Pain & End of Life Issues
About the issue:
See: The Role of State Attorneys General in Improving End-of-Life Healthcare: Holding Hospitals and Nursing Homes Accountable for Undertreatment of Pain by Leah Heifetz
The literature of the health care profession has documented a serious problem regarding the undertreatment of pain and the failure to effectively address suffering in the clinical environment. The two most serious barriers to solving this problem are a lack of education among healthcare providers about palliative care and a fear that prescribing controlled substances, even when they are the only way to relieve a patient’s pain, will result in regulatory and legal consequences. In the past several years, state attorneys general have become increasingly aware of the problem and willing to use their offices to improve the quality of end-of-life care in their states.
In 2002, more state attorneys general became further involved in palliative care policy when the National Association of Attorneys General (NAAG) launched the End-of-Life Healthcare Project. The NAAG End-of-Life Healthcare Project has provided an invaluable resource for attorneys general working to improve palliative care for their constituents.
State legislatures have an important role to play in improving palliative care education, and New York’s recent passage of the Palliative Care Education and Training Act is an important first step.
Overcoming physicians’ fear of legal repercussions is not presently possible since state attorneys general do not have the power to override the DEA’s authority to investigate “merely on suspicion that the law is being violated, or even just because it wants assurances that it is not” (Interim Policy Statement). On March 21, 2005, 32 attorneys general signed an official comment, which, in part, asked the DEA to focus on factors that differentiate criminal drug activity from legitimate medical practice in its investigations. With its final policy statement, the DEA refused to comply with this petition. However, repeated petitions on the part of attorneys general are anticipated in the near future.
National Association of Attorneys General (NAAG) End-of-Life Healthcare Project: Initiated in 2002 by Oklahoma Attorney General Drew Edmondson, who chaired NAAG that year. The project identified three areas in which attorneys general could make a difference in their states: pain management, recognition of the wishes of people at the end of their lives, and ensuring quality end-of-life healthcare. A report was issued in 2003 with the goal of educating attorneys general about the issue.
DEA FAQ on Pain Treatment (released and subsequently withdrawn Oct. 6, 2004)
Dispensing of Controlled Substances for the Treatment of Pain, 69 Fed. Reg. 67 (2004) (Interim Policy Statement)
Dispensing Controlled Substances for the Treatment of Pain, on September 6, 2006, 71 Fed. Reg. 172 (2006) (Final Policy Statement)
The DEA released a set of guidelines regarding the dispensation of pain medication which has been twice revised, yet still suffers from failing to clearly differentiate between criminal activity and legitimate medical practice.
National Pain Care Policy Act 2003: This piece of legislation is a response to the Decade of Pain Research declared by Congress, which began January 1, 2001. The goal of the bill is the too-long-awaited federal recognition of pain as a critical health care crisis in the United States.
Palliative Care Education and Training Act (codified as amendment to New York Public Health Law § 63-f at § 2807-n) (2007): The act provides significant funding for training physicians in pain management and allows for the development of a New York State Palliative Care and Education Council, the establishment of Department of Health-designed Centers for Palliative Care Excellence, and the formation of Department of Health-certified palliative care practitioner resource centers. PEAT is used to evaluate how much grant funding each center will be allotted.
New York Academy of Medicine PEAT (Palliative Education Assessment Tool): An instrument by which medical schools can assess their curricula with regard to content on end-of-life care in order to plan and implement measures to improve medical education across domains including palliative medicine, pain, neuropsychologic symptoms, ethics and the law, and patient/family/caregiver/nonclinical perspectives on end-of-life-care.
Montana Ruling Bolsters Doctor-Assisted Suicide (December 31, 2009)
In a 4-3 decision, the Montana Supreme Court has ruled that physicians who help terminally ill patients die are protected from prosecution. However, the Court did not comment on whether physician-assisted suicide is a right guaranteed by the Montana state constitution.
Why This Wisconsin City Is the Best Place to Die (November 16, 2009)
La Crosse, Wisconsin has established a system of end-of-life care that has resulted in the highest rate of adults with completed advance directives in the country, as well as drastically lowered costs within the last years of patients' lives. These advance end-of-life consultations, which are not covered by Medicare, have been promoted by the organization Respecting Choices, founded by medical ethicist Bud Hammes.
For the Elderly, Being Heard About Life’s End (May 5, 2008)
“Slow medicine” is a healthcare approach, grounded in research at the Dartmouth Medical School, that encourages less aggressive — and less costly — care at the end of life. Slow medicine encourages physicians to put on the brakes when considering care that may have high risks and limited rewards for the elderly, and it educates patients and families how to push back against emergency room trips and hospitalizations designed for those with treatable illnesses.
Researchers Find Huge Variations in End-of-Life Treatment (April 7, 2008)
New research shows huge, unexplained variations in the amount, intensity and cost of care provided to Medicare patients with chronic illnesses at the nation’s top academic medical centers (the last two years of life ranges from an average of $93,842 for patients who receive most of their care at U.C.L.A. Medical Center to $53,432 at the Mayo Clinic’s main teaching hospital in Rochester, Minn.), raising the possibility that the government could save large amounts of money.
5 documents that can help you, your family with medical decisions (November 27, 2007)
Arizona's Life Care Planning Packet, includes five documents that deal with often-vexing topics such as artificial life support, resuscitation and care if you become incapacitated.
Trafficker or Healer? And Who’s the Victim? (March 27, 2007)
Article provides details on the case of the United States v. William Eliot Hurwitz, and a brief history of the arc of prosecution that has recently been leveled against doctors. It portrays a battle over who sets the rules for treating patients who are in pain: narcotics agents and prosecutors, or doctors and scientists.
National AG association installs Edmondson as president (June 27, 2002)
Oklahoma Attorney General Drew Edmondson uses his inaugural address as president of NAAG to address the importance of end-of-life-care.