Dr Drew Carter, The University of Adelaide

1. Dr Drew Carter, The University of Adelaide Pain management relative to other priorities in the emergency department: explicating moral logic with practitioners

2. Background • A body of recent literature accents both the importance of adequately treating pain and systematic failures to do so in emergency departments (EDs). • One hypothesised cause is practitioners prioritising diagnosis over pain relief. • Berben, S.A., et al., Pain prevalence and pain relief in trauma patients in the Accident & Emergency department. Injury, 2008. 39(5): p. 578-85. • Zohar, Z., et al., Pain relief in major trauma patients: an Israeli perspective. J Trauma, 2001. 51(4): p. 767-72. • Compared to other hypothesised causes, this has been neglected in research. The University of Adelaide

3. Aim • To explicate the moral logic of treatment decisions made in relation to acute pain and its role in diagnosis in EDs • How do practitioners approach – both conceptually and practically – pain and its management in emergency departments, especially relative to other clinical priorities, such as diagnosis? By ‘pain’ we mean pain that is severe, acute and not post-operative, cancer-related or chronic. • What is the moral logic of different approaches? The University of Adelaide

4. Approach • We conducted semi-structured in-depth interviews with five participants, sampled to provide a diversity of perspectives relevant to ED pain management, including some outside the Australian context. • a junior doctor, a senior doctor, a nurse, and two anaesthetists • We conducted a pilot interview, refined the interview protocol before and between the interviews, and kept a reflexive journal. • Interview domainswere: under-treating pain; priorities; metrics; the taught approach; the practitioner’s feelings; the patient’s feelings and views. • Thematic analysis, with a Wittgensteinian attention The University of Adelaide

5. Treating pain is important • It is part of being human. • It is part of being a doctor or nurse (role-related virtue). • Badly managed acute pain leads to chronic pain or to other poor physical health outcomes • Badly managed acute pain leads to poorer mental health outcomes(e.g. post-traumatic stress disorders) • A number of interviewees explicitly distinguished 1 & 2 from 3 & 4. That is, they did not reduce 1 & 2 to 3 & 4. In this respect, they were not consequentialists. One might say they were attentive to what it means to tend to another in pain, both as a fellow human being and as a doctor or nurse. The University of Adelaide

6. Pain relief relative to other priorities • Saving life is the first priority (outside of palliative care). • Very seldom do you need to make a trade-off between short-term pain relief and long-term health. • Opiates can risk death, but no other harms, including addiction. • Nerve blocks risk long-term damage to the nerve. • there’s no logical reason to maintain pain for diagnostic purposes • That’s an outdated idea. • Pain can still aid diagnosis and monitoring after the associated distress has been removed. The University of Adelaide

7. The aim of pain management • You’re going for a substantial reduction in pain so it is now comfortable and bearable. • they will still be able to give you feedback that something hurts … what we’re talking about is unexplained, unexpected pain as a trigger for ‘Go back and look at that patient again’. • You will reduce the risk of medicating a patient to a level that becomes dangerous after some improvement in the patient’s condition or environment. • Eliminating the pain may not be technically possible, short of general anaesthesia, whose risks of harm outweigh its potential benefits, both on its own and relative to alternative treatments. The University of Adelaide

8. The aim of pain management • The object of pain management is ultimately distress: What we’re treating when we treat pain is distress.  If pain was not distressing, we wouldn’t treat it. • Practitioners want to reduce pain, a distressing symptom, to mere tenderness, a non-distressing sign. • This statement has the potential to serve as a new textbook definition for the aim of pain management, at least in the case of acute pain. The University of Adelaide

9. Symptoms v. signs • The total picture of clinical reasoningsencompasses • symptoms: reported by the patient and recorded by the practitioner as a history • signs: obtained by the practitioner via clinical examination or a diagnostic test • The comedy of ‘pain v. maximal tenderness’ • there’s quite a difference between a sign and a symptom, because a sign for us is very clear, we have a common sense on that, but a symptom is prone for interpretation between all of us and that make things difficult The University of Adelaide

10. Two simultaneous diagnoses • Some practitioners defer pharmacological pain management until adequately progressing two very different kinds of diagnosis, undertaken simultaneously: • diagnosis of what is the medical problem; and • diagnosis of whether the patient is drug-seeking. • When the nature or severity of a medical problem is not obvious, then (2) can only be progressed via (1), which can take some time and thereby result in a delay before pharmacological pain management is employed. The University of Adelaide

11. Anchoring and adjusting • Tversky, A., and D. Kahneman. 1974. Judgment under Uncertainty: Heuristics and Biases. Science 185: 1124-31. • Clinicians adjust the patient’s pain rating “in response to its degree of ‘discordance’ with” pain behaviour and clinical signs. • Marquie, L., P.C. Sorum, and E. Mullet. 2007. Emergency Physicians’ Pain Judgments: Cluster Analyses on Scenarios of Acute Abdominal Pain. Qual Life Res 16: 1267-73. • Most interviewees anchored their judgement of a patient’s pain on the patient’s report, with or without adjustment. The University of Adelaide

12. Anchoring and adjusting • Anchor:the observable severity or mechanism of the medical problem, as indicated by clinical examination and diagnostic tests (signs), which a patient history (symptoms) simply serves to guide. • Adjust: • the quality and, in particular, involuntariness of pain behaviour • their facial expression; • being physically guarded • the range of activities in which the patient is interested and of which they are capable • the degree to which patients are persistent in their requests for relief and are willing to wait and to comply with the practitioner’s plan • the patient’s pain report • any accumulating oddities or inconsistencies in the patient’s account • the judgements of fellow practitioners The University of Adelaide

13. A novel hypothesis The approach of practitioners can itself work against improvements in pain if patients experience that approach as a kind of “social threat”, which worsens pain affect. Peeters, P.A. and J.W. Vlaeyen, Feeling more pain, yet showing less: the influence of social threat on pain. J Pain, 2011. 12(12): p. 1255-61. What do you think of this hypothesis? What related phenomena or experiences come to mind? What are the terms you would use to discuss it? The University of Adelaide

14. Acknowledgements The Brocher Foundation and Visiting Scholars The University of Basel and Stuart McLennan JaquelineAltree, for research assistance Research team: Annette Braunack-Mayer, JaklinEliot, Paul Sendziuk, Jackie Street, GertJan van der Wilt. Hossein Haji Ali Afzali ‘Health Care in the Round’ Capacity Building Grant (NHMRC Grant 565501). The University of Adelaide