ABCD Exchange : September 1998 : President's Letter - Suffering in Nursing Homes

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"If a tree falls…." — The Sound of Suffering In Nursing Homes
by Joanne Lynn, M.D.

One of the time-honored conundrums of children and philosophers is the question, "If a tree falls and no one is around to hear it, does it make a sound?" That is the image that came to mind on reading the disturbing report on non-treatment of pain in nursing home residents (Bernabei, R., et al, "Management of Pain in Elderly Patients With Cancer," Journal of the American Medical Association, June 17, 1998, vol. 279(23), pp. 1877-1882). If people suffer terribly but don't complain, should anyone notice? Did they make a sound?

Surely we who might someday be in those nursing home beds must be horrified at the apparent inattention to pain. Of 4,000 patients who reported daily pain, only 16 percent received acetaminophen, and almost no one got regular doses of opioids. What should be done?

Assessing pain in demented or communication-impaired people is a perplexing challenge. Few people with chronic pain still cry out or moan or have sweating or a rapid heartbeat. Most just reduce activity and withdraw from interaction. It takes having an attentive and enduring caregiver to notice, and a carefully observed trial of treatment to test the observation—and, by the way, relieve the pain.

How could anyone efficiently determine whether a nursing home might be treating pain well? Maybe some simple measures would get evaluation underway:

  1. Does the facility require periodic assessments of possible pain?
  2. When potential pain is identified, does anyone respond?
  3. Does the response to serious pain include opioid drugs on a regular schedule?
  4. Are the rates of acetaminophen and opioid use within a reasonable range?
I'm not sure these are the best questions, and I know we don't have data for the last one, but this looks promising.

Consumer information about a particular nursing home could warn people away if the facility had no routine procedures to find and treat pain. If opioid use was nearly absent and if acetaminophen was ordered only on an "as-needed" basis, consumers could also be wary.

We need to make sure that those who have no voice are not left to suffer just because they cannot make a sound.

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