The Exploration Of Effective Pain Management
Relief from pain is deemed a basic human right. Although, adequate pain management is not provided in many hospitals across Canada. To not acknowledge or respond to a client's pain is not only inhumane but against the oath of a nurse. In fact, according to the Registered Nurses' Association of Ontario (RNAO, 2013), "nurses are required to intervene within their scope of practice to a person's self-reported pain, and work with the person toward managing the pain appropriately" (p.18).
The purpose of this paper is to explore effective pain management, in hospitalized patients, using nursing ethical values and the IDEA framework. Later on, we will determine possible contextual factors including patient preferences, clinical indications, and practice standards. After, relevant ethical principles will be discussed, including professional and personal responsibilities. Then, 3 potential options will be examined by assessing the benefits, limitations, and policies. Finally, the option that will bring the most optimal results will be emphasized. Next up, will be a brief description of the dilemma.
Ethical Situation
A 16-year-old female patient has been admitted with cholelithiasis, otherwise known as gallstones. Considering her severe pain, as she waits for surgery, the physician ordered 5mg of morphine to administered every 1-2 hours as needed. As her surgery approaches, the patient starts to complain of severe pain and then I notice that her last dose was given 3 hours ago. Before I took any action, I informed the co-assigned nurse about the state of our patient and she advises me not to relieve the patient's suffering due to the reason that she is due to surgery in about 30 minutes. By definition, this is an ethical issue because I am fixed between obeying my superior and my duty to advocate for my patient.
Identifying the Facts
There are many contextual factors that affect this ethical situation. Of course, the main consideration should always be the patient; the 16-year-old may have her own religious beliefs or values when it comes to managing pain, thus, having to consider other means of relief. Perhaps she's concerned about drug tolerances, developing a drug addiction, or maybe she doesn't want to be on medication this close to her surgery, this anxiety could dramatically affect the patient's health and outcome if not dealt with the understanding and support of her nurse. All possible clinical indications should be considered as well to ensure the patient well-being. Unfortunately, the client's pain has increased severely since her medication hasn't been administered for 3 hours. The effects of untreated pain "can lead to respiratory, cardiac, and endocrine complications as well as [delayed] healing and potentiate the onset of chronic pain issues for an individual" (Bernhofer, 2011, para. 6).
On the other hand, the patient's impending surgery is also a crucial factor to examine being that she will be put on many other drugs during the operation. Therefore, side effects, dosages, and drug-drug interactions need to be reviewed in advance. As part of her health care team, along with the co-assigned RN and the physician, we are contributing factors to the patient's satisfaction, hence, it is our obligation to meet practice standards according to the organization. Working in the surgical unit is to prepare patients for surgery which includes "treatments to reduce pre-existing pain and anxiety, pre-medications before surgery… and patient and family education [on pain control]" (American Society of Anesthesiologist, 2012, p.252).
Determining Relevant Ethical Values and Responsibilities
A nurse's job is to provide a safe, effective, and ethical environment for all patients (Colleges of Nurses of Ontario [CNO], 2009, p. 9). This ensures that all nursing practices will refrain from doing any harm, known as nonmaleficence. Administering pain medication could potentially cause harm when considering the possible side effects that can manifest, but no relief could cause detrimental physical and emotional stress effects. In order to solve this problem and ensure my patient's safety, I need to weigh all the options and discuss them with the physician and the patient. Also, the co-assigned RN is deliberately causing harm to our patient by recognizing her pain but withholding any relief or treatment. CNO (2009) claims that "nurses are obliged to refrain from abandoning, abusing or neglecting clients" (p.9). Therefore, despite the co-assigned nurse's opinion, it is my responsibility to advocate and relieve the client's suffering.
Beneficence and client well-being are one of the most important nursing ethical values. However, it can sometimes be hard to determine what is good or bad for your client. In order to apply beneficence, I simply need to be compassionate towards my patient's feelings and be open to communicating to about treatment alternatives. I believe that my patient has the right to know all her options in regards to relieving her pain; this is supported by 2 nursing ethical values: autonomy and client-choice. According to the CNO (2009), "legislation and common law require that the wishes of clients or substitute decision-makers be respected" (pg. 6). Each patient has their own beliefs and values, thus, having the ability to know what technique would show the most improvement. If the patient has been properly educated on pain management, then there is no reason to not include the patient in treatment decisions.
Exploring the Options
One option to resolve this ethical situation would be to acknowledge my patient's pain and administer a pharmaceutical drug. With the physician's consent, I would then administer my patient 3-5mg of morphine depending on how severe the pain according to the pain assessment. Potential benefits to this option not only cover reducing the patient's pain but also eliminates any chance of her developing further complications caused by untreated acute pain. Psychologically, this may even help reduce the patient's anxiety and/or concerns with her upcoming surgery. Benefits of effective pain management are "decreased length of stay, lower readmission rates, earlier overall recovery, improved quality of life, increased productivity, and decreased costs for patients and the health care system" (Glowacki, 2015, para. 9).
A second option would be to administer no medication at all, ultimately providing no pain relief for the patient. In this case, there aren't many benefits that can result, other than eliminating any possible, but rare, complications from any drug-drug interactions during her surgery. Potential hazards that could arise from unrelieved pain include both physical and emotional pressure, which could ultimately prolong the stress response. The body can react in many different ways including tachycardia, increased blood pressure, fever, shock, and even death (Wess et al., 2008, para 10-11). Furthermore, in regards to policy, not providing adequate pain relief in patients defies the role of the nurse which is to promote patient quality care. Thus, not properly assessing and managing of pain can lead to multiple legal lawsuits.
A third option to resolve this ethical situation would be to use non-pharmacological interventions to relieve my patient's pain. This can be carried out through either physical or psychological means. Physical techniques include heat and/or cold application and massages, which has been shown to "improve pain intensity and function" and "to improve circulation, promote comfort, and enhance sleep" when used continually (Wess et al., 2008, para 61, 58). Psychological interventions include relaxation, music, and hypnosis. However, many nondrug methods require a trained therapist, which is not always available 24/7 in hospital settings.
Taking Action
Carefully looking at all the options, I would choose to administer 2-5mg of morphine intravenously to relieve the client's pain faster, with her consent of course. This seems like the best option since she has already been in such discomfort for over an hour or so and to prolong that pain, by not giving medication, or to decrease pain over time, by using non-pharmaceutical means, seems quite unpleasant. Though her surgery is in 30 minutes, that could feel endless when experiencing excruciating pain. I also wanted to reduce the chance of developing consequences related to untreated pain, if she hasn't already. I want to make sure that she is both physically and emotionally able to withstand her surgery and recover quickly.
Conclusion
I have considered many influencing factors, relevant ethical values, assessed three different responses, and chose an option that would be most beneficial to my patient. By doing so, I have illustrated an example of proper ethical practice. Others may not have chosen the same intervention, but nonetheless, all nurses should consider ethics when providing care. Nurses will "see their own biases clearly and make evidence-based decisions that provide optimal pain relief" (Bernhofer, 2011, para. 14).
