considerations for practice, ethics and policy
The Casea
A 61-year-old woman with metastatic colon cancer presents with intractable abdominal pain. Since her initial diagnosis 13 years ago, she has undergone chemotherapy, multiple colon surgeries, radiofrequency ablation of liver metastases, and excision of a solitary pulmonary metastasis. A CT scan shows enlarging liver metastases involving the capsule and para-aortic lymph nodes.
The patient has been relatively pain-free until 7 months prior to consultation with a local anesthesiologist who specializes in interventional pain managmeent. Prior to consultation, initial treatment of pain consisted of oxycodone and acetaminophen, followed by sustained-release morphine titrated over several months to a total of 1200 mg daily. Sustained release morphine was then supplemented with immediate-release morphine (600 mg) up to four times daily for breakthrough pain. Most recently, she was switched to fentanyl patches plus continued oral morphine. At the time of consultation she was using thirty 100 mcg/h patches every 3 days.
Despite somnolence, she continues to complain of severe constant sharp, aching and “knife-like: upper and lower abdominal pain, with self-rated pain intensity between 7 and 10 on a 0 to10 scale, with minimal movement bringing pain intensity up to 10.
The anesthesiologist performs a neurolytic celiac plexus block, which decreases her baseline pain from a 7 rating to a 4. A 4 mg intrathecal test dose of morphine reduces her pain rating further to 1–2, with no adverse effects. The anesthesiologist would like to refer her to a multidisciplinary pain clinic for possible implantation of a morphine spinal delivery system, but the patient’s insurance company has thus far refused to approve the consultation or implantation, because studies suggest that these devices are cost-effective over continued systemic analgesic management only after 18–30 months of therapy. They point out that she has had significant improvement in her pain after neurolytic block, and is unlikely to survive long enough to make intraspinal therapy cost-effective, even if it provides better quality of pain relief.
A moral obligation to treat pain
Technological advancements within science and medicine have enabled prolongation of the lifespan for those patients with incurable diseases. Yet, at the same time, such relative successes have fostered an increased prevalence of chronic illness and subjective suffering – including intractable pain – due in part to the inability to completely eradicate symptoms, and to the progressive use and sometimes exhaustion of therapeutic and economic resources available to the patient. This has compelled an increased impetus for medicine to develop those dimensions of practice that seek to heal what cannot be cured. To a significant extent, pain medicine and palliative care have arisen from, and seek to meet, this need.
The obligation to treat pain and suffering, while inherent to all of medicine, is by definition most fundamental to the profession of pain medicine and palliative care.1 Clearly, pain management can be, and often is necessary, albeit not sufficient for rendering sound, palliative care. But technically effective pain care must also be rendered in ways that uphold the moral affirmations of medicine, and while certain ethical (and legal) frameworks exist to guide the tenor, scope and limits of the profession, the actual implementation of care is reliant upon the physician. In this way, the physician is both a therapeutic and moral agent, given that any (if not all) clinical decisions affect the vulnerability of the patient, reflect the asymmetries of knowledge and power between physician and patient, and impact trust within the medical relationship.
The complexity of pain and pain care is such that a simple, “one-size fits all” approach to management is not practical, nor ethically justifiable. An integrative use of interventional, pharmacologic, physiatric, and psychiatric pain management may represent a viable option, both early in and throughout the care of long-term and terminal pain patients. In this context, interventional techniques may be especially useful because of their capacity to effectively reduce pain, make patients more amenable to other therapeutics, and enhance patients’ quality of life.
Interventional pain medicine in integrative pain care: practical and ethical claims
If the past 10 years’ congressionally declared “decade of pain control and research” in the US has done nothing else, it has certainly instigated: (1) a more internationalized interest in the problem of pain and the difficulties and responsibilities of pain care; and (2) a more well-defined need – and thus goal – for biomedical research to facilitate improved translational applications and models.2 Despite such progress, interventional management techniques still tend to be under-utilized within palliative care – particularly that which is provided in a paradigm of long-term (i.e., not end-of-life) treatment.
A number of long-held beliefs may contribute to under-utilization. Integrative pain medicine and palliative care may appear to be expensive or not cost-effective from the perspective of hospital operators and insurance companies. The problem chiefly lies in an inability to calculate the cost of pain- and palliative care given the relative uncertainties of matching objective medical treatments to subjectively defined states (i.e., pain and suffering) and ends (e.g., palliation). Long-term pain care can be viewed as cost intensive by insurance providers and hospital operators, with perceived high expenses evoked by the requirements for both medical staff and equipment/facility resource utilization. From a perspective of hospital economics, prima facie it might not seem to be “worthwhile” to care for chronic pain patients, given costs incurred relative to payment schedules established according to existing diagnosis-related group (DRG) treatment classification systems. The development and expansion of inpatient and/or outpatient pain- and palliative-care networks are not generally facilitated by current DRG systems. This is because DRGs are not designed to reflect: (1) the wide pathological variance of chronic pain patients; and (2) the finances required to support services necessary to effectively and ethically treat chronic pain conditions.3 Thus, if the goal of providing high-quality pain medicine and palliative care is to be achieved in light of (1) the noted achievements of technology in medicine and (2) the explicit call to use such advancements to address the increasing incidence and prevalence of chronic pain, then special provisions for adequate funding of both inpatient and outpatient approaches must be developed and implemented.
However, to safely, effectively, and ethically deal with the often complex pathologies of chronic pain patients, it is necessary to maintain multi-disciplinary and integrative treatment provided by professions focal to pain- and palliative care (e.g. specialized physicians, social workers, physiotherapists, psychologists, clergy and secular spiritual counsellors, et al.). In this way, treatment would constitute a service of ongoing assessment and interventions that are rendered by a multi-professional, closely-knit team on a regular basis, as appropriate to both the changing status and needs of each specific patient.
It is difficult to categorize chronic pain patients in a homogeneous cost group within current DRG systems, and so an inter-disciplinary pain/palliative care could be seen as impossible to finance because of its requisite utilization of diverse resources. The lack of a more encompassing integrative pain/palliative care paradigm reflects the inchoate nature of the profession of “pain medicine.” This has given rise to misconceptions that interventional pain management is a “stand-alone” approach, and led to the opinion that its ongoing, collaborative use with other disciplines (e.g., primary care, physiatry, and psychiatry/psychology) would incur unnecessarily high costs that would be difficult to advocate.
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