The Fifth Vital Sign: Fetish or A Functional Parameter?
I would like to extend the discussion of the December 23, 2006 thread on pain and the relief of pain.
As many of my visitors might know, in the United States there has been an addition to the list of physical examination “vital signs”, which formerly only included the patient’s temperature, the respiratory rate, the heart or pulse rate and the patient’s blood pressure. Because of the concern that patients were not being initially asked about nor monitored for pain, within the past decade, pain was included as a necessary requirement to be included in the list of vital signs. Patients were to be asked about the intensity of any pain at the time of the examination which was to be expressed as numbers from 0 to 10, where 0 was no pain, 1 was the most minimal pain and 10 was the most severe pain that the patient could imagine.
It had been hoped that by physicians and nurses alerted by the patient’s numerical expression of their current pain, the information would encourage appropriate physician initiation of treatment to reduce the pain or if treatment was already in progress to evaluate the efficacy of the treatment and make adjustments in therapy if not adequately effective, the goal being the professional duty to attempt to relieve the patient’s pain and suffering.
So, we teach our medical students, nursing students, physicians and nurses about the “fifth vital sign” and to never forget to take it. The question is how consistently has this requirement been followed by the healthcare providers and also whether the inclusion of pain in the vital signs has made any difference in the quality of pain management. I can’t find much in the way of studies on this topic beyond a 2006 publication of a study at a Veteran’s Affairs medical center which showed that “the routine documentation of pain levels, even with system-wide support and broad-based provider education, was ineffective in improving the quality-of-care.”
The question is whether requiring the asking about and quantifying pain to be included as the fifth vital sign represents simply a kind of routine clinical fetish (an irrational, or abnormal, fixation or preoccupation ) or a rational and functional parameter which can and does promote benefit for the patient.
Without naming names in your commentary, I would most like to read from my visitors whether their doctors or nurses routinely ask them about whether they had any pain and, if present, instructed them to formally quantitate (1-10) their pain when the other vital signs were taken or independently at other times. And, if so, then, was there some action taken based on the information provided with the initiation of pain therapy, change of therapy or ordering of additional diagnostic testing regarding the origin of the pain? ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:36:00 PM
12 comments
12 Comments:
I have been asked this fairly often, but never when vitals are being taken.
I was recently in the hospital for nearly 4 weeks, and for quite awhile there was a guy in the next room who who would frequently cry out in pain. It was obvious that he needed more pain medication, but he was being given enough to block his pain.
He had a few choice names that he sometimes used on th nurses and doctors because they were letting him suffer for extended periods before he would get more medication. Sounded similar to what I would expect if someone were being tortured.
When, as a patient in the hospital, you were asked about whether you had pain, did they ask you to estimate it on a scale of 1-10, if you had any pain? If you did respond that you had pain, what happened next? The reason pain has been hooked to the vital signs is simply since vital signs are regularly performed as part of a hospitalization or a physical exam or office visit, it was intended to provide a regular opportunity to ask about pain. The question is what happens after the answer, if the question is indeed asked. ..Maurice.
I've been hospitalized twice for surgery, and never asked to rate my pain on a pain scale. At one hospital, the nurses would ask if I was okay, and I always said yes. My pain was well managed, and this was pretty obvious to anyone watching me.
At the other hospital, no one asked, and my pain was not well managed. Later, I needed to get records from both hospitals, and all the nurses had put in numberical values for my pain, (every value they gave was a 2 on a 10 point scale).
AG
AG what you observed was totally unprofessional, unethical and just plain wrong behavior--"dry-labbing", making up and documenting a response that was either not requested or was not the response the patient gave!
One important point to make and perhaps some healthcare professionals are confused about is that this quantitation of pain is obviously not something that an onlooker can estimate and then document. Pain is a sensation felt only by the patient, the one who is experiencing the pain. The scale of 0 to 10 is for the patient to estimate NOT the nurses or doctors. Now, it certainly is true that if a patient states that their pain is currently 10 and there is no physical signs or behavior which is consistent with what would be clinically observed in most patients with the "worst possible pain imagined", the healthcare providers may have some valid reason to question that the patient has such a magnitude of suffering. But they must write down the number 10 as relayed by the patient and not some other assumed number. The healthcare providers, however, can write a statement describing why the number is not consistent with their observations.
If this is a common occurance, the value of this 5th vital sign becomes clearly a fetish, a routine clinical fetish, an irrational, or abnormal, fixation or preoccupation which promotes and provides NO benefit for the patient and only demonstrates that the nurse or doctor has complied with a routine requirement and completed the requirement by filling in some number.
Is there ever a good, ethical exuse for "dry-labbing"? Well, that's a topic for another thread. ..Maurice.
The subject of pain has you have mentioned has garnered much attention over the years. Historically pain has been treated inadequately. The numeric scale, as well as other scales that have come out are still very much subjective and even with the explanation that providers give to patients we still hear “my pain is a 10” or higher when they are sitting quietly or talking with friends and family.
My twenty years in emergency and critical care medicine have shown me that as a community, healthcare providers under treat pain much of the time. In the ED setting I see pain often ignored by ED physicians unless it is brought up by nursing. I also see nursing not being as much as an advocate for patients. On the other hand as you know in the ED arena we are faced with several drug seeking individuals that have very convincing presentations of pain that are only looking for some Dilaudid. Even on the inpatient side we see the addicts constantly trying to obtain analgesics.
Treating pain appropriately is difficult. Providers have to sift through the subjectivity of a pain scale which is many times unreliable, the patient that is only looking to get high, and the patients that are truly in pain and need some relief. It is not as easy as it seems all the time. That being said do you just give every patient morphine or Dilaudid regardless? When you have a 24 year old patient who is speaking on her cell phone and you interrupt her and she says her pain is an 8 do you treat that? Do you even chart that her pain is that high and then withhold medication? At the end of the day I think it ends up being a provider specific issue whether they are going to give analgesics. That being said it is also up to the patient to report their level of discomfort appropriately, request medication if it is not offered, and if need be discuss their pain management with their provider.
I agree with Mike's assessment of the pain issue. But it is a difficult issue because understanding a patient's pain (not necessarily just quantitatively--and granted the specificity of particularly the intermediate range on the scale of 0-10 is obviously vague--but also qualitatively)requires time to get to talk to, observe and understand the patient and what the pain means to the patient. The time, itself, is definitely unavailable to those who practice emergency room medicine. In addition, though some patients are repeaters, many patients have been unknown to the ER staff. In other practices, time is still a limiting factor. In addition, since the pain the patient carries is not felt by the healthcare provider, this limits the degree of empathy (the full understanding of the burden of the pain on the patient) that the nurse or physician can express to the patient and also guide the need for, the urgency and the degree of appropriate therapy. So even when there is more time available in other practice environments (and often there isn't)evaluation of the patient's pain is still difficult and incomplete.
Further, many physicians are not trained in pain analysis and management, are not trained in addiction management and so while they may be competent in other areas of diagnosis and treatment may find that evaluating a patient who expresses pain as a symptom and appropriately responding to that expression is a challenge. This may lead to a tendency not to ask, not to evaluate fully, not to adequately and appropriately treat and to fail in proper followup.
I have a feeling that much more is needed than just assigning pain as the 5th vital sign. What is needed is a more intensive training program in pain and pain management for medical students, residents and for the physicians out in practice. In California, a year or so ago, physicians had to take a 9 hour course about pain management for license renewal. But even one 9 hour education experience is really not enough.
The secret to better pain management is not simply making pain, the 5th Vital Sign but by a concerted effort for education of all healthcare providers about pain and as Mike suggests, education of the patient in the need "to report their level of discomfort appropriately, request medication if it is not offered, and if need be discuss their pain management with their provider." ..Maurice.
There is nothing wrong with the concept of "Pain as a Fifth Vital Sign," or the idea that pain assessment is so critical it is literally as important as the other vital signs. The problem arises in the way that this requirement has been implemented, and also with the way the 1 to 10 scale has become the standard for "objectifying" pain. While I don't want to write a dissertation on the subject, suffice it to say that the 1 to 10 scale is counterintuitive to a lot of patients (disabling, level 8 pain is not twice as bad as bearable, level 4 pain, it is 100 times worse, since being disabled is far worse than just being impaired). The definition of 10 as "the worse pain you can imagine" is poorly considered, as no matter how bad your pain is, you can always imagine it being worse, so in theory level 10 pain doesn't exist—a point which lends itself well to patients claiming level 10 pain being demonized as fakers and exaggerators.
You mention the VA and studies that show that PTFVS programs have not improved the quality of care for pain patients. As a veteran, I can definitely vouch for that. While almost every room at my local VA hospital has that cutesy smiley face 1 to 10 pain diagram on the wall and they have rarely failed to ask my pain level, asking you about your pain is as far as it ever gets. They might as well be asking me about the weather. They have never once offered me treatment based on my reports, and when I began to insist on some kind of treatment, I was very quickly labeled a drug-seeker and malingerer and thus began a very long and tortuous battle to have my pain taken seriously and treated appropriately. It never was, and I finally gave up as the physical, emotional and psychological stress just weren't worth the inadequate dose of medication I fought for years to get them to prescribe. I was abused, slandered, threatened, humiliated, lied to and lied about, and finally taken off my meds with no notice whatsoever and forced into cold turkey withdrawal, all because a doctor had lied and said that I told him I was hoarding pills.
The problem here is not the program, but the doctors who are being asked to implement it and the primevel attitudes many of them still hold towards people whose only crime is they suffer from chronic pain—and in America, having chronic pain for all practical purposes is treated as a crime by many in the medical profession, law enforcement and society as a whole, as the torture we suffer as a result is as real as any jail cell, however much you may disagree with my point of view. So to question whether PTFVS is a good tool or not based on improvements in the quality of care makes as much sense as asking whether a hammer is a good tool or not, based on whether the widespread purchase of hammers has led to greater quality in home improvement projects. There may be better tools than hammers and Pain as a Fifth Vital Sign, but they are only as good as the people wielding them, and that is where efforts at improving the quality of care have to be aimed: at doctors and their outdated, puritanical and primevel mentality towards pain patients.
The biggest problem we as chronic pain patients face is that many doctors really don't give a damn whether we suffer or not, still others think we deserve it somehow, and only a minority are seriously committed to taking their patients seriously and treating pain aggressively. We also have a problem getting doctors to believe our reports of pain, which is what the 1 to 10 scale was supposed to help but obviously few doctors believe their patients when they report severe pain, particularly when they don't show it. Accusations of drug-seeking and exaggeration are the rule rather than the exception. Unfortunately, there are a lot of myths out there adhered to by many doctors as to how someone in severe pain is supposed to react, such as that someone is severe pain will show elevated blood pressure, and it can be crazy-making for people with chronic pain to be labeled as malingerers or fakers if they show any sign of pain or distress, and to be labeled as malingerers and fakers if they don't show any signs of distress. As such I have to strongly disagree with your opinion that a doctor should note in a patient's chart whenever that patient's reports of pain don't appear to jibe with physical or emotional signs the doctor may or may not have observed in patients reporting similar pain levels. This kind of questioning and judgementalism is extremely unfair and frustrating to patients who feel they are being called liars when this happens, and what is more the idea that a person should react a particular way to pain is often based on widely-held medical myths, many of which are refuted here:
http://www.med.umich.edu/pain/apainmgt.htm
Believe it or not, most of us with severe pain do not spend all our time moaning and writhing in agony. At some point, we have to learn to control obvious signs of pain behavior to function in society, so in time we become quite adept at hiding our pain even when the pain is excruciating. Additionally, as the above site explains, chronic pain is different than acute pain, and over time chronic pain patients may no longer show such signs as elevated blood pressure or cortisol levels or other biological indicators one would expect in someone who was just recently injured. PTFVS is just a tool to bridge the gap between the doctor's perception and the patient's reality, but if the doctor chooses not to believe the patient's reality, or is indifferent to human suffering, then no tool, no matter how well-designed, is going to work. Clearly, a lot of education is still needed for the medical profession, but I firmly believe that until patients win back the right to treat their own pain which they had prior to passage of the Harrison Act in 1914, the torture, abuse and destruction of the lives of people in pain will continue to be a reality in this country. No one should wield this kind of power over other human beings.
Payne Hertz has posed valid issues. The goal is to provide the best pain management to all patients who are in pain. The question is how to do it, since clearly most of the pain management, certainly from the patient's point of view is inadequate. One could recommend that all patients who have pain beyond brief and minor (relieved by short aspirin or NSAID therapy) should be referred to a palliative care specialist or get consultation from establish multi-discipline pain management clinics which are now available.
Another approach would be beyond compulsory pain management education for physicians and nurses, physicians should be legally free to prescibe effective medication, including potent opiods, to anyone who says they are in pain. Physicians should not be responsible for sorting out the relatively few individuals who are drug addicted (not in pain but hoping for a "high") from those who are in real pain or have developed narcotic tolerance as a complication of prior pain therapy. In other words, respond to the request for pain medication from all and leave the identification and labeling of drug addicts to investigative and legal authorities if that is what society wants. Anyone have any other suggestions? ..Maurice.
hmm...at my PCP office, the conversation usually goes something like:
"Are you having any pain?"
"yes"
"Could you rate your pain?"
"About a 4"
"Okay"
As far as I can tell, this info is collected only for purposes of writing it down somewhere in the medical record. When I was in the hospital after surgery, the nurses didn't really use the scale, but we talked about my pain and they did the best they could, and I was managed as well as could be expected. The main obstacle (esp. bad at night) was that nurses can hardly do anything without getting the doc to order it. At night, this was a mysterious figure called the "covering resident", who apparently couldn't be reached for anything short of your impending death. If nurses are thinking about pain control, it gets taken care of with or without the scale. If they aren't, I'm not sure the scale does any good.
As a followup to the 5th Vital Sign discussion here, if the following
bill introduced into the Mississippi House is an example of what is going through the minds of the legislatures, no wonder doctors should be cautious in the prescribing of opoid pain medication to those who request it.
By the way, the bill died in the Justice committee. ..Maurice.
MISSISSIPPI LEGISLATURE
1998 Regular Session
To: Judiciary A
By: Representative Moak
House Bill 196
AN ACT TO AUTHORIZE THE REMOVAL OF A BODY PART IN LIEU OF OTHER SENTENCES IMPOSED BY THE COURT FOR VIOLATIONS OF THE CONTROLLED SUBSTANCES LAW; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. In lieu of any other penalty prescribed by law, the court may allow any person who is convicted for a violation of the Controlled Substances Law to have a body part removed. The convicted person and the court must agree on which body part shall be removed.
SECTION 2. This act shall take effect and be in force from and after July 1, 1998.
A physician wrote e-mail to me yesterday which is pasted below. ..Maurice.
I curse the day that the pain scale was foisted upon nurses and clinicians. It is completely useless, and, in my opinion, dangerous..I had a patient just post op from a hysterectomy, when some idiot asked her if she had pain, and whether it was from one to ten. This young women, groggy from the surgery she has just had, naturally said 10. She then received 100mgm of demerol and 50 of phenargan twice in a short time and was found dead in bed later.
To a stoic a "10" can be "1" and to a neurotic a "1" can be a "10". Is a 9 really different from a 10 or an 8, etc.?
A mistake wa made in my treatment, I wanted to protect those responsible and I went to doctors who have deliberately done worse to me on purpose. Because of pain I agreed to a colostomy, developed a hernia. I took radiation and have pictures showing ''AIDS''used in radiation to the left thoraci area. I was told ''we're doing an x-ray''. to be brief, I have had a mastectomy due to duct-invasive cancer: IT IS DUE TO IONIZED RADIATION. I've had several episodes of scarg, severe pail in the abdominal area, I have a huge hernia in th stoma. I had a haemangioma all my life, a scar on the outer curvature of my stomach [from a frozen n/g tube] and every year for 40 yrs I've had g.i series and barium enemas as well as cat scans, mri, bone scans with radio-active isotopes. In one year 2009 to 2010, I've run into ego maniacal liars who used everything possible to win my confidence and keep me from going elsewhere untill evidence was destroyed. Ive had cat scan because of the abd. pain but I'll never know what it shows because I cannot find a local christian doctor and the ones I've dealt with are purveyors of death and destrction,an employee insinuated that I was immmoral and when hospital employees insulted me, I apologized for not being responsible for what I said or did under influence of drugs or anesthesia,I assured them I am not a femme fatale at 75yrs nor am I a geriatric seductress, Iwas told the statement of a doctor's employee. GUESS THEY TAKE THE hypocrits oath now days. So calloused cold inhuman hope no one else ever suffers from burdens put on them by the medical profession making pain and suffering greater.
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