The ethics of considering vulnerability in decision making and chronic pain<br />Or<br />“do we consider issues of vulnera...
Philosophy & Ethics Society(SIG of British Pain Society)<br />    Discussion of philosophical and ethical issues associate...
Pain Management Services – Good practice <br />Specific arrangements for the treatment of vulnerable groups<br />such as t...
A vulnerable adult is someone aged 18 or over:<br />who is or may be in need [of care] due to<br />age, illness, mental or...
Q. What is the definition of a vulnerable adult?<br />A. A vulnerable adult means a person aged 18 or over who has a condi...
As seen in the pain clinic?<br />Dependence on alcohol, drugs or food; self-medication<br />Denial of <br />dependence<br ...
Patients may feel powerless because of their illness, the relationship with <br />the doctor, the workings of the hospital...
49% people suffering chronic pain also suffer from depression25%  lose their jobs 16%  sometimes feel suicidal.Vulnerable ...
A half of all new patients attending a UK pain clinic had diagnosed mental illness<br />PainVol32, (2) 1988, p185-195 <br />
Child sexual abuse• 16% of young people have experienced sexual abuse during childhood (11% boys and 21% girls). • 31% of ...
Physical Symptoms of Childhood Sexual Abuse<br />Chronic back pain<br />Chronic pelvic pain<br />Musculoskeletal complaint...
Psychological and Behavioural Symptoms of Childhood Sexual Abuse<br />Depression and anxiety<br />Somatising disorders<br ...
POWER and CONTROLAbusers believe they have a right to control their partners in the abusive relationships by:Telling them ...
POWER and CONTROLDoctorsbelieve they have a right to control their patients in the pain clinic by:Telling them what to do ...
Blaming the patient<br />western medicine is reductive<br />absence of visible pathology = absence of illness<br />medical...
Blaming the patient<br />“we can’t find anything”<br />“it’s all in her/his head”<br />“s/he doesn’t believe me”<br />“s/h...
upset, hostile patient = defensive, hostile doctor   (who is blaming the patient for making him/ her feel incompetent and ...
Develop self-awareness<br />Clinicians should develop self-awareness – to observe and understand their own feelings and ac...
Through self-awareness, clinicians learn more about themselves, develop as therapists and become better able to manage the...
                            Tracey Emin   Self Portrait    2000<br />
Tracey Emin   If I could just go back and start again  1995<br />
Tracey Emin      Exorcism of the last painting I ever made    1996<br />
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Pain masterclass

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RCA study day October 2011

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  • I am not going to talk about children or adolescents at all –Suellen Walker will be covering those issues.I am also not going to talk about treating much older adults - whatever that means (arbitarily I’ll suggest 75) – So that just leaves all the rest – ie 95% of the patients in your average chronic pain clinic!That brings me to my second problem, which is that there is no such thing as an average pain clinic. We know that the philosophy of pain clinics covers a wide spectrum, from very interventional clinics to those (like my old clinic) which changed working practice significantly and became almost totally non-interventional.I am going to talk specifically about the sort of patients that I have seen in our pain clinic throughout 20y of practice, those who are often called the ‘heartsink’ patients, the ones who may end up in the pain clinic after having been passed through various different doctors on the way.
  • Pain masterclass

    1. 1. The ethics of considering vulnerability in decision making and chronic pain<br />Or<br />“do we consider issues of vulnerability when meeting a patient with chronic pain?” <br />Dr Diana Brighouse<br />
    2. 2. Philosophy & Ethics Society(SIG of British Pain Society)<br /> Discussion of philosophical and ethical issues associated with pain and suffering and their management.<br /> Multidisciplinary & international – medics, pain nurses, psychologists, theologians, clergy, academic philosophers, ethicists, and others<br /> Emphasis on discussion rather than hierarchical teaching or academic point scoring<br />
    3. 3. Pain Management Services – Good practice <br />Specific arrangements for the treatment of vulnerable groups<br />such as the elderly, children, non-verbal, disabled, intellectually<br />handicapped and those whose primary language is not English.<br />RCoA/ Pain Society 2003<br />
    4. 4. A vulnerable adult is someone aged 18 or over:<br />who is or may be in need [of care] due to<br />age, illness, mental or physical disability<br />who is or may be ... <br />unable to protect him/herself against significant harm or exploitation<br />(Department of Health 2002)<br />
    5. 5. Q. What is the definition of a vulnerable adult?<br />A. A vulnerable adult means a person aged 18 or over who has a condition of the following type:<br />a learning or physical disability<br />a physical or mental illness, <br />chronic or otherwise, <br />including an addiction to alcohol or drugs<br />a reduction in physical or mental capacity <br />www.guysandstthomas.nhs.uk<br /> <br />
    6. 6. As seen in the pain clinic?<br />Dependence on alcohol, drugs or food; self-medication<br />Denial of <br />dependence<br />is common<br />
    7. 7. Patients may feel powerless because of their illness, the relationship with <br />the doctor, the workings of the hospital, the housing or benefits system and unemployment. <br />They may feel especially vulnerable if in extreme distress, physical or emotional, chronic or acute. <br />Vulnerable patients, safe doctors. RCPsych 2007<br />
    8. 8. 49% people suffering chronic pain also suffer from depression25% lose their jobs 16% sometimes feel suicidal.Vulnerable adults?Chief Medical Officer 2009<br />
    9. 9. A half of all new patients attending a UK pain clinic had diagnosed mental illness<br />PainVol32, (2) 1988, p185-195 <br />
    10. 10. Child sexual abuse• 16% of young people have experienced sexual abuse during childhood (11% boys and 21% girls). • 31% of disabled young people experienced abuse during childhood, almost four times the rate of abuse experienced by other children.• 72% of young people who were abused during childhood, did not tell anyone about the abuse at the time.50% women in adult mental health system were victims of childhood sexual abuse<br />
    11. 11. Physical Symptoms of Childhood Sexual Abuse<br />Chronic back pain<br />Chronic pelvic pain<br />Musculoskeletal complaints<br />Gastrointestinal symptoms/distress<br />Obesity, eating disorders<br />Insomnia, sleep disorders<br />Chronic headache<br />
    12. 12. Psychological and Behavioural Symptoms of Childhood Sexual Abuse<br />Depression and anxiety<br />Somatising disorders<br />Eating disorders<br />Poor adherence to medical recommendations<br />
    13. 13. POWER and CONTROLAbusers believe they have a right to control their partners in the abusive relationships by:Telling them what to do and expecting obedienceUsing force to maintain power and control over partnersFeeling their partners have no right to challenge their desire for power and controlFeeling justified making the victim complyBlaming the abuse on the partner and not accepting responsibility for wrongful acts. <br />
    14. 14. POWER and CONTROLDoctorsbelieve they have a right to control their patients in the pain clinic by:Telling them what to do and expecting complianceUsing status and authority to maintain power and control over partnersFeeling their patients have no right to challenge the doctors right of power and controlFeeling justified in making the patient complyBlaming the abuse on the patient and not accepting the possibility that there may be other options<br />
    15. 15. Blaming the patient<br />western medicine is reductive<br />absence of visible pathology = absence of illness<br />medical and patient/ family faith in tests, xrays, scans<br />search for definitive diagnosis<br />passage through multiple clinics <br />
    16. 16. Blaming the patient<br />“we can’t find anything”<br />“it’s all in her/his head”<br />“s/he doesn’t believe me”<br />“s/he thinks I’m imagining it”<br />
    17. 17. upset, hostile patient = defensive, hostile doctor (who is blaming the patient for making him/ her feel incompetent and unable to provide and answer and a cure)<br />“we’ll send you to the pain clinic – I’m sure they’ll be able to sort you out”<br />
    18. 18.
    19. 19.
    20. 20.
    21. 21. Develop self-awareness<br />Clinicians should develop self-awareness – to observe and understand their own feelings and actions within the therapeutic relationship. <br />In so doing, they can disentangle what comes directly from the patient and what colours their reactions to the patient from their own attitudes, beliefs and experiences. <br />They also gain a better understanding of what the therapeutic relationship feels like from the patient’s point of view. <br />Vulnerable patients, safe doctors. RCPsych 2007<br />
    22. 22. Through self-awareness, clinicians learn more about themselves, develop as therapists and become better able to manage themselves in the service of the patient.<br />Vulnerable patients, safe doctors. RCPsych 2007 <br />
    23. 23. Tracey Emin Self Portrait 2000<br />
    24. 24. Tracey Emin If I could just go back and start again 1995<br />
    25. 25. Tracey Emin Exorcism of the last painting I ever made 1996<br />

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