Among the most significant findings of SUPPORT was that 50% of ICU patients suffered from moderate to severe pain during the last days of life. At the time of its publication late in 1995, SUPPORT was merely the latest in a long series of articles in the medical literature documenting the widespread and significant undertreatment of pain, beginning with a 1973 study of hospital inpatients. Much has been written about the phenomenon of undertreated pain and inadequate care of patients at (...) the end of life, and many positive suggestions for reform of clinical education and clinical practice have been iterated and reiterated in the two decades separating the studies. Proposals for modifying clinician behaviors in this aspect of patient care have tended to focus on particular barriers to effective pain management and palliative care. (shrink)

In a familiar moral dilemma faced by physicians who care for the dying, some patients who are within days or hours of death may experience suffering in a degree that cannot be relieved by ordinary levels of analgesia. In such cases, it may sometimes be possible to honor a competent patient's request for pain relief only by giving an injection of narcotics in a dosage so large that the patient's death is thereby hastened. Doctors rightly worry that taking an action (...) likely to result in a patient's death may violate the Hippocratic injunction against the direct killing of anyone in their care. (shrink)

In a familiar moral dilemma faced by physicians who care for the dying, some patients who are within days or hours of death may experience suffering in a degree that cannot be relieved by ordinary levels of analgesia. In such cases, it may sometimes be possible to honor a competent patient's request for pain relief only by giving an injection of narcotics in a dosage so large that the patient's death is thereby hastened. Doctors rightly worry that taking an action (...) likely to result in a patient's death may violate the Hippocratic injunction against the direct killing of anyone in their care. (shrink)

Pain is undertreated in the American health-care system at all levels: physician offices, hospitals, long-term care facilities. The result is needless suffering for patients, complications that cause further injury or death, and added costs in treatment overall. The health-care system's failure to respond to patient pain needs corrective action. Excuses for such shortcomings are simply not acceptable any longer.Physicians have long been accused of poor pain management for their patient. The term “opiophobia” has been coined to describe this remarkable clinical (...) aversion to the proper use of opioids to control pain. If the professional mandate of the health-care professional is to relieve suffering, then physicians are falling far short of their obligations by accepting myths about the use of opioids in the face of evidence to the contrary. (shrink)

Two significant, apparently unrelated, trends have emerged in American society and medicine. First, American medicine is reexamining its approach to dying. The Institute of Medicine, the American Medical Association and private funding organizations have recognized that too many dying people suffer from pain and other distress that clinicians can prevent or relieve. Second, this past decade has marked a sharp increase in the number of physicians prosecuted for criminal negligence based on arguably negligent patient care. The case often cited as (...) a watershed is People u. Einaugfer, which involved a New York nursing home patient whose physician was convicted in 1993 of two criminal misdemeanors after he ordered an elderly dialysis patient to be tube fed through a peritoneal dialysis Catheter.How is the growing awareness of dying patients’ pain and the increasing willingness of prosecutors to charge physicians with crimes connected? Pain at the end of life is frequently treated with narcotics, prescription drugs that are closely regulated by state and federal law. That complex web of laws—and a growing fear of legal sanctions—has deterred physicians from prescribing controlled substances. As those legal sanctions move from disciplinary actions to criminal charges, physicians’ fears may expand. (shrink)