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In an ambitious effort to promote better care for the dying, leaders of the Death With Dignity movement have called on state medical boards to discipline physicians who undertreat pain.
Leaders of Compassion in Dying, the group that successfully promoted an Oregon referendum legalizing assisted suicide, held a national teleconference on January 13 to publicize its pain-relief initiative. The organization sent a letter to all 50 state medical boards and the national Federation of State Medical Boards suggesting seven steps to correct medical practice that now causes many patients to suffer unnecessarily.
The initiative is, in part, an effort to seek common ground between opponents and proponents of physician-assisted suicide. Both agree that many patients suffer needlessly and have a right to adequate palliative care. But because the initiative includes the possibility of severe sanctions for physicians who fail to provide adequate pain relief, it has spawned some controversy in the medical community.
Former APA presidents Lawrence Hartmann, M.D., and Joseph English, M.D., spoke with Psychiatric News about the initiative.
"Good palliative care and energetic pain relief for dying people have been widely documented as being inadequate in America - far less available than would be technically and decently possible," said Hartmann. "Reform is overdue. We should reform ourselves but also our organizations and our systems in that direction."
Because the initiative includes the idea of physician sanctions for failing to provide pain relief, it is "somewhat controversial," Hartmann observed. At this time, however, "the situation is one-sided, leading to significant undertreatment of terminal pain and suffering," he added.
"Good palliative care and pain relief will not eliminate the ethical desirability of physician-assisted suicide or the debate about physician-assisted suicide, but they are important and valuable in their own right and far too rarely available," he continued.
He urged APA to "play a more active part than [it has] in understanding the need" and helping promote better care.
English, who opposes legalizing assisted suicide, agreed that many people suffer needlessly at the end of life. But he voiced misgivings about that part of the initiative calling for sanctions, adding that "you’ve got to be very careful that advocates don’t turn this into a witch hunt."
"The principal problem is doctors not knowing what they ought to know and being perceived as abandoning patients," he commented. English, who chairs the AMA Section Council on Psychiatry, noted that the AMA is implementing an educational initiative to encourage physicians to treat pain more aggressively.
Robert Brody, M.D., chief of the pain consultation clinic at San Francisco General Hospital and a clinical professor of medicine at the University of California at San Francisco, chairs Compassion in Dying’s executive committee.
"Medical boards could be and must be more proactive in removing the perceived barriers to pain management," said Brody. Medical boards can take some specific steps. One of these is lobbying for removal of barriers to pain management, such as the triplicate prescriptions required to prescribe opiates in some states, he added.
Rather than "reprimanding physicians who perhaps use more than the usual amounts of opiates," said Brody, medical boards could begin to encourage physicians to see the effective use of strong pain medication as a routine aspect of medical care.
Many physicians cite fear of medical board action as a reason for failing to prescribe adequate amounts of opiates, he noted. That is "the first thing we would like boards to come out against," he said. The medical literature is replete with accounts of "egregious violations" of pain relief standards, Brody said. Many patients are "for no good reason whatsoever just left in pain when that pain could be treated."
A reporter from Health Law Report asked Brody how the Compassion in Dying initiative would address physicians’ fears of running afoul of the federal Drug Enforcement Administration (DEA), which plays a central role in controlling narcotics.
Medical boards "have a great deal of prestige and power and as a group could turn around the DEA much more effectively than Compassion [in Dying] alone could do in making it a priority that strong pain medications be available and be used by all physicians in the appropriate situations," Brody replied.
Kathryn Tucker, J.D., lead counsel for Compassion in Dying, pointed out that the states and their medical boards are the chief determinants of what constitutes acceptable medical practice.
"That state recognition becomes acceptable medical practice," said Tucker. "That’s not an area where DEA typically intrudes. And it’s well recognized that use of strong pain medication for relief of pain is appropriate medical practice. It should not invite DEA or state scrutiny."
Brody added that "we need to encourage state boards to take a stand where scientific knowledge is not reflected in public policy as set by the DEA. For instance, we know that the use of marijuana may have a role, but this has been blocked by the DEA."
The intent of the initiative is not to seek out physicians for disciplinary action, said Brody. Tucker added that educational efforts "from the AMA on down" are having an impact "but what we haven’t yet seen, and we assert it is time to see, is that there be real professional consequences attendant upon failure to provide adequate pain relief." The consequences could range from education and probation to revocation of a physician’s license, she said.
In general, medical boards have had "a chilling effect on prescribing of strong pain medications" because they have focused on diversion and overprescribing of narcotics, Brody contended.
Tucker, who was lead counsel in two key cases on assisted suicide heard by the U.S. Supreme Court last year, noted that the Court, while finding no Constitutional right to assisted suicide, stressed that physicians face no legal barriers to providing adequate pain relief "even to the point of causing unconsciousness and hastening death." Such "double effect" is both legal and ethical, observed English.
The court recognized "that no dying patient need suffer needlessly for want of adequate pain medication," said Tucker. There is now "an emergent recognition that patients do not get adequate pain treatment at the end of life, and that as many as 50 percent of dying patients are suffering needlessly for want of adequate pain treatment as they die," Tucker said.
At present, physicians fear sanctions for prescribing strong pain medication and therefore are reluctant to do so, Tucker commented. Conversely, the physician who fails to prescribe adequate amounts of pain medication fears no disciplinary action for letting patients suffer needlessly, said Tucker. "So you have the imbalance of too much concern from the physicians on the one hand and not enough concern on the other."
The initiative asks state medical boards to make clear to physicians that "failure to treat dying patients to relieve their pain, where this is possible, will itself invite scrutiny, and is itself a form of medical behavior below an acceptable standard. And this really is the first time that call has been directly made. We have seen a tremendous recognition in the medical community, partly ignited by the Supreme Court cases and the ensuing debate, that there needs to be a better job of caring for the pain of dying patients. . . .There’s a lot of hand-wringing over the need to correct this state of affairs. But actual concrete improvements at the bedside have yet to arrive."
Although Compassion in Dying will "work hard to eliminate the laws that lead physicians to fear prescribing strong pain medications - to remove that inappropriate perception of risk," they also wish to "create an emergent recognition that failure to relieve pain is itself cause for discipline and professional consequences," said Tucker.
"We are failing miserably as a society in relieving pain at the end of life," said former APA president Hartmann. "I do think they are correct in their premises - that physicians fear sanctions for overusing pain-killing medications."
Patients have a right to adequate pain management, said Barbara Coombs-Lee, Compassion in Dying’s executive director. Compassion in Dying has encouraged families to complain to state medical boards, she added. The "stimulus for change" will come largely from individual families "who insist that their loved ones die a peaceful death," she added.
Pain management guidelines do exist, said Brody. "There is consensus in the medical community about what can be done, what should be done to relieve pain. It really isn’t a mystery."