The Ethical Responsibility to Manage Pain and the Suffering It Causes – Position Statement of the American Nurses Association, Apr 2018 – Repost
I’m reposting this from last year because it’s such a good (and rare) example of a reasonable attitude toward opioids. The Nurses Association gets credit for standing up for patients a year earlier than others.
The purpose of this position statement is to provide ethical guidance and support to nurses as they fulfill their responsibility to provide optimal care to persons experiencing pain.
The national debate on the appropriate use of opioids highlights the complexities of providing optimal management of pain and the suffering it causes.
In these first sentences, the difference between nurses and doctors shine through:
Nurses are much more concerned with suffering, while doctors nit-pick about what is painful and what isn’t, who is “really” hurting and who is “catastrophizing”.
While effective in treating acute pain and some types of persistent pain, opioids carry significant risks. This causes a tension between a nurse’s duty to manage pain and the duty to avoid harm.
While there are many important topics related to pain management, this document will not attempt to address many of the specific terms, including suffering and the definitions and management of drug tolerance, dependence, or addiction.
Statement of ANA Position
American Nurses Association (ANA) believes:
- Nurses have an ethical responsibility to relieve pain and the suffering it causes
- Nurses should provide individualized nursing interventions
- The nursing process should guide the nurse’s actions to improve pain management
- Multimodal and interprofessional approaches are necessary to achieve pain relief Pain management modalities should be informed by evidence
- Nurses must advocate for policies to assure access to all effective modalities
- Nurse leadership is necessary for society to appropriately address the opioid epidemic
Existing body of knowledge
Pain may serve as a protective physiologic function. Individuals experience pain in a variety of ways. The International Association for the Study of Pain (1994) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (para. 4).
Nurses and other healthcare professionals have a moral obligation to respond to this patient need (Institute of Medicine, 2011; Interagency Pain Research Coordinating Committee (IPRCC), 2016). Thus, nurses are “ethically obligated to take action against the disparities associated with access to pain management” (ANA, 2016, p. 28).
The statements above differentiate nursing from “doctoring” too: nurses are oriented toward the patient under their care. Their sole concern is the patient’s well-being while the doctor’s concerns may be more technical (like whether an operation was successful or whether the patient is discharged on time).
“Effective pain control strategies emphasize shared decision-making, informed and thorough pain assessment, and integrated, multimodal, and interdisciplinary treatment approaches that balance effectiveness with concerns for safety”
Careful discernment is required to limit the ripple effect of under-prescribing when opioid use is indicated or over-prescribing when non-opioid analgesics and/or non-pharmacologicals may be equally effective.
Pharmacogenomics, the study of how genes affect drug metabolism in individuals, promises to be a useful tool to help determine the appropriate dosing plan for an individual’s pain management
The nurse “uses advocacy, education, and a supportive approach to honor the patient’s right to self-determination, autonomy, and dignity”
I think these are exactly the factors that doctors don’t value because doctors see themselves as the experts, while patients are just the “subjects” of their clever interventions.
All nurses have an ethical obligation to provide respectful, individualized care to all patients experiencing pain regardless of the person’s personal characteristics, values, or beliefs.
Moral distress occurs in pain management nursing when nurses see patients with untreated or undertreated pain but are unable to provide adequate relief. This may occur because of the patient’s condition, inadequate treatment orders, or providers not believing the patient’s report of pain.
Pain management nurses must have the moral self-respect and courage to deal with these situations and seek professional help when needed (ANA, 2016, p. 26).
Constraints on meeting nurses’ moral obligation to relieve pain and the suffering it causes
Many factors make it difficult and sometimes impossible to help patients who are experiencing pain. Among these are moral disengagement, knowledge deficits, biases, environments not conducive to optimal practice, and economic limitations.
Moral disengagement is the interaction of personal and social influences that can reinforce the nurses’ separation of their moral values and obligations from actions consistent with those values and obligations.
Nowadays, with our health care so dominated by the corporate mentality, and “goals” about cost-savings are imposed from far above, it must be very frustrating to work at the spot where “the rubber meets the road”, with the patients that have been subjected to all those dictatorial edicts set at the corporate level.
several mechanisms that can impede the ethical and professional duty to manage pain and may include:
- blaming and dehumanizing patients for health problems like substance use disorder, e.g., opioid addiction
- displacement of responsibility, in which nurses relinquish their responsibility for their actions by citing their duty to implement treatment orders
- diffusion of responsibility so that nurses, prescribers, dispensers, risk managers, etc., are not held accountable because where everyone is responsible, no one really feels responsible and the division of labor clouds accountability; and
- disregard or distortion of consequences of incompetent pain management, which can be rationalized because a greater harm from addiction is prevented; this reasoning often overlooks the distinction between tolerance, dependence, and addiction and can mute the differences among pain experiences and causes.
Harm from addiction is limited to a tiny percentage of patients being treated for pain, yet it is managed as though it were almost a certainty.
Moral disengagement is a systems dilemma
Pain management modalities should be informed by evidence. Lack of knowledge and understanding of best practices for assessing and optimally managing pain constrains the nurse’s ability to minimize pain and the suffering it causes
Nurses’ biases and prejudices influence their approach to collaboratively managing pain with patients. Prejudices and biases are preconceived and not based on reason or fact.
By reflecting on their own experiences or background regarding pain and the suffering it causes, nurses can minimize the influence of biases by first identifying these biases. This might include the nurse’s own experiences with pain, personality, values, or accompanying family or friends throughout a pain trajectory.
Nurses can use the following questions, among others, to reflect on their own experience, background, or biases. To what extent:
- Do I worry about causing addiction in my patients?
- Do I feel some people are more likely to game the system to obtain medications?
- Do I feel anxious about discussing pain management with colleagues or other members of thehealthcare team?
- Do I ever feel guilty about too much or too little pain relief?
- Do I recognize that pain is whatever the person who has it says it is but really feel the patient sometimes is not right?
- Do I impose my own experience with addiction, opioid misuse, and drug-seeking behaviors?
- Do I resist the idea that some patients may require more aggressive pain management than prescribed? For example, patients undergoing minor procedures, children or adolescents, emergency Department patients, patients with substance use disorder who undergo surgery, etc.
Environments not conducive to optimal practice
The need for ethical practice environments is articulated in many interpretive statements (IS) throughout the Code. Creating such environments starts with how nurses interact with each other.
Beyond this, nurses must step up as leaders, especially in society’s efforts to alleviate the many problems surrounding opioid use. IS 1.3 states,
“Nurses are leaders who actively participate in ensuring the responsible and appropriate use of interventions in order to optimize the health and well-being of those in their care.”
Nurses have an ethical responsibility to provide clinically excellent care to address a patient’s pain.
Clinically excellent pain management considers
- clinical indications,
- mutual identification of goals for pain management,
- ongoing reassessment with the patient of the efficacy of pain relief interventions,
- interprofessional collaboration, and
- awareness of professional standards for the assessment and management of different types of pain.
Nurses should ensure that each patient experiencing pain has an individualized pain management plan with appropriate monitoring to avoid under-treatment, over-treatment, or addiction.
Nurses have an ethical obligation to assess and address the factors in themselves and their practice environments that constrain their ability and willingness to relieve pain and the suffering it causes.
Nurses may experience moral distress when external constraints keep them from optimally managing their patients’ pain. Nurses need to preserve their professional and personal integrity by developing the moral courage and resilience necessary to reduce moral distress when managing pain.
Because nurses deal so intimately with patients “as they are”, it makes sense that they are more concerned with the welfare of their charges. To push back against corporate business policies requires exceptional courage and moral fortitude (and the ability to change jobs).
In some ways, nurses are far more necessary than doctors. Doctors are like the generals camped out far behind the front and nurses are the soldiers sent out to confront the fallout from their impersonal orders.
While doctors can easily work according to some guidelines that have been set (often by business people), nurses must face the patients affected by them.