JCAHO grasps the initiative on pain: New standards within two years
Surveys show widespread differences in practice
Ethics committee members soon will have a powerful new weapon in the battle against one of their most visceral moral challenges. The Joint Commission on Accreditation of Healthcare Organiza-tions, in collaboration with the Madison-based Wisconsin Cancer Pain Initiative, is developing pain control standards that will be incorporated throughout almost all of the accreditation chapters by the year 2000.
"We expect that all of the ethical issues will be brought to the forefront in these standards," says Carole Patterson, MN, RN, deputy director of the department of standards. "The message we have heard is that doctors know how to ensure appropriate management of patient pain. What we will be trying to do is make sure they do it uniformly."
June L. Dahl, PhD, executive director of the Wisconsin Cancer Pain Initiative, says, "The most intractable barriers to good pain management are in the institutional setting. Pain is not necessarily given a high priority because it is not visible."
Measurement of pain needs to become the fifth vital sign, Dahl argues, because the undertreatment of symptoms and pain results in human suffering that is a moral outrage.
Despite the existence of general standards on pain management in its patients’ rights areas, she says the Joint Commission has been looking at the need to adopt more detailed standards, including those, for instance, that would touch on the human resource responsibility to train staff in effective pain management.
The new standards will not prescribe an actual pain assessment tool "unless the medical literature supports use of a certain tool in a certain patient population" such as geriatrics, Patterson says. Over the next several months, the collaborative effort between the Joint Commission and state pain initiatives will focus on conducting interviews with pain management experts and reviewing literature on the subject.
After the standards are implemented, Patterson says, "health care providers will have to meet the ethical challenges of relieving human suffering." Ethics committees will be included in field testing of the new standards next summer, she says.
Getting started now
What can ethics committees do now to encourage and even ensure better pain management? Although many institutions have a pain service, often they do not use standard tools for measuring patient pain. The problem, say Dahl and others, is that different units may use different tools, and not all patients who need this care may be identified.
The Wisconsin pain group recently conducted a pilot project with the state’s peer review organizations and 25 hospitals in the state. They found that acute postoperative pain was treated differently, for example, than intensive care pain. Hospitals used different tools within different units, and staff often had no or limited protocols on appropriate time intervals for pain management and other standards, Dahl says. Furthermore, there were glaring exceptions of pain control efforts never written into patient charts.
Dahl says, "A major priority should be adopting a standard pain assessment tool and getting it in the chart routinely." (See sample pain audit and patient survey of pain, Medical Ethics Advisor, April 1994.)
The first step your committee should take in achieving this goal is to conduct an extensive internal review of current pain management, experts say.
"The challenge for ethics committees is to put this issue under a microscope," urges David E. Joranson, MSSW, director of the pain and policy studies group at the University of Wisconsin Medical School in Madison, author, and national conference speaker on pain management.
"Find out whether patients in your institution are undertreated for pain," he advises. "Develop a floor to stand on that says, This is the least we can do for patients,’ then start a dialogue about how high the ceiling can be."
The Joint Commission standards will concentrate on end-of-life care, but Joranson and Dahl say institutional efforts can and should go further. Plan an internal research effort that aims to look at how pain management is handled before and after standards are implemented, Dahl urges. If your institution has standards, begin a study of how your efforts at creating uniform guidelines for use affect the overall care of patients, she adds.
In essence, initiate a quality improvement plan (see sample, pp. 117-118) and use the following eight steps:
1. Develop an interdisciplinary team. To achieve quality pain management, it is crucial to influence the practice of all clinicians, say Dahl and Joranson.
2. Analyze current pain management practices in your care setting. Dahl recommends determining what you want to know about pain management in the best-case scenario and then reviewing whether this is happening. Draw from a variety of data sources, such as:
• pain assessment tools used (medical/surgical practice standards, institutional policy and procedures);
• general patient satisfaction surveys;
• incident reports;
• survey of staff knowledge;
• flowcharts detailing how pain is managed;
• observation and documentation of pain.
3. Implement a standard of practice. Set guidelines on how and when to obtain pain history, a psychosocial assessment, physical and neurological examination, and diagnostic evaluation. Determine a method to be used in assessment.
Ethics committees can play a pivotal role in helping the institution’s staff understand the need to address both physical and psychosocial pain from an ethical perspective, Joranson and Dahl say, adding that committee members can discuss these issues routinely in retrospective case review.
4. Establish accountability. Strategies to define accountability may include the following:
• develop a specialized pain management team to provide consultation and management;
• develop pain management roles, competencies, and limits of practice for all health care professionals;
• add accountability clauses for pain management to existing policies that address treatment known to cause pain (i.e., nasogastric intubation);
• establish minimally acceptable pain management outcomes. (For a sample critical pathway that includes a pain outcomes section, see insert.)
5. Educate physicians about pharmacologic and non-pharmacologic interventions and their appropriate application.
6. Assure patients that pain control is a commitment. This may include a written statement regarding pain management in the institution’s mission statement and patient bill of rights.
7. Provide professional education on all levels of pain management. Develop and implement a plan for continuing medical education for all staff that includes clinical and nonclinical applications, management of side effects, and barriers and ethical issues in pain management.
8. Continue to evaluate and improve pain management long term. Use survey methods from the original review. Initiate additional quality improvement measures that address areas such as cost-effectiveness, patient length of stay, and readmission.
Ethics professionals who have been involved in national efforts to improve pain management as well as end-of-life care are encouraged by the Joint Commission’s commitment to create new standards and hope it will make a profound difference in how patients and their families approach death.
"Fear of unrelieved pain is one of the greatest worries that people have when they face death," says Rosemary Gibson, senior program officer at the Robert Wood Johnson Foundation in Princeton, NJ, which is funding the three-year $1.6 million effort. Gibson is spearheading Last Acts, the foundation’s major initiative on changing end-of-life care. (See story on Last Acts in MEA, April 1997, p. 37.)
"Studies have shown that in many cases, people suffer needlessly, when modern pain control can alleviate their agony," Gibson says.
Pain often goes untreated because of physicians’ fear of legal risk in using narcotic medications, says Sandra H. Johnson, JD, LLM, president of the Boston-based American Society of Law Medicine and Ethics and chairwoman of a national pain initiative led by that group last year. (See story on national meeting, p. 114.) Johnson applauds the Joint Commission effort and says the focus must shift to how institutions can implement change.
Foundation to address legal barriers
The Robert Wood Johnson Foundation also has announced a pilot project that will seek to reduce the legal barriers to effective pain management. (See story, at right.) Unlike the American Society of Law Medicine and Ethics initiative that is seeking a model law on pain medication, Joranson, who is leading the foundation project, says this effort will highlight changes in the state regulatory system and in institutional policy.
"We should strive to achieve a balance so that the management of pain, including the use of opioids when needed, is not impeded by state laws, regulations, or other policies that are based on outdated information" and often misinterpreted by physicians," she says.
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