Patients at all health facilities are generally checked for four major health indicators: pulse, temperature, respiration and blood pressure. But the Veterans Administration’s health care workers will now add pain as a fifth vital sign.
VA officials said the change in routine is designed to call physicians’ attention to what is widely considered one of the most unrecognized and untreated symptoms in American health care. In a study of 10,000 dying patients published in 1995 in the Journal of the American Medical Association, for instance, researchers found that almost half died in severe pain; other studies report that as many as three-quarters of advanced cancer patients are in pain.
"Assessing pain can make a tremendous difference in the lives of patients," said Shashidhar Kori, a neurologist at the James Haley VA Medical Center in Tampa. "Patients with serious illness and terminal illness sometimes equate pain with a worsening of the disease, so they don’t want to complain or volunteer information about pain. They will say the doctor doesn’t want to hear about a ‘minor’ issue like pain, or worry that it will distract the doctor from ‘real’ issues."
Routine pain evaluation, experts suggest, can help patients learn that it is worth telling doctors about pain, that effective treatments are available, and that early treatment of pain can reduce future hospitalizations and improve quality of life.
According to Betty Ferrell, a research scientist at the City of Hope National Medical Center in Duarte, Calif., many studies indicate that most pain can be relieved and treated. She pointed to guidelines issued by the U.S. Agency for Health Care Policy and Research, which recommended protocols for pain management. Ferrell explained that pain management requires a careful balance between relieving patients’ pain while not making them too sleepy or sedated to function.
"We want patients to be as functional as possible," she said. "For example, we want to give an older patient pain relief while keeping him alert enough not to fall. We want post-surgical patients to be comfortable, but awake enough to do the things necessary to recover. It is really about striking a balance."
The VA project has the potential to transform pain management nationwide: The Veterans Administration is the country’s largest trainer of health care practitioners, with 1,100 health care facilities. Approximately half of all medical students and a quarter of all medical residents rotate through the VA medical system, which creates an opportunity to improve medical education around pain management. In addition, the VA patient census is large: Last year the VA treated 3.5 million patients.
"Through our end-of-life initiatives, it’s become clear that pain is not well addressed in end-of-life care, or anywhere else for that matter," said Kenneth W. Kizer, undersecretary of health at the Veterans Health Administration. "From the demographics of our population, we know that pain is a significant problem."
Measuring pain as a vital sign, Kizer said, is the first step in what will be a long-term process to make pain management a routine part of patient care.
A team with representatives from an array of disciplines—anesthesiology, nursing, psychiatry, surgery, oncology, pharmacology and neurology—is coordinating the project. Despite the broad base of support, the program will face many challenges, officials said.
Toni Mitchell, a physician who is the Veterans Health Administration’s chief consultant for acute care, said that improving pain management will require educating new doctors and reeducating practicing physicians. "We simply don’t remember to take care of pain, we’re so focused on the technical part" of treating patients’ disease.
Judith Salerno, a physician and chief consultant for geriatrics and extended care, said that training new doctors to address pain is critical to the project’s success. "We hope to make pain assessment a habit, and to inculcate new doctors with skills to manage pain. We want to give them these skills in a place where there’s a commitment to better pain management," Salerno said. "We need to make pain assessment something that front-line workers can easily use, so that pain as a vital sign works as a clue for more help."
The VA initiative comes as some members of Congress have also expressed interest in finding ways to encourage physicians and other health care workers to alleviate patients’ pain.
Pain management has even drawn congressional interest. Sen. Ron Wyden (D-Ore.) and Rep. Darlene Hooley (D-Ore.) have established a working group to examine what role the federal government should play in alleviating pain and in other end-of-life issues. At a meeting in November, Wyden invited experts and families to testify about barriers to pain management. One of the speakers was Linda Hay Crawford, who works for the American Cancer Society and who chronicled her late husband’s five-year struggle with cancer and his death in March 1996 (see December 1998 Exchange).
Victor Crawford, a veteran Maryland politician and attorney, had lung cancer that spread. He had some of the best medical care available, yet, she said, he was unable to receive the pain relief he needed. Crawford noted, "There was not one moment during the course of his disease that he was not experiencing or handicapped by pain."
In January 1996 he collapsed while arguing a case in court, and began a five-week hospitalization from which he never returned home. "[He] screamed in pain most of the rest of his life," said Crawford. "Very few of the physicians, outside the cancer centers, had any sensitivity to the pain or their responsibility in managing that pain. . . . The ICU doctors did not prescribe any pain medication, because they said it was not needed."
The VA initiative is designed to help prevent such experiences among veterans and by example in other health facilities, too. "Now we have an opportunity to step up to the plate, to be a real resource," Kizer said. "People often view us as only taking care of vets, but we can influence medicine throughout the country."
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