PAIN MANAGEMENT - A PLEA FOR LESS PAIN DYING PATIENTS

Families Want Relief When It's Needed Most

Dr. Stephen Knox walks a tightrope as he seeks to treat the intractable
pain of his many patients with AIDS and cancer.

The San Francisco doctor has found that morphine and other narcotics often
- - - but not always -- are the most effective way to ease his patients'
suffering.

But he fears the scrutiny of state authorities, who closely regulate such
drugs.

"Pain can be debilitating," Knox said. "It consumes people and affects
their well-being. Sometimes by getting them on adequate medication, they
can go on with their lives. But I keep getting worried that the
government's going to investigate me."

Doctors in California and across the nation face a quandary as a
traditional approach to pain -- in which physicians were skeptical of
patients seeking medication and worried they could lose their licenses for
prescribing too many narcotics -- gives way to an emerging standard that
doctors should listen to their patients and treat pain aggressively.

Although doctors still face sanctions for overprescribing, the changes in
pain management are backed by recent research and have led to a handful of
lawsuits accusing doctors of undermedicating pain, including one case in
trial in Alameda County.

"It used to be that doctors were really patrician, and what they said was
what the patient did," said Dr. John Fletcher, a San Francisco internist
practicing since 1964. "But (the demands of) patients have put doctors in
the middle. We are walking a fine line. It's frustrating at times."

The East Bay case is the first in the nation to charge a doctor with elder
abuse for alleged undermedicating. The children of 85-year-old William
Bergman of Hayward, who died of lung cancer, are suing his internist for
failing to prescribe enough painkillers to ease the torment of his final days.

Medical experts say the case shows how patients are becoming better
educated about their options and more willing to be outspoken, while
patient advocacy groups are becoming more militant in demanding better
care, especially for the terminally ill.

One example of that activism, the passage by Oregon voters of a 1997 ballot
measure permitting assisted suicide, was influential in persuading the
medical establishment to work harder to make people comfortable in their
dying days, according to Dr. Robert V. Brody, chief of the pain
consultation clinic at San Francisco General Hospital and a professor of
medicine at the University of California at San Francisco.

"There's an understanding finally that the biggest drug problem we have is
with the undertreatment of pain," said Brody, who testified last week in
the Alameda County trial.

The new consensus on aggressive pain treatment has been fueled by research
that has attempted to quantify America's pain problem.

A 1995 study, funded by the Robert Wood Johnson Foundation, found that half
of those who died in acute-care hospitals nationwide were in moderate to
severe pain in their last days.

A Brown University study, published in the Journal of the American Medical
Association last month, found that 40 percent of nursing home patients
nationwide with acute or chronic pain are not getting treatment that brings
them relief.

These findings, combined with patient activism, have led to new laws and
professional standards encouraging more prompt and effective treatment of pain.

In 1994, after years of disciplining doctors for overmedicating, the
California Medical Board issued guidelines reassuring physicians that it
was acceptable to use narcotics to treat persistent, incurable pain. And in
1997, the Legislature approved the Pain Patient's Bill of Rights allowing
patients to ask for the painkillers of their choice. Similar laws went into
effect in other states.

Nationally, the Department of Veterans Affairs has directed doctors and
nurses at VA hospitals to monitor a patient's pain level as a "fifth vital
sign."

In January, the Joint Commission on Accreditation of Healthcare
Organizations began requiring hospitals, hospices and nursing homes to
assess and treat pain in order to be accredited. And the federal agency
that certifies health care providers receiving reimbursement from Medicare
or Medicaid also established standards for pain management.

"Unrelieved pain has enormous psychological and physiological impacts. It
delays healing, it increases anxiety, and those are increased costs that
health care organizations bear," Joint Commission spokeswoman Charlene Hill
said.

In San Francisco, a 2-year-old hospice at the University of California
Medical Center is serving as a model for so-called "palliative" care, which
is focused on alleviating pain. Families are encouraged to be with the
dying patient and even spend the night. Patients stay in homelike suites
where music plays and nurses administer morphine and help keep patients
comfortable, to allow them a dignified death.

But such treatment is still the exception to the rule, says Barbara Coombs
Lee, executive director of the Oregon nonprofit Compassion in Dying, one of
the principal groups advocating for improved end-of-life care.

The group, which is assisting the East Bay family in its lawsuit, also is
sponsoring legislation that would force the California Medical Board to
require doctors to get education in pain management if the board finds they
have treated a patient's pain inadequately. The medical board did say the
Hayward man's pain treatment was insufficient, but his physician, Dr. Wing
Chin, was not disciplined because the board did not find he had violated
state law.

"There are currently no consequences for abandoning patients to their pain,
" she said. "But there are at least perceived consequences for being seen
as an excessive prescriber."

Physicians who deal with pain say the change will take time.

"The fear of (abetting drug) abuse is legitimate, but it's something we
have to live with," Brody said. "On the first pass, you have to take the
patient's word for it. And that's a big leap for doctors."