An ethical responsibility for pain management
First published in 1993: Copp L.A. (1993) An ethical responsibility for pain management. Journal of Advanced Nursing18, 1–3
Well documented is the underprescribing of analgesia by physicians (Marks & Sachar 1973) and the concomitant under-administration by nurses of ordered pain medication (Cohen 1980). Examples of nursing judgements about patients who are pushed past their endurance and who are made to wait for relief can represent matters of negligence and perhaps even conscience. Let us think about ethical principles and their bearing on pain management, both of which are included in expected nursing conduct.
Values and moral judgements
Nurses’ professional judgements may also be moral judgements, because of values held by the person in pain and the person who chooses to or not to relieve that pain (Lisson 1989).
Meinhart & McCaffery (1983) remind us:
Moral judgements such as whether pain is ‘real’ and how the patient must express his or her pair for staff to consider the expression acceptable, along with misconceptions, such as exaggerated fears about addiction, often result in the nurse withholding pain relief measures especially narcotics.
Hence the nurse is involved in ethical issues in daily practice, and the identification and acknowledgement of personal values which lead to moral judgements may provide an opportunity to share concerns with colleagues, and to analyse and improve patient care through practising nursing more ethically.
Non-malfeasance and beneficence
Do no harm. This basic tenant of ethics may be applied in a mistaken manner. Too often nurses believe that doing nothing is avoiding harm. But inattending to a patient's pain may be causing harm through negligence. Bonica believes that unrelieved pain may cause tissue damage and even death (National Institutes of Health 1985). Some settings permit the nurse choices to: (a) attend to pain therapeutically; (b) attend non-therapeutically (delaying, withholding); (c) mismanage pain (not identifying all relevant alternatives or making bad choices); or (d) inattend to pain for many reasons including lack of awareness on the part of the nurse and denial of pain (Copp 1985).
Responsibility and judgement
Pain management is in the purview of the nurse and is an essential component of care, since it is the nurse and patient who face pain alone, in the long hours of the night and morning. Preparing for the pain onset is part of pain prevention (Copp 1990a). Although most nurses with whom we have talked have a commitment to pain reduction, far fewer work for alleviation. Pain prevention seems to fail to inspire nurses to imaginative nursing care and pain management. This appears to be true even when pain can be anticipated, such as in episodic pain, intermittent pain, and in pain associated with diagnostic procedures, or pain in the labouring woman (Copp 1990b).
When pain medication is ordered p.r.n (as is needed), every nurse may interpret ‘need’ differently. And what of those nurses who do not assess for pain at all, considering medication only when the patient requests it? And many patients in pain have not been informed that authorization for analgesia exists. Nurses assigned to medications where primary care is not the mode often give priority to medications ordered at regular intervals and for which there are medication cards (or similar) to remind staff of the established hours of administration. Analgesics ordered on a p.r.n basis may have to wait until this and other ward work is completed, and frank pain behaviour ‘is noticed’.
In addition to the pain problem, for patients hospitalization curtails freedom, separates them from home and work responsibilities, and converts an autonomous, independent, functioning individual into one who is dependent on others for the most simple and intimate needs. At home they take their own pain medication as they judge it to be needed. In hospital, medication is not entrusted to them, and pain reduces them to desperation and even to begging for what is rightfully theirs. Even checking if there is an analgesic order seems to be an imposition to some staff members, communicating that there is more important work to which to attend.
Medications given when the pain is so bad that ‘the patient can't stand it’ puts them in a kind of roller-coaster regime when they are given analgesics only when they are groaning, writhing and dancing with the agitation of unrelieved pain. Patients are robbed of autonomy, positive self-concept and dignity and may be made to feel guilty they weren't ‘a good patient’ and, instead of being generous with analgesics, the nurse congratulates them ‘for being strong’, and not needing anything. Unfortunately, not needing analgesia, not asking for it, or hiding the need for it are quite different manifestations. Finally, offsetting these practices is the increasing acceptance of patient-administered analgesics. Through these other changes in pain management, the patient can be empowered as a capable adult.
In order to demonstrate competency throughout their professional life, nurses must learn an array of ever-changing analgesics and adjuvant drugs. Further, competence in pain management entails demonstrating a basic knowledge of the nature and action of the drug, proper dosages, the length of coverage, the time it takes for the drug to take effect, the variety of routes of administration, the conversion of dosages related to choice of routes, the recognition of drug tolerance, and dealing with problems with break-through pain.
Truthfulness, basic to trust, is an ethical principle. The nurse who promises to return with a pain medication and neither comes nor gives an explanation doesn't enhance truth or trust. But for some pain patients, the system requires that they ‘prove’ their pain, either through laboratory test of pain behaviour.
For the chronic pain patient who has adapted to pain, pain behaviours are vastly different from persons in acute pain. Nurses noting the composure or self-control of the chronic pain patient may disbelieve their pain report, requiring that they ‘earn’ the attention of the nurse, who is ever on guard for a lie factor. How common it is to hear even hospitalized health professionals decry, ‘They refuse to believe me. They act as though I am making it up or the pain is all in my head.’
A nurse was observed to say, ‘See, I knew he was lying. After all that fuss for something for pain, would you believe he was asleep when I brought it?’ The pain, the disease, the fatigue, the relief of finally convincing the nurse of the authenticity of their need, each or all may have accounted for their behaviour. Yes, patients hurt even in their sleep and pain nightmares are common.
The nursing staff often experience an ethical dilemma when there is not enough staff for adequate care for all and some patients require inordinate amounts of nursing care hours. Yet, it seems unjust and unfair when all who deserve care, pay for care and need care, cannot receive enough of the resources to be therapeutic or in some cases in which rationing of resources delays recovery. And the nurse's time is precisely one of the resources for which there is most competition. To make choices between patients or to choose what part of the care is to be given or withheld brings ethics into the choices nurses may be required to make.
Professional choices may also involve moral decision-making. They may have to decide not only which patients are vulnerable but which are the most vulnerable and advocate for special persons or groups (Copp 1986).
Patient advocacy and nursing care
A positive approach to the nursing care of the patient in pain is patient advocacy. Some patients in pain cannot speak for themselves, such as babies and little children who withstand the most complicated interventions with little or no analgesia, or the sphasic or comatose elderly. And Alzheimer's patients often groan with observable discomfort which they are unable to verbalize.
Caring acknowledges connectedness. In explicating Gilligan's ethic of care, Cooper (1989) states:
Caring acts occur in response to the needs that arise within the natural connectedness of one human to another. Given that humans are naturally connected, and that care arises from this connection, caring is understood as intrinsic to the process of human activity.
Our colleagues in hospices have made the moral judgement to relieve their patient's pain unconditionally and within the parameters of sophisticated pain management and nursing care. Can we accept the challenge in hospitals, nursing homes, out-patient clinics and in the home to manage pain as an ethical and professional imperative?