Comments on: Are hospice doctors relying too much on symptom scores to assess pain?

By: Healthcare Today

Healthcare Today — Fri, 02 Oct 2009 05:41:06 +0000

Are hospice doctors relying too much on symptom scores to assess pain? | KevinMD.com…

An article focused on the question of whether there is overuse of pharmaceuticals to treat various forms of suffering in hospice and palliative….

By: MillCreek

MillCreek — Thu, 01 Oct 2009 20:30:44 +0000

One of the sticky wickets in hospice care is that the Medicare COPs, accreditation surveys and patient satisfaction surveys all place great emphasis on the measurement and control of pain. Given the tightly-regulated environment of hospice care in the US, I suspect we will not be moving away from pain scales any time soon.

By: Eric Widera

Eric Widera — Wed, 30 Sep 2009 17:52:28 +0000

I wholeheartedly agree with all the above comments – suffering is terrible in any form. I’m not against symptom scores – I think they are great. However, just focusing on physical pain misses much of the suffering that occurs at the end of life. Suffering comes in many forms, whether it is physical, psychological, emotional, or spiritual suffering. It is easy to reach for a four drug cocktail to sedate someone who is suffering, but much harder to really evaluate someone’s suffering on a more personal level. Through a thorough evaluation the patient and the healthcare providers can decide the most appropriate treatment plan (which could include the use of opioids or a greater involvement from chaplaincy or psychology).

As suffering takes many forms, an overreliance on the physical aspects of suffering may not be consistent with a patients preferences or goals. For some patients their personal goal may be to be awake enough on a particular day so they can say goodbye to their loved ones. An incentive structure that mandates that everyone should have 0/10 pain score may actually go directly against a patient’s wishes. What I love about palliative care and hospice is that it respects people’s choices and values. What I don’t like about some quality improvement initiatives is that they forget that people are unique (and thus may make different choices than you or I).

By: Erik

Erik — Wed, 30 Sep 2009 17:04:02 +0000

Who cares if dying patients suffer less now than when Tolstoy was writing? No one needs to suffer; no one needs to watch their loved ones suffer either.

Do we rely too much on symptom scores? Of course. We use them for all patients (which face is most like the pain you’re having?). Somewhere in US medical history, assessment of the patient fell by the wayside and we need scores instead of clinical judgement to figure out how to treat people.

By: Carol

Carol — Wed, 30 Sep 2009 03:02:44 +0000

Ivan found redemption in suffering but… Ivan WASN’T REAL. We’re only now getting to the point where doctors seem to be comfortable using enough pain medicine when asked for it – heaven forbid they be put in a position where they are made to feel that they are depriving a dying person of a greater understanding of life by writing that Rx.

Bring on the opioids! Bah to a greater understanding of life. I understand pain – I have a great understanding of pain! Bring on the opioids.

By: Classof65

Classof65 — Wed, 30 Sep 2009 01:03:26 +0000

What is so hard about asking the patient which he/she would prefer? Suffering is overrated — and it should not be up to the doctor to decide whether I should suffer or not. And, if at first I choose to suffer, allow me the privilege of changing my mind if the pain gets too much for me to bear. Let me go, floating on a cloud, rather than white-knuckling it to the blessed end. But let ME choose!

By: Gail Cooney

Gail Cooney — Tue, 29 Sep 2009 20:59:03 +0000

I just reread “The Death of Ivan Ilyich” and was not convinced that his suffering was necessary to reach understanding and life closure. It seems preferable to have conversations that bring peace to both the dying and the surviving loved ones. Imagine how you’d feel if you were Ivan’s wife! Regardless, the goal of care in the actively dying is controlling symptoms to the extent desired by the patient. Suffering is overrated!

By: Nick

Nick — Tue, 29 Sep 2009 20:11:24 +0000

according to JAMA, many physicians lack the knowledge to diagnose and manage pain. They recommend a team approach. physicians using symptom score cards for pain are great!

“Trends in opioid use in US ER departments” Vol. 299 No. 1, January 2, 2008

Improving the practice of pain management JAMA. 2000;284:2785.