Legal issues in pain management: Striking the balance

Pain is a symptom, but can often be the presenting chief complaint for many patients in the emergency department. Although the disease or condition causing the pain may not be within the realm of the emergency physician to definitively manage or even in some cases diagnose, there still remains an expectation to treat the symptom. In recent years, due to changes in accreditation standards, many have come to argue that pain has become the fifth vital sign, and new expectations have been created for health care providers [1]. Physicians have an ethical obligation to treat patient's pain and suffering as outlined in the Hippocratic Oath, American Medical Association Code of Medical Ethics, and more specifically, for emergency physicians in the American College of Emergency Physicians (ACEP) Code of Ethics [2,3]. In the ACEP Code of Ethics, the principle of beneficence would suggest the responsibility for physicians to "respond quickly to acute illnesses and injuries to prevent or minimize pain and suffering" [2]. In addition, the ACEP policy statement, Ethical Issues for Resuscitation, outlines physician responsibility to provide appropriate comfort measures to the dying patient when resuscitation is not indicated [4]. However, despite the above obligations, several studies still cite physician's continued failure to appropriately treat pain [5-7]. Inadequate pain management is becoming recognized as a serious public health concern [8]. Undertreatment of pain has been well documented in a diversity of patient populations [9-11], with the greatest frequency being noted in patients with chemical dependency [12], a group of patients frequently encountered in some emergency departments.