Source: New England Journal of Medicine (MA) Edition: Volume 338, Number 17 Contact: April 23, 1998 Website: http://www.nejm.org/ Author: Kathryn L. Tucker TREATMENT OF PAIN IN DYING PATIENTS 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 References 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.