NO MEDICINE IS BETTER THAN BAD MEDICINE The Ethics of Saying No ISSUES ISSUES 10/1/18

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1 NO MEDICINE IS BETTER THAN BAD MEDICINE The Ethics of Saying No Karl J. Haake, MD 2018 Health Ethics Conference October 5, 2018 Columbia, 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 1

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 Nonmalefic ence Auton omy Benefic ence Justice Beauchamp & Childress,

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) 3

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 4

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 5

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. 6

7 THE MAGNIFICENT SEVEN 1. Focus 2. Establish a connection 3. Assess patient s response to illness/suffering 4. Communicate to foster healing 5. Touch 6. Laugh 7. Empathy Egnew, 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 7

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. 8

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 9

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

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,

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. 12

13 THANK YOU! 13