Pain Control Is Becoming a Legal Issue
Is there such a thing as "too much" pain medicine for the terminally ill?
Recent news reports reveal that U.S. Attorney General Ashcroft seeks to overturn Oregon’s voter-mandated "right to die" law. Whatever one’s opinion of this law, Oregon observers report that the government’s move to eliminate it is already having a chilling effect on the conduct of doctors who treat severe pain. Because pain medications are often used to end life, by individuals seeking a quiet and dignified death, doctors who prescribe such drugs fall under close scrutiny and run a higher risk of prosecution for over-prescribing certain drugs.
It is now generally understood that in our country there has been a lag in awareness about pain control techniques, fueled by fear of creating drug addicts, fear of being targeted for prosecution, lack of education in medical schools, and a Puritanical notion that pain is something we ought to put up with, even in our dying days.
A 1998 study found that 1/4 of all elderly cancer patients in nursing homes received NO medication for pain!
How much pain medication to give terminally ill patients, when the medication itself might hasten death, has long been a difficult issue. A 1998 study found that 25% of elderly cancer patients in nursing homes received NO treatment for daily pain!
The trend is starting to change. At least 15 states have recently passed laws ensuring that doctors’ licenses won’t be revoked for prescribing powerful controlled substances like morphine for severe pain, but since prescribing "adequate" medication is an art as much as a science, doctors are still subject to governmental suspicions, and ongoing efforts to monitor their work. A further complication occurs when a patient in great pain is not able to communicate with the physician and a health care agent (usually a family member) is acting on behalf of the patient.
The organization that accredits hospitals approved standards in 1999, declaring that "all patients have a right to proper pain management."
What constitutes "proper" and adequate pain management for YOU may very well depend on what you have written in your own Health Care Advance Directive!
Congress has considered and rejected the Pain Relief Promotion Act, which would have formally declared that prescribing controlled substances to alleviate pain is a legitimate medical decision, even if those drugs increase risk of death. The problem seems to be it is difficult to make a political distinction that allows for strong and adequate pain relief but somehow does not "cross the line" into assisted suicide. Many believe that only a patient and her doctor should be the judges of what constitutes " "adequate" medication. Since it is virtually impossible to set an objective standard that delineates the pain relief/assisted suicide differential, legislators have taken a cautious or timid approach, not trusting such decisions to the medical community, and pain management specialists continue to practice at some risk.
One of the best things you can do for yourself is to put your pain management choices in writing, and discuss them with those whom you have designated as your health care agents.
Many physicians, including those opposed to assisted suicide, raise a health concern. They fear that judging whether prescribing decisions are proper or improper could cause a backlash against pain treatment. What if a patient needed a high dosage of a pain-relieving drug, but that same drug could prolong his death? Should a doctor be disciplined if a week’s worth of morphine is given to a patient, who then intentionally overdoses and dies? Under most current state laws, the physician is at risk. The current state and federal laws are not supportive of pain relief advances and many doctors and patients pursue adequate pain relief in fear and secrecy. If patient wishes are clear and choices are not made under duress, pain management decisions may be less subject to questioning.
For the vast majority of terminally ill patients, pain can be controlled. Many in the medical and bioethics fields now believe that it is a patient’s right to choose to live comfortably and possibly die sooner, rather than to die a lingering and painful death. In testimony before Congress, Dr. James Rathmell, of the University of Vermont, said "I would plead for better pain control. Focus the physician’s attention on pain being the issue, not preservation of life."
Most of our patients have given thought to the terms of their Advance Health Care Directives. Do you remember the advance choices you made? As medical knowledge and social attitudes shift, and your awareness of health issues grows, it’s a good idea to review your Directive annually, and fine tune it.
