Toward A Standard Of Care For Pain

Let's hope that veterinary practice leads in embracing opportunities to find and eliminate pain.


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In his autobiography “What I Have Lived For,” humanitarian Bertrand Russell reflected on his past, writing:

“Three passions, simple but overwhelmingly strong, have governed my life: the longing for love, the search for knowledge, and unbearable pity for the suffering of mankind. … Love and knowledge, so far as they were possible, led upward toward the heavens. But always pity brought me back to earth. Echoes of cries of pain reverberate in my heart. … I long to alleviate the evil, but I cannot, and I too suffer.”1

Many veterinarians similarly experience unbearable pity for the suffering of animal kind. Unlike Russell, who longed to reduce suffering but could not, we hold in our hands, hearts and minds a dramatic capacity to intervene on behalf of animals and lobby for better treatment, whether in the feedlot, the research lab or in the veterinary clinic. 

We can upgrade standards of care from within our profession or wait for them to be imposed by public pressure. For better pain management in particular, science supports it, caregivers want it and we can provide it.  

Ethics of Pain

It's unclear why some veterinary patients are sent home to live a life of chronic pain after not receiving adequate pre-emptive, intraoperative or postoperative analgesia. That prompts one to ask what the medical or ethical justifications might be for letting animals live in pain.

Similar frustrations exist in the human medical community regarding insufficient pain control by practitioners who lack adequate awareness and education in pain medicine. This problem led the National Pain Foundation to assemble a Pain Patient Bill of Rights.2

The bill highlights the “five pillars” of pain management:

  • Emotional and cognitive comfort. 
  • Physical restoration by means of therapy and rehabilitation measures. 
  • Pain medication. 
  • Interventional pain procedures (e.g., injections, regional blocks, epidural analgesia). 
  • Integrative pain medicine approaches such as acupuncture and manual therapy.3

5 More Rights

Whether pain management can be considered a human “right” remains unresolved; it is questionable whether a parallel set of veterinary patient rights to proper pain management would be upheld by the profession.4

At the very least, welfare standards advocated for animals used for food should apply to companion animals. Back in the 1970s, the Farm Animal Welfare Council assembled a list of “five freedoms” for farm animals.5 Thirty years later, these freedoms still ring true no matter the animal's role in life: freedom from hunger and thirst; freedom from discomfort; freedom from pain, injury or disease; freedom to express normal behavior; and freedom from fear and distress. 

Based on the five freedoms and the five pillars, a starting point emerges around which to begin discussion for standards of care regarding veterinary patients' pain management:

1. Caregivers should receive pain management information and have their questions answered before invasive procedures are performed on their animal.

Pre-emptive and intraoperative analgesia increases the likelihood of effective pain relief after surgery and reduces the risk of the animal developing chronic pain.6

In human medicine, “Failures of pain management can have catastrophic consequences for patients and for health care institutions.

Undertreatment may also lead to patient suffering, surgical complications and other negative treatment results. Pain is not just a background noise ... to be stoically ignored or endured; it is the cause of somatic failures and expensive hospitalization and of patient resistance to treatment.”7   
 

2. Options for the treatment of pain should include collaborative, science-based integrative medicine and multidisciplinary efforts.

Nonpharmacologic modalities including medical acupuncture, massage and other physical medicine approaches can boost pain control without risking further drug-related adverse effects (e.g., constipation from opioids).8-9 A paper on the law and ethics of pain treatment in humans holds that physicians are required to disclose the options, risks, benefits and consequences of alternative treatment methods if the medical community deems them feasible.10

3. Caregivers should receive details about the source of their animal's pain and be educated about the potential cause of that pain, how to avoid causing it in the future and how to monitor for signs of recurrence. A comprehensive physical examination needs to include a myofascial palpation examination to identify soft tissue pain because it cannot be detected sufficiently otherwise.

The satisfactory prevention and treatment of pain involves identifying the affected tissue and type of pain likely to be or that are being experienced.11

Neurologic and myofascial palpation examinations yield vital insights as to why a dog no longer willingly goes on walks or jumps into a vehicle. Effective neuromodulatory interventions such as acupuncture, massage and laser therapy require identification of the sources of discomfort for optimal results.12

4. Patients should receive routine assessment for pain at their regular check-ups and frequently after surgery. This allows veterinarians to institute or modify analgesic measures.
 
Pain, while common, remains underdiagnosed in veterinary patients and particularly in geriatric individuals.13 Not looking for it and not asking about it translate to not knowing about it and not treating it.

5. Caregivers and veterinarians need to communicate openly about pain.

To stop underdiagnosing and undertreating pain, veterinarians need to use the tools already readily available (i.e., broadened examination skills, acute and chronic pain scales and recommended analgesic regimens for perioperative and long-term care).14  

Veterinary educational institutions can do their part to graduate cadres of pain-conscious veterinarians by improving student exposure to pain assessment and treatment measures during every clinical rotation as part of a system-wide, team approach to pain. 

Establishing a standard of care, let alone a bill of rights, for the treatment of pain in animals may seem incendiary to some. Nevertheless, a law review detailing the liability effects of developing pain management standards for human medicine stated that “bioethical debates help shape the development of accepted professional standards which, if violated, often form the basis for imposition of civil, criminal, and administrative penalties. … [W]here ethical debates do not result in an overall consensus with respect to the appropriate professional standard under consideration, legislatures and regulatory bodies will often step in to fill the gap.”15

In human medicine, “Failure to properly manage pain—to assess, treat and manage it—is professional negligence.”16 The American Medical Association Code of Ethics states, “Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care.”17

At the same time, however, “Medical practice at all levels lags behind these ethical expressions of the duty to treat pain.”18

Let's hope that veterinary practice leads and not lags in embracing opportunities to find and eliminate pain and to develop standards that reflect our commitment to eliminating suffering. <HOME>

Narda Robinson, DVM, DO, Dipl. ABMA, FAAMA, offers an evidential and scientific perspective on trends in complementary and alternative veterinary medicine. She oversees complementary veterinary education at Colorado State.

This article first appeared in the June 2010 issue of Veterinary Practice News. 

FOOTNOTES

1. Russell B.  The Autobiography of Bertrand Russell.  July, 1956.  Accessed here on April 26, 2010.

2. National Pain Foundation.  Pain Patient Bill of Rights.  Accessed here on April 26, 2010.

3. National Pain Foundation.  NPF's policy statement.  Accessed here on April 26, 2010.

4. Hall JK and Boswell MV.  Ethics, law, and pain management as a patient right.  Pain Physician.  2009;12:499-506.

5. Rollin BE.  Veterinary ethics and production diseases.  Animal Health Research Reviews.  2009;10(2):125-130.

6. Farsi M and Gitto L.  A statistical analysis of pain relief after surgical operations.  Health Policy.  2007;83:382-390.

7. Furrow BR.  Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

8. Greene SA.  Chronic pain: pathophysiology and treatment implications. Topics in Companion Animal Medicine.  2010;25(1): 5-9.

9. Etzioni S, Chodosh J, Ferrell BA, et al.  Quality indicators for pain management in vulnerable elders.  JAGS.  2007;55:S403-S408.

10. Furrow BR.  Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

11. Grubb T.  Where do we go from here?  Future treatment strategies for chronic pain.  Topics in Companion Animal Medicine.   2010;25(1):59-63.

12. Grubb T.  Chronic neuropathic pain in veterinary patients.  Topics in Companion Animal Medicine.  2010;25(1):45-52.

13. Etzioni S, Chodosh J, Ferrell BA, et al.  Quality indicators for pain management in vulnerable elders.  JAGS.  2007;55:S403-S408.

14. Grubb T.  Where do we go from here?  Future treatment strategies for chronic pain.  Topics in Companion Animal Medicine.   2010;25(1):59-63.

15. Stark SE.  Bio-ethics and physician liability:  the liability effects of developing pain management standards.  St. Thomas Law Review.  Spring, 2002.  14 St. Thomas L. Rev. 601.

16. Furrow BR.  Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

17. American Medical Association, Code of Medical Ethics.  1996:40.  Cited in:  Furrow BR. Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

18. Furrow BR.  Pain management and provider liability:  no more excuses.  Journal of Law, Medicine & Ethics.  2001;29:28-51.

Whether pain management can be considered a human “right” remains unresolved; it is questionable whether a parallel set of veterinary patient rights to proper pain management would be upheld by the professionIt's unclear why some veterinary patients are sent home to live a life of chronic pain after not receiving adequate pre-emptive, intraoperative or postoperative analgesia. care for pain, pain, pain treatment, veterinary, pain management3/27/2013 2:29 PM

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