Ethical dilemmas in pain management

Ferrell, Betty; Novy, Diane M.; Sullivan, Mark D.; Banja, John D.; Dubois, Michel Y.; Gitlin, Melvin C.; Hamaty, Daniel; Lebovits, Allen H.; Lipman, Arthur G.; Lippe, Philipp M.; Livovich, Jeffrey

doi:10.1054/jpai.2001.21596

Cited by 55 publications

(56 citation statements)

References 9 publications

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“…4,5,[10][11][12][13] Given findings such as those of Kaasalainen et al 9 and Morrison and Sui, 3 the undertreatment of pain among seniors represents one of the most pressing ethical concerns for pain clinicians. 14 The under-treatment of pain among older adults has been attributed to a variety of factors, including erroneous beliefs and myths about the ageing process. For example, it has been suggested that, in addition to difficulties of assessing pain among those who cannot self-report, under-treatment of pain in this population may also result from (1) the myth that pain is a natural and expected part of the ageing process; a (2) the myth that seniors with dementia may be insensitive to pain; and (3) exaggerated fears about the risk of addiction to opioid medications.…”

Section: The Under-treatment and Under-assessment Of Painmentioning

confidence: 99%

Practice Guidelines for Assessing Pain in Older Persons with Dementia Residing in Long-Term Care Facilities

Hadjistavropoulos

Fitzgerald²,

Marchildon³

2010

Physiotherapy Canada

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Purpose: Frail patients with dementia most frequently present with musculoskeletal pain and mobility concerns; therefore, physiotherapy interventions for this population are likely to be of great benefit. However, physiotherapists who work with older adults with dementia confront a considerable challenge: the communication impairments that characterize dementia make it difficult to assess pain and determine its source. For an effective physiotherapy programme to be implemented, valid pain assessment is necessary. This paper is intended to provide practice guidelines for pain assessment among older persons with dementia. Summary of Key Points: Over the last several years, there has been tremendous research progress in this area. While more research is needed, several promising assessment methodologies are available. These methodologies most often involve the use of observational checklists to record specific pain behaviours. Recommendations: We encourage the ongoing and regular evidence-based pain assessment of older persons with dementia, using standardized procedures. Without regular and systematic assessment, pain problems will often go undetected in this population. Given the need for systematic pain assessment and intervention for long-term care populations with mobility concerns and muculoskeletal pain problems, we call for increased involvement of physical therapists in long-term care facilities.Key Words: Alzheimer's disease, assessment, dementia, long-term care, older adults, painHadjistavropoulos T, Dever Fitzgerald T, Marchildon GP. Practice guidelines for assessing pain in older persons with dementia residing in long-term care facilities. Physiother Can. 2010;62:104-113. RÉ SUMÉObjectif : Les patients de santé fragile atteints de dé mence sont les plus sujets aux douleurs musculosquelettiques et aux problè mes de mobilité . Par consé quent, les interventions en physiothé rapie apporteront sans doute de grands bienfaits à cette clientè le. Toutefois, les physiothé rapeutes travaillant auprè s des personnes â gé es atteintes de dé mence doivent faire face à un dé fi de taille : la dé gradation des capacité s de communication caracté risant la dé mence fait en sorte qu'il est difficile d'é valuer la douleur et d'en dé terminer la source. Pour qu'un programme efficace de physiothé rapie puisse ê tre mis en oeuvre, une é valuation valide de la douleur doit ê tre ré alisé e. Cette documentation tente de proposer des directives de pratique pour l'é valuation de la douleur chez les personnes â gé es atteintes de dé mence. Ré sumé des points clé s : Au cours des derniè res anné es, des progrè s considé rables ont é té ré alisé s au chapitre de la recherche dans ce secteur. Mê me si plus de recherche est né cessaire, plusieurs mé thodes d'é valuation prometteuses sont disponibles. Ces mé thodologies font souvent appel à l'utilisation de listes de vé rification des observations comprenant la consignation de comportements douloureux particuliers. Recommandations : Nous encourageons l'é valuation continue ...

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Section: The Under-treatment and Under-assessment Of Painmentioning

confidence: 99%

Practice Guidelines for Assessing Pain in Older Persons with Dementia Residing in Long-Term Care Facilities

Hadjistavropoulos

Fitzgerald²,

Marchildon³

2010

Physiotherapy Canada

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“…In particular, the finding that the odds of filling a prescription for a strong opioid decreased by 3% for each additional year of age suggests that elderly patients may not be receiving needed opioid therapy. There is evidence in the literature of undertreatment of pain in the elderly [48][49][50] and, specifically, underuse of opioids. 51 Potential barriers to opioid use inelderly populations may includepatient underreporting of pain, 11,52 patient apprehension (e.g., fear of addiction, worry over side effects, and fear that increasing dose indicates worsening condition), 48 and/or provider concerns related to age-related changes in physiology and altered pharmacology.…”

Section: Discussionmentioning

confidence: 99%

Use of Opioid Analgesics Among Older Persons With Colorectal Cancer in Two Health Districts With Palliative Care Programs

Fisher

Urquhart

Johnston

2013

Journal of Pain and Symptom Management

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Context-Prescription of opioid analgesics is a key component of pain management among persons with cancer at the end of life.Objectives-To use a population-based method to assess the use of opioid analgesics within the community among older persons with colorectal cancer (CRC) before death and determine factors associated with the use of opioid analgesics.Methods-Data were derived from a retrospective, linked administrative database study of all persons who were diagnosed with CRC between January 1, 2001 and December 31, 2005 in Nova Scotia, Canada. This study included all persons who 1) were 66 years or older at the date of diagnosis; 2) died between January 1, 2001 and April 1, 2008; and 3) resided in health districts with formal palliative care programs (PCPs) (n = 657). Factors associated with having filled at least one prescription for a so-called "strong" opioid analgesic in the six months before death were examined using multivariate logistic regression.Results-In all, 36.7% filled at least one prescription for any opioid in the six months before death. Adjusting for all covariates, filling a prescription for a strong opioid was associated with enrollment in a PCP (odds ratio [OR] = 3.18, 95% CI = 2.05-4.94), residence in a long-term care facility (OR = 2.19, 95% CI = 1.23-3.89), and a CRC cause of death (OR = 1.75, 95% CI = 1.14-2.68). Persons were less likely to fill a prescription for a strong opioid if they were older (OR = 0.97, 95% CI = 0.95-0.99), male (OR = 0.59, 95% 0.40-0.86), and diagnosed less than six months before death (OR = 0.62, 95% CI = 0.41-0.93).Conclusion-PCPs may play an important role in enabling access to end-of-life care within the community.

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“…Not only are issues related to treating seniors ethically intense and complicated, they have been recognised by clinicians, themselves, as being one of the most pressing concerns facing physicians. For instance, in a 2001 survey of members of the American Pain Society, Ferrell et al 24 found that under-management of pain among seniors and concerns about the inadequate assessment of pain among people with cognitive impairments were among the most imperative ethical issues for pain clinicians. Both the frequency of ethical dilemmas encountered when working with seniors, as well as the importance of healthcare decisions provide a rich context for studying physicians’ perceptions of ethical decisions cross-culturally 25…”

Section: Ethical Dilemmas In a Geriatric Contextmentioning

confidence: 99%

Ethical decision-making about older adults and moral intensity: an international study of physicians

Malloy

Williams²,

Hadjistavropoulos³

et al. 2008

J Med Ethics

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Through discourse with international groups of physicians, we conducted a cross-cultural analysis of the types of ethical dilemmas physicians face. Qualitative analysis was used to categorise the dilemmas into seven themes, which we compared among the physicians by country of practice. These themes were a-theoretically-driven and grounded heavily within the text. We then subjected the dilemmas to an analysis of moral intensity, which represents an important (albeit novel within healthcare research) theoretical perspective of ethical decision making. These constructs (ie, culture and moral intensity) represent salient determinants of ethical behaviour and our cross-cultural sample afforded us the opportunity to consider both the pragmatic aspects of culture, as they are perceived by physicians, as well as the theory-driven concept of moral intensity. By examining both culture and moral intensity, we hope to better elucidate the complexities of ethical decision-making determinants among physicians in their daily practice. Doing so may potentially have practical implications for ethics training of medical students and foreign physicians.

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Ethical dilemmas in pain management

Cited by 55 publications

References 9 publications

Practice Guidelines for Assessing Pain in Older Persons with Dementia Residing in Long-Term Care Facilities

Practice Guidelines for Assessing Pain in Older Persons with Dementia Residing in Long-Term Care Facilities

Use of Opioid Analgesics Among Older Persons With Colorectal Cancer in Two Health Districts With Palliative Care Programs

Ethical decision-making about older adults and moral intensity: an international study of physicians

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