What to Do If Doctors or Nurses Refuse to Acknowledge and Treat Pain
Beginning at the bedside, you, as a patient's advocate, can take a sequence of steps to enforce the right to pain management.
If the pain is very severe, you will need to move quickly through the list. Even an hour of severe pain seems to last forever. Doctors and hospitals or nursing homes can be very intimidating, but in this situation, doctor does not always know best. A physician can determine how best to solve the problem, but only the patient can say that the problem is solved.
As you move through the following steps, keep a list of the people you talk with and what they say. Advocacy while someone you love is in pain is intensely stressful. Keeping a record will help you stay focused and will enable you to be accurate if you eventually have to file a formal complaint, either with the hospital or with an outside agent.
- Let the attending physician know that pain management is a priority, according to the Education for Physicians on End-of-Life Care Project (EPEC) Participants Handbook.
- Tell the doctor that you have heard that pain is very often overlooked and undertreated and ask what his or her plan is for pain management.
- By requesting pain management, you are not "telling the doctor how to practice medicine." Excuses such as "he'll become an addict" or "morphine will depress his respiration" or "I'll lose my license" are outdated myths. If the response to your request is such an excuse, you may not be able to change the doctor's mind, nor is that your responsibility. You will just have to get busy as an advocate.
- Talk to the nurse. He or she can be an advocate for the patient. Get the nurse to acknowlege and record the pain. Ask what strategies sometimes work for patients who are hurting. For example, if the patient is yo-yoing from comfort to pain because the pain medication is short-acting, the nurse can suggest to the doctor switching to a longer-acting medication or a patient-controlled pump.
- Talk with the head nurse of the unit. He or she has an important responsibility for quality care. These nurses are generally well-respected in the hospital. They can "cover" for the patient's nurse and address the doctor frankly.
- Ask for a palliative care consultation. Doctors have an ethical obligation to consult with a specialist in pain management if they cannot successfully relieve pain (or will not try). Under the American Medical Association's Ethical Standard E-8.04, a doctor who cannot adequately treat pain, or whose patient believes he or she cannot adequately treat pain, is obliged to obtain an outside consultation. The patient may also ask to be referred to a consultant. Under Ethical Standard E-8.041, a doctor may not abandon a patient simply because the patient asks for a second opinion. If your doctor appears insulted by a request for an outside consultation or delays a referral, you have a problem doctor.
- Many hospitals do not yet have a formal palliative care service, but all hospitals have at least one anesthesiologist. These specialists are trained in pain management, although their education concentrates more on procedures than on pharmacological relief of pain. A consultation may be helpful.
- Nursing homes rarely have palliative care doctors or teams. The patient many need to be moved to a hospital to stabilize pain, or a consulting physician may be called into the nursing home.
- Doctors have an ethical obligation to manage pain competently. If the patient is still in pain, find out what the hospital's procedure is for filing a patient/family complaint. Write out a short statement that tells management what the problem is and take a copy directly to the hospital medical director's office. Be sure to keep a copy.
- In your complaint let the hospital know that you consider undertreatment of pain to be medical malpractice.
- Also state that you believe the hospital has failed to meet the standards for pain management of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Say that unless the complaint is quickly resolved you will fax a copy of the complaint to 1) the state medical board and 2) JCAHOBand then do it. The Federation of State Medical Boards has a list of the state boards and JCAHO complaint forms are available online. If the patient's care is paid for by an HMO, add the state insurance commissioner to your list. Follow-up with formal complaints is covered in the next section.
- If the complaint is not resolved immediately, talk with your lawyer and have him or her follow up the complaint with a telephone call. Or involve a patient-advocacy group such as the Bazelon Center's Palliative Care Law Project.
- The media are excellent attention-getters, but only someone who knows the local media and the community can decide whether publicity would help or hurt. Your goal as an advocate is to use all the leverage available to relieve the pain.
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This content is provided by the Project on Palliative Care Law of the Bazelon Center for Mental Health Law. For more information visit the Project's web site at www.painlaw.org.