Wednesday, May 30, 2007

Drawbacks of pain measurement; Annas on the Supreme Court


1)
Journal of Clinical Oncology has a wonderful 'art of oncology' piece written by a social worker about the 0-10 pain scale (free full-text appears to be available). It describes her experience being in severe pain in the hospital and, essentially, having her experience of pain, her suffering, erased by her care-providers' insistence on talking only about her pain rating. She has no complaints about her actual pain management - people took her seriously and treated her appropriately - it was the lack of engagement with her about her experience that she felt like the 0-10 scale engendered.

"Sometimes, consoling presence is the needed medication—something I did not find in reporting and noting scores of 0 to 10."

She contrasts this with previous experiences with pain:

"Before I had
renal cell carcinoma, I had a "10" that was much lower than my current "10", which was derived after I survived a nephrectomy that included the removal of a rib. For several months after that operation, I could have made a strong argument that bone pain is a 20 on a scale of 0 to 10. A thoughtful urologist worked with me to help me to understand my pain, to frame it in terms of the day before, not in terms of my never to return prerenal cell carcinoma normal. My "10" got ratcheted a little further with treatment for breast cancer and a little more with a knee replacement. Peripheral neuropathy and orthopedic issues have also done their part to increase my tolerance. Through all ofthese experiences, what has been extraordinarily helpful to me is the patient presence of physicians, including pain specialists, who sit and listen, who help me assess and redefine, through conversation, what is tolerable and what needs pharmacologic intervention. Their willingness to talk about what causes particular types of pain and to evaluate the effects of pain on other areas of my life inform my choices with dignity and integrity."

A welcome reminder that as clinicians, faced with the suffering of our patients, our impulse to measure, intervene, and "fix" needs to be tempered by our deeper mandate to listen, console, and offer presence.


2)
On the medicine-ethics-government-law front, the NEJM has several pieces about the recent US Supreme Court abortion procedure ruling including one by George Annas (free full-text available). The article mostly summarizes the history of US Supreme Court decisions on reproductive rights and abortion rights, following how the concepts of privacy, liberty, and respect for physician-patient decisions about health played in those decisions. Annas' take on the decision is that it is rather remarkable insofar as it upholds a law which criminalizes physician behavior (performing a specific medical procedure) which at times is necessary to protect the health of a patient ( this is per the ACOG) and offers no protection to physicians even if they perform the procedure to protect a patient's health. That is, it is government intrusion into the doctor-patient relationship to the highest degree (criminalizing, albeit in a very narrow situation, a physician acting in the best interest of a patient). Of course society/the state has an obligation to promote and protect life - this is what the abortion debate is all about & I respect that & sympathize with that as I contemplate the morality of euthanasia or assisted suicide. I'll point out however that this law does not outlaw abortion, declare it immoral or an affront to human dignity, or even (really) restrict the circumstances under which it can happen. Instead it criminalizes a procedure which is rarely necessary to protect the health of a sick person & the Supreme Court upheld it. Why am I bothering about this? It's because we live in a country in which congress and the president have seen fit to go out of their way to interfere in the terminal care of a single person and I get a little queasy whenever something happens which appears to further state interference in our profession. End of life issues rank only second in the US in controversy to reproductive ones. Annas says it best:

"Now that states (and Congress) have been given the green light to regulate medicine on the basis of their own views of morals and ethics, detached from medicine and science, these legislators may have to make real decisions. For the sake of their patients and the profession of medicine, physicians will have to pay more attention to politics."

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