Virginia Nurses Today - August 2020

Page 16 | August, September, October 2020
Continuing Education
Virginia Nurses Today | www.VirginiaNurses.com
How Can We Ethically Care for Our Patients with Pain?
Disclosures
• Nurses can earn one nursing contact
hour for reading How Can We Ethically
Care for Our Patients with Pain.
Participants must also complete the
continuing education post-test found at:
https://virginianurses.com/page/On-
DemandContinuingEducation
• This continuing education activity
is FREE for members and $15 for
nonmembers!
• The Virginia Nurses Association is
accredited as a provider of nursing
continuing professional development
by the American Nurses Credentialing
Center’s Commission on Accreditation.
• No individual in a position to control
content for this activity has any relevant
financial relationships to declare.
• Contact hours will be awarded for this
activity until August 15, 2023.
Phyllis Whitehead, PhD, APRN/CNS,
ACHPN, RN-BC, FNAP
Bio:
Dr. Phyllis Whitehead
is a clinical ethicist and
clinical nurse specialist
with the Carilion Roanoke
Memorial
Hospital
Palliative Care Service
and associate professor at
the Virginia Tech Carilion
School of Medicine.
She initiated the Moral
Distress Consult Service
at CRMH. She is certified
in pain management and is an advanced practice
hospice and palliative care nurse. Dr. Whitehead
has done numerous presentations on pain and
symptom management, opioid induced sedation,
moral distress, and patients’ end of life preferences
locally, regionally, nationally and internationally.
Her research interests include moral distress
and improving communication with seriously ill
patients. She is a board member of the National
Association of Clinical Nurse Specialists, co-lead of
the Virginia Nurses Foundation’s Action Coalition,
and member of the VNF Board of Trustees. She
was also a member of the ANA Moral Resilience
Advisory Committee, and is a founding member
and board member of the Virginia Association of
Clinical Nurse Specialists. Dr. Whitehead was
selected for Governor Ralph Northam’s Policy
Council on Opioid and Substance Abuse this
year. In 2020 she was elected as a distinguished
practitioner fellow in the National Academy of
Practice in Nursing. She is a graduate of Radford
University where she earned her BSN and MSN and
earned her doctorate degree at Virginia Tech.
I am often asked, how can I safely and
effectively care for my patients with acute and/
or chronic pain? There is a fear that we may
unintentionally cause harm to our patients if we
administer opioids that result in addiction and
contribute to the opioid crisis. Both the American
Nurses Association’s (ANA) Code of Ethics for
Nurses with Interpretive Statements and American
Society for Pain Management Nursing’s (ASPMN)
2019 Pain Position Statements 1 have documents
that should guide our nursing pain management
practice. Nurses in all settings and specialties
care for patients who are in pain. An important
question is, do we know and apply best practice
principles in caring for patients with pain?
Historical Perspective: How Did We Get Here?
Improvements in recognizing, assessing and
treating pain significantly increased during the
last decade of the 20th century. Although some of
these efforts from that time have been perceived
negatively, when introduced they were considered
pioneering and crucial. In 1998, the Veterans
Health Administration adopted “Pain as the 5th
Vital Sign” as the slogan for their initiative to
improve the management of pain for all veterans. 2
We must remember the intention of these efforts
was to increase the awareness, diagnosis and
treatment of pain, not to increase opioid use. As
the increased focus on recognizing and assessing
pain was gaining attention, pharmaceutical
companies were working to improve analgesic
preparations and little attention was dedicated
to the ethical principles of beneficence and
maleficence with increased reliance upon
pharmacological interventions. Although we “can”
prescribe an opioid, we must consider whether we
should if there are other appropriate modalities
available. Please keep in mind that how payers
reimburse for therapies and interventions
determines how physicians and other providers
prescribe. For example, payers cover opioids but
not non-pharmacological interventions such as
massage, guided imagery, and physical therapy
(limited coverage at best).
During the last five years, the pain
management specialty has faced multiple
challenges and changes related to the opioid
crisis. In many instances the pendulum swung
too far in the direction with renewed opioid
phobia. An unintentional consequence is a
dying patient being unable to receive necessary
opioid medications. It has been appalling to see
handwritten signs on primary and urgent care
offices stating, “We do NOT prescribe opioids.”
Opioids are a necessary class of medications that
should be accessible to appropriate patients using
evidence-based principles.
Many of the negative consequences may be
the result of using the term opioid crisis rather
than the more accurate term opioid misuse/
abuse crisis. Opioids did not create the crisis,
but rather, it is the misuse and abuse of them
which led to this point. Although mis-prescribing
of opioids has played a role in the opioid crisis,
an evolving illicit drug market is causing an
increasing number of deaths as a result of
overdoses. Most recently, opioid-related deaths
from synthetic opioids have risen from 3,100
deaths in 2013 to more than 19,400 in 2016. The
rapid rise of heroin and illicit fentanyl overdose in
the United States is related to prescription opioid
abuse; 45% of individuals who use heroin report
their first opioid exposure to be a prescription
opioid analgesic, and more importantly, not
necessarily prescribed to them. 1 It is imperative
for nurses at all practice levels and settings to
possess the fundamental historical knowledge
and skills to effectively identify and intervene with
individuals who are at risk for Opioid Use Disorder
(OUD) and to properly advocate for our patients.
The Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS)
questions historically asked patients how satisfied
they were with their pain management. These
questions pressured hospitals and prescribers to
increase the use of opioids as opposed to evidencebased
interventions that include both opioids,
nonopioids and nonpharmacological interventions.
Today these HCAHPS questions have been replaced
with the more appropriate pain management
questions such as “During this hospital stay, how
often did hospital staff talk with you about how
much pain you had?” and “During this hospital
stay, how often did hospital staff talk with you
about how to treat your pain?“ 3
Additionally, during the last several years
nurses have increasingly been performing quality
improvement projects to enhance how we assess
and manage pain. Although self-report remains
an important aspect of nursing pain assessment,
it is not nor should it be the only basis upon
which pain medications are administered. Instead,
instruments are needed to focus on patients’
functionality, not solely on how patients selfreport
pain intensity scores. Nurses have begun to
evaluate the reliability, validity and effectiveness
of using the Clinically Aligned Pain Assessment
(CAPA) tool to holistically assess pain as more
than just an intensity score. 4 This is a promising
instrument. Please check it out if you are
unfamiliar with it.
Nurses must remain dedicated to pursuing safe
and effective pain management care, education
and advocacy for our patients who suffer with
pain management acutely and chronically.
Multimodal analgesia must be integrated into
effective pain management interventions. Ongoing
nursing research is needed as well to explore the
role of various cognitive behavioral interventions,
relaxation therapies, meditation, spirituality,
movement, and energy work among other options.
Additional research is needed to more fully
understand how patients living with substance
use disorders (SUD) and acute and/or chronic
pain can have their pain best managed and
quality of life improved. 4
As nurses, we must never forget that pain is a
subjective and distressing experience associated
with actual or potential tissue damage, with
sensory, emotional, cognitive, and social
components. 2 Presently, we do not have tools
that can determine when patients are or are not
experiencing pain. Although researchers continue
to seek physiological measures to evaluate pain,
no valid and reliable objective test currently
exists to measure pain.
It is important to understand that the
hierarchy of pain assessment has changed. The
first step is now to be aware of potential causes
of pain. The most common painful experiences
in healthcare settings are iatrogenic. Preventing
iatrogenic pain from needle procedures, wound
care, diagnostic tests, and even repositioning,
requires clinician awareness and interventions
before these painful events. It is important to be
proactive in anticipating pain in known painful
conditions and experiences before soliciting
a patient’s self-report of pain or identifying
behavioral responses to the pain. Improving
functionality is key to effective pain management.
Nurses need to understand these strategies and
work towards integration of non-pharmacological
interventions into their practice in order to
minimize the use of opioids and other controlled
substances.
Another positive effect is the acknowledgement
of the necessity to proactively assess and
identify patients who are at risk for OUD 1 and
work towards minimizing risk of misuse and
abuse. This is another opportunity for improved
understanding and implementation of evidence
based instruments and how we care and view our
patients living with pain.
Ethical Considerations in Caring for Patients
in Pain
The ethical principles of beneficence (the duty
to benefit another) and nonmaleficence (the
duty to do no harm) oblige nurses to provide
pain management and comfort to all patients,
including vulnerable individuals such as those
who are unable to speak for themselves and living
with SUD and OUD. 5 Providing comparable and
high quality care to patients who are vulnerable
is required by the principle of justice (the equal
or comparative treatment of individuals). Respect
for human dignity, the first principle in the Code
of Ethics for Nurses (American Nurses Association,
2015), directs nurses to provide and advocate
for humane and appropriate care. Based on
the principle of justice, patient care is given
with compassion, unrestricted by consideration
of personal attributes, economic status, or
the nature of the health problem. This can be
challenging at times, especially when caring for
demanding patients.
In alignment with these ethical tenets, the
International Association for the Study of Pain
(IASP) initiated the Declaration of Montreal at
the International Pain Summit, a statement
acknowledging access to pain management as a
fundamental human right endorsed by 64 IASP
Chapters, the World Health Organization and
many other organizations and individuals. 6
The declaration acknowledges the importance
for individuals who are experiencing pain to
receive evidence-based, appropriate pain-relieving
treatment. 7 Concerns about the opioid crisis
have created hesitancy that may affect treatment
decisions despite the status of pain assessment
as fundamental to effective and evidence-based
treatment.