Case Studies: Walking The Tightrope
Linda Johnson, ACSW, and Robert Potter, MD, PhD
Undermanaged Pain Makes for an Unattractive Patient
An eighty-five-year-old widow has been in a long-term care facility for six months. She was admitted with severe osteoarthritic and osteoporotic pain. Her family initiated her placement because she was overmedicating herself at home, confusing her medications, and not eating adequately. She has been a “complainer” for years, the family reports. The family and physician are reluctant to give her strong pain medicines; they don’t want her to be “doped up” like she was at home. She currently takes two Tylenol every four hours which does not adequately control her pain (and risks liver and kidney toxicity). She is in too much pain to walk, but quickly becomes uncomfortable in the wheelchair. So she requests bed rest and frequent repositioning. Staff feels she is demanding and hard to please. She has a son who calls and tries to visit once a week, but who becomes tired of hearing her constant complaints of pain. Her daughter lives out of town, and calls weekly.
The son asks the doctor to make her more comfortable and assuage her complaints. But the son also requests that the doctor not give her whatever she received six months ago (at the time of admission) when she drooled and was unable to sit up or eat.
Her sister has called the state regulatory agency to complain that the facility staff is neglecting her and not taking care of her pain.
The doctor agrees to try Nalfon, a nonsteroidal anti-inflammatory drug (NSAID). After two weeks, she has dark, tarry stools, suddenly vomits blood, and is hospitalized for a severe gastric bleed.
Questions for discussion
• Is the patient’s autonomy being respected by involving her in the decision-making process?
• How could a meeting of all parties involved have been more effective and/or ethical than piecemeal decision making?
• Are the pain treatment policies of the facility meeting the standards set by regulators?
• Does the nurse have a moral responsibility to be more assertive in advocating for the patient’s relief?
• Given that the doctor is likely to see the resident only every two months, what role should the doctor take in assessing and monitoring the pain and its treatment?
• What ethical theory or principle can function as a basis for good pain management?
• What other issues do you think this case explores?