Source: New England Journal of Medicine (MA)
Edition: Volume 338, Number 17
Contact:  April 23, 1998
Author: Kathryn L. Tucker


To the Editor:

A disturbingly large percentage of dying patients experience unrelieved
pain. (1) This percentage is far higher than it should be, given the
availability of pain medications and the knowledge of how to use them. 

Many physicians believe that they could risk disciplinary action if they
use high doses of narcotics or other controlled substances to manage pain
at the end of life. (2) They also believe that if they undertreat pain,
they risk no professional consequenc es. Dying patients clearly have the
right to adequate pain medication; this was recently recognized by the
Supreme Court. (3,4) 

Physicians have not been held responsible for failing adequately to treat
the pain of their dying patients. I am unaware of any medical-negligence
actions against a physician for such a failure. Medical disciplinary
boards have not been active in investig ating these situations. In the
past, a physician might have successfully defended such a stance by
asserting that there was no medical consensus about how to provide
adequate pain care. However, with the emergence of national, state, and
medical-board gui delines in this area, this is no longer a viable
strategy. (5) 

The time is ripe for such cases to result in professional accountability,
including actions by medical disciplinary boards. Compassion in Dying, a
public-interest organization that acts as an advocate on behalf of
terminally ill persons, recently called o n state medical boards to take
on this responsibility. (6) It is also necessary to eliminate or change
the laws that cause physicians to fear prescribing strong pain medications
to their terminally ill patients. Undertreatment of pain should become a
risk that physicians will strive to avoid, thus increasing the likelihood
that more vigorous, concerted efforts will be made to relieve the pain of
terminally ill patients. 

Kathryn L. Tucker, J.D. Perkins Coie Seattle, WA 98101-3099


1. The SUPPORT Principal Investigators. A controlled trial to improve care
for seriously ill hospitalized patients. JAMA 1995;274:1591-8. [Erratum,
JAMA 1996;275:1232.]

2. Shapiro RS. Health care providers' liability exposure for inappropriate
pain management. J Law Med Ethics 1996;24:360-4. 

3. Washington v. Glucksberg, 117 S. Ct. 2258, 1997.

4. Vacco v. Quill, 117 S. Ct. 2293, 1997.

5. Joranson DE, Gilson AM. Improving pain management through policy making
and education for medical regulators. J Law Med Ethics 1996;24:344-7. 

6. Letter to all 50 state medical boards from the Compassion in Dying
Federation, Portland, Oreg., January 12, 1998.