Ben A. Rich

An Ethical Analysis of the Barriers to Effective Pain Management

Among the most significant findings of SUPPORT was that 50% of ICU patients suffered from moderate to severe pain during the last days of life. At the time of its publication late in 1995, SUPPORT was merely the latest in a long series of articles in the medical literature documenting the widespread and significant undertreatment of pain, beginning with a 1973 study of hospital inpatients. Much has been written about the phenomenon of undertreated pain and inadequate care of patients at the end of life, and many positive suggestions for reform of clinical education and clinical practice have been iterated and reiterated in the two decades separating the studies. Proposals for modifying clinician behaviors in this aspect of patient care have tended to focus on particular barriers to effective pain management and palliative care.

A legacy of silence: bioethics and the culture of pain.

For over 20 years the medical literature has carefully documented the undertreatment of all types of pain by physicians. During this same period, as the field of bioethics came of age, the phenomenon of undertreated pain received almost no attention from the bioethics literature. This article takes bioethicists to task for failing to recognize the undertreatment of pain as a major ethical, and not merely a clinical, failing of the medical profession. The nature and extent of the problem of undertreated pain is examined, as well as possible reasons for its disregard by bioethicists. The factors contributing to undertreated pain in the clinical setting are considered, as well as the hazards posed by recent failures to address ethically questionable clinical practices. Finally, suggestions are offered for refocusing the attention of bioethicists to this significant problem.

A historical perspective of informed consent in clinical practice and research

OBJECTIVES To review the historical perspective of informed consent in clinical practice and research as it pertains to human subjects. DATA SOURCES Published professional journals, books, case law, and the internet pertaining to the historical development of informed consent. CONCLUSIONS The history of informed consent is complex. Informed consent as a fundamental principle of clinical ethics has developed within the past 50 years. Full disclosure and shared decision making have not come naturally to clinicians. Consequently, respecting the autonomy of patients and research subjects requires a conscious, sustained effort by clinicians. IMPLICATIONS FOR NURSING PRACTICE Knowledge of the history of informed consent is important for practicing cancer nurses to ensure they understand the significance of preserving patient autonomy and advocate for the patient and research subject.

A Review of Forensic Implications of Opioid Prescribing with Examples from Malpractice Cases Involving Opioid-Related Overdose

OBJECTIVE To provide a forensic overview and trace common threads among malpractice lawsuits involving patients who overdosed while consuming therapeutic opioids. METHODS One of us (LRW) reviewed 35 medical records of patients with chronic pain who overdosed, 20 of them fatally, while consuming therapeutic opioids, leading to lawsuits against physicians for malpractice. The reviews were requested by plaintiff and defense attorneys from across the United States from 2005 to 2009 to ascertain which drug(s) were primarily responsible for each death and whether the death was due to physician error, patient nonadherence, or some other reason. Complaints against pharmaceutical companies were excluded. Cases were examined for common trends, and comment is offered. RESULTS Methadone was responsible for the most deaths at 10 (50%), and hydrocodone was second at four deaths (20%) The most common risk factors found in the medical records of decedents included prescriber error in initiating, converting or titrating doses, patient nonadherence to medical instruction, presence of comorbid mental disorders, toxicological presence of benzodiazepines, middle age, and unrelieved pain. This article focuses on examples of physician errors and how they can be prevented. CONCLUSIONS Common trends emerge from medical records of opioid decedents. Patient actions con-tribute, but physician error, particularly regarding prescribing methadone for pain, is apparent as well. A focused effort to determine the types and causes of common physician errors and how they might be avoided may lead to safer, more effective clinical interventions in the management of pain.

Legal Liability Perspectives on Abuse-Deterrent Opioids in the Treatment of Chronic Pain

ABSTRACT Abuse-deterrent opioid analgesic formulations can help reduce the risk of opioid diversion and abuse. Not all opioid analgesics are available as both extended- and immediate-release dosage forms in abuse-deterrent formulations. Clinicians may have to balance the clinical benefit of a product that does not use abuse-deterrent technology versus the regulatory benefit of using a product with this technology. There is the possibility that a health care professional may be held legally liable when a product without abuse-deterrent qualities is used and a person suffers harm that would not have occurred had an abuse-deterrent formulation been provided. This article reviews legal precedents that inform an understanding of the need to reduce malpractice exposure by identifying patients who are at high risk of opioid diversion and/or abuse and considering the use of an abuse-deterrent formulation for these patients.

Complex bioethics consultation in rural hospitals: using telemedicine to bring academic bioethicists into outlying communities.

Bioethics consultations are necessary to ensure excellent patient care and all US hospitals are required to provide access to bioethics consultants for cases raising ethical or moral dilemmas. However, there is a paucity of trained clinical ethicists. While assistance from trained bioethicists may be obtained via telephone or email, such methods of contact do not allow a bioethicist to engage fully with all members of the health-care team, the patient and family members. In two recent cases, rural hospitals contacted our centre for assistance with complex ethics cases. We provided a clinical ethics consultation via videoconferencing. The outcomes of the consultations would probably have been inferior had they been performed via telephone. For example, the non-verbal cues allowed the consultants to have a better understanding of the team dynamics, and led them to ask important questions that directly affected the recommendations which were made. Because patients are likely to benefit significantly from access to bioethicists when ethical questions arise, rural and community hospitals should consider teleconsultation when local ethics committees decide that further assistance is warranted.

Prospective Autonomy and Critical Interests: A Narrative Defense of the Moral Authority of Advance Directives

In the mid to late 1980s a debate arose over the moral and legal authority of advance medical directives. At the center of this debate were two point-counterpoint law journal articles by Rebecca Dresser and Nancy Rhoden. What appeared to have the makings of an ongoing critical dialogue ended with the untimely death of Nancy Rhoden. Rebecca Dresser, however, has continued her challenge of advance directives in numerous publications, most recently in a critique of Ronald Dworkins Lifes Dominion . Like Rhoden, Dworkin has been a staunch advocate of advance directives as an exercise of what has come to be referred to as prospective or precedent autonomy. In this paper I will consider a number of the issues that Dresser has repeatedly raised about the infirmities of advance directives, and suggest that it is from an understanding of and appreciation for the narrative dimension of the life of a person that advanced directives draw one of their most powerful justifications.

Clinical Criteria for Physician Aid in Dying.

Abstract More than 20 years ago, even before voters in Oregon had enacted the first aid in dying (AID) statute in the United States, Timothy Quill and colleagues proposed clinical criteria AID. Their proposal was carefully considered and temperate, but there were little data on the practice of AID at the time. (With AID, a physician writes a prescription for life-ending medication for a terminally ill, mentally capacitated adult.) With the passage of time, a substantial body of data on AID has developed from the states of Oregon and Washington. For more than 17 years, physicians in Oregon have been authorized to provide a prescription for AID. Accordingly, we have updated the clinical criteria of Quill, et al., based on the many years of experience with AID. With more jurisdictions authorizing AID, it is critical that physicians can turn to reliable clinical criteria. As with any medical practice, AID must be provided in a safe and effective manner. Physicians need to know (1) how to respond to a patients inquiry about AID, (2) how to assess patient decision making capacity, and (3) how to address a range of other issues that may arise. To ensure that physicians have the guidance they need, Compassion & Choices convened the Physician Aid-in-Dying Clinical Criteria Committee, in July 2012, to create clinical criteria for physicians who are willing to provide AID to patients who request it. The committee includes experts in medicine, law, bioethics, hospice, nursing, social work, and pharmacy. Using an iterative consensus process, the Committee drafted the criteria over a one-year period.

Personhood, Patienthood, And Clinical Practice: Reassessing Advance Directives

This article considers 2 major critiques of advance directives and offers a defense to each of them. The 1st critique is philosophical in nature and maintains that the moral authority of an advance directive is undercut by a failure of personal identity to survive the loss of decisional capacity. The response in this article is that this critique relies on a flawed and disfavored concept of persons and their persistence over time. The 2nd critique, pragmatic in nature, argues that advance directives cannot be authoritative because the requisite elements of an informed consent to or refusal of treatment are rarely present, and many such instruments are ambiguous. The author argues that if the creation of advance directives, as a form of advance care planning, is made an integral aspect of clinical practice, many more patients will elect to execute directives, and those directives will not be ambiguous.

Defining and delineating a duty to prognosticate

Prognostication, the process offormulating and communicating a prognosis, isno longer considered by most physicians to bean essential task in caring for patients withserious illness. Because of this fact, it isnot surprising to find that when physiciansattempt to engage in prognostication, they doit poorly. What may be surprising to thoseoutside the medical community is the extent towhich professional norms have developed whichactively discourage physicians from engaging inprognostication. This article explores thecauses of this state of affairs and thejustifications offered for it. The conclusionis reached that physicians have a professionalresponsibility to competently engage inprognostication based upon the doctrine ofinformed consent, and that a failure or refusalto do so has not only potential legalramifications, but serious negativeimplications for many of the core issues inbioethics, such as the use of advancedirectives, palliative medicine, and medicalfutility.