Pain Management and Palliative Care

A critical area of concern with important ethical and legal implications and considerations, the assessment of pain is commonly referred to as "the fifth vital sign." The International Association for the Study of Pain (1979) describes pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" [see also Stedman’s Medical Dictionary, 26^th Edition (Baltimore, MD: Williams & Wilkins, 1995)]. Dame Cicily Saunders, the founder of Hospice, coined the term total pain, in order to think of pain not only as physical, but also as mental, social and spiritual. Pain management denotes the alleviation of pain symptoms in conjunction with curative, palliative, or end-of-life care, in response to chronic, acute and cancer-related pain. Palliative care denotes the alleviation of symptoms without curing the underlying pathology. In 1997, the World Health Organization identified "pain management and palliative care" as one of six areas of priority for international action in Health. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has developed a set of standards in the assessment and management of pain by which all member organizations will be evaluated.

Patient and surrogate fears that pain control may be inadequate or impossible to achieve are widespread, and may be responsible, in part, for the increasing interest in euthanasia and physician-assisted suicide. [See: Junkerman, C. and D. Schniedermeyer, Practical Ethics for Students, Interns, and Residents (Frederick, MD: University Publishing Group, 1994)]. The U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (formerly Agency for Healthcare Policy and Research) provides many guidelines, as do many professional societies.

In the context of appropriate care at the end of life, the Ethical and Religious Directives states that:

n. 61

This moral perspective on the permissibility of using narcotics for the relief of terminal pain, even if it indirectly hastens death, has been reiterated several times in Church teaching since the 1950s (most recently by John Paul II in the encyclical Evangelium Vitae, n. 65, paragraph 3). Moreover, Catholic health care’s support for the aggressive use of pain relieving drugs and palliative care has become even stronger since Directive 61 came out in 1994. Appropriate pain management must be distinguished from physician-assisted suicide and euthanasia, through the principle of double effect.

Directive 61 goes on to state that, "patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering." This Directive does not imply that suffering is to be encouraged in Catholic hospitals. Rather, it acknowledges that much of human suffering goes beyond what medical science can address. In particular, existential and spiritual suffering may need to be interpreted in light of higher spiritual meaning. Given this distinction, Directive 61 does not impose a restrictive injunction nor diminish, in any way, the moral obligation of caregivers in Catholic institutions to alleviate suffering as much as possible, but requires care providers to recognize that suffering is broader than the experience of mere physical pain. In this way, Directive 61 emphasizes the holistic care that is characteristic of the healing ministry of Jesus. This duty to address suffering in a holistic manner, is illustrated by the parable of the Good Samaritan in the Gospel according to Luke, by Jesus curing the leper and the woman with the hemorrhage in Mark’s Gospel, and by Matthew’s account of Jesus healing the two blind men of Jericho.

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