ROSEBURG DOCTOR FACES PENALTY ON PAIN CONTROL

* The state medical board says Dr. Paul A. Bilder failed to give seriously
ill or dying patients adequate medication

The Oregon Board of Medical Examiners intends to discipline a Roseburg
doctor for failing to give six seriously ill or dying patients adequate
pain medication.

The case, detailed in a March board order, sends a message that in an era
of heightened focus on pain control, the board is as concerned about
undertreatment as it is about overtreatment of pain.

"In the area of pain medication, it's important for physicians to stay
current and be addressing these needs for patients," said Kathleen Haley,
executive director of the state board.

The board accuses Dr. Paul A. Bilder, a 54-year-old pulmonary disease
specialist, of unprofessional or dishonorable conduct and gross or repeated
acts of negligence. Between 1993 and 1998, according to the March 19 board
order, Bilder:

* Treated an elderly man who was dying of cancer and in pain with
"substantially inadequate amounts of pain medication," contrary to a
hospice nurse's request for stronger pain drugs and anti-anxiety
medication. He also refused a hospice nurse's request to give the man a
urinary catheter. Bilder told the board he thought the catheter would cause
infection. The patient died of his cancer three weeks later.

* Ordered removal of a urinary catheter from a dying and incontinent cancer
patient, against the wishes of the patient and family. Bilder told the
hospice nurse to use diapers instead. Bilder ordered .25 milligrams of the
pain drug Roxanol every four hours, a small fraction of the amount the
hospice nurse suggested, and Tylenol for high fever. He believed the
nurse's request for additional pain drugs was excessive. The patient died
that evening.

* Stopped giving sedatives and pain medication to a 35-year-old woman with
pulmonary disease while she was on a mechanical ventilator at Mercy Medical
Center in Roseburg. He ordered a paralytic agent, which relaxes the
breathing muscles to accommodate the breathing tube, without the use of
sedatives. (Sedatives are often used to combat panic from having the
breathing tube in the throat.) Bilder refused to put her back on pain
medication or sedatives later that day when the woman became restless and
fought her ventilator. The woman subsequently pulled out her breathing
tube. Bilder was asked to return to reinstall it. He did not respond in
time, and an emergency room physician performed the task instead.

* Refused a nurse's request to give morphine to treat anxiety in a
63-year-old woman with pulmonary disease and diabetes who was put on a
ventilator at Mercy Medical Center because of acute respiratory failure.
Bilder ordered paralytic agents only.

* Refused morphine or other pain medication for a hospitalized 82-year-old
patient with congestive heart failure. The patient told a nurse, "I just
can't breathe, and I'm getting tired." The patient became increasingly
agitated, and his breathing and heart rates increased. Bilder ordered
Lasix, a diuretic. The patient's symptoms continued, but Bilder again
refused to give morphine. The patient was subsequently treated and
stabilized by another physician and left the hospital several days later.

* Failed to give a 33-year-old pneumonia patient narcotic painkillers or
anxiety medication while installing a breathing tube through the patient's
nose. The medical staff made multiple attempts to get the tube in, causing
the patient's nose to bleed. The staff had to restrain the patient to
complete the procedure.

Bilder declined to comment on his case before the board. He has 21 days
from when he received the board order this week to decide whether he would
like a hearings officer to review the case. If so, the board will wait for
the hearings officer's report before deciding on disciplinary action.

Disciplinary action could range from a reprimand to revocation of Bilder's
medical license. In cases involving a doctor's knowledge in a particular
area, the board often recommends additional training and counseling.
Bilder, who was first licensed as a physician in Oregon in 1976, has no
previous disciplinary history with the board.

The Oregon Board of Medical Examiners has made it a point in recent years
to educate doctors about the need for adequate but appropriate pain
control. Board officials speak on the topic at medical conferences and
served on a statewide task force on pain issues.

The board's new approach is in contrast to its hard-line treatment of
doctors who overprescribed narcotic painkillers in the past, particularly
in the 1980s during the national "War on Drugs." Bilder's case is the first
time in recent memory that the board has gotten a complaint about
undertreatment of pain, Haley said.

The issue of adequate pain control came to the forefront with a national
study, published in 1989, that showed that more than half of seriously ill
and hospitalized patients die in pain. In recent years, the debate over
physician-assisted suicide has pushed the medical community to do a better
job with pain control in an effort to dissuade patients from wanting to end
their lives.

You can reach Erin Hoover Barnett at 503-294-5011 or by e-mail at
ehbarnett@news.oregonian.com.