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An ethical approach to pain management.

Pain management continues to be a dilemma in the care of patients within the hospital environment. Contributing to this is the nature of the subjective experience of pain itself. How a nurse responds to the phenomenon may be laden with misconceptions and prejudices. Furthermore, a lack of education about analgesia may cause the nurse to act inappropriately or not at all, violating universal moral principles underpinning the framework for conduct delineated by the American Nurses Association (ANA) Code for Nurses (1985). Universal moral principles pertinent to pain management are autonomy, or self-determination; beneficence, or doing good; nonmaleficence, avoiding/preventing harm; veracity, or truth telling; justice, or treating people fairly; and fidelity, faithfulness to promises or duties.

Nursing research is rich with examples of patients receiving substandard pain management and sparse individualized education. Weaknesses prevail in the areas of pain assessment, intervention and evaluation strategies, and general knowledge deficiencies concerning principles of analgesia. Additionally, the nurse's lack of familiarity with the ANA Code may only aggravate practice issues surrounding pain management. Davis' (1991) study of 27 advanced practice nurses revealed that not one nurse from this sample knew the content of her/his code of nursing practice. These nurses used other sources such as clinical, personal, research, and student experiences, socializing their practice with experiences assimilated from these encounters. Solving ethical dilemmas was done by sensitization to the aforementioned experiences. When these nurses met repeated frustrations concerning dilemmas in practice, the nurses became desensitized to the situation, thus protecting themselves from the negative feelings associated with the situation. Further exploration of this phenomenon is warranted to answer the question of whether nurses desensitize themselves concerning their patient's pain.

Ferrell, Lester, McCaffrey, and O'Neil-Page (1990) conducted a national study of 2,459 nurses which revealed severe knowledge deficits concerning commonly prescribed analgesics such as pentazocine and propoxyphene. Approximately 70% of those sampled were unable to classify these drugs as opiates, leading to clinical practice issues concerning concomitant administration with other opiates, thus potentiating respiratory depression. This group asserts that the confusion rests with the physician prescribing pentazocine along with codeine, allowing for the simultaneous, or alternating administration of these drugs resulting in decreased analgesia for the patient (violating the ethical principles of beneficence/nonmaleficence). Additionally, the ANA Code for nurses states that neither physician's orders nor the employing agency's policies relieve the nurse of accountability for actions taken and judgments made.

Communication Concerns

Insufficient communication between the nurse and patient regarding pain can result in poorly documented assessments and inadequate interventions. Francke and Theeuwen (1994) conducted a qualitative study of 26 women who had undergone breast cancer surgery. Three important communication barriers that surfaced related to a patient's propensity to express pain to the nurse. First, patients lacked assertiveness to express pain, related to the desire to conform to the preconceived notion of being a "good patient." Second, patients held myths regarding pain analgesics and administration, fearing addiction and expecting that pain medication would be administered as needed by the "experts." Third, the nurse-patient interaction as perceived by the patient did not foster expression or verbalization of pain stemming either as a failure of the nurse to notice the patient as suffering with pain or failure by the nurse to "connect" with the patient. Not only do such cases violate an individual's autonomy, but the nurse violates the ANA Code by failing to provide the patient with professional conduct coinciding with the duty to support nursing practice with the moral principles of beneficence, nonmaleficence, veracity, justice, and fidelity. One of the 26 patients reported adequate pain control in the aforementioned study. This patient had a systematic 24-hour evaluation of her analgesic needs, supported by personalized teaching and nonpharmacologic intervention provided by the nurse assigned to her care, upholding all moral principles inherent to the ANA Code. A nurse-patient interaction which facilitates free expression of pain, affords the patient an opportunity to receive information regarding analgesics and ultimately enforces the patient's autonomy.

Judgments and Documentation

Nursing assessments may be misguided by poor interpretative judgments of facial expressions exhibited by the patient. Prkachin, Berzins, and Mercer (1994) reported a 50% to 80% discrepancy between observer judgments and patient accounts of pain, again in violation of all stated moral principles involved in patient care. Replication of this study using health care professionals as the observers could lead to dispelling a common myth. As stated by Alspach (1994), "Those who do not evidence overt signs of pain are not experiencing pain that requires treatment" (p. 14).

Francke and Theeuwen (1994) and Greipp (1992) reported that less than 50% of patient pain assessments are accurately documented with an overall lack of knowledge regarding the need for documentation. Not only is this a legal risk, this practice makes the assessment of the effectiveness of the pain regimen difficult, further threatening the patient's inherent right to autonomy and the duty of the nurse to fulfill justice and fidelity obligations to the patient. Nursing research is needed to develop adequate pain measurement scales appropriate for different patient populations. Current pain scales force patients to conform to one numerical system, whether the pain is postpartum or pain from invasive lines. These scales force health care providers to generalize a subjective and personal experience. Nurses are also obligated to advocate for individualized dosage schedules to fit patient needs and not vice-versa.

Blaming the Patient

The issue of culpability as described by Omery (1991) is a phenomenon among health care providers needing to blame the patient for his/her disease state. This further threatens the patient's autonomy. Personal lifestyle choices such as a patient's drug/alcohol use or noncessation of smoking, each resulting in a vast array of disease entities, cause some health care providers to scrutinize these patients' rights against society's restricted expenditure of health care dollars and allocation of limited resources. Withholding pain medication or undermedicating a patient in these instances violates the moral commitment within the ANA Code in which all nurses are accountable for protecting, promoting, and restorating health.

Pain Management

Finally, the ethical issues of high-tech pain management force the nurse to assume responsibility and accountability for the assessment and management of patient pain, thus preserving the patient's autonomy. The patient has an inherent right to be educated about choices concerning pain management, especially when the choices are expensive. Issues typically confronting health care providers and patients are choices between routes for medication -- transdermal versus oral or invasive procedures such as epidural or intrathecal catheters. Ferrell and Whedon (1991) reported the cost per month for oral codeine at $54.70; transdermal $240.80; and patient-controlled devices (PCA) including medication and supplies at $4,624 per month. To intelligently participate in decisions involved in their treatment, patients have a right to this information. Nurses are obligated by the ANA Code to plan and collaborate in their patient's care, and to educate the patient and themselves about current trends in treatment.

While the ANA Code is not intended to provide specific direction or answers to ethical dilemmas involving pain control, it can provide rationale for nursing action. Coupling this moral framework with individual reasoning will give strength to the nurse's decision-making process, and a better chance of achieving a desirable outcome for the patient.


Alspach, G. (1994). Pain management: Dispelling some myths. Critical Care Nurse, 5, 13-15.

American Nurses Association: Code for Nurses. (1985). Kansas City, MO: American Nurses Association.

Davis, A. (1991). The sources of a practice code of ethics for nurses. Journal of Advanced Nursing, 16, 1358-1362.

Ferrell, B., Lester, M., McCaffrey, M., & O'Neil-Page, E. (1990). Nurse's knowledge of opioid analgesic drugs and psychological dependence. Cancer Nursing, 13, 21-27.

Ferrell, B., & Whedon, M. (1991). Professional and ethical considerations in the use of high-tech pain management. Oncology Nursing Forum, 1fl 1135-1143.

Francke, A., & Theeuwen, I. (1994). Inhibition in expressing pain. Cancer Nursing, 17, 193-199.

Greipp, M. (1992). Undermedication for pain: An ethical model. Advanced Nursing Science, 15, 44-53.

Omery, A. (1991). Culpability and pain management\control in peripheral vascular disease using ethics of principles and care. Critical Care Clinics of North America 3, 551-558.

Prkachin, K. Berzins, S., & Mercer, S. (1994). Encoding and decoding of pain expressions: A judgement study. Pain, 58, 253-259.

Elizabeth Behrens, MS, RN, CCRN is Project Coordinator, Case Management, Sherman Hospital, Elgin, IL.
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Author:Behrens, Elizabeth
Publication:MedSurg Nursing
Date:Dec 1, 1996
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