Fear and loathing on the care path: treating pain and suffering.

Two recent court cases have gained widespread media attention and may create considerable worries among physicians. A precedent-setting verdict in a recent California case found, for the plaintiff, that insufficient pain management in a dying patient constituted abuse by a physician.1,2,3 In Utah, a physician who provided comfort care to terminally ill patients was accused of performing euthanasia, and he was tried on 5 counts of first-degree murder. He was convicted on several counts of negligent homicide and aggravated manslaughter.4 The conviction was over-turned after 6 months of imprisonment. This was due to the prosecutors' failure to disclose exculpatory evidence consisting of information revealed to the prosecution just before trial that care, as documented, reflected a good-faith effort to provide ethically justified treatments that may or may not have contributed to the timing of these patients' deaths. There is good cause for nervousness. These cases are a loud wake-up call to the medical profession. Fears of doing too little or too much should strongly motivate providers to attend carefully to the needs, goals, and values of their patients (or proxies). Clearly, the public is now demanding proficiency in palliative care, and it is a correct assertion that much can be done to mitigate suffering in the vast majority of cases without either killing patients or allowing intolerable distress. It is not surprising that most patients and their families know very little about palliative interventions and so act in seemingly irrational ways. Unfounded fears that opioid analgesics inevitably lead to addiction or hasten death are typical examples we must overcome through informed dialogue and counseling. However, we cannot enlighten them if we have not educated ourselves. Anxieties that physicians may have about being helplessly trapped by the public's current expectations into one type of error or another are certainly valid if they are insufficiently educated and trained in this area. With training and experience, it is rare that a physician would find herself or himself caught in one of the untenable extremes of what is actually an extensive and relatively safe field of palliative management strategies. However, like all other clinical areas that require expertise, what may be comfortable ground for knowledgeable and skilled practitioners may feel like a razor's edge to the ill prepared. What should scare us the most is not knowing and not acknowledging what we don't know. The obligation to know one's strengths, weaknesses, and limitations is fundamental to the integrity of our profession. Should the ethical imperatives to assess and relieve suffering be insufficient motivation, these legal cases should inspire each of us who cares for patients with chronic diseases, especially in their advanced states, to attend closely to quality-of-life issues. Individual physicians, medical societies and specialty organizations, schools of medicine, and postgraduate training programs need to acknowledge the lack of formal, disciplined grounding in palliative medicine. They then need to rapidly narrow the gap between society's appropriate expectations for adequate symptom management and our current capability to meet those expectations. These events are a call to action. Let's not be tempted to hunker down out of fear and defend the status quo but to embrace the opportunity to make a meaningful, positive difference in many peoples' lives.