Hailey Tran
Pain management is a crucial aspect of healthcare, and hospitals play a vital role in providing relief to patients experiencing various forms of pain. While the concept of access to pain management as a human right has gained traction, there are still concerns about inadequate pain relief in hospitals. Legal cases, such as the James case and the Chin case, highlight the disparity between healthcare professionals and the public regarding the importance of adequately treating pain. Hospitals have obligations under EMTALA to provide medical screening examinations and stabilize patients with emergency medical conditions, which include severe pain. This includes offering appropriate transfers to hospitals with the necessary capabilities if they cannot provide the required treatment. Additionally, hospitals are responsible for monitoring patients at high risk for adverse outcomes related to opioid treatment and ensuring the availability of non-opioid pain management options. The adequacy of pain relief in hospitals is a complex issue involving legal, ethical, and human rights considerations.
| Characteristics | Values |
|---|---|
| Hospitals' obligations under EMTALA | To provide a medical screening examination to determine if an emergency medical condition exists |
| EMTALA applicability | When an individual comes to the emergency department |
| EMTALA signage requirements | Emergency departments must post signs notifying patients and visitors of their rights to a medical screening examination and treatment |
| EMTALA transfer provisions | If the hospital cannot treat the emergency medical condition, an "appropriate" transfer to another hospital must be arranged |
| Pain management as a human right | Recognized by the United Nations and regional human rights bodies |
| Obligations of governments | Provide education, access to health information, and appropriate training for health personnel |
| Obligations of individual clinicians | Ensure adequacy of medical education and quality of healthcare |
| Core obligations of countries | Ensure access to health facilities, goods, and services without discrimination, provide essential medicines, and adopt a national public health strategy |
| WHO's Essential Medication List | Nonsteroidal anti-inflammatory drugs, muscle relaxants, antidepressants, and opioid analgesics |
| Pain assessment and management | Hospitals must monitor patients at high risk for adverse outcomes related to opioid treatment |
| Non-pharmacologic pain treatment | Acupuncture, massage therapy, physical therapy, relaxation techniques, music therapy, cognitive behavioral therapy, etc. |
| Multimodal analgesia | Combining two or more analgesic agents or techniques for improved pain relief while reducing opioid use |
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What You'll Learn
Pain management as a human right
The ethical responsibility of healthcare professionals to manage pain is well-established in ethical codes and has been acknowledged by prominent organizations. For instance, the American Medical Association asserts that "Physicians have an obligation to relieve pain and suffering," while the World Health Assembly resolved that it is an "ethical duty of health care professionals to alleviate pain and suffering." This ethical duty is further emphasized by pain and palliative care professional associations, which have declared that pain management and palliative care are basic human rights.
The global burden of pain is significant, encompassing acute pain from trauma, cancer pain, and chronic non-cancer pain. The management of pain necessitates a multidisciplinary approach that addresses the physical, psychosocial, and spiritual dimensions of pain. However, despite calls for improved pain management, undertreated pain remains a pervasive issue. Data accumulated over the years reveals that various types of pain, including acute, cancer, and chronic non-malignant pain, are often undertreated. This has led to legal cases where the failure to provide adequate pain relief has resulted in substantial damages awarded to patients and their families.
To address these concerns, standards and requirements have been established for pain assessment and management in healthcare settings. Hospitals are required to have defined criteria for screening, assessing, and reassessing pain, taking into account the patient's age, condition, and ability to understand. Additionally, hospitals must monitor patients at high risk for adverse outcomes related to opioid treatment and ensure timely detection of opioid-induced respiratory depression. While opioids are commonly used for pain management, there is also a focus on non-pharmacologic treatment modalities, such as acupuncture, massage therapy, physical therapy, and cognitive behavioral therapy.
In conclusion, the recognition of pain management as a human right has led to increased advocacy and the development of standards to ensure adequate pain relief for patients. However, the challenge of undertreated pain persists, highlighting the need for continued efforts to address this fundamental human right.
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Legal duty to relieve suffering
In the context of healthcare, the relief of suffering is considered a primary objective by patients, laypersons, and the law. Hospitals and physicians have a legal and ethical duty to relieve pain and suffering, as evidenced by the outcomes of two legal cases: the James case and the Chin case. In the James case, a North Carolina jury awarded $15 million in damages to the family of a nursing home patient who passed away from terminal metastatic prostate cancer. The jury found that the nurse's refusal to administer opioid analgesics to relieve pain on the grounds of potential addiction constituted gross negligence.
The legal duty to relieve suffering is further supported by EMTALA (Emergency Medical Treatment and Active Labor Act), which mandates that hospitals provide medical screening examinations to determine emergency medical conditions, including severe pain. If such a condition is identified, treatment must be provided to stabilize the patient, and if the hospital is incapable of providing adequate treatment, an appropriate transfer to another hospital must be facilitated.
The concept of access to pain management as a human right has gained increasing recognition by the United Nations, regional human rights bodies, and mainstream human rights organizations. This right to pain management under human rights law places obligations on governments to ensure the availability and accessibility of health services, goods, and essential medicines as defined by the WHO.
Hospitals are required to have defined criteria for screening, assessing, and reassessing pain, taking into account the patient's age, condition, and ability to understand. Additionally, hospitals must monitor patients at high risk of adverse outcomes related to opioid treatment and provide non-pharmacologic pain treatment modalities for patients who refuse opioids or could benefit from complementary therapies.
While the legal duty to relieve suffering is clear, there is a disparity between healthcare professionals and the lay public regarding the importance attached to undertreated pain. This disparity has been noted for nearly 30 years, with accumulated data showing that various types of pain, including acute, cancer, and chronic non-malignant pain, are often undertreated.
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Inadequate pain treatment
There are several reasons why inadequate pain treatment occurs. One major factor is the attitudes and educational barriers among both physicians and patients. For example, a nurse's refusal to administer opioid analgesics to a patient due to concerns about addiction constitutes a gross departure from acceptable care. Additionally, the limitations of available therapies, such as the side effects associated with opioid use, can hinder their clinical effectiveness and impact their usage.
To address these issues, organizations like the Joint Commission have implemented standards for pain assessment and management in hospitals. These standards emphasize the need for appropriate screening and assessment tools that are tailored to the patient's age, condition, and ability to understand. Hospitals are required to have defined criteria for screening, assessing, and reassessing pain consistently and appropriately.
Furthermore, the importance of patient preferences in pain management is recognized. Non-pharmacologic treatment modalities, such as acupuncture, massage therapy, physical therapy, and cognitive behavioral therapy, are recommended for patients who refuse opioids or may benefit from complementary therapies. However, hospitals are not expected to fulfill all requested non-pharmacologic therapies. Instead, they should educate patients on where they can access their preferred treatment after discharge.
The use of multimodal therapy, which combines multiple analgesic agents or techniques, is also gaining prominence as it can improve pain relief while reducing the reliance on opioids. Additionally, the role of psychology in inpatient pain services is being explored, and there is a growing need for effective and well-tolerated analgesic therapies to mitigate the negative consequences of undermanaged acute pain.
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Non-pharmacological pain treatment
While hospitals are indeed obligated to provide pain relief, the nature and extent of the treatment depend on several factors, including the patient's age, condition, and ability to understand. Non-pharmacological pain treatment methods are often used in conjunction with medication to manage mild to moderate pain or on their own for low-intensity pain. These methods can also be beneficial for patients who refuse opioids or those who may benefit from complementary therapies. Here are some examples of non-pharmacological pain treatment modalities:
- Physical methods: Massage, movement restriction/rest, repositioning, and the application of hot and cold packs can provide important pain-relieving effects.
- Cognitive-behavioral and psychological therapies: Relaxation techniques, patient education, breathing exercises, and attention distraction are all effective in managing pain.
- Alternative therapies: Acupuncture, music therapy, and pet therapy can also be used to complement traditional pain management techniques.
- Multimodal analgesia: Combining two or more analgesic agents or techniques that act through different mechanisms can improve pain relief while reducing opioid use.
- Palliative care: In the context of palliative care, non-drug tools like radiation therapy can help treat pain from tumour growth and ease bone pain related to cancer. Maintaining a comfortable and relaxing atmosphere around the patient can also ease their pain.
The choice of non-pharmacological treatment depends on patient preference and the specific circumstances of their condition. While hospitals are not expected to provide any and all requested non-pharmacological therapies, they should educate patients on where they can access their preferred treatment post-discharge.
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EMTALA obligations
EMTALA, or the Emergency Medical Treatment and Labor Act, is a federal law enacted by the US Congress in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). EMTALA applies to nearly all hospitals, as very few hospitals do not accept Medicare.
EMTALA mandates that any individual who comes to the emergency department and requests it must receive a medical screening examination (MSE) to determine whether an emergency medical condition (EMC) exists. This applies to anyone seeking treatment for a medical condition, regardless of their insurance status or ability to pay. Hospitals are not allowed to delay examination and treatment to inquire about methods of payment or insurance coverage.
EMTALA defines an emergency medical condition as a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health, serious impairment to bodily functions, or serious dysfunction of bodily organs. It is important to note that “severe pain” alone is not sufficient to establish the presence of an emergency medical condition. The medical screening requirement is triggered by any individual requesting "examination or treatment for a medical condition," which includes pain.
If an emergency medical condition is identified, the hospital must provide treatment within its capabilities until the condition is resolved or stabilized. If the hospital does not have the capability to treat the condition, an “appropriate” transfer of the patient to another hospital with such capability must be done in accordance with EMTALA provisions. This includes transfers to long-term care or rehabilitation facilities for patients unable to provide self-care. Hospitals with specialized capabilities are obligated to accept these transfers and may not discharge the patient until the condition is resolved or the patient can be transferred elsewhere.
EMTALA also governs the transfer of unstable patients between hospitals. A patient is considered stable for transfer if the treating physician determines that no material deterioration is reasonably likely to occur during or as a result of the transfer. If the patient is stable, the hospital has no further obligations under EMTALA law.
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