Ethical Obligations in the Context
of the “Problem” ED Patient
Kenneth V. Iserson, M.D., MBA, FACEP
Professor of Emergency Medicine
Director, Arizona Bioethics Program
University of Arizona College of Medicine
Tucson, AZ 85724
What you think you are seeing is not real!
Emergency Dept. Case: 2003
• Triage note: “32-year-old man c/o severe intermittent
severe abdominal pain. Multiple ED visits. ?Drug
seeker” “Allergy/Side effect to NSAIDS.”
• Third visit to ED (while working) in last two weeks.
No diagnosis. Prior labs normal; Abdominal CT
normal.
• “I don’t do well with morphine; Demerol is better.”
• Secondary gain from being in ED? Off work—
hospital is his employer.
• One prior surgery: laparoscopic fundoplication.
There is no valid objective test for the
presence, quality or intensity of pain.
Pain is real when you get
other people to believe in it. If no
one believes in it but you, your
pain is madness or hysteria.
—“Violence,” The Beauty Myth (1990)
Naomi Wolf
Who are “Problem” Pain Patients?
Those who demand specific
evaluations/treatments.
Abusive (out-of-control and often demanding)
patients
“Frequent flyers”
Those with whom we have difficulty
communicating—infants/children, geriatrics,
communication-limiting injuries or illnesses,
language barriers, cultural barriers
Who are “Problem” Pain Patients?
Those with chronic “pain” conditions (e.g.,
fibromyalgia, sickle cell pain crises,
chronic back/leg pain, migraine/chronic
headaches)
Those followed by pain clinics (who cannot
be contacted) or out-of-town physicians (“I
don’t remember his name”).
Who are “Problem” Pain Patients?
Drug addicts/alcoholics
Those with “the story”
(My pills were: stolen,
flushed down the toilet,
forgotten when I moved
to town, the dog ate them.
I lost my prescription
—from yesterday.)
Why do EM clinicians see them as
“problems”?
Cultural norms differ from practitioners’
Emergency personnel see their job as intervening in
acute, identifiable illnesses/injuries
Take time & other resources from the care of
seriously ill & injured
They do not want to be manipulated or “fooled”
(peer pressures/ego). Changes with age &
experience?
Disinterest in being the primary care physician.
Iserson KV: The problem patient. In: Hamilton GC, et al., Emergency Medicine: An
Approach to Clinical Problem Solving WB Saunders, Phil. pp 1133-1139, 1991.
Why are EDs particularly vulnerable
to receiving “problem patients”?
Rotating groups of physicians/nurses.
Episodic care
Limited ability to access outside patient
information (after hours, weekends,
holidays)
Many EDs/Urgent Care centers (“doctorshopping”)
Why are EDs particularly vulnerable
to receiving “problem patients”?
Need to move patients through quickly (Time
pressures)
Patients in need often have nowhere else to
turn—and may feel that (based on their
prior experiences) they must be
“problems” to get appropriate evaluation
and treatment.
Society’s venue of “last resort.”
Whose problems are these?
Are the “problems in
 the medical system,
 in us, or
 in our patients?
Perhaps, all three!
What are the ethical questions?
• What duties do we owe patients?
• Beneficence; Nonmaleficence “Do good, but
at least do no harm.” Hippocrates
• What rights does this confer on patients?
• How do these affect “problem” patients?
• Do we have more, less, the same obligations
toward them as we do for other patients?
Ethical Principle & the Basis of
Medical Practice
"To cure sometimes, to relieve often, to
comfort always -- this is our work. This is
the first and great commandment. And the
second is like unto it - Thou shalt treat thy
patient as thou wouldst thyself be treated."
— Anonymous, 15th C.
What goes wrong?
• Clinicians who themselves have not experienced
severe or chronic pain may not fully empathize
with those who do.
• “Good” vs. “Bad” (patient-caused, chronic, hardto-substantiate) causes of pain; “Moral
judgments.
• Patients often have difficulty accurately
quantifying—or even locating the source of
their pain.
Other Causes of “Oligoanalgesia”
• Misunderstanding of “addiction,”
“pseudoaddicition”
• Leads to unwillingness to treat potential
drug “seekers”
• ***Government threats—regulations and fear
of regulatory actions—excuse for inertia
• Lack of adequate personnel, time, interpersonal
communications among healthcare team
• Costs (e.g., gabapentin) & unavailability
(sustained-release narcotics)
• Little research into acute pain treatment.
U of AZ EM Pain Study
• Prospective study.
• Evaluate patient’s, accompanying adult’s,
treating physician’s, and nurse/medic’s
assessment of patient’s pain and treatment.
• Follow-up evaluations.
Ken Iserson, M.D., MBA
Svetlana Reznikova, MS III
U of AZ EM Pain Study
10/10/04: Enrolled 32/50
Research “units”
• Each research unit:
1) Patient at the ED with the main complaint of pain;
2) An accompanying adult;
3) A nurse taking care of this patient;
4) A physician taking care of this patient
• Follow-up for 16 patients (so far)
U of AZ EM Pain Study
Trends:
1.
Too long a wait from being triaged to getting
pain control (usually with medications).
2.
Unclear (so far) about correlation between
patients’ assessments of time waiting for pain
control and assessment of accompanying adult.
3.
Insufficient communication among the medical
personnel involved in each patient’s care.
Conclusions: What Can We Do?
As Clinicians
 Recognize areas in our practices where we
can alleviate acute suffering—especially if the
norm is to ignore it—act as a role model for
others.
 Believe our patients who say they are in pain.
Humility: Simply because we cannot
categorize or name a disease does not mean
that it is not real.
 Our moral duty is to do good. Prescribe
analgesics—even if doubt exists as to whether
the patient has “real” pain.
Conclusions: What Can
As Bioethicists/Educators
We Do?
 Announce—on a local and national level—that
this is an ethical problem, with a number of
moral dilemmas that need resolution.
 Publically defend the more liberal use of
analgesics—and work to change laws
threatening proper analgesic use.
Conclusions:
What Can We Do?
As Bioethicists/Educators
Remind our colleagues that clinicians are not
the police; our job is to treat patients.
 Encourage Bioethics Committees to solicit
problematic acute-pain management cases as a
forum for initiating discussion of the problem.
Conclusions: Why Must We Act?
 Moral imperative: Treat our patients’ pain!
 Improve patients’, society’s and our own image of
ourselves and our profession.
 Basis of good medical care.
 Basis of good medical treatment.
 Right thing to do.
 We have delayed too long already.
It is time that we better epitomized
medicine’s underlying value
—Relieve Always!
Points to ponder
1. There is no valid objective test for the
presence, quality or intensity of pain.
2. “Problem” patients have problems: the
system, us, or both.
3. We have a professional duty/obligation to Do
The Right Thing.
Doing “The Right Thing” means:
1. Treating pain complaints:
–
–
In a timely manner.
With appropriate medications & dosing.
2. Not judging whether it is “good” or “bad” pain.
3. Not being cops; being caring healthcare
providers.
CASE—Resolution
• Patient “given the benefit of the doubt.”
• He was scheduled for an ERCP.
• Found to have an herniated,
intermittently strangulated fundoplication.
• Laparotomy (open surgery).
• Pain relieved. Working full time. Not needing
analgesics.