Pain-free advice for palliative care
New JCAHO pain standards due in 2000
When the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed a policy a few years back that required home care agencies to offer palliative care to patients, Earleene Betterton, RN, patient care coordinator at House Call Hospice in Cookeville, TN, was pretty sure that she would start seeing more referrals from home care agencies. But that never happened. And the few referrals she gets tend to be patients within a day or two of death, when there is little that a hospice can provide to patient and family.
That past experience has made Betterton view a new JCAHO push to improve palliative care in health care organizations with some skepticism. According to the commission, standards that create new expectations for the assessment and management of pain in accredited health care settings will be included in the 2000-2001 manual and scored for compliance in 2001.
The new standards, endorsed by the Chicago-based American Pain Society, will require home care agencies to:
• recognize the right of patients to appropriate assessment and management of pain;
• assess the existence and, if present, the nature and intensity of pain in all patients;
• record the results of the assessment in a way that facilitates regular reassessment and follow-up;
• determine and assure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff;
• establish policies and procedures which support the appropriate prescription or ordering of effective pain medications;
• educate patients and their families about effective pain management;
• address patient needs for symptom management in the discharge planning process.
The spin-off of pain
"Unrelieved pain has enormous physiological and psychological effects on patients. The Joint Commission believes the effective management of pain is a crucial component of good care," says Dennis S. O’Leary, MD, president, Joint Commission. "Research clearly shows that unrelieved pain can slow recovery, create burdens for patients and their families, and increase costs to the health care system."
The standards were sent out to accredited health care organizations, a variety of professional groups and associations, consumer groups, and purchasers for comment. Overall, O’Leary says they were well received, achieving an approval rating of 92%.
To help organizations prepare for the new standards, JCAHO has started to work on ways to "engage key professional organizations in the promotion of effective pain assessment and management." The effort will include production of an educational video, presentations at national and regional conferences, and educational seminars for accredited organizations.
In the middle of next year, JCAHO will assess the ability of accredited organizations to comply with the standards, and put in place a plan for full or phased implementation.
Advice from those who know
Betterton has her own advice for agencies that are trying to bring pain management policies and procedures up to snuff:
1.Set an acceptable pain threshold. "If you use zero to 10 and five is as good as it gets for patients, that is not acceptable," she says. "Pain when a patient is inactive should never be more than two or three."
2. Know what pain your patients experience. You should also develop good procedures for determining the pain level your patients are having. (For more tips on getting this information from patients, see box, left.)
3.Understand how pain medications work. If you have a patient in considerable pain, the problem may be easily relieved by changing the dosing schedule, says Betterton, or ensuring that the patient is taking the medication as directed. "If someone is taking a sustained release pain medication, it absolutely must be taken on schedule." You should also educate your nurses on the increasing difficulty of treating pain as it increases. "Different drugs peak at different times. You have to know how these things behave."
4. Don’t make patient generalizations. While we all have preconceived notions about men being babies when they are in pain, and women dealing with it stoically, you quickly learn that those notions are false when you deal with the dying, says Betterton. "I have had male patients who were babies, and those who were not. I have seen women crumble under pain, and those who do not." One generalization that Betterton feels safe in making, though, is that male patients will often deny themselves the right to be comfortable until they have taken care of the details that ensure their families’ future.
5. Understand the psychological nature of pain. Pain can be exacerbated by emotional trauma and fear, says Betterton. That doesn’t mean the pain is false, but that pain reacts to non-physical stimuli.
6.Know medication side effects. Sometimes, the pain medications cause their own problems, says Betterton. For instance, narcotics often cause constipation. Be sure to treat those, too.
7.Educate physicians about pain. Many doctors are still uneducated about how pain and palliative care work. Betterton says you have to find ways of giving them information without challenging their authority. She recommends you do this by reminding them of the effect their orders will have on specific patients. For example, if you have a patient who can’t swallow pills, you might have to remind the physician so that a suppository can be prescribed instead. "If the patient is in out-of-control pain, then a patch that takes 18 hours to get into the system isn’t a good choice," she explains. "You have to be a very strong advocate for your patients. Tell the doctor, We need something faster acting than this.’"
8. Find the information you need. If you don’t know enough about palliative care and pain management to meet the new standard requirements, go out and get it, says Betterton. Talk to your peers in hospices. There are also a large number of books, articles, courses, and organizations that can help you get the education you and your nurses will need to meet the new standards. (For more on further reading and information, see box, left.)
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