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NEW HAVEN, CT — August 13, 2004 — How often nurses assess pain and communicate their findings to doctors and other staff members varies among nursing homes, according to a recent Yale University Medical School study (Arch Intern Med. 2004 Jul 26; 164(14): 1508–12). The study focused on a four–step process: the nurse’s initial assessment of pain, informing the doctor about the patient’s pain, the doctor’s intervention, and reassessing the effectiveness of any pain treatment.
The study authors interviewed directors at 63 nursing homes in New Haven, Connecticut. They also obtained the total number of nursing staff hours (registered nurses, licensed practical nurses, and certified nursing assistants) per resident per day from the government web site, Nursing Home Compare. They asked these questions:
In 76% of nursing homes, residents who did not complain about pain were nevertheless checked for pain at least quarterly, according to the survey of the nursing home directors. Only 55% of the facilities assessed residents for pain at least every two months. Less than half of the nursing homes required the nursing staff to examine patients for pain on every shift, even for those patients who had reported that they were feeling pain.
When pain medication was considered ineffective, nurses in 42% of the nursing homes notified doctors. In 73% of nursing homes, pain reassessment occurred at least one hour after a new treatment. The authors noted much variation in how frequently nurses assessed pain, when they notified clinicians, when clinicians assessed pain, and how frequently nurses reassessed pain following an intervention.
The 1999 American Medical Directors Association guidelines recommend that nursing staff assess pain on admission, quarterly, and with any change in condition. However, this schedule may be too infrequent for residents with severe pain, according to the study investigators. Another issue is the lack of clear guidelines—the degree of pain analysis can range from a simple verbal report to a full nursing examination and assessment. LTC Exchange, a pain management newsletter, suggests that pain should be reassessed one to two hours after a patient is given an analgesic. The authors point out that this schedule does not take into account that some sustained–release medications require longer than two hours before their effectiveness can be measured.
The study authors believe that more work needs to be done to determine which pain assessment methods to use at different times. For example, should pain be fully assessed quarterly and verbally assessed at every shift? They hope that their study will lead to further research on the process of pain management and the development of pain management guidelines.
Many nursing home residents suffer from untreated pain. One study shows that 70% are in pain (J Am Geriatr Soc. 1990 Apr; 38(4): 409–14). Another report looks at nursing homes on a state–by–state basis and finds startling rates of severe, persistent pain among residents (Facts on Dying, Center for Gerontology and Health Care Research, Brown University)
Because clinicians do not always assess pain properly, it is often underreported. Elderly patients may be afraid to mention their discomfort because they fear retaliation or feel that they must be stoical. They may even falsely believe that pain is a natural part of aging. Some clinicians equate pain management with addiction or mistakenly think that the elderly are less sensitive to pain.
Monitoring the use of pain medication is time consuming. In nursing homes, pain management may be limited if staffing is inadequate. The Yale University study relied on interviews with nursing home directors. However, there may be a gap between a director’s idea of “best practices” and the reality of what duties the nursing staff may actually be performing. The study investigators suggested that further reports be done using hospital charts and observations of staff.
Underrating pain has been considered neglect, negligence, or even elder abuse. In one landmark case, a doctor was held liable for elder abuse for under medicating a terminally ill hospital patient, allowing him to die in extreme pain (Beverly Bergman et al. v. Wing Chin M.D.). The patient’s family was awarded $1.5 million based on the doctor’s reckless conduct and on California’s elder abuse statutes.
Clayton Kent of our law firm, Brayton Purcell, successfully represented the plaintiffs. We have also worked on other elder abuse issues, including nursing home neglect and financial abuse. If you have a question about the legal rights of your elderly relative, please feel free to contact us. We are experienced elder abuse lawyers, and work tirelessly on behalf of our clients.
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