The face of poor pain management

Why two physicians ended up on the firing line

Two physicians recently made headlines for failing to understand that the American public finds the undertreatment of pain to be an unacceptable standard of care. The following is an overview of how Wing Chin, MD, of Castro Valley, CA, and Paul A. Bilder, MD, of Roseburg, OR, wound up in the national spotlight, according to Kathryn Tucker, JD, director of legal affairs for Compassion in Dying Federation.

The Oregon Board of Medical Examiners ruled in late 1999 that Bilder showed unprofessional conduct and gross and repeated acts of negligence in six cases for failure to adequately relieve pain in seriously ill or dying patients. The nine physicians and two consumers on the board required Bilder to complete the Physicians Evaluation Education Renewal program, a one-year program that requires another physician to work with Bilder to improve the way he manages pain in his patients, complete a course on physician-patient communication, and continue meeting with a psychiatrist who will report to the board for at least a year. In making its ruling, the board noted that Bilder:

• used acetaminophen to treat an elderly man who was in pain caused by terminal cancer. The patient was hospitalized for pain. After discharge, a hospice nurse told Bilder the patient required a urinary catheter, stronger pain medication, and anti-anxiety medication. Bilder refused the catheter on the basis it might cause infection and ordered inadequate pain medication. The patient died the next day.

• ordered removal of a urinary catheter from a dying patient against the wishes of the patient and family. Bilder told the hospice nurse to use diapers instead to manage the patient’s incontinence. He also ordered a fraction of the pain medication suggested by the hospice nurse. The patient died that night.

• stopped sedatives and pain medication for a patient with pulmonary disease while she was on a ventilator. Bilder failed to resume pain medication or sedatives when the patient became restless and fought her ventilator. The patient pulled out her breathing tube. Another physician reinserted the tube. Bilder then ordered a paralytic agent to relax the throat muscles but did not order sedatives to ease the patient’s anxiety.

• refused a request to order morphine to treat anxiety in a patient with pulmonary disease and diabetes who was put on a ventilator for acute respiratory failure.

• refused morphine or other pain medication for an elderly patient hospitalized with congestive heart failure, despite the patient’s assertion that he could not breathe and was tired. Bilder ordered Lasix but refused to order morphine or a similar pain medication. Another physician treated and stabilized the patient, allowing him to be discharged several days later.

• failed to use narcotic painkillers or anti- anxiety drugs while inserting a breathing tube through the nose of a patient with pneumonia. The hospital staff made several unsuccessful attempts to insert the tube, causing the patient’s nose to bleed. The staff had to restrain the patient to complete the procedure.

Court deems inadequate care elder abuse’

A California Superior Court judge recently ruled that Chin should stand trial for elder abuse for inadequately treating pain in an 85-year-old man dying of lung cancer. The patient was admitted to the hospital complaining of intolerable pain. He was treated by Chin. Nurses charted pain levels ranging from seven to 10 on a 10-point scale throughout his five-day stay. The patient was discharged to die at home, still in intolerable pain. His family finally persuaded another physician to prescribe pain medication for the patient. He died the next day.

The patient’s family filed a complaint with the Medical Board of California, which investigated and concluded that the pain care provided by Chin was inadequate yet declined to take disciplinary action against the physician. The family then filed suit in California state court against Chin and the hospital for medical malpractice and elder abuse. Attorneys for Chin and the hospital asked the court to dismiss the elder abuse claims, arguing that the plaintiffs were only entitled to the limited remedies available from a medical malpractice claim. The court denied the defense motions to dismiss, allowing the claim for elder abuse to go forward to trial.

(For a discussion of pain assessment and standards, see stories, pp. 57 and 58.)