Health Issues

The Problem Of Unrelieved Pain

Concern over unrelieved pain for terminal patients has become a national public policy issue, say legal experts. For example, in two assisted suicide cases, several U.S. Supreme Court justices said that if there are legal barriers to effective pain management at the end of life, the constitutionality of assisted suicide could be reconsidered.

According to a survey by New York State's Public Health Council:

  • Even where a medication is legal and medically indicated for a patient, 71 percent of doctors responding say they do not prescribe effective medication for cancer pain if that prescription would require them to use a special state-monitored controlled-substances prescription form.

  • Instead, nearly three-fourths of the doctors reported prescribing less effective drugs.

  • Currently, doctors who prescribe controlled substances for the relief of pain risk investigation, disciplinary action, criminal action and liability.

  • Although they have the power to do so, medical disciplinary boards have not disciplined doctors for the under-treatment of pain.

Several states have established commissions to study the problem of pain management, especially at the end of life, and state legislatures are currently considering legislative action. And an in-depth study of the problem by the American Society of Law, Medicine and Ethics recommended state medical boards reform their standards and practices.

Source: Sandra H. Johnson (St. Louis University School of Law), "Prescription of Controlled Substances for the Relief of Pain," Health Law News, June 1998, University of Houston Health Law and Policy Institute, Houston, Texas 77204, (713) 743-2101.

Terminal Care Varies Widely Across The U.S.

Where an elderly patient nearing the end of life resides in the U.S. will greatly determine the kind of treatment he or she will receive, according to a new study from the Dartmouth Medical School. John Wennberg, who led the study, says different approaches to end-of-life care have sprung up haphazardly around the country.

The research, based on 1994 and 1995 Medicare records of 37 million elderly patients, does not judge which region's end-of-life care is best.

  • Older people in Miami, New York City and parts of south Texas are especially likely to spend their final days in a hospital -- often in an intensive-care unit (ICU).

  • Elderly residents of many Western states are much more likely to die at home -- without nearly as much in the way of last ditch effort at medical intervention.

  • The study found strikingly uneven distributions of hospital beds, specialist physicians and other medical resources.

  • Wennberg says "it is not clear that terminally ill people benefit" by spending a lot more money -- "either in terms of mortality rates or quality of life."

A few examples demonstrate the magnitude of the cost differences involved.

  • Medicare patients in Miami are five times more likely to be treated in an ICU during the final six months of life than are residents of Sun City, Arizona.

  • Those in Newark, N.J., and several New York City boroughs are likely to spend at least 20 days in a hospital during their final six months of life, compared to 5.3 days for those in Salt Lake City.

  • Medicare pays an average of $16,571 for hospital bills in Manhattan during patients' final six months, versus about $6,000 in several Oregon districts -- even after making adjustments for local cost differences.

Experts report that many Oregon patients are choosing to die at home, while receiving pain-relieving care through local hospice organizations.

Nationwide, about 35 percent of all Medicare patients die in hospitals.

Source: George Anders, "ZIP Code Is a Key to Course of Terminal Care," Wall Street Journal, October 15, 1997.

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