Virginia Nurses Today - August 2020

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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.
www.VirginiaNurses.com | Virginia Nurses Today August, September, October 2020 | Page 17 In 2018, the American Nurses Association affirmed the ethical responsibility to provide clinically excellent care to address patients’ pain with assessment and reassessment being key to informing treatment decisions (ANA, 2018). Pain should be routinely assessed, reassessed, and documented to facilitate treatment and communication among all healthcare clinicians. The requirement to provide effective and appropriate pain and symptom management is paramount. While vital signs (e.g., changes in heart rate, blood pressure, respiratory rate) may be important for identifying adverse effects of severe pain, 8 vital signs are not valid for discriminating pain from other sources of distress. 1 Correlation of vital sign changes with behaviors and self-reports of pain has been weak or absent. 8 Each patient should be evaluated regularly using methods of pain assessment that have been identified as significant and appropriate for the population to which they belong. Nurses have a moral, ethical, and professional obligation to advocate for all patients in their care, particularly those who are vulnerable to undertreatment. Be sure to read the upcoming ethics article in our November publication! The next article in our ethics series will examine the challenges and opportunities of caring for patients with chronic pain. Can you imagine having persistent pain every moment of your day and night? How can you sleep, work, or function if you can’t get comfortable? Patients with persistent pain are challenging and to be honest, I always take a deep breath when I learn that one of my patients suffers from it. In the upcoming article we will take a look at which ethical principles provide guidance in caring for these patients. References 1. Herr K, Coyne PJ, Ely E, Gélinas C, Manworren RCB. ASPMN 2019 Position Statement: Pain Assessment in the Patient Unable to Self-Report. Pain Manag Nurs. 2019;20:402-403. doi:10.1016/j.pmn.2019.07.007 2. Wilson M. Revisiting Pain Assessments amid the Opioid Crisis. Pain Manag Nurs. 2019;20(5):399-401. doi:10.1016/j.pmn.2019.10.002 3. American Hospital Association. 4. Quinlan-Colwell A. The Times They are a Changing! Pain Manag Nurs. 2019;20(6):517-518. doi:10.1016/j. pmn.2019.10.003 5. Ashkenazy S, DeKeyser Ganz F. The Differentiation Between Pain and Discomfort: A Concept Analysis of Discomfort. Pain Manag Nurs. 2019;20(6):556-562. doi:10.1016/j.pmn.2019.05.003 6. Madaus SM, Lim LS. Teaching Pain Management in Interprofessional Medical Education: A Review of Three Portal of Geriatric Online Education Modules. J Am Geriatr Soc. 2016;64(10):2122-2125. doi:10.1111/ jgs.14309 7. Wolters Kluwer (Firm), International Association for the Study of Pain. Pain Reports. http://journals.lww. com/painrpts/Pages/default.aspx. Accessed July 29, 2017. 8. Herr K, Coyne PJ, Ely E, Gélinas C, Manworren RCB. Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement. Pain Manag Nurs. 2019;20(5):404-417. doi:10.1016/j. pmn.2019.07.005
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