Mr. T was an 85-year-old patient with mesothelioma, an incurable, progressive, terminal and painful cancer in the lining of the lungs.
Shortly after his diagnosis in late 2000, he executed an advance directive that designated his wife as his health-care proxy and emphasized his request for all pain relief necessary to ensure that he did not suffer in his dying.
As his condition worsened, he was admitted to a local hospital, where for the next six days, despite complaining of severe pain, he received only one or two Vicodin tablets at four-hour intervals on an "as-needed" basis. The same medication had proven inadequate at home.
Mr. T was then transferred to a skilled nursing facility. His mental status had deteriorated to such an extent that his advance directive would have become operative. His transfer orders included several medications, but none for pain relief.
Four days after the transfer, he finally began receiving pain medication – Vicodin. He was now under the care of another physician, whom he had never seen or been examined by. His wife and daughter began what would prove to be a long and difficult period of weeks in which they struggled with his caregivers in the skilled nursing facility, with only minimal success, to secure for him stronger and more effective pain relief.
Mr. T died after four weeks at the facility, having been seen by the physician responsible for his care only once.
Public policy and pain management
Six years before Mr. T was diagnosed with cancer, an agency of the federal Department of Health and Human Services convened a distinguished interdisciplinary panel of health-care professionals and through their efforts promulgated clinical practice guidelines entitled Management of Cancer Pain. In the executive summary of these guidelines, the panel states:
"Pain control in people with cancer remains a significant problem even though cancer pain can be managed effectively in up to 90 percent of patients."
Recognition of the widespread undertreatment of cancer pain has prompted recent corrective efforts from health-care disciplines, professional and consumer organizations, and governments throughout the world.
The same year these guidelines were issued, the Medical Board of California adopted a policy advocating the prompt and effective assessment and management of pain in all patients. Both the federal guidelines and the state policy were sent to all licensed physicians in California.
The law and ethics of pain and palliative care
Just a few months after Mr. T died, an Alameda County jury awarded $1.5 million in damages for elder abuse to the family of another elderly man who had died with lung cancer in 1998. Like Mr. T, this patient's family did not believe that the pain he experienced in the last days of life had been effectively managed at the local hospital.
Regardless of one's views about litigating such matters, there is no question that the verdict galvanized the attention of health-care institutions and providers and reminded them of an astute observation made by the physician Eric Cassell in a seminal 1982 article in the New England Journal of Medicine: "The relief of suffering, it would appear, is considered one of the primary ends of medicine by patients and lay persons, but not by the medical profession."
Moreover, the magnitude of the jury's response seemed to signify that the duty to relieve pain and suffering is both professional and moral. What is regrettable, as David Morris presciently noted in his seminal work, THE CULTURE OF PAIN, is that it would take a lawsuit against a physician in order to convince some of what should have been axiomatic: to allow a patient to experience unbearable pain and suffering is unethical medical practice.
The elder-abuse verdict and the circumstances of the case prompted the California Assembly to enact legislation mandating that all physicians in California, with certain narrow exceptions, obtain a minimum of 12 hours of continuing medical education (CME) in pain management and end-of-life care by the end of 2006.
Pain and palliative care at UC Davis
There is ample evidence that UC Davis faculty and staff are determined to be part of the solution to the persistent challenge of pain relief in patient care. In order to meet the need for more professional education, the Division of Pain Medicine, under the direction of Dr. Scott Fishman, in collaboration with the Office of Continuing Medical Education, offered an extensive series of CME programs entitled "The War on Pain."
Also within the UC Davis Health System are the West Coast Center for Palliative Care Education and Research and the Hospice Program, both under the direction of Dr. Fred Meyers, and a new UC Davis Medical Center interdisciplinary palliative-care consult service. Major developments in research and treatment at NCI-designated cancer centers like UC Davis are now being combined with state-of-the-art pain and palliative medicine so as to fully honor the spirit of that ancient, anonymous medical maxim: to cure sometimes, to relieve suffering often, to comfort always.