Patients suffer from lack of training
More education needed to ease pain at death
One of the worst fears of patients with debilitating and terminal illnesses is that they will suffer from pain. Sadly, they probably will because physicians and other providers are inadequately trained in pain management, says Diane Meier, MD, director of palliative care at Mount Sinai Medical Center in New York City.
That perception was validated in a national survey of physicians conducted by Meier and several colleagues on physician attitudes toward assisted suicide. Respondents said they had a difficult time distinguishing between giving pain medicine to relieve suffering and administering a lethal injection. Physicians are fearful of prescribing narcotics because they don't know how to administer the medications and view them as dangerous, Meier says. Plus, many physicians fear legal problems from government agencies and even patients' families when narcotics are involved.
"Practitioners' experience in Oregon is very productive when it comes to caregiver education. The patient's quality of life and the physician's prescribing patterns for morphine are increasing exponentially. The assisted suicide debate is a distraction to the real issues in health care, which are the patient's quality of life and access to health care. However, getting the issues out in the public's eye has helped us to focus more on the profession and the problems that need to be corrected," Meier says.
The issue of educating providers on pain management is a tricky one for ethics committees, suggests Jan Hare, PhD, associate professor in the College of Human Development at the University of Wisconsin - Stout. The issue can get complicated because several disciplines need education, she adds. (For suggestions on what to include in an educational program, see box, at right.)
"I suppose the best place to start when educating physicians is to cite the SUPPORT [Study to Understand Prognoses and Preferences for Out comes and Risks of Treatment] studies which provide evidence for how poorly we as clinicians manage end-of-life care. But those studies also imply that physicians may find it difficult to learn anything from anyone other than a physician," Hare explains.
One hospital, however, is blazing the trail in palliative care and providing education to providers. Last January, Beth Israel Medical Center in New York City established the first hospital-based clinical department, the Department of Palliative Care and Pain Medicine. It consists of three components: a division of pain medicine, a division of palliative care, and an educational and research institute.
The department is chaired by Russell Portenoy, MD, who supervises interdisciplinary teams working with the clinical leadership in other medical disciplines in the hospital. He has a twofold task:
· to develop clinical initiatives throughout Beth Israel's health system so all patients can benefit from the pain management and palliative care services;
· to create educational and research programs to further improve the diagnosis and treatment of pain.
The goals of the entire department are to implement tools to measure pain and other symptoms and develop treatment approaches for patients who require access to comprehensive palliative care.
Included in the department is an 18-bed palliative care and pain management inpatient unit with an eight-bed inpatient hospice unit. Also, an outpatient practice enables patients to be treated with less associated costs.
One area, aside from provider education, that needs change is the patient's quality of life, says Portenoy. "We need to change the paradigm so that patients' quality of life concerns can be more effectively addressed, and families can receive the support services that they need, at an earlier stage of the terminal illness."
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