Pubdate: Sun, 27 May 2001
Source: San Francisco Chronicle (CA)
Section: Page A - 4
Copyright: 2001 San Francisco Chronicle
Contact:  http://www.sfgate.com/chronicle/
Details: http://www.mapinc.org/media/388
Author: Tyche Hendricks, Chronicle Staff Writer

PAIN MANAGEMENT - A PLEA FOR LESS PAIN DYING PATIENTS

Families Want Relief When It's Needed Most

Dr. Stephen Knox walks a tightrope as he seeks to treat the intractable 
pain of his many patients with AIDS and cancer.

The San Francisco doctor has found that morphine and other narcotics often 
- - - but not always -- are the most effective way to ease his patients' 
suffering.

But he fears the scrutiny of state authorities, who closely regulate such 
drugs.

"Pain can be debilitating," Knox said. "It consumes people and affects 
their well-being. Sometimes by getting them on adequate medication, they 
can go on with their lives. But I keep getting worried that the 
government's going to investigate me."

Doctors in California and across the nation face a quandary as a 
traditional approach to pain -- in which physicians were skeptical of 
patients seeking medication and worried they could lose their licenses for 
prescribing too many narcotics -- gives way to an emerging standard that 
doctors should listen to their patients and treat pain aggressively.

Although doctors still face sanctions for overprescribing, the changes in 
pain management are backed by recent research and have led to a handful of 
lawsuits accusing doctors of undermedicating pain, including one case in 
trial in Alameda County.

"It used to be that doctors were really patrician, and what they said was 
what the patient did," said Dr. John Fletcher, a San Francisco internist 
practicing since 1964. "But (the demands of) patients have put doctors in 
the middle. We are walking a fine line. It's frustrating at times."

The East Bay case is the first in the nation to charge a doctor with elder 
abuse for alleged undermedicating. The children of 85-year-old William 
Bergman of Hayward, who died of lung cancer, are suing his internist for 
failing to prescribe enough painkillers to ease the torment of his final days.

Medical experts say the case shows how patients are becoming better 
educated about their options and more willing to be outspoken, while 
patient advocacy groups are becoming more militant in demanding better 
care, especially for the terminally ill.

One example of that activism, the passage by Oregon voters of a 1997 ballot 
measure permitting assisted suicide, was influential in persuading the 
medical establishment to work harder to make people comfortable in their 
dying days, according to Dr. Robert V. Brody, chief of the pain 
consultation clinic at San Francisco General Hospital and a professor of 
medicine at the University of California at San Francisco.

"There's an understanding finally that the biggest drug problem we have is 
with the undertreatment of pain," said Brody, who testified last week in 
the Alameda County trial.

The new consensus on aggressive pain treatment has been fueled by research 
that has attempted to quantify America's pain problem.

A 1995 study, funded by the Robert Wood Johnson Foundation, found that half 
of those who died in acute-care hospitals nationwide were in moderate to 
severe pain in their last days.

A Brown University study, published in the Journal of the American Medical 
Association last month, found that 40 percent of nursing home patients 
nationwide with acute or chronic pain are not getting treatment that brings 
them relief.

These findings, combined with patient activism, have led to new laws and 
professional standards encouraging more prompt and effective treatment of pain.

In 1994, after years of disciplining doctors for overmedicating, the 
California Medical Board issued guidelines reassuring physicians that it 
was acceptable to use narcotics to treat persistent, incurable pain. And in 
1997, the Legislature approved the Pain Patient's Bill of Rights allowing 
patients to ask for the painkillers of their choice. Similar laws went into 
effect in other states.

Nationally, the Department of Veterans Affairs has directed doctors and 
nurses at VA hospitals to monitor a patient's pain level as a "fifth vital 
sign."

In January, the Joint Commission on Accreditation of Healthcare 
Organizations began requiring hospitals, hospices and nursing homes to 
assess and treat pain in order to be accredited. And the federal agency 
that certifies health care providers receiving reimbursement from Medicare 
or Medicaid also established standards for pain management.

"Unrelieved pain has enormous psychological and physiological impacts. It 
delays healing, it increases anxiety, and those are increased costs that 
health care organizations bear," Joint Commission spokeswoman Charlene Hill 
said.

In San Francisco, a 2-year-old hospice at the University of California 
Medical Center is serving as a model for so-called "palliative" care, which 
is focused on alleviating pain. Families are encouraged to be with the 
dying patient and even spend the night. Patients stay in homelike suites 
where music plays and nurses administer morphine and help keep patients 
comfortable, to allow them a dignified death.

But such treatment is still the exception to the rule, says Barbara Coombs 
Lee, executive director of the Oregon nonprofit Compassion in Dying, one of 
the principal groups advocating for improved end-of-life care.

The group, which is assisting the East Bay family in its lawsuit, also is 
sponsoring legislation that would force the California Medical Board to 
require doctors to get education in pain management if the board finds they 
have treated a patient's pain inadequately. The medical board did say the 
Hayward man's pain treatment was insufficient, but his physician, Dr. Wing 
Chin, was not disciplined because the board did not find he had violated 
state law.

"There are currently no consequences for abandoning patients to their pain, 
" she said. "But there are at least perceived consequences for being seen 
as an excessive prescriber."

Physicians who deal with pain say the change will take time.

"The fear of (abetting drug) abuse is legitimate, but it's something we 
have to live with," Brody said. "On the first pass, you have to take the 
patient's word for it. And that's a big leap for doctors."
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