Clinical Ethics in Anesthesiology. A Case-Based Textbook

3. Pain management

24. Conjoining interventional pain management and palliative care: considerations for practice, ethics and policy

James Giordano and Gerhard Höver

The Casea

A 61-year-old woman with metastatic colon cancer presents with intractable abdominal pain. Since her initial diagnosis 13 years ago, she has undergone chemotherapy, multiple colon surgeries, radiofrequency ablation of liver metastases, and excision of a solitary pulmonary metastasis. A CT scan shows enlarging liver metastases involving the capsule and para-aortic lymph nodes.

The patient has been relatively pain-free until 7 months prior to consultation with a local anesthesiologist who specializes in interventional pain managmeent. Prior to consultation, initial treatment of pain consisted of oxycodone and acetaminophen, followed by sustained-release morphine titrated over several months to a total of 1200 mg daily. Sustained release morphine was then supplemented with immediate-release morphine (600 mg) up to four times daily for breakthrough pain. Most recently, she was switched to fentanyl patches plus continued oral morphine. At the time of consultation she was using thirty 100 mcg/h patches every 3 days.

Despite somnolence, she continues to complain of severe constant sharp, aching and “knife-like: upper and lower abdominal pain, with self-rated pain intensity between 7 and 10 on a 0 to10 scale, with minimal movement bringing pain intensity up to 10.

The anesthesiologist performs a neurolytic celiac plexus block, which decreases her baseline pain from a 7 rating to a 4. A 4 mg intrathecal test dose of morphine reduces her pain rating further to 1–2, with no adverse effects. The anesthesiologist would like to refer her to a multidisciplinary pain clinic for possible implantation of a morphine spinal delivery system, but the patient’s insurance company has thus far refused to approve the consultation or implantation, because studies suggest that these devices are cost-effective over continued systemic analgesic management only after 18–30 months of therapy. They point out that she has had significant improvement in her pain after neurolytic block, and is unlikely to survive long enough to make intraspinal therapy cost-effective, even if it provides better quality of pain relief.

A moral obligation to treat pain

Technological advancements within science and medicine have enabled prolongation of the lifespan for those patients with incurable diseases. Yet, at the same time, such relative successes have fostered an increased prevalence of chronic illness and subjective suffering – including intractable pain – due in part to the inability to completely eradicate symptoms, and to the progressive use and sometimes exhaustion of therapeutic and economic resources available to the patient. This has compelled an increased impetus for medicine to develop those dimensions of practice that seek to heal what cannot be cured. To a significant extent, pain medicine and palliative care have arisen from, and seek to meet, this need.

The obligation to treat pain and suffering, while inherent to all of medicine, is by definition most fundamental to the profession of pain medicine and palliative care.1 Clearly, pain management can be, and often is necessary, albeit not sufficient for rendering sound, palliative care. But technically effective pain care must also be rendered in ways that uphold the moral affirmations of medicine, and while certain ethical (and legal) frameworks exist to guide the tenor, scope and limits of the profession, the actual implementation of care is reliant upon the physician. In this way, the physician is both a therapeutic and moral agent, given that any (if not all) clinical decisions affect the vulnerability of the patient, reflect the asymmetries of knowledge and power between physician and patient, and impact trust within the medical relationship.

The complexity of pain and pain care is such that a simple, “one-size fits all” approach to management is not practical, nor ethically justifiable. An integrative use of interventional, pharmacologic, physiatric, and psychiatric pain management may represent a viable option, both early in and throughout the care of long-term and terminal pain patients. In this context, interventional techniques may be especially useful because of their capacity to effectively reduce pain, make patients more amenable to other therapeutics, and enhance patients’ quality of life.

Interventional pain medicine in integrative pain care: practical and ethical claims

If the past 10 years’ congressionally declared “decade of pain control and research” in the US has done nothing else, it has certainly instigated: (1) a more internationalized interest in the problem of pain and the difficulties and responsibilities of pain care; and (2) a more well-defined need – and thus goal – for biomedical research to facilitate improved translational applications and models.2 Despite such progress, interventional management techniques still tend to be under-utilized within palliative care – particularly that which is provided in a paradigm of long-term (i.e., not end-of-life) treatment.

A number of long-held beliefs may contribute to under-utilization. Integrative pain medicine and palliative care may appear to be expensive or not cost-effective from the perspective of hospital operators and insurance companies. The problem chiefly lies in an inability to calculate the cost of pain- and palliative care given the relative uncertainties of matching objective medical treatments to subjectively defined states (i.e., pain and suffering) and ends (e.g., palliation). Long-term pain care can be viewed as cost intensive by insurance providers and hospital operators, with perceived high expenses evoked by the requirements for both medical staff and equipment/facility resource utilization. From a perspective of hospital economics, prima facie it might not seem to be “worthwhile” to care for chronic pain patients, given costs incurred relative to payment schedules established according to existing diagnosis-related group (DRG) treatment classification systems. The development and expansion of inpatient and/or outpatient pain- and palliative-care networks are not generally facilitated by current DRG systems. This is because DRGs are not designed to reflect: (1) the wide pathological variance of chronic pain patients; and (2) the finances required to support services necessary to effectively and ethically treat chronic pain conditions.3 Thus, if the goal of providing high-quality pain medicine and palliative care is to be achieved in light of (1) the noted achievements of technology in medicine and (2) the explicit call to use such advancements to address the increasing incidence and prevalence of chronic pain, then special provisions for adequate funding of both inpatient and outpatient approaches must be developed and implemented.

However, to safely, effectively, and ethically deal with the often complex pathologies of chronic pain patients, it is necessary to maintain multi-disciplinary and integrative treatment provided by professions focal to pain- and palliative care (e.g. specialized physicians, social workers, physiotherapists, psychologists, clergy and secular spiritual counsellors, et al.). In this way, treatment would constitute a service of ongoing assessment and interventions that are rendered by a multi-professional, closely-knit team on a regular basis, as appropriate to both the changing status and needs of each specific patient.

It is difficult to categorize chronic pain patients in a homogeneous cost group within current DRG systems, and so an inter-disciplinary pain/palliative care could be seen as impossible to finance because of its requisite utilization of diverse resources. The lack of a more encompassing integrative pain/palliative care paradigm reflects the inchoate nature of the profession of “pain medicine.” This has given rise to misconceptions that interventional pain management is a “stand-alone” approach, and led to the opinion that its ongoing, collaborative use with other disciplines (e.g., primary care, physiatry, and psychiatry/psychology) would incur unnecessarily high costs that would be difficult to advocate.

But is this latter opinion correct? Previous studies have shown that the employment of collaborative interventional techniques within an inter-disciplinary pain/palliative care paradigm can be both cost- and time-effective.4 For example, when compared with long-term use of systemically administered primary and adjunctive/adjuvant analgesics, interventional techniques reveal a very favorable cost: benefit ratio. In the case of the aforementioned patient, the large doses of opioid required to achieve even dissatisfactory pain control were estimated to cost approximately $10 000 per month, while the estimated total combined cost of intrathecal pump placement, intrathecal and oral morphine and the neurolytic block was approximately $5000 per month over the first 3 months.5 Thus, as this case illustrates, even in those cases in which analgesia is less than complete, but meaningful pain relief is nonetheless achieved, the cost and time savings incurred by reducing the amount of systemic drugs used, and the time needed to obtain stable effects might well balance and justify the initial expenses of interventional procedures. Clearly, however, the use of nerve blocks and (rather than “or”) pharmacological, physical medicine and psychiatric/psychological approaches within a methodologically conjoined treatment protocol affords considerable complementary attributes.

For interventional pain medicine to be truly effective within such a collaborative, integrative system, the interventional pain specialist must realize that the use of techniques and technologies – despite being a significant component of practice – does not in any way lessen the pain physician’s practical and moral role and obligations qua physician. Interventional pain specialists must assume at least some level of responsibility for the ongoing management of the patients in their charge. The sole provision of interventional techniques without accepting and meeting the broader medical needs of the pain patient, either singularly, or in collaboration with other physicians, might be regarded as a form of abandonment, and in this way rebuts the physician’s act of profession. Pharmacologic and psychological management of chronic pain – and the intricacies of dealing with the chronic pain patient in an often litigious environment – can be difficult, but such is the nature of the profession and practice.

Ethically sound practice requires that the physician: (1) use the most current information on pain and pain-related pathologies (e.g., substance abuse, psychopathology); and (2) recognize and understand the medically relevant bio-psychosocial needs a particular patient may have, and how these needs may be served through an integrative, pluralist approach that conjoins other specialties (e.g., psychiatry, etc.).

It is important to remember that from the medical perspective, the “pain patient” is defined by signs and symptoms (i.e., pain and its resultant bio-psychosocial suffering). Assessing and diagnosing pain is often difficult, and establishing precise trajectories and limits of care can be equally troublesome – practically, ethically, and legally. Although interventional pain medicine and palliative care seem to have somewhat different clinical structures, both are focal to apprehending the subjectivity of pain and suffering, and merging patients’ subjective experience of pain – and clinicians’ personal and professional knowledge and perspectives – to the objectivity of pain assessment and treatment. As well, both disciplines encounter and must deal with the clinical, economic, moral, and legal problems that are related to medical decisions regarding the nature, scope and extent of such care. Therefore, interventional pain medicine and palliative care could benefit from a shared orientation and inter-disciplinarity, and can be seen as mutual and reciprocal, constituting a larger professional domain that is centered upon the treatment of pain – not merely as an object, but as an existential predicament of the patient who is the moral subject of clinical responsibility.

On the need for policy: bringing stakeholders together

Clinical moral responsibility dictates that when cure is no longer possible, healing care must be maximized. In this way, the collaboration and conjoining of interventional pain management and palliative care may well serve the scope, purposes and obligations of pain treatment. However, facilities committed to this type of inter-disciplinary approach are limited and diminishing, and therefore assembling these resources becomes problematic and non-sustainable. Multi-practitioner pain management practices can be found in most urban areas in the US and throughout western Europe, yet in the US the number of multi-disciplinary pain centers (MPCs) is declining as a result of prior economic concerns, constraints, and misuses. This both reflects the economic turn away from complementarity in pain care, and contributes to it.

This decline has become a quantitative and qualitative barrier to the effective practice of integrative pain/palliative care, and is an intimidating prospect that compels the proposal and ratification of reformed guidelines and policies, both in the US, and on a more global scale. Recent calls for insurance companies, as well as government agencies to establish programs of long-term pain care reflect these concerns and promptings. The primacy of patients’ best interests cannot, nor should not be denied, nor subordinated to other, extraneous goals. But medicine does not exist in a socio-economic vacuum, and if these therapeutic and ethical “goods” are to be appropriately rendered to those in pain, the systems utilized toward these ends must be practically enacted, and we must recognize how the relative interests of practitioners, the healthcare and insurance community, and the public at-large affect any realistic dynamic of costs and benefits in the provision of care. In this way, it is important to consider the needs and values of each of these stakeholder groups, not in isolation, but in concert. A strategy of rapprochement is necessary to reconcile the tensions that exist among and between these groups in the best interests of the patient, so as to develop policies that incorporate “… an ethical ‘infrastructure and function’ that engages ethical systems and approaches in ways that support and sustain the good to be provided on individual and public levels”.6 Physicians should advocate policy development that is directed toward enabling the profession and practice of pain/palliative care to empower the pain patient.

It is important to see the patient not only as a victim of her disorder, despite the reality that medical treatment is, in the first place, based upon the presence of identifiable and categorical symptoms and distress. It is also important to see that the pain patient has fears and hopes. Reflection upon her existential problems is not only a personal challenge for the patient, as well as her family, friends, and others, but can also pose professional challenges and opportunities to the clinician.

Unavoidably, life entails some measure of pain and suffering. This should not foster a sense of existential nihilism. To the contrary, it serves as a motivation to move away from any passive consideration or experience of pain and suffering, and assume a more active, anticipatory and therefore authentic approach to care. In this sense, “care” may be translated from its Latin origin, cura, as “concern” or “regard,” and this is philosophically consistent with the goals, ends, and “promise” of pain/palliative medicine.7

It has been said that philosophy teaches humanity how to suffer. In light of this, the authors propose that a philosophical, and practical conjoinment of pain/palliative care affords purchase to learn not only how we suffer (i.e.- a focus upon pain and its meanings), but how we can – and should – concern, regard, and treat those in pain.

Key points

• As prolonged survival of previously terminal medical conditions has increased, so has the prevalence of chronic and/or intractable pain and suffering.

• A “one-size-fits-all” approach to pain management is not practical, nor ethically justifiable.

• Interventional pain management techniques and integrative pain medicine are under-utilized, due to misperceptions by hospital operators and insurance companies about cost effectiveness.

• Employment of collaborative interventional techniques, however, has been shown to be both cost and time effective.

• Even in cases of incomplete pain relief, meaningful pain relief may nevertheless be achieved by use of a multi-disciplinary approach.

• Physicians should advocate policy development that is directed toward developing and enabling the profession and practice of pain/palliative care.

Acknowledgments

This work was supported, in part, by funding from the Nour Foundation, and an American Academy of Pain Medicine-Pfizer National Visiting Professorship at Texas Tech University Health Sciences Center (JG). This work was completed as part of the N3P3 Project (Neuroscience, Neurophilosophy and Neuroethics of Pain, Pain Care, and Pain Policy) that conjoins the authors and their respective institutions. Thanks to Drs. Mark V. Boswell, Carlos Gomez and James Harrison for intellectual collaboration on prior work regarding the role of interventional pain medicine in palliative care.

Notes

a Although this is a fictional case, some facts and cost analysis are based on an actual case reported in the literature: (Seamans, D.P., Wong, G.Y., and Wilson, J.L. (2000). J Clin Oncol28(7), 1598–1600.)

References

1* Giordano, J. (2006). Hospice, palliative care, and pain medicine: meeting the obligations of non-abandonment and preserving the diginity of terminally ill patients. Del Med J78(11), 419–22.

2 Boswell, M.V. and Giordano, J. (2009). Reflection, analysis and change: the decade of pain control and research and its lessons for the future of pain management. Pain Physician12, 1–7.

3* Ewald, H. (2004). Stationäre Palliativmedizin. Finanzierung und Qualitätskriterien unter DRG-Bedingungen, 3. Petersberger Gesundheitssymposium; Palliativmedizin: Herausforderung für das Gesundheitssystem. 1 July.

4 Manchikanti, L.Singh, V.Kloth, D. et al. Interventional techniques in the management of chronic pain. Pain Physician 2001; 4(1): 24–98.

5 Seamans, D.P.Wong, G.Y., and Wilson, J.L. (2000). Interventional pain therapy for interactable abdominal cancer pain. J Clin Oncol18(7), 1598–600.

6 Giordano, J.Schatman, M.E., and Höver, G. (2009). A crisis in chronic pain care – an ethical analysis, Part I. Facts, issues, and problems. Pain Physician12, 803–13.

7* Graf, G. and Höver, G. (2006). Hospiz als Versprechen: Zur ethischen Grundlegung der der Hospizidee. Der Hospizverlag.

Further reading

Giordano, J. (2006). Pain, the patient and the physician: philosophy and virtue ethics in pain medicine. In Ethical Issues in Chronic Pain ManagementSchatman, M.E. (ed.) NY: Informa, pp. 1–18.

Giordano, J. (2009). Pain: Mind, Meaning and Medicine. Glen Falls, PA: PPM Communications.

Giordano, J.Benedikter, R. and Schatman, M.E. (2009). In: Giordano JBoswell MV (eds.) Pain Medicine: Philosophy, Ethics and Policy. Oxon, UK: Linton Atlantic, pp. 39–50.

Höver G (2001/2) Qualität“ Bedeutung und ethische Dimensionen einer Schlüsselkategorie hospizlicher Arbeit. Rheinisches Jahrbuch für Volkskunde34, 205–12.

Maricich, Y. and Giordano, J. (2009) Chronic pain, subjectivity, and the ethics of pain medicine: A deontic structure and the importance of moral agency. In: Giordano JBoswell MV . (eds.) Pain Medicine: Philosophy, Ethics and Policy. Oxon, UK: Linton Atlantic, pp. 85–94.