accountable for pain relief

Traditionally, healthcare institutions have been dominated by their organized medical staff, at least with regard to determinations of what constitutes appropriate patient care. It logically follows that if effective pain management is not a priority of the medical staff, neither will it be an institutional priority of the hospital, long-term care facility, or clinic. The notable exception that proves the general rule is hospice. Since the defining role and mission of hospice is to provide palliative care to dying patients, only physicians who share that priority tend to associate themselves with it. However, even hospices and their physicians sometimes fail to make the relief of a patient's pain the cardinal principle

of care.49

Decades ago, a seminal study of the institutional response (or lack thereof) of hospitals and their medical and nursing staffs framed the issue as the "politics of pain management.''50 The modern hospital is preeminently an acute care facility, typically consisting of an emergency room, diagnostic facilities, surgical suites, one or more intensive care units, and other units where generally short-term therapeutic measures are undertaken. Pain in such settings, as previously noted, is viewed as an important diagnostic tool, a symptom of some more serious underlying condition that must be diagnosed and hopefully cured. Eliminating or significantly mitigating the pain would be (or so it has been assumed) counterproductive to the diagnostic and therapeutic agenda. Similarly, patients who have recently undergone a procedure are monitored closely for complications, one indication of which is pain. Patients who are receiving optimal pain control will be at risk of unnoticed problems. Finally, many of the interventions that are indicated in the pursuit of diagnosis or cure themselves cause pain, only some of which may be alleviated without in some manner compromising its ultimate success.

Anecdotal evidence abounds, and has found its way into plays, motion pictures, and television, of patients and families who are subjected to considerable distress (physical and emotional) by healthcare professionals who scrupulously titrate pain medications and rigidly adhere to dosages and administration schedules. Complaints of severe pain are met with the staff response that another administration of the prescribed form of pain relief is not due yet, and the patient is then admonished not to complain because everything that can be done has been done. Particularly influential in the care of hospitalized patients are anticipated pain trajectories. When a patient demonstrates an unexpected pain trajectory, particularly one where the pain persists beyond the paradigm or is reported to be more severe than that which is usually reported, the staff may not be organizationally or emotionally equipped to respond appropriately.50 A not uncommon response of the staff in such situations is to question the accuracy of the patient's complaints of pain, or to dismiss the patient as histrionic or attention-seeking. If the complaints persist, and focus on the need for more pain medication, the patient is at risk for being labelled a drug-seeker or even an addict. Such labelling constitutes the ultimate means of discrediting the patient's complaints, which at bottom constitute a charge that the staff has failed in one of its fundamental responsibilities - to relieve patient suffering.

The study to which we have been referring concludes that "staff is not really accountable ... for the actions it takes in regard to the patient in pain.'' Furthermore, the prognosis for any demonstrable improve-

ment was grim:

Genuine accountability concerning pain work could only be instituted if the major authorities on given wards or clinics understood the importance of that accountability and its implications for patient care. They would then need to convert that understanding into a commitment that would bring about necessary changes in written and verbal communication systems. This kind of understanding and commitment can probably come about only after considerable nationwide discussion, such as now is taking place about terminal care, but that kind of discussion seems to lie far in the future.

Ironically, phase II of the SUPPORT study undertook precisely such an intervention designed to improve written and verbal communication on wards or clinics with the aim of improving the care of seriously ill patients. The intervention was a notorious failure, and the failure was attributed in significant part to the prevailing culture of medicine, which is driven by the therapeutic rather than the palliative model of care.

Realistically, boards that regulate healthcare professionals cannot be a patient's first line of defense against substandard medical care. Neither can medical malpractice litigation serve this function. That role and responsibility falls upon the institutions and organizations in which patient care is most commonly provided: the hospital and its clinics, ambulatory care centers, and long-term care facilities. Their tolerance of healthcare professionals who are unable or unwilling to provide appropriate pain relief to patients is an abrogation of their social and moral responsibility. For example, several of the patients whose inappropriate pain management served as the basis of the Oregon Board of Medical Examiner's ground-breaking disciplinary action against Dr Paul Bilder were receiving their treatment at the same institution. Yet there is no indication that any of the standing committees of the hospital responsible for the monitoring of the quality of patient care, e.g. quality assurance or medical staff credentials, had undertaken any measures to protect future patients from similar instances of unnecessary suffering. Hence, a period of five years and a total of six patients had to accrue before the medical board was in a position to initiate corrective action.

Within the last few years, a more concerted effort has been initiated by some leaders in the field, particularly nurses, to institutionalize good pain management and to institute mechanisms for holding the staff accountable for providing it.51 However, what holds the greatest promise for actually bringing about systematic changes in the way in which pain is managed in most healthcare institutions are the new standards that have been promulgated and implemented by the Joint Commission for the Accreditation of Health Care Organizations (JCAHO).52 In order to comply with these standards, institutions must do the following:53

• recognize the right of patients to appropriate assessment and management of their pain;

• identify patients with pain in an initial screening assessment;

• when pain is identified, perform a more comprehensive pain assessment;

• record the results of the assessment in a way that facilitates regular reassessment and follow up;

• educate relevant providers in pain assessment and management;

• determine and assure staff competency in pain assessment and management;

• address pain assessment and management in the orientation of all new staff;

• establish policies and procedures that support appropriate prescription or ordering of effective pain medications;

• ensure that pain does not interfere with participation in rehabilitation;

• educate patients and their families about the importance of effective pain management;

• address patient needs for symptom management in the discharge planning process;

• collect data to monitor the appropriateness and effectiveness of pain management.

The expedited introduction of these standards into the JCAHO institutional survey process is a strong indication of the perceived need to bring healthcare organizations promptly into compliance. Because of the importance that is attached to the JCAHO survey process, these standards create a realistic expectation that we may be in the process of moving from mere rhetoric to genuine reform of pain management practises in the United States. A final important note about the JCAHO standards is that they do not undertake to emphasize distinctions among acute, cancer, and chronic nonmalignant pain. Accredited institutions, through their professional staffs, are to be held accountable for appropriate management of all types of pain.

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