10/1/18

1

NO MEDICINE IS BETTER THAN BAD MEDICINE

The Ethics of Saying “No”

Karl J. Haake, MD2018 Health Ethics Conference

October 5, 2018Columbia, Missouri

ISSUES• Patients with pain are perceived and judged in

certain ways, many times negatively

• Pressure to say yes and prescribe medications that may not be appropriate or indicated

• Over the last 10 years treatment of pain has equaled the prescribing of pain medications

ISSUES

• Physical vs. psychological vs. spiritual

• Chronic pain and mental illness

• Psychological/psychiatric illness and opioids

10/1/18

2

TREATING PAIN

• The vast majority of pain treatment occurs at the primary care level

• Lack of education

• No time

• Hard to say no (real pressure to say yes)

TREATING PAIN

• What’s in my toolbox?

• Treating to pain score

• Elimination of pain

ETHICAL PRINCIPLES

Beauchamp & Childress, 2008

Autonomy

JusticeBeneficence

Non-maleficence

10/1/18

3

AUTONOMY

• Informed consent

• Ability to make one’s own medical decisions

• What if one’s decision is bad?

JUSTICE

• Treat others fairly

• Equal treatment for equal conditions

BENEFICENCE

• A duty to care for a sick person

• “Moral imperative to treat pain” (Institute of Medicine, 2011)

10/1/18

4

NON-MALEFICENCE

• Primum non nocere

• Any medical decision has the potential to do harm

• Do benefits outweigh the risks?

PAIN MANAGEMENT• Autonomy: “I hurt, therefore I need my pain

treated”

• Justice: “All people with pain should get pain treatment.”

• Beneficence: “Relieve my suffering”

• Non-maleficence: “This pain treatment has risks.”

OPIOIDS AND PAIN MANAGEMENT

• Pain treatment does not necessarily equal pain pill

10/1/18

5

DOCTOR-PATIENT RELATIONSHIP

• Historically, adversarial

• Not equal

• “Smart doctor, dumb patient”

• Kind of like the parent-child relationship

PARENTING

• Where we learn how to say no

• “This is going to hurt you more than it hurts me”

• “I am doing what is best for you”

• “Go ask your mother.”

PATIENTS

• Patients have autonomy and free will

• Maybe they just don’t know

10/1/18

6

PATIENTS

• Getting to shared decision making which incorporates autonomy

PHYSICIANS

• Art vs. Science of Medicine

PHYSICIANS

• “Oh my God, this is the worst back I’ve ever seen.”

• “Get up and get moving, you’ll be fine.”

10/1/18

7

THE MAGNIFICENT SEVEN1. Focus

2. Establish a connection

3. Assess patient’s response to illness/suffering

4. Communicate to foster healing

5. Touch

6. Laugh

7. EmpathyEgnew, 2014

FOCUS

• Deep breath before entering the patient’s room

• Forget about the last patient

• Look patient in the eye

ESTABLISH CONNECTION

• Don’t even look at the computer

• Look at the patient

10/1/18

8

ASSESS PATIENT’S RESPONSE

• Quick behavioral health assessment

• Ability to cope

• History of trauma

• Catastrophizing

COMMUNICATION

• Avoiding big medical terms

• Meet them where they’re are.

TOUCH

• “Cold stethoscope on the chest.”

10/1/18

9

LAUGH

• Laughter is the best medicine

• Shows patient you’re human too

• De-escalates the situation

EMPATHY

• Often confused with sympathy, it is not the same

• Sympathy is a statement of emotional concern while empathy is a reflection of emotional understanding

Hirsch, 2007

SCIENCE OF MEDICINE

• Evidence based medicine

• Clinical experience/judgment

10/1/18

10

EVIDENCE BASED MEDICINE• The conscientious, explicit, judicious and

reasonable use of modern, best evidence in making decisions about the care of individual patients

• A movement which aims to increase the use of high quality clinical research in clinical decision making

Masic et al., 2008

OPIOIDS AND EVIDENCE BASED MEDICINE

• Few studies support the long term use of opioids in chronic pain

• SMART study (2018): Opioids no better than NSAIDs

• CBT better than opioids (Kroenke)

OPIOIDS AND HARM

• Real risk of dependence

• The opioid epidemic

• Risk of death

10/1/18

11

FEELINGS IN DECISION MAKING

• “I just feel like this is right for me.”

• Open to bias

• Not based in fact (usually)

BALANCE

• Use both art and science to say no if opioid prescribing is inappropriate

• Honesty and respect for the patient

• Avoid: “the doctor didn’t do anything for me”

SHARED DECISION MAKING

• Key component of patient-centered care

• Working together to make decisions

• Knowledgeable patients

National Learning Consortium, 2013

10/1/18

12

SHARED DECISION MAKING

• It is not the patient deciding his or her treatment

• “I need antibiotics”

• “I need an MRI”

• “I need surgery”

SHARED DECISION MAKING

• Provide options

• Facilitate the patient thinking about care

• Lay out the next steps

• Repetition, consistent messaging

SHARED DECISION MAKING

• “We are in this together.”

10/1/18

13

THANK YOU!