Ethical Dilemma in Pain Management
Measuring pain is usually a perceptive exercise considering that some patients can manipulate the medical practitioners in the belief that they are in too much pain, while all they want is some analgesic drug for their underlying substance abuse problems. This is the very reason why medical practitioners tend to exercise caution while dealing with pain management. An ethical dilemma presents itself rather frequently in palliative care where the patients are usually racked with excruciating physical or other pain and are, thus, likely to develop dependence on the offered medication. The question that is asked frequently within this setting is whether or not to increase the patients’ dosage as they continue to complain about their pain despite being on strong pain medication. This essay focuses on the pain management scenario and use of opioids to manage pain. In addition, the essay examines the ethical dilemma issues that often arise in such situations.
The Clinical Situation
While working in palliative care, pain management makes up a great part of the duties of the physician and in my case it was no different. One of my patients suffered complications with her pelvic bone and was thus in consistent pain. As a result, the doctor prescribed some extended-release morphine to manage her pain and make the situation bearable. However, as time went by, she grew tolerant to the medication and started complaining of pain more frequently. At some point, she was moaning in pain continuously for hours despite being on her pain medication. This got most of the patients concerned and rather uncomfortable since it seemed that the facility was unwilling or unable to attend to the patient. The problem, however, was that she was already on such high doses of morphine that increasing the dosage may not have been in her best interests either. However, the patient’s family lodged complaints and I was forced to introduce the patient to some short-term morphine to work with the extended-release medication and calm her down whenever she started moaning in pain. The doctors were later unable to find the cause of her severe pain, thus raising suspicion that she had become addicted to the medication and thus needed higher doses.
Morphine is a pain medication that falls under the category of opioids, which are simply narcotics being in the same category as a number of illegal drugs like cocaine and others (Stanley, 2010). This means that while morphine is a break-through drug in palliative care, it may also result in the same severe consequences upon addiction just like the illegal substances. Prescription drugs are important in health care but they too have a high rate of addiction. Thus, it is often important for the patients to understand what they are getting into when using prescription drugs such as opiates (Stanley, 2010). The effects of the drug are often impressive, especially when the patients are at an advanced stage of their illness and thus are not strong enough to withstand a prolonged period of pain. The right dosage of morphine is a life saver within palliative care, particularly considering the intensity of pain that is expected amongst the patients. Without morphine, these patients would be forced to live through their last days with unbearable pain, which would in some cases even bring them to the end much faster. There is, however, a problem with this medication and this is mainly regarding its addictive characteristics. Most practitioners would gladly avoid the drug since it is a narcotic and could easily create or trigger substance abuse problems in the patient.
The entire practice of healthcare is based on a number of objectives that include doing no harm and meeting the needs of the patients. It can, however, be stated that these two do not always go hand in hand. The duty of a medical practitioner is to ensure that the patient is treated as per the best practices of the profession. Nevertheless, in some cases, the job requires thinking beyond the borders, which implies that there is room for the medical practitioners to make critical decisions while handling the patients, especially in palliative care, where pain is extreme and occurs rather frequently. In order to do the right thing, the practitioner must be able to meet both objectives and, in some cases, there is a lot of grey area involved. This particular situation presented a multiple-commitment dilemma where the practitioners had to ensure that they do not harm the patients while trying to alleviate their pain.
The Ethical Principles
Taking the case of cancer patients in palliative care into consideration, the pain that they feel is often beyond measurement and it is common to find patients doubling over or moaning in pain. On the one hand, the patient could be truly in pain and thus there will be a need for the primary nurse to administer some pain medication immediately so as to alleviate the pain. This did not happen in my case since there were doubts regarding the pain the patient was complaining about. What held me back was the possibility that the patient had grown dependent on pain medication and was thus willing to feign severe pain in order to get a dose. On the other hand, it is the health practitioner’s duty to ensure that the patient’s pain is managed effectively without endangering the patient’s life or even turning him or her into an addict (Dossey, 2010). In order to alleviate pain in an ethical manner, there are a number of considerations that must be taken into account (Dossey, 2010).
The first one is how honest the patient is with her or himself reporting the pain? Most patients start being honest about how much pain they feel, but with time they become dependent and they start to need higher dosages or simply enjoy the feeling of being high on pain medication. As a result, they end up exaggerating their self-reported pain assessment so as to manipulate the nurse into giving them more pain medication. Thus, the main problem here is in finding out if the patient is really in pain and how intense it is. (Dossey, 2010).
Most of the morphine prescriptions in palliative care are administered as needed and without the right indicators for the patient’s pain it becomes rather impossible to observe accuracy when seeking to alleviate pain. The fact that morphine is just as addictive as it is lifesaving makes it really difficult for the nurse to decide on whether to hold it back or to give it to the patients and alleviate their pain (Hamric et el., 2014). In most cases, the choice will depend on the circumstances within which the nurse is operating and their ability to decide on whether to give more pain medication or not.
Doing No Harm
Holding back a dose of pain medication when it is really needed is in some way harming the patients, but so is allowing them to overindulge in a drug that could easily get them addicted. Morphine, like many other drugs, has serious side effects that are also in their own way rather painful. These include nausea, itching, dizziness and exhaustion among others. It should be noted here that doing no harm is all about helping the patients to manage their symptoms without causing more damage than has already been done. With inadequate pain assessment techniques, which rely on the patients to state how much pain they feel and hence determine the dosage that they should be given, it is really difficult for the practitioner to provide the right amount of medication when it is actually needed. Allowing the patient to get too much morphine is just as, if not more, dangerous than holding back the drug, especially in cases where the patient is likely to be faking it in order to get more narcotics into his or her system. This presents a situation where the practitioners will have to trust their position and choose to do no harm depending on the variables involved in that particular situation (Hamric et el., 2014).
Barriers to Ethical Practice
The main barrier in this situation is the pain assessment mechanism employed in healthcare. The patient is the best source of information regarding the intensity and severity of the pain he or she feels, but as long as a narcotic is involved, reliability is a big issue. Pain management should be all about alleviating the patients’ pain and not worrying about endangering their life or doing them harm. With opioids, however, the possibility of addiction and overdosing is too real and this often affects ethical practice significantly (Hall & Roussel, 2012).
If presented with a similar situation, I would apply the feminist theory to decide on what needs to be done. The feminist theory allows for an examination of the context within which the problem is occurring, thus implying that the decisions made are expected to be relevant to the situation within which they occur. Increasing the dosage of the pain medication in this case, for example, should be justifiable since the patient is in palliative care and that the pain is expected.
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The rules are often quite clear in pain management, but the ethics of medical practice require a more tactical approach with considerations of doing no harm while alleviating pain. This implies the need to be cautious while also proactive and effective aiming to help the patients through their discomfort. The situation here raised a lot of suspicion but, in the end, the main role of the practitioner is to ensure that the patient’s pain is managed. With the feminist theory, it is easier for the practitioners to capture all the relevant signs of the situation and use them to choose their course of action regarding the patient’s pain management needs.
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