Case Report - (2019) Volume 9, Issue 2
Lilly is a seventy nine year old white female with an extensive medical history including Chronic Obstructive Pulmonary Disease (COPD), osteopenia, osteoarthritis, multiple recurrent muscle strains, sciatica and chronic lumbago. Due to all her ailments she has required increasingly more medication and high doses of narcotics to manage her multi-factorial pain. Her PCP, having reached her maximum prescribing comfort in response to the recent awareness of narcotics abuse and overuse in the United States, referred her to pain management. Upon review of her history, pain management quickly refused to accept Lilly as a patient labelling her an addict. What follows is a series of ethical questions with known and unknown facts, listing stakeholder's values with possible solutions. The intention is to generate awareness and questions about the ethical involvement of the treatment of narcotics abuse where different disciplines and specialists could work together.. Lilly and her sons all agreed not to adhere to the pain management specialist’s advice.
Keywords: Osteopenia; Narcotics abuse; Osteoarthritis; Dump
Lilly is a seventy nine year old white female with an extensive medical history including Chronic Obstructive Pulmonary Disease (COPD), osteopenia, osteoarthritis, multiple recurrent muscle strains, sciatica and chronic lumbago. She lives alone in a house built by her grandfather, and struggles with her finances. She has difficulty performing her Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) due to limited ambulation and endurance. She uses a walker to ambulate and has kyphosis of the thoracic region, which prevents her from walking erect.
Lilly has three adult sons, one of which is in active treatment for cancer and is struggling with a history of drug abuse. None of her children live in her near vicinity and rarely visit. However, they remotely assist with some decisions and provide medical treatment guidance. Lilly’s children are not involved or contribute to her financial, social or physical needs. Due to all her ailments she has required high doses of narcotics to manage her multifactorial pain. She has been under the care of the same Primary Care Provider (PCP) for over five years. Lilly’s PCP, having reached her max prescribing comfort in response to the recent awareness of narcotics abuse and overuse, referred her to a pain management specialist [1]. The PCP diligently provided a written history including past treatment and medications to the pain management specialist. Upon review of her history, pain management refused to accept Lilly as a patient labeling her an addict, calling the referral a “Dump” and advising immediate admission to an inpatient detoxification program. Lilly and her sons all agreed not to adhere to the pain management specialist’s advice and requested for her PCP to continue managing her pain.
• Should her PCP continue managing her pain?
• Should Lilly be mandated to attend a detox program?
• Should her sons be part of the decision process?
• Should Lilly be allowed to continue living alone?
• Should autonomy and independence be taken away from her?
• Should pain management specialists refuse to treat patients seeking treatment?
• Should there be management guidelines to taper off use of narcotics by a PCP?
Known
• Lilly lives alone and is having difficulty managing financiallyno physical support available.
• Lily is unable to self-care.
• Lilly has medical diagnoses which are related to pain and discomfort.
• Lilly has been using narcotics long term.
• Lilly needs pain management-She suffers from chronic pain.
• Lilly’s sons are not involved in her daily life, but are involved in her medical decisions.
• Lilly and her PCP have a long term patient-provider relationship.
• Lilly is unsafe under her current living arrangement.
Unknown
• Are there any other relatives available willing to assist?
• Are her sons willing to accept Lilly in their home?
• Are her sons willing to be part of the care plan and offer more support?
• Is Lilly willing to decrease or eliminate use of narcotics?
• Can Lilly’s pain be managed without narcotics?
• Have alternate treatments been attempted?
• Is she competent to self-direct care?
• Would she consider assisted living?
• Is her son benefiting from her medications?
• Has she been evaluated by psychiatry? Should she be evaluated by psychiatry?
• Is she using all the meds prescribed, has a toxicology screen been done?
• Would she be willing to do a toxicology test?
Lilly
She has the right to self-determine a course of action for her treatment. She has the right to decide if she wants to proceed with an inpatient detox treatment or continue care under her PCP. Her autonomy needs to be respected and she needs to be allowed to make independent decisions [2]. This brings controversies with her PCP who wants her to be managed by the pain clinic. Controversies also arise with the pain management specialist who ordered inpatient admission in a drug detoxification program without discussing it with Lilly. She might feel it unnecessary to change since the present treatment meets all her needs while managing her pain.
Son
Lilly’s sons are offering advice to their mother in the hopes of keeping her comfortable and pain free. They are acting to protect their mother and might be feeling betrayed by a PCP unwilling to continue the current “effective” treatment to manage their mother’s ailments. They feel betrayed by a system that wishes to punish their mother instead of just managing her pain. They view the referral of the PCP as an abandonment after years of trust and fidelity. It is also possible the personal experiences of Lilly’s sons, in regards to pain management, are influencing the advice they provide; therefore Lilly’s decision is directly affected by their experiences leading Lilly to refuse in-patient detoxification.
PCP (Primary Care Provider)
The PCP is considering different principles of ethics while making the difficult decision of changing the treatment for her patient. She is attempting to improve her care by adding a specialist to collaborate to manage her pain in a better way that would decrease risk. She is displaying compassion, beneficence, by taking a positive action to help Lilly [3]. She desires “to do good” while at the same time attempting to avoid harm [4]. She is struggling between beneficence and nonmaleficence. The PCP wants to be loyal and truthful to Lilly, and wants to continue advocating for her care and health. It is possible that the PCP is seeking collaboration to manage the complexity of the case and is acting in a somewhat paternalistic way to protect Lilly’s health.
Pain management specialist
The pain management specialist reacted unfairly by refusing treatment to a patient willingly seeking for different ways to manage her pain. The pain specialist views the referral as a way for the PCP to delegate the responsibilities of a complex case with years of abuse and neglect. Poor communication with good intentions between the PCP and the pain management specialist allowed for confusion and misinterpretation of an attempt for collaboration. The pain management specialist viewed the referral as complex and difficult, particularly since no relationship or contact with the patient was ever made attempted for further discussion of history. He was unwilling to accept the responsibility and the risk involved with Lilly’s treatment. There seems to be an underlying prejudice against addiction disrupting the ability to do good by accepting the burden society demands under justice.
• Convene a conference where all stakeholders could be present and proceed with a plan that could be beneficial for all parties while respecting Lilly’s autonomy.
• Continue treating Lilly with no change in her treatment plan. This solution might eventually raise a “red flag” and cause the PCP to go under investigation for excessive prescribing of narcotics. Under this solution the ethical dilemma of nonmaleficence needs to be considered.
• Assist Lilly in finding an alternate pain management specialist willing to manage her pain while decreasing the use of narcotics.
• Involve Lilly’s sons in the planning process and allow them to be an active part in her treatment.
• Discuss a collaboration plan with pain management to reduce the use of narcotics and introduce other pain management options.
• Seek assistance elsewhere. Consider other ways to assist Lilly possibly involving psychotherapy, psychiatry, adult protective services, or, a pain management specialist willing to accept the case and collaborate with the PCP.
The ethical principle of autonomy governs my choice among the possible solutions. By allowing Lilly to collaborate in devising the best plan increases the success rate of compliance with treatment. Her autonomy has to be balanced with the PCP’s dilemma between beneficence, non-maleficence and justice. Although Lilly refuses inpatient detoxification, the present treatment is no longer a choice and needs to be altered to decrease the use of narcotics. The treatment plan needs to allow for compassion, fairness and cause no harm to Lilly. The treatment plan also has to maintain the loyalty and fidelity shared during the past five years between the PCP and Lilly. The best feasible decision is to have a collaborative agreement between all the stakeholders to develop the best plan of treatment to assist Lilly wean off narcotics while respecting her autonomy, maintaining her trust and being fair to her and all the stakeholders.
Presently Lilly is being slowly weaned off the narcotics under the care of the PCP. Her PCP enlisted the collaboration of a psychiatrist specializing in addiction to create a plan that allowed Lilly autonomy and fairness. The pain management specialist refused involvement, even after the PCP and the psychiatrist made multiple attempts of collaboration. Lilly was allowed to stay home with additional home care services. The decision-making process involved mainly the PCP and Lilly under the close guidance of the psychiatrist. Lilly was given the opportunity to be an active participant in the process. She fully understood the need to change treatment plan to ultimately improve her quality of life.
Every two weeks her short-acting medication is being decreased and other pain management agents are being added. She is participating weekly of psychotherapist sessions with positive improvement. Her sons have remained marginal with their social interactions but continue to voice their opinion. A referral to Adult Protective Services (APS) was made to assist Lilly with housekeeping, personal care and financial needs. Lilly continues to make progress and receives weekly visits from her PCP to manage her medications. Although Lilly suffers chronic pain, she is adhering to the plan to slowly wean off the narcotics with use of alternate treatments and psychotherapy.
