Pain Management in Health Care:  Implications
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Pain Management in Health Care: Implications

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Pain Management: physiology, legal implications, addiction, and more in this informative slide show.

Pain Management: physiology, legal implications, addiction, and more in this informative slide show.

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Pain Management in Health Care: Implications Presentation Transcript

  • 1. Pain ManagementPain Management The Legal SideThe Legal Side References:References: Pain: Clinical Manual-M. McCaffery & C. Pasero &Pain: Clinical Manual-M. McCaffery & C. Pasero & Core Curriculum For Pain Management Nursing-B. St.MarieCore Curriculum For Pain Management Nursing-B. St.Marie ANA Pain Management Nursing: Scope and Standards of PracticeANA Pain Management Nursing: Scope and Standards of Practice NANDA Nursing Diagnosis approved list.NANDA Nursing Diagnosis approved list.
  • 2. Millions of dollars are awarded every year toMillions of dollars are awarded every year to patients who have suffered and endured painpatients who have suffered and endured pain needlessly. Nurses, like doctors, have beenneedlessly. Nurses, like doctors, have been held accountable for failure to adequatelyheld accountable for failure to adequately treat pain and suffering.treat pain and suffering. When we as professionals fail to treat pain, weWhen we as professionals fail to treat pain, we put ourselves at risk for licensure suspension,put ourselves at risk for licensure suspension, disciplinary action, fines or having ourdisciplinary action, fines or having our privileges revoked.privileges revoked.
  • 3.  Every state has a nurse practice act and a board of nursing rules and regulations. This act defines the practice of APN, RN, and LPN’s.  The NPA is designed to help protect the public by broadly defining the legal scope of nursing practice.  Every nurse is expected to care for their patients within these defined practice limits.  If a nurse practices outside these limits or fails to provide care within these limits, they become vulnerable to charges of violating the law and losing his/her licensure.
  • 4. For a copy of your State Nursing PracticeFor a copy of your State Nursing Practice Act or Board of Nursing rules andAct or Board of Nursing rules and regulations call:regulations call: (312) 419-2900(312) 419-2900
  • 5. Know your StandardsKnow your Standards  ANA-Nursing StandardsANA-Nursing Standards  APS-American Pain SocietyAPS-American Pain Society  ASPMN-American Society of PainASPMN-American Society of Pain Management NursesManagement Nurses  AANA-American Association of NurseAANA-American Association of Nurse AnesthetistsAnesthetists  JCAHO-Joint Commission on Accreditation ofJCAHO-Joint Commission on Accreditation of Healthcare OrganizationsHealthcare Organizations
  • 6. STANDARDS OF CARESTANDARDS OF CARE Standards of care: include safeStandards of care: include safe and accepted nursing careand accepted nursing care practices. The standard ofpractices. The standard of care is assessed by policiescare is assessed by policies and guidelines that areand guidelines that are written by nationallywritten by nationally recognized organizations orrecognized organizations or specialty societies.specialty societies. Standards include formalStandards include formal training, as outlined intraining, as outlined in hospital policies orhospital policies or contained in authoritativecontained in authoritative textbooks and articles.textbooks and articles.
  • 7.  Standards of Care are written byStandards of Care are written by nationally accredited organizationsnationally accredited organizations such as the ANA, ASPAN andsuch as the ANA, ASPAN and JCAHO. These standards are oftenJCAHO. These standards are often used as guidelines for best practiceused as guidelines for best practice and are evidence based.and are evidence based.  They are referred to and used asThey are referred to and used as evidence in malpractice trials.evidence in malpractice trials.  Standards of care are theStandards of care are the goldgold standards used in healthcare.standards used in healthcare.
  • 8. JCAHOJCAHO  1992-Standards manual now includes1992-Standards manual now includes effective pain management as one of the rightseffective pain management as one of the rights of a dying patient.of a dying patient.  1994-Previous statement was broadened to1994-Previous statement was broadened to include all patients, not just the dying.include all patients, not just the dying.  1997-JCAHO begins working with institutions1997-JCAHO begins working with institutions to create standards for pain assessment,to create standards for pain assessment, treatment and national quality improvementtreatment and national quality improvement programs.programs.
  • 9. JCAHO STANDARDS FOR PAINJCAHO STANDARDS FOR PAIN MANAGEMENT.MANAGEMENT.  Patients are involved in all aspects of their care,Patients are involved in all aspects of their care, including effective pain managementincluding effective pain management  Patients have the right to adequate assessment andPatients have the right to adequate assessment and treatment of pain.treatment of pain.  Pain is assessed in all patientsPain is assessed in all patients  Policies and procedures support safe medicationPolicies and procedures support safe medication prescription or ordering, including scheduledprescription or ordering, including scheduled prescriptions and patient controlled analgesia. Spinalprescriptions and patient controlled analgesia. Spinal administration of pain management technologies usedadministration of pain management technologies used in patients with pain.in patients with pain.
  • 10. JCAHO STANDARDS ( Continued )JCAHO STANDARDS ( Continued )  Their pain is monitored during the post procedure period forTheir pain is monitored during the post procedure period for pain intensity, duration, location, character, and response forpain intensity, duration, location, character, and response for treatments, among other items.treatments, among other items.  Standards, intents, and examples for rehabilitative care andStandards, intents, and examples for rehabilitative care and services, includes pain interfering with function and mobility.services, includes pain interfering with function and mobility.  Patients are educated about pain and its management as part ofPatients are educated about pain and its management as part of treatment, as appropriate.treatment, as appropriate.  The discharge planning process provides for continuing careThe discharge planning process provides for continuing care based on the patient’s assessed needs at the time of discharge,based on the patient’s assessed needs at the time of discharge, including symptom management.including symptom management.
  • 11. JACHO now closely monitors pain management andJACHO now closely monitors pain management and patient satisfaction related to pain management.patient satisfaction related to pain management.
  • 12. Patients RightsPatients Rights  Patients have the right toPatients have the right to receive optimal pain relief andreceive optimal pain relief and be involved in their painbe involved in their pain management treatments,management treatments, benefits and risks ofbenefits and risks of procedures, alternative painprocedures, alternative pain management modalities, andmanagement modalities, and expected outcomes.expected outcomes.
  • 13. PATIENT RIGHTSPATIENT RIGHTS FOR PAIN CONTROLFOR PAIN CONTROL BILL of RIGHTS for people with painBILL of RIGHTS for people with pain  I have the right to have my reports of pain accepted andI have the right to have my reports of pain accepted and acted on by health care professionals.acted on by health care professionals.  I have the right to have my pain controlled, no matter whatI have the right to have my pain controlled, no matter what its cause or how severe it may be.its cause or how severe it may be.  I have the right to be treated with respect at all times.I have the right to be treated with respect at all times. When I need medication for pain, I should not be treatedWhen I need medication for pain, I should not be treated like a drug abuser.like a drug abuser. ……Remember, the single MOST RELIABLE indicator ofRemember, the single MOST RELIABLE indicator of pain is the PATIENT’S SELF REPORT!!!pain is the PATIENT’S SELF REPORT!!!
  • 14. Poor pain management andPoor pain management and substandard documentation cansubstandard documentation can trigger:trigger:  Survey citations for abuse, violation of patient rightsSurvey citations for abuse, violation of patient rights and substandard care.and substandard care.  Litigation against hospitals, outpatient clinics,Litigation against hospitals, outpatient clinics, nursing homes, doctors, nurses, therapist andnursing homes, doctors, nurses, therapist and administrative personnel.administrative personnel.  Legal action against individual professionals who failLegal action against individual professionals who fail to act in the patients best interest.to act in the patients best interest.
  • 15.  Nurses are held accountable for their individualNurses are held accountable for their individual actions. Healthcare organizations are likely to holdactions. Healthcare organizations are likely to hold negligent employees accountable for their actions.negligent employees accountable for their actions. If you fail to follow your employer’s policies andIf you fail to follow your employer’s policies and procedures you may stand alone in a legal battle.procedures you may stand alone in a legal battle.
  • 16. Patients ExpectPatients Expect  Knowledgeable and competent healthcareKnowledgeable and competent healthcare staffstaff  High quality careHigh quality care  Safe environmentSafe environment  Attentive and compassionate careAttentive and compassionate care  Comfort care and management of painComfort care and management of pain  Privacy and confidentialityPrivacy and confidentiality
  • 17. Why Suffer?Why Suffer?  Resources andResources and knowledge exist toknowledge exist to provide satisfactoryprovide satisfactory and safe pain reliefand safe pain relief in 90% of all peoplein 90% of all people who suffer pain.who suffer pain.
  • 18. ……HoweverHowever  50% of conscious patients who die in the hospital50% of conscious patients who die in the hospital setting will experience moderate to severe pain.setting will experience moderate to severe pain.  61% of acute pain sufferers reported pain ratings of61% of acute pain sufferers reported pain ratings of 7-10 on the pain scale.7-10 on the pain scale.  67% of metastatic cancer patients reported pain and67% of metastatic cancer patients reported pain and 62% of those had pain severe enough to impair their62% of those had pain severe enough to impair their ability to function. 42% of those patients were notability to function. 42% of those patients were not prescribed analgesic capable of relieving their pain.prescribed analgesic capable of relieving their pain.
  • 19. LEGAL IMPLICATIONS ANDLEGAL IMPLICATIONS AND JOINT COMMISSION ASIDE…JOINT COMMISSION ASIDE… we want to provide thewe want to provide the best care for THE PATIENTbest care for THE PATIENT!!  There areThere are significant harmfulsignificant harmful effects ofeffects of UNRELIEVED painUNRELIEVED pain  The stress responses activate theThe stress responses activate the sympathetic nervous systemsympathetic nervous system andand cause effects involvingcause effects involving multiplemultiple systems.systems.
  • 20. UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE ENDOCRINE SystemENDOCRINE System  Increased adrenocorticotrophic hormone (ATCH)Increased adrenocorticotrophic hormone (ATCH)  Increased cortisol & antidiuretic hormone (ADH)Increased cortisol & antidiuretic hormone (ADH)  Increased epinephrine & norepinephrineIncreased epinephrine & norepinephrine  Increased growth hormone (GH), catacholamines & reninIncreased growth hormone (GH), catacholamines & renin  Increased angiotensin II & aldosteroneIncreased angiotensin II & aldosterone  Increased glucagon & interleukin-1Increased glucagon & interleukin-1  Decreased insulinDecreased insulin  Decreased testosteroneDecreased testosterone  All totalingAll totaling The STRESS RESPONSE!The STRESS RESPONSE!
  • 21. HOLY COW!HOLY COW! Who would have thought that so manyWho would have thought that so many changes could occur in the body with pain?changes could occur in the body with pain? But, that was just theBut, that was just the ENDOCRINE SYSTEM!ENDOCRINE SYSTEM!
  • 22. UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE METABOLIC SystemMETABOLIC System  Gluconeogenesis – breakdown into glycogen of aminoGluconeogenesis – breakdown into glycogen of amino acids & fatacids & fat as though the body is in starvationas though the body is in starvation  Hepatic glycogenolysis – Conversion of glycogen toHepatic glycogenolysis – Conversion of glycogen to glucose in the liverglucose in the liver  HyperglycemiaHyperglycemia  Glucose intolerance – poor use of available glucoseGlucose intolerance – poor use of available glucose  Insulin resistanceInsulin resistance  Muscle protein catabolism (destruction) as well asMuscle protein catabolism (destruction) as well as destruction of carbohydrates and fatdestruction of carbohydrates and fat  Increased lipolysis – destruction of fat cellsIncreased lipolysis – destruction of fat cells ……Imagine the implicationsImagine the implications for the diabetic or if the patientfor the diabetic or if the patient is on steroids!is on steroids!
  • 23. IMPLICATIONS FOR THEIMPLICATIONS FOR THE ENDOCRINE & METABOLICENDOCRINE & METABOLIC SYSTEMSSYSTEMS  Overall, the endocrine & nervous systems, regulate theOverall, the endocrine & nervous systems, regulate the metabolic system to maintain normal body growth andmetabolic system to maintain normal body growth and function. Multiple cascading events occur when pain isfunction. Multiple cascading events occur when pain is not controlled:not controlled:  Protein, fat & CHO catabolism/destructionProtein, fat & CHO catabolism/destruction  Poor glucose conversion and use of available glucosePoor glucose conversion and use of available glucose  INFLAMMATION + ENDOCRINE/METABOLIC changesINFLAMMATION + ENDOCRINE/METABOLIC changes = weight loss, tachycardia, increased respiratory rate, fever,= weight loss, tachycardia, increased respiratory rate, fever, shock and eventually deathshock and eventually death
  • 24. UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE CARDIOVASCULAR SystemCARDIOVASCULAR System  Increased heart rateIncreased heart rate  Increased cardiac outputIncreased cardiac output  Increased Peripheral vascular resistanceIncreased Peripheral vascular resistance  Increased Systemic vascular resistanceIncreased Systemic vascular resistance  HYPERTENSIONHYPERTENSION  Increased coronary vascular resistanceIncreased coronary vascular resistance  Increased myocardial oxygen consumptionIncreased myocardial oxygen consumption  HypercoagulationHypercoagulation  Deep vein thrombosisDeep vein thrombosis ULTIMATELY…PAINULTIMATELY…PAIN actuallyactually CONTRIBUTESCONTRIBUTES TOTO Heart Attacks, Strokes and DVTs!Heart Attacks, Strokes and DVTs!
  • 25. UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE RESPIRATORY SystemRESPIRATORY System  Decreased flows and volumesDecreased flows and volumes  AtelectasisAtelectasis  ShuntingShunting  HypoxemiaHypoxemia  Decreased coughDecreased cough  Sputum retentionSputum retention  InfectionInfection CAUSING…CAUSING… Decreased oxygen carrying capacityDecreased oxygen carrying capacity ……and evenand even PneumoniaPneumonia
  • 26. UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE GU SystemGU System  Decreased urinary outputDecreased urinary output  Urinary retentionUrinary retention  Fluid overloadFluid overload  HypokalemiaHypokalemia  ……Causing increased cardiac workload & HTN,Causing increased cardiac workload & HTN, dysrhythmias…dysrhythmias… UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE GI SystemGI System - Decreased gastric & bowel motilityDecreased gastric & bowel motility - …… Potential constipation & ileus (GI paralysis)Potential constipation & ileus (GI paralysis)
  • 27. UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE MUSCULOSKELETAL SystemMUSCULOSKELETAL System  Muscle spasmMuscle spasm  Impaired muscle functionImpaired muscle function  FatigueFatigue  ImmobilityImmobility  ……More risk for DVT, pneumonia, increased staysMore risk for DVT, pneumonia, increased stays -- Reduction in cognitive functioning-- Reduction in cognitive functioning -- Mental confusion-- Mental confusion UNRELIEVED PAIN ANDUNRELIEVED PAIN AND COGNITIVE FUNCTIONCOGNITIVE FUNCTION
  • 28. UNRELIEVED PAIN ANDUNRELIEVED PAIN AND DEVELOPMENTAL IssuesDEVELOPMENTAL Issues  Increased behavioral and physiologic responses to painIncreased behavioral and physiologic responses to pain  Altered temperamentsAltered temperaments  Higher somatization –Higher somatization – to convert anxiety into physical symptomsto convert anxiety into physical symptoms  Infant distress behaviorInfant distress behavior  Possible altered development of the pain systemPossible altered development of the pain system  Increased vulnerability to stress disordersIncreased vulnerability to stress disorders  Addictive behaviorAddictive behavior  Anxiety statesAnxiety states UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE IMMUNE SYSTEMIMMUNE SYSTEM -- Depression of the immune system-- Depression of the immune system
  • 29. UNRELIEVED PAIN AND RELATIONSHIP TOUNRELIEVED PAIN AND RELATIONSHIP TO FUTURE PAINFUTURE PAIN  Predisposed to debilitating chronic pain syndromesPredisposed to debilitating chronic pain syndromes  Postmastectomy pain increasedPostmastectomy pain increased  Postthoracotomy pain increasedPostthoracotomy pain increased  Increased episodes of Phantom pain if pain not controlledIncreased episodes of Phantom pain if pain not controlled adequately pre-operativelyadequately pre-operatively  Posttherpetic neuralgia – pain following an attack ofPosttherpetic neuralgia – pain following an attack of herpes zoster/shinglesherpes zoster/shingles ……Yes,Yes, pain your patients have todaypain your patients have today will affectwill affect their pain thresholds and their ability to copetheir pain thresholds and their ability to cope with pain later in life!with pain later in life!
  • 30. UNRELIEVED PAIN ANDUNRELIEVED PAIN AND QUALITY OF LIFE (QOL)QUALITY OF LIFE (QOL) ISSUESISSUES  Increased sleeplessnessIncreased sleeplessness  Problems with anxiety & fearsProblems with anxiety & fears  Hopelessness, depression and thoughts of suicideHopelessness, depression and thoughts of suicide -- certainly not to be seen as “benign,” but on the contrary,-- certainly not to be seen as “benign,” but on the contrary, can be life threateningcan be life threatening  Increased stress within familiesIncreased stress within families
  • 31. MISCONCEPTIONMISCONCEPTION ““PAIN NEVER KILLED ANYONE”PAIN NEVER KILLED ANYONE”  Unrelieved pain may be dangerous and is, therefore,Unrelieved pain may be dangerous and is, therefore, unacceptable. Research now shows that past attitudesunacceptable. Research now shows that past attitudes of expecting surgery to hurt and believing that “painof expecting surgery to hurt and believing that “pain never killed anyone” are no longer justified.never killed anyone” are no longer justified.  Post-op painPost-op pain can killcan kill by delaying healing andby delaying healing and contributing to complications that are life-threatening.contributing to complications that are life-threatening.  Unrelieved post-op pain must now be viewed andUnrelieved post-op pain must now be viewed and treated as a complication or risk, not as an acceptabletreated as a complication or risk, not as an acceptable consequence of surgery.consequence of surgery.  Chronic pain also has many serious adverse effectsChronic pain also has many serious adverse effects such as suppressing immune function.such as suppressing immune function.
  • 32. -OVERALL –OVERALL – Poor pain managementPoor pain management  Increases patient lengthsIncreases patient lengths of stayof stay  Causes unnecessaryCauses unnecessary stress on the heart &stress on the heart & HTNHTN  Causes DVT,Causes DVT, pneumonia or otherpneumonia or other serious complicationsserious complications  Decreases the ability toDecreases the ability to heal efficientlyheal efficiently  Increases relationshipIncreases relationship stresses between thestresses between the patient, family & staffpatient, family & staff  Can seriously affect theCan seriously affect the patient’s long-termpatient’s long-term health and welfarehealth and welfare  Increases the risk ofIncreases the risk of liability for the hospitalliability for the hospital AND the individualAND the individual staff member – YOU!staff member – YOU!
  • 33. PAIN IS THE #1 REASONPAIN IS THE #1 REASON patients seek medical carepatients seek medical care  Document as though aDocument as though a jury/attorney will bejury/attorney will be reviewing it – they may!reviewing it – they may!  Know theKnow the organizational policiesorganizational policies and procedures for painand procedures for pain management andmanagement and documentationdocumentation  Follow those guidelinesFollow those guidelines  Question if the policiesQuestion if the policies need updating orneed updating or improvementsimprovements  Pain managementPain management should always be ashould always be a priority in yourpriority in your continuing educationcontinuing education  Always provide careAlways provide care which is conscientiouswhich is conscientious and compassionate, andand compassionate, and document accordinglydocument accordingly  Your patients depend onYour patients depend on YOU to be an advocateYOU to be an advocate for them in their time offor them in their time of needneed
  • 34. Thorough Assessment tools are moreThorough Assessment tools are more than just a convenience…than just a convenience…
  • 35. ……Pain assessment should bePain assessment should be at leastat least as often as vital signs:as often as vital signs: PAIN IS THE 5PAIN IS THE 5THTH VITAL SIGNVITAL SIGN  Pain assessment is required to be completed onPain assessment is required to be completed on ALL patients a MINIMUM of every shiftALL patients a MINIMUM of every shift  Even if the patient appears asleep, the FLACCEven if the patient appears asleep, the FLACC scale can and should be usedscale can and should be used  Remember, sleep does not guarantee that the patient is pain-free –Remember, sleep does not guarantee that the patient is pain-free – Sleep can be a coping mechanismSleep can be a coping mechanism  Always reassess pain level when the patient wakes up!Always reassess pain level when the patient wakes up!  Tolerable levels of pain should be assessed &Tolerable levels of pain should be assessed & documented regularly, as this is the objective/documented regularly, as this is the objective/ goal to be achievedgoal to be achieved
  • 36. As a patient advocateAs a patient advocate YOUR care determines outcomesYOUR care determines outcomes  If the pain goal is not achievable with theIf the pain goal is not achievable with the current medications/interventionscurrent medications/interventions  Call the physician for additional ordersCall the physician for additional orders  Seek a referral for further pain treatmentSeek a referral for further pain treatment  Ask for order allowing alternative therapiesAsk for order allowing alternative therapies  If pain control is still inadequate, continue upIf pain control is still inadequate, continue up the chain of command until adequatethe chain of command until adequate management is achieved…remember, this is amanagement is achieved…remember, this is a VITAL SIGN and essential for basic careVITAL SIGN and essential for basic care
  • 37. NANDA - Nursing Diagnoses & PainNANDA - Nursing Diagnoses & Pain The most OBVIOUS Nursing Diagnosis is “Pain relatedThe most OBVIOUS Nursing Diagnosis is “Pain related to…” (chronic vs. acute) …and then the apparentto…” (chronic vs. acute) …and then the apparent cause.cause. But, there are MANY different possibleBut, there are MANY different possible affectsaffects ofof uncontrolled pain, we must consider the possibilitiesuncontrolled pain, we must consider the possibilities of other issues CAUSED BY PAINof other issues CAUSED BY PAIN Consider… “Activity intolerance R/T (acute orConsider… “Activity intolerance R/T (acute or chronic) pain”chronic) pain” Which of the following Nursing Diagnoses could youWhich of the following Nursing Diagnoses could you have found useful for some of your patients?...have found useful for some of your patients?...
  • 38. NANDA - Nursing Diagnoses & PainNANDA - Nursing Diagnoses & Pain - Other Possible Diagnoses -- Other Possible Diagnoses -  Activity IntoleranceActivity Intolerance R/T painR/T pain  Sleep pattern disturbanceSleep pattern disturbance R/TR/T painpain  Ineffective individual copingIneffective individual coping R/T painR/T pain  ConstipationConstipation R/T painR/T pain  Urinary retentionUrinary retention R/T painR/T pain  HopelessnessHopelessness R/T painR/T pain  PowerlessnessPowerlessness R/T painR/T pain  Spiritual distressSpiritual distress R/T painR/T pain  Acute confusionAcute confusion R/T painR/T pain  Altered thought processesAltered thought processes R/TR/T painpain  Ineffective family copingIneffective family coping R/TR/T painpain  NoncomplianceNoncompliance R/T painR/T pain  Impaired home maintenanceImpaired home maintenance managementmanagement R/T painR/T pain  Violence, actual/risk for:Violence, actual/risk for: directed at self/othersdirected at self/others R/T painR/T pain  Altered family processesAltered family processes R/TR/T painpain  Impaired Social InteractionImpaired Social Interaction R/TR/T painpain  Altered growth andAltered growth and development (behavioral)development (behavioral) R/TR/T painpain  Knowledge deficitKnowledge deficit (specify: pain(specify: pain management, coping skills, meds,management, coping skills, meds, education for other pain relatededucation for other pain related diagnoses…) R/T paindiagnoses…) R/T pain ……Others, actually numerous, can beOthers, actually numerous, can be affected by different levels ofaffected by different levels of painpain
  • 39. ……A final note aboutA final note about CHRONIC PAINCHRONIC PAIN  Decreased Quality of Life (QOL) in patientsDecreased Quality of Life (QOL) in patients with chronic pain represents the greatest harmwith chronic pain represents the greatest harm of all…it is the most unforgivable.of all…it is the most unforgivable.  Chronic pain is so easily treated, but if notChronic pain is so easily treated, but if not treated, is completely dehumanizing to thetreated, is completely dehumanizing to the patient and the family.patient and the family.
  • 40. KNOWLEDGE is POWERKNOWLEDGE is POWER  Patients and Staff are empowered to determinePatients and Staff are empowered to determine outcomes with effective careoutcomes with effective care  We are coming out of the dark ages with painWe are coming out of the dark ages with pain management and moving forward with truly effectivemanagement and moving forward with truly effective assessment & treatments for pain: the reason patientsassessment & treatments for pain: the reason patients came here in the first placecame here in the first place GRASP ONTOGRASP ONTO THE KNOWLEDGE!THE KNOWLEDGE!