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Journal of Nursing

Applying Ethical Standards to the Assessment of Pain

Connie Boehman, BSN RN Indiana Wesleyan University MSN student [email protected]


A nurse's role and responsibility is to ensure that our patient(s) receive adequate care and our assessments are comprehensive and thorough. According to Lewthwaite, Jabusch, Wheeler, Schnell-Hoechn, Milles, Estrella-Holder, and Fedorowicz (2011), "Despite decades of research, advance technology, and improvement in therapeutic measures, pain management continues to be a challenge for health providers" (p. 252). In this article, this writer will discuss fictitious assessment scenarios to discourse methods to improve assessment findings and converse ethical principles to ensure patients receive adequate care in regards to their pain. Denny and Guido (2012) states, "Although prevalent in patients of all ages and across all settings, being older than 70 years is the number one risk factor for pain undertreatment" (p. 801).

The International Association for the Study of Pain (n.d.) pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (Pain Terms, para. 1). Pain has been defined in scientific explanations as early as the 17th century. Pain is subjective in nature, therefore, making it difficult to assess and treat for clinicians. Diminutive research has been performed in regards to the effectiveness of data collected by the numeric pain scale. Dijk et al. (2012) states, "...nurses should not rely soley on the NRS [Numeric Rating Scale] score in determining pain treatment" (p. 3023).

According to Denny and Guido (2012), "Some authors have even claimed that the failure to treat pain or reckless undertreatment of pain in older patients can be legally characterized as elder abuse" (p. 801). Imagine being persecuted in a court of law for not effectively treating a patient's pain with allegations being abuse, does the following statement make you think of a pain assessment that you should have handled differently? According to Lewthwaite et al. (2011), "Providing adequate pain management is contingent on knowledge, skills, and attitudes of providers" (p. 255).

As a nurse working in a hospital setting, you enter the room of an 86-year-old female with severe osteoarthritis pain who is grimacing and moaning with moving. You ask the patient what she rates her pain on the numeric rating scale at rest and she rates her pain zero out of ten. You make the clinical judgment that no further pain assessment is required. Minutes later an irate family member approaches you stating that their loved one is in severe pain and you have neglected caring for her. Let us review the following assessment to see how as a nurse, the pain assessment completed would ensure accuracy with attention to the ethical behavior of nonmalfeasance.

The patient stated zero of ten, however, her pain was assessed at rest. The nurse should have obtained a more through pain assessment based on the diagnosis of osteoarthritis by evaluating the patient's pain during rest and activity. National Pharmaceutical Council (n.d.) suggests the following:

Consider all reasons for any discrepancies between a patient's self report of pain and his or her behavior. Such discrepancies may reflect good coping skills or diversionary activities (e.g., distraction, relaxation techniques). Alternatively, a patient may be denying pain because of stoicism or fear of inadequate pain control. (p. 25).

If a nurse or healthcare provider under assesses pain, then potential harm could occur to the patient. Dijeck, Kappen, Kalkman, and Schuurmans (2012) informs clinicians that, "...undertreatment of pain in older patients increase the risk for functional decline, atelectasis, pneumonia, thromboembolism, and depressed immune function (Won et. al. 1999)" (p. 3019). Looking at the assessment findings, the ethical principle of nonmaleficence was not incorporated into the nurse's assessment because the nurse did not complete her pain assessment thoroughly. Porsche (2012) states, "Nonmaleficence is the ethical principle of 'doing no harm' " (p. 220). The nurse should have obtained a more thorough pain assessment history based on the diagnosis of osteoarthritis. "Harm through adverse effects of undertreated pain is the evil that can be prevented through effective pain assessment and management" (Denny & Guido, 2012, p. 19).

The nurse enters the home of a 70-year-old male admitted hospice with a diagnosis of hepatocellular carcinoma. The patient is able to voice his needs, wants and make sound decisions. The visceral pain to his abdomen is increasing in nature and he will require the use of opiods to control his pain. The nurse completes a detail assessment and notifies the physician promptly with the findings. The physician refuses to order pain medication because the daughter abuses all the patient's prescription medications. According to Borigini (2008):

Nevertheless, in the minds of many [physicians] there has been a consequent attitude among physicians that can, depending on the day of the week, range from hesitant to paranoid, and which has in turn stifled the prescribing of pain medications in even those end-of-life cases where pain can become a cloud that hangs over every dwindling minute of the terminal patient. (para. 4)

The ethical situation in this scenario is how is the nurse going to go forward ensuring that his or her patient is comfortable during the dying process? The nurse must first discuss the reasons why the physician has chosen not to order pain medication with the patient. In this particular case, the nurse may feel the need to obtain orders for additional interdisciplinary team members, such as the social worker to discuss options such as relocating to a facility, remaining at home, or being admitted as a general hospice inpatient to control pain. The assessment findings determine that the patient is in his right mind, therefore, the ethical principle that should be applied to this particular case would be autonomy. Skinner (2013) states, "The principle of respect for autonomy holds that people should decide for themselves how they want to live their lives, as long as it does not harm others" (p. 12). The patient should be able to make a well-informed decision that is venerated by the members of the hospice's interdisciplinary team. The nurse should inform the patient, "Adverse effects may include a decreased level of mobility and independence, an increased susceptibility to infection..." (Denny & Guido, 2012, p. 19). The nurse should incorporate nonpharmacological interventions to treat a patient's pain while the patient makes a decision.

A 20-year-old female patient returns to the physician's office with frequent complaints of headaches, backaches, and stomachaches. She is requesting an intramuscular injection of Demerol and Phenergan to relieve her headache. The nurse practitioner has performed all imaging and laboratory testing with no significant findings. The etiology is unknown for the patient's pain and the nurse practitioner is fearful that continuing to give her narcotics to control her pain may cause an addition. According to Bernhofer (2011):
Practitioners who would likely not judge the character of a patient who needs increased amounts of medication to treat hypertension; yet they may believe that a patient whose persistent pain does not respond to standard medications is 'drug-seeking', a narcotic abuser, or has a current need to 'escape reality'. (para. 2).

The ethical situation in this particular scenario is how is the nurse practitioner going to go forward treating the patient's pain? "At least 40 to 60 percent of women and at least 20 percent of men with chronic pain disorders report a history of being abused during childhood and/or adulthood" (Rubin, 2005, p. 1099). The nurse practitioner is going to assess the patient further for psychosomatic pain. Psychosomatic pain is frequently overlooked, as it cannot be objectively measured. The nurse practitioner must facilitate an environment that does not make the patient feel as if the pain is in their head, but rather define treatment that will be prescribed in overcoming psychosomatic pain. Rubin (2005) states, "...particularly when existing treatment seems inappropriate and/or drug-seeking behavior is obvious, is to make a clear that only new treatment will be administered" (p. 1106). The ethical behavior that must be considered for this scenario is the principle of beneficence. Porsche (2012) states, "Beneficence consists of norms providing the greatest benefits to an individual, group, or community" (p. 220). In this scenario, the nurse practitioner could administer the medication; however, this would not be the greatest benefit to the individual.

When looking at the management of pain, clinicians must look at how the principle of justice can be applied to pain management. Crane (2001) depicts the following lawsuit against a physician, "A jury found that Chin had committed elder abuse by inadequately treating a patient's pain. The patient's family argued that the drugs the physician had prescribed were the wrong ones and weren't nearly strong enough" (p. 66). As clinicians, we have a duty to ensure the assessment findings are comprehensive and meet the needs of the patient. A comprehensive approach must be consistent of interviewing the patient, assessing the patient's pain at rest, and reviewing data collected by all clinicians involved in the patient's care. In the case against Chin, Crane (2011) reports the data collected by nurses indicated the patient's pain was moderate to severe (p. 66).

A fear in adequate pain management is addition and continues to be a reason pain is undertreated. According to the National Institute on Drug Abuse (2011) states, "In 2010, approximately 7.0 million persons were current users of psychotherapeutic drugs taken nonmedically [sic] (2.7 percent of the U.S. population), an estimate similar to that in 2009" (para. 2). No healthcare professional wants to aide in doing harm to a patient; however, pain is subjective in nature and must be treated. "The principle of beneficence is upheld when the appropriate amount of medication or other treatment is administered to the patient in a timely fashion resulting in the best pain control with acceptable side effects" (Bernhofer, 2011). Addiction must not be ignored, but identified and discussed in order for the principle of beneficence to be present while caring for the patient.

In conclusion, "Expert nurses enter the care of particular patients with a fundamental sense of what is good and right and a vision for what makes exquisite care" (Tanner, 2006. p. 209). Ethical standards such as the principle of respect for autonomy, the principle of nonmalfeasance, the principle of beneficence, and the principle of justice must be utilized in assessment of pain to determine appropriate treatment for the patient, so exquisite care can occur. When confronted with an ethical dilemma, the healthcare provider must look at which ethical standard carries the most significance.

References
Bernhofer, E. (2011). Ethics and pain management in hospitalized patients. OJIN: The Online Journal of Issues in Nursing, 17(1).
Borigini, M. (2008). Prescribing narcotics: A doctor's point of view. Health Guide.
Crane, M. (2001). Treating pain: Damned if you don't? Medical Economics, 22(66).
Denny, D., & Guido, G. (2012) Undertreatment of pain in older adults: An application in beneficence. Nursing Ethics, 19(6), 800-809. doi: 10.1177/0969733012447015
Dijk, J., Kappen, T., Wijck, A., Kalkman, C., & Schuurmans, M. (2012). The diagnostic value of the numeric pain rating scale in older postoperative patients. Journal of Clinical Nursing, 21(21/22), 3018-3034. doi: 10.1111/j.1365-2702.2012.04288x
International Association for the Study of Pain. (n.d.). Pain terms.
Lewthwaite, B., Jabusch, K., Wheeler, B., Schnell-Hoehn, K., Mills, J., Estrella-Holder, E., & Fedorowicz, A. (2011). Nurses' knowledge and attitudes regarding pain management in hospitalized adults. The Journal of Continuing Education in Nursing, 42(6), 251-257.
National Pharmaceutical Council. (n.d.). Section II: Assessment of pain.
National Institute on Drug Abuse. (2011). Topics of Drug Abuse.
Porsche, D. (2012). Healthcare policy: Application for nurses and other healthcare professionals. Sudbury, MA: Jones & Bartlett Learning.
Rubin, J. (2005). Psychosomatic pain: New insights and management strategies. Southern Medical Journal, 98(11), 1099-1110.
Skinner, T. (2013). Understanding unethical behavior. New Mexico Board of Nursing, 8(2), 12.
Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.

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