Ethical Obligations in the Context Ethical Obligations in the Context of the “Problem” ED Patientof the “Problem” ED Patient

Kenneth V. Iserson, M.D., MBA, FACEP

Professor of Emergency Medicine

Director, Arizona Bioethics Program

University of Arizona College of Medicine

Tucson, AZ 85724

What you What you thinkthink you are seeing is you are seeing is not real!not real!

Emergency Dept. Case: 2003

• Triage note: “32-year-old man c/o severe intermittent severe abdominal pain. Multiple ED visits. ?Drug seeker” “Allergy/Side effect to NSAIDS.”

• Third visit to ED (while working) in last two weeks. No diagnosis. Prior labs normal; Abdominal CT normal.

• “I don’t do well with morphine; Demerol is better.”

• Secondary gain from being in ED? Off work—hospital is his employer.

• One prior surgery: laparoscopic fundoplication.

There is no valid objective test for the presence, quality or intensity of pain.

Pain is real when you get other people to believe in it. If no one believes in it but you, your pain is madness or hysteria. —“Violence,” The Beauty Myth (1990) Naomi Wolf

Who are “Problem” Pain Patients?Those who demand specific

evaluations/treatments.

Abusive (out-of-control and often demanding) patients

“Frequent flyers”

Those with whom we have difficulty communicating—infants/children, geriatrics, communication-limiting injuries or illnesses, language barriers, cultural barriers

Who are “Problem” Pain Patients?Those with chronic “pain” conditions (e.g.,

fibromyalgia, sickle cell pain crises, chronic back/leg pain, migraine/chronic headaches)

Those followed by pain clinics (who cannot be contacted) or out-of-town physicians (“I don’t remember his name”).

Who are “Problem” Pain Patients?

Drug addicts/alcoholics

Those with “the story” (My pills were: stolen, flushed down the toilet, forgotten when I moved to town, the dog ate them. I lost my prescription—from yesterday.)

Why do EM clinicians see them as “problems”?

Cultural norms differ from practitioners’

Emergency personnel see their job as intervening in acute, identifiable illnesses/injuries

Take time & other resources from the care of seriously ill & injured

They do not want to be manipulated or “fooled” (peer pressures/ego). Changes with age & experience?

Disinterest in being the primary care physician.Iserson KV: The problem patient. In: Hamilton GC, et al., Emergency Medicine: An

Approach to Clinical Problem Solving WB Saunders, Phil. pp 1133-1139, 1991.

Why are EDs particularly vulnerable to receiving “problem patients”?

Rotating groups of physicians/nurses.

Episodic care

Limited ability to access outside patient information (after hours, weekends, holidays)

Many EDs/Urgent Care centers (“doctor-shopping”)

Why are EDs particularly vulnerable to receiving “problem patients”?

Need to move patients through quickly (Time pressures)

Patients in need often have nowhere else to turn—and may feel that (based on their prior experiences) they must be “problems” to get appropriate evaluation and treatment.

Society’s venue of “last resort.”

Whose problems are these?Whose problems are these?

Are the “problems in

the medical system,

in us, or

in our patients?

Perhaps, all three!Perhaps, all three!

What are the ethical questions?

• What duties do we owe patients?

• Beneficence; Nonmaleficence “Do good, but at least do no harm.” Hippocrates

• What rights does this confer on patients?

• How do these affect “problem” patients?

• Do we have more, less, the same obligations toward them as we do for other patients?

Ethical Principle & the Basis of Ethical Principle & the Basis of Medical PracticeMedical Practice

"To cure sometimes, to relieve often, to comfort always -- this is our work. This is the first and great commandment. And the second is like unto it - Thou shalt treat thy patient as thou wouldst thyself be treated." — Anonymous, 15th C.

What goes wrong?• Clinicians who themselves have not experienced

severe or chronic pain may not fully empathize with those who do.

• “Good” vs. “Bad” (patient-caused, chronic, hard-to-substantiate) causes of pain; “Moral judgments.

• Patients often have difficulty accurately quantifying—or even locating the source of their pain.

Other Causes of “Oligoanalgesia”• Misunderstanding of “addiction,”

“pseudoaddicition”

• Leads to unwillingness to treat potential drug “seekers”

• ***Government threats—regulations and fear of regulatory actions—excuse for inertia

• Lack of adequate personnel, time, interpersonal communications among healthcare team

• Costs (e.g., gabapentin) & unavailability (sustained-release narcotics)

• Little research into acute pain treatment.

U of AZ EM Pain StudyU of AZ EM Pain Study• Prospective study.• Evaluate patient’s, accompanying adult’s,

treating physician’s, and nurse/medic’s assessment of patient’s pain and treatment.

• Follow-up evaluations.

Ken Iserson, M.D., MBA

Svetlana Reznikova, MS III

U of AZ EM Pain StudyU of AZ EM Pain Study

10/10/04: Enrolled 32/50 Research “units”

• Each research unit:

1) Patient at the ED with the main complaint of pain;

2) An accompanying adult;

3) A nurse taking care of this patient;

4) A physician taking care of this patient

• Follow-up for 16 patients (so far)

U of AZ EM Pain StudyU of AZ EM Pain Study

Trends:Trends:1. Too long a wait from being triaged to getting

pain control (usually with medications).

2. Unclear (so far) about correlation between patients’ assessments of time waiting for pain control and assessment of accompanying adult.

3. Insufficient communication among the medical personnel involved in each patient’s care.

Conclusions: What Can We Do?As Clinicians

Recognize areas in our practices where we can alleviate acute suffering—especially if the norm is to ignore it—act as a role model for others.

Believe our patients who say they are in pain. Humility: Simply because we cannot categorize or name

a disease does not mean that it is not real. Our moral duty is to do good. Prescribe analgesics—

even if doubt exists as to whether the patient has “real” pain.

Conclusions: What Can We Do?As Bioethicists/Educators

Announce—on a local and national level—that this is an ethical problem, with a number of moral dilemmas that need resolution.

Publically defend the more liberal use of analgesics—and work to change laws threatening proper analgesic use.

Conclusions: What Can We Do?What Can We Do?As Bioethicists/Educators

Remind our colleagues that clinicians are not the police; our job is to treat patients.

Encourage Bioethics Committees to solicit problematic acute-pain management cases as a forum for initiating discussion of the problem.

Conclusions: Why Must We Act?Why Must We Act? Moral imperative: Treat our patients’ pain!

Improve patients’, society’s and our own image of ourselves and our profession.

Basis of good medical care.

Basis of good medical treatment.

Right thing to do.

We have delayed too long already.

It is time that we better epitomized medicine’s underlying value—Relieve Always!

Points to ponderPoints to ponder

1. There is no valid objective test for the presence, quality or intensity of pain.

2. “Problem” patients have problems: the system, us, or both.

3. We have a professional duty/obligation to Do The Right Thing.

DoingDoing “The Right Thing” “The Right Thing” means:means:

1. Treating pain complaints:– In a timely manner.– With appropriate medications & dosing.

2. Not judging whether it is “good” or “bad” pain.

3. Not being cops; being caring healthcare providers.

CASE—CASE—ResolutionResolution

• Patient “given the benefit of the doubt.”

• He was scheduled for an ERCP.

• Found to have an herniated, intermittently strangulated fundoplication.

• Laparotomy (open surgery).

• Pain relieved. Working full time. Not needing analgesics.