Pain management still a puzzling problem
Pain management still a puzzling problem
Overzealous enforcement may be harmful
The saying that politics makes strange bedfellows certainly can be applied to the efforts of providers and patient advocates trying to improve pain relief for dying patients. While all groups might not agree on whether patients have the right to commit suicide, they do agree that regulatory barriers and laws need to change to improve the care of dying patients.
And for ethics committees grappling with the challenges of developing policies and procedures for palliative care, the changes could mean wider acceptance of an often ignored topic among physicians and nurses.
"The Joint Commission [on Accreditation of Healthcare Organizations in Oakbrook, Terrace, IL] is very specific about what needs to be in place within hospitals concerning pain management. Current general standards are in place in the patients' rights areas, but more guidance on training staff will help with the revisions expected in the year 2000," says Bruce White, MD, clinical director of St. Thomas Hospital's Clinical Ethics Center in Nashville, TN.
Finding common groundPatient advocate groups such as the Portland, OR-based Compassion in Dying Federation, for example, and the St. Louis-based Catholic Health Association of the United States, are finding common ground on issues surrounding palliative care. Both groups are calling for improvements to ensure patients receive appropriate pain relief.
The Catholic Health Association, which represents 1,200 Catholic-sponsored hospitals and long-term care facilities, along with other Catholic health systems, already has joined in a collaborative effort called Supportive Care of the Dying: A Coalition for Compassionate Care. St. Thomas in Nashville is participating in the project through its hospital system, the Daughters of Charity National Health System in St. Louis. (For more on the coalition, see Medical Ethics Advisor, September 1997, pp. 97-100.)
The association has publicly asked President Clinton to "remain consistent" regarding the federal government's opposition to assisted suicide while exploring all available and legitimate methods to improve pain relief for the terminally ill.
The association also requests that President Clinton support the U.S. Department of Justice's ruling that the Drug Enforcement Administration (DEA) does not have jurisdiction to prosecute physicians who prescribe medications to patients under the Controlled Substances Act. That news is particularly important to physicians in Oregon, where prescribing controlled substances to a patient meant possible criminal charges or punitive damages.
"This is the decision we expected from the Justice Department. It removes the last cloud hanging over Oregon's law. Doctors and patients can proceed with the provisions of the Act with the full confidence that what they are doing is completely legal," adds Barbara Coombs Lee, chief petitioner of Oregon's Death With Dignity Act and director of the federation.
Enforcement could have chilling effectThe President's support of the Justice Depart ment's ruling over the DEA would be "completely consistent" with his previous action last year to support a funding restriction bill, notes the Rev. Michael D. Place, STD, president and chief executive officer of the Catholic Health Association. Last year, President Clinton signed the Assisted Suicide Funding Restriction Act that prevents federal funds from being used to further assisted suicide.
Both groups, however, warn that overaggressive or misguided enforcement of the Controlled Substances Act could have a chilling effect on pain relief for patients at the end of life. While the DEA decision clears physicians in Oregon from liability, physicians in other states could face prosecution under current law, says Kathryn Tucker, JD, legal affairs director for the Compassion in Dying Federation.
Critics such as White, however, argue that the DEA shouldn't have the authority to infringe on the physician-patient relationship. "The existing laws are ethically and legally proper regarding pain relief. Even in cases where a medication may hasten a patient's death, I don't see how the DEA can find fault. As long as the medication is prescribed for legitimate medical purposes and is considered acceptable medical practice, I don't see how there's a case [for prosecution]," he argues.
In an effort to provide a unified approach to appropriate pain relief, Compassion in Dying is petitioning state medical boards to formulate guidelines for physicians on providing adequate pain relief, but the group is taking the request one step further. It also is asking that physicians who fail or refuse to provide adequate pain relief be sanctioned.
To offer help, officers of Compassion in Dying suggested seven steps that state medical boards could take to correct faulty perceptions among physicians about treating the terminally ill. (For a list of the suggestions, see box, p. 53.) "What's worse than not providing adequate pain relief is that physicians also believe they can undertreat pain in the dying without risking any professional consequences. The result is a lot of unnecessary suffering among the terminally ill," says Coombs Lee.
"As many as 50% of dying patients in the United States are suffering needlessly due to lack of adequate pain treatment as they die. What we've called on state medical boards to do is make it clear to physicians that the failure to treat dying patients to relieve their pain where possible is in itself a form of medical behavior below an acceptable standard," Tucker says.
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