Ethical implications of pain management in a nursing home: a discussion

The objectivity and subjectivity of pain practices in older adults with dementia: A critical reflection

Providing nursing care for people with dementia residing in long-term care facilities poses specific challenges regarding pain practices. With underlying communication barriers unique to dementia pathologies, this population is often unable to communicate verbal sentiments and descriptions of pain. In turn, nurses caring for older persons with dementia have difficulty assessing, managing and treating pain. Objectivity is an imperative factor in healthcare pain practices; however, it is difficult to objectively evaluate someone who cannot accurately communicate their experience of pain. Therefore, the authors believe that subjectivity is also an essential part of evaluating the person with dementia's experience of pain. In this critical reflection, the authors explore objectivity and subjectivity in relation to pain practices for dementia in long-term care. A historical summary of pain is provided outlining the evolution of objectivity and subjectivity related to pain practices. The authors discuss the complexities of assessing and managing pain and offer a new perspective about the role of objectivity (and co-existence of subjectivity) for nurses treating pain in the older adults with dementia.

A systematic review of ethical and legal issues in elder care

BACKGROUND

Ethical and legal issues are increasingly being reported by health caregivers; however, little is known about the nature of these issues in geriatric care. These issues can improve work and care conditions in healthcare, and consequently, the health and welfare of older people.

AIM

This literature review aims to identify research focusing on ethical and legal issues in geriatric care, in order to give nurses and other health care workers an overview of existing grievances and possible solutions to take care of old patients in a both ethical and legally correct way.

METHODS

Using a systematic approach based on Aveyard, a search of the PubMed, CINAHL, and Ethicshare databases was conducted to find out the articles published on ethical and legal issues in geriatric care.

ETHICAL CONSIDERATIONS

The approval for the study was obtained from UMIT-The Health and Life Sciences University, Austria.

RESULTS

Only 50 articles were included for systematic analysis reporting ethical and legal issues in the geriatric care. The results presented in this article showed that the main ethical issues were related to the older people's autonomy, respect for their needs, wishes and values, and respect for their decision-making. The main legal issues were related to patients' rights, advance directives, elderly rights, treatment nutrition dilemma, and autonomy.

CONCLUSION

Further education for professional caregivers, elderly people, and their families is needed on following topics: care planning, directive and living wills, and caregiver-family member relationships to guide and support the elderly people within their decision-making processes and during the end-of-life care.

Chronic Pain Management Among Older Adults: A Scoping Review

Chronic pain is a significant problem for older adults. The effect of chronic pain on older people's quality of life needs to be described and identified. For a decade, the Roy Adaptation Model has been used extensively to explain nursing phenomena and guide nursing research in several settings with several populations. The objective of this study was to use the Roy Adaptation Model to describe chronic pain and present a systematic scoping review of the literature about the middle-range theory of chronic pain among older adults. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses model guided a scoping review search method. A literature search was undertaken using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Ovid, and ProQuest. The search terms were "chronic pain," "pain management," "older adult," "Roy Adaptation Model," and "a scope review." The search included articles written in English published for the period of 2004-2017. All articles were synthesized using concepts of Roy's Adaptation Model. Twenty-two studies were considered for the present review. Twenty-one articles were reports of quantitative studies, and one was a report of a qualitative study. Two outcome measures were found in this systematic scoping review. The primary outcomes reported in all articles were the reduction of pain due to interventions and an increase in coping with chronic pain. The secondary outcome measures reported in all studies were the improvement of physical function, quality of life, sleep disturbance, spiritual well-being, and psychological health related to pain management interventions among older adults. Many interventions of all studies reported improvement in chronic pain management among older adults. However, to improve chronic pain management, nurses need to understand about nursing theories, the context which instruments work, and develop empirical instruments based on the conceptual model.

An ethical framework for the management of pain in the emergency department

Pain is a ubiquitous problem, affecting more than 100 million individuals in the United States chronically and many more in the acute setting. Up to three-quarters of patients presenting to the emergency department (ED) report pain as a key component of their reasons for requiring acute care. While pain management is a fundamental component of emergency medicine (EM), there are numerous attitudinal and structural barriers that have been identified to effectively providing pain control in the ED. Coupled with public demands and administrative mandates, concerns surrounding ED pain management have reached a crisis level that should be considered an ethical issue in the profession of EM. In this article, the authors propose an ethical framework based on a combination of virtue, narrative, and relationship theories that can be used to address the clinical dilemmas that arise in managing pain in ED patients.

Pain and persistent pain in nursing home residents in Norway

The objective of this study was to examine the nature of pain and persistence of pain in nursing home residents. The study was carried out with 201 participants drawn from six nursing homes in Norway. The participants rated their pain on 5 different days within a 14-day period on the modified McGill Pain Questionnaire regarding the intensity and location of pain. Four patterns in the persistence of pain were extracted, with the results showing approximately 50% of the participants experiencing persistent pain of a moderate to intense level. Pain ratings and persistent pain were significantly associated with number of body areas with pain, sleeping problems, number of medical diagnoses, and number of medications. The findings of this study suggest that both persistence and fluctuation of pain within short time periods may be related to inadequacy in pain management in nursing home residents, and fill the gap in the literature regarding patterns of persistent pain in nursing home residents.

Educational needs of health care providers working in long-term care facilities with regard to pain management

BACKGROUND

The prevalence of chronic pain ranges from 40% to 80% in long-term care facilities (LTCF), with the highest proportion being found among older adults and residents with dementia. Unfortunately, pain in older adults is underdiagnosed, undertreated, inadequately treated or not treated at all. A solution to this problem would be to provide effective and innovative interdisciplinary continuing education to health care providers (HCPs).

OBJECTIVE

To identify the educational needs of HCPs working in LTCF with regard to pain management.

METHODS

A qualitative research design using the nominal group technique was undertaken. Seventy-two HCPs (21 physicians⁄pharmacists, 15 occupational⁄physical therapists, 24 nurses and 21 orderlies) were recruited from three LTCF in Quebec. Each participant was asked to provide and prioritize a list of the most important topics to be addressed within a continuing education program on chronic pain management in LTCF.

RESULTS

Forty topics were generated across all groups, and six specific topics were common to at least three out of the four HCP groups. Educational need in pain assessment was ranked the highest by all groups. Other highly rated topics included pharmacological treatment of pain, pain neurophysiology, nonpharmacological treatments and how to distinguish pain expression from other behaviours.

CONCLUSION

The present study showed that despite an average of more than 10 years of work experience in LTCF, HCPs have significant educational needs in pain management, especially pain assessment. These results will help in the development of a comprehensive pain management educational program for HCPs in LTCF.

The fragmented story of pain: a saga of economic discourse, confusion and lack of holistic assessment in the residential care of older people

The long-standing problem of overlooked and/or undertreated pain experienced by so many older people living in Australian residential care facilities condemns these people to a life robbed of quality. Such a degree of suffering experienced by older people calls into question the pain assessment skills of staff who work in residential care. However, the problem of undetected and unresolved pain experienced by older people is not simply a skill or knowledge issue. It is much broader than that. In this paper we portray pain as likened to a story; a narrative that only the older person, as the author, can impart and one in which only they can communicate their experience of pain. Nevertheless, as opposed to seeking the older person's pain narrative, nurses attempt to measure the immeasurable. In part, their actions relate to the confusing terminology which envelops pain assessment. However, political policy and economic discourse also influences nurses' pain assessment practises to the detriment of older people and the profession of gerontological nursing. Discussion in this paper includes the experience of pain for the older person, an overview of the specific role of pain-screening tools compared with the requirements of a person-centred pain assessment, and person-centred pathways to help nurses and others interpret and heed the older person's pain story. Analysis also incorporates the argument that current and previous Federal Government funding tools for residential care subtly impact on holistic pain assessment causing confusion for caregivers and fragmentation of the older person's pain story.

A survery of commitment and compassion among nurses in residential aged care

AIM

To assess the views and attitudes of aged care staff providing direct care towards palliative care and to identify their learning needs.

DESIGN

Survey design using purposive sampling methods.

FINDINGS

Nurses and care assistants (n=222) employed within nine residential aged care facilities in regional Australia completed the survey. The majority had received 'on the job training' and were committed to providing end-of-life care. Differences in the level of confidence to deal with patient/family interactions and manage complex palliative care scenarios were evident between nurses and care assistants (p<0.05). Both nurses and care assistants perceived a need for further education in symptom management and communication, yet their content need differed significantly between groups.

CONCLUSIONS

Nurses and care assistants in residential aged care facilities demonstrate commitment to the delivery of palliative care and express a need for increased palliative care competencies. The heterogeneity of roles and educational preparation within the aged care workforce indicate that tailored palliative care education initiatives are required to meet the learning needs of aged care nurses and care assistants, particularly in relation to end-of-life care. These data have implications for skill-mix and model of care development.

Barriers to Managing Pain in the Nursing Home: Findings From a Statewide Survey

OBJECTIVES

The objective of this study was to identify pain management demographics, perceived resources, and perceived barriers to adequately manage pain in the nursing home setting.

DESIGN

Mailed survey.

SETTING

All licensed Connecticut nursing homes.

PARTICIPANTS

Directors of Nursing (DONs).

MEASUREMENTS

Survey eliciting pain management demographics, perceived resources, and perceived barriers to adequately manage pain in respondents' nursing home.

RESULTS

A total of 113 of 260 DONs (43%) responded to the survey. Respondents believed pain was suboptimally managed, particularly for residents with malignant and nonmalignant chronic pain. Perceived barriers to providing adequate pain management included lack of knowledge about pain management among nurses and physicians, lack of a standardized approach to treating pain, physicians' personal attitudes toward treating pain (eg, fear of addiction or overdose), lack of diagnostic precision in treating pain, and difficulty in choosing the right analgesic. Other barriers are also discussed, including low hospice enrollment of nursing home residents.

CONCLUSION

Improving pain management in nursing homes requires improving provider knowledge and attitudes, enhancing diagnostic precision, standardizing pain treatment, and achieving an institutional commitment. Although responding DONs seemed aware of the need for improved pain management outcomes at their facilities, the required institutional commitment to accomplish this was not evidenced by these findings.

The assessment and management of pain among older people in care homes: current status and future directions

Pain is highlighted as a significant, yet neglected problem among older people, particularly in long-term care settings. The effects of inadequate assessment and treatment of pain among older people may lead to multiple problems. Problems arise due to cognitive impairment of clients and inadequate assessment by healthcare professionals. Analgesics are under-used and there is a need for improved education of both healthcare professionals and older people regarding attitudes to pain and ageing. Research is needed into the prevalence of pain among older people in United Kingdom (UK) care homes, how best to further educate healthcare professionals regarding pain management and how to enable older people to be facilitative partners in this process.

Older persons' ethical problems involving their health

Although older persons (aged 65 years and older) experience stressful ethical problems involving their health, research is lacking about this phenomenon. The purpose of this study was to describe and examine the content and basic nature of older persons' ethical problems concerning their health. The conceptual framework and method combined ethical enquiry and phenomenology. The participants were 18 older persons and 12 of their children or grandchildren (for contextual understanding). The 19 women and 11 men, 73% of whom were Caucasian, described 184 ethical problems, from which emerged 10 content categories. The basic nature of the ethical problems consisted of conflict, resolution and rationale. The results could assist health professionals to promote older persons' ethical decision making, quality of life, and good death.

Chronic non-cancer pain in older people: current evidence for prescribing

Chronic pain is a serious problem for many older people, yet its management in this population is often less than satisfactory. The high incidence of toxicity and side effects with some medications and irrational fears of opioid dependence are significant barriers to effective pain management. In this article, the research evidence relating to these issues is examined, and their impact on nurse prescribing considered. More studies are needed to assess the veracity of opposing arguments, and to support effective assessment and prescribing by nurses.