Columns, Patient Care

The Ethics of Treating Patients in Pain

Issue 11 and Volume 41.

A 46-year-old patient, Oscar, is lying on his living room floor when you and your partner find him. He’s a moderately obese man who’s awake and alert, being very vocal that his back hurts and he needs something for his pain.

As you begin your assessment, Oscar tells you he needs “some fentanyl right now.” You reach for his wrist and feel his pulse. His skin is warm and clammy and his pulse is strong at a rate of about 100 beats per minute. He tells you he injured his back a couple of years ago and has had two surgeries to repair disks. Last evening he bent over to pick up his dog and his back began to hurt again. The pain increased through the night to the point he called you for help.

His physical exam reveals no obvious deformities to his lower back. He has what appears to be full range of motion to both of his legs. Bilateral pedal pulses are present and strong and Oscar is able to sense your touch.

Your partner takes a set of vital signs and reports a pulse rate of 106, blood pressure of 168/92 and a respiratory rate of 22 with an oxygen saturation of 98% on room air. As you and your partner discuss the best way to move and transport Oscar to the hospital, he aggressively requests fentanyl.

Discussion

On the surface this call may appear to be a simple back strain or a potential drug seeker. There are multiple points to be considered.

First, we should always consider our patients to be critical and let them prove us wrong. In other words, rather than seeing this patient as having just a back problem or seeking drugs, life-threatening conditions such as an abdominal aneurysm must be considered.

A thorough evaluation should be completed to help determine the cause of the pain. When the exact cause of pain isn’t identifiable in the prehospital setting, treatment should focus on symptoms. This patient doesn’t have a problem with breathing or circulation. There are no obvious bleeds or deformities requiring stabilization. Treatment should now focus on patient comfort and pain control.

Keeping patients comfortable and relieving pain should be a goal of prehospital treatment. Too frequently, however, patients arrive at the hospital by EMS in uncomfortable positions, cold without blankets, splinted with no padding or in the care of an ALS provider who hasn’t administered any or enough pain medication.

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The perception of pain is subjective and varies from person to person. When a patient is experiencing pain, there are multiple physiologic responses that can have negative effects on the body.

Pain generates a sympathetic response that causes an increase in heart rate and blood pressure. Cortisol, sometimes called the stress hormone, is increased in the body. Long-term effects of high cortisol levels can include alterations in blood pressure, alterations in blood glucose levels and slowed wound healing. Additionally, EMS providers should remember that pain by nature is uncomfortable and will be associated with an emotional response, such as anger, aggressive behavior, or sadness and crying.

The World Health Organization has not only identified pain control as an essential component of patient care but also as a basic human right.1,2

EMS providers have the opportunity to help mitigate a patient’s pain and discomfort early in the process of their injury or illness. At minimum, EMS has the obligation to not increase pain or discomfort.

At all levels, providers can help patients find a comfortable position on the stretcher. If immobilization or splinting is required, padding the splint and voids can help make a potentially uncomfortable procedure less so; the application of ice to a potential fracture or dislocation may also help to mitigate pain. Simple comfort procedures such as a blanket and pillow can help patients be more comfortable during transport.

At the advanced level, providers commonly have analgesics at their disposal to help patients manage pain. The goal of pain management should be patient comfort. Pain management should be offered based on what the patient feels they need, not what the provider thinks they need.

There are concerns about opioid addictions, but refusing a patient relief of pain in the prehospital setting based on the assumption of the patient being a drug seeker is less than optimal patient care and has resulted in legal actions against physicians in some cases.3

Conclusion

The American College of Emergency Physicians has identified that it’s an ethical responsibility to help manage a patient’s pain.4 Use all the tools and opportunities you have to help your patients be as comfortable as they can be during what may be a very negative time in their lives. 

References

1. Apfelbaum JL, Chen C, Mehta SS, et al. Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534–540.

2. Brennan F, Carr DB, Cousins M. Pain management: A fundamental human right. Anesth Analg. 2007;105(1):205–221.

3. Rich BA. Physicians’ legal duty to relieve suffering. West J Med. 2001;175(3):151–152.

4. Aswegan AL. (September 2007.) Our ethical duty is to relieve pain and suffering. ACEP. Retrieved Sept. 22, 2016, from www.acep.org/Clinical—Practice-Management/Our-Ethical-Duty-Is-to-Relieve-Pain-and-Suffering/.