In previous columns, we presented Jonsen and colleagues' practical, user-friendly paradigm for a case-based approach to ethical questions. The paradigm consists of four topics that are fundamental for analysis in every clinical encounter where an ethical issue is identified. We focused on medical indications in the case of Mr. T., contextual features in Ms. R.'s case, and patient preferences in the case of Mr. S. In our fourth and final case introducing this series, we will review the case of Ms. C. and focus on quality of life (QOL). When QOL is limited, the loss seems apparent from the PA's viewpoint. However, as in previous cases, respect for autonomy is the guiding principle in the analysis.
The core issue of this case is the use of opioids in the treatment of chronic nonmalignant pain. Complicating the case is the patient's history of addiction. Of the ethics papers that I review for PA students and the ethics questions I receive from PA colleagues, approximately one third involve pain control and the use of opioids. The questions commonly involve patients with a current or past history of addiction. I would like to thank Jennifer Tso, PA-C, for this case.
Case
Ms. C. is a 49-year-old woman who has been receiving care at a community clinic for a number of years. The PA member of the primary care team has been her provider for most of this time. Ms. C. is in today for a routine visit. Her medical history includes osteoarthritis, suboccipital and sacroiliac myofascial pain, gastroesophageal reflux, coagulopathy, hepatitis C virus infection, cirrhosis, and polysubstance abuse, including a history of addiction to heroin and a 15-pack-year history of cigarette smoking. Her current medications include baclofen, nadolol, furosemide, spironolactone, docusate sodium, rabeprazole, trazodone, oxycontin, morphine, and methadone. She has a history of therapeutic and pharmacologic noncompliance. Mrs. C was the vice president of a prominent software group until approximately 5 years ago, when she took medical retirement. She has always preferred to receive her health care from the community clinic, and she volunteered at the clinic during its formative years.
Physical examination reveals an ill-appearing, jaundiced female with scleral icterus. She is oriented to time, place, and person. She has multiple spider angiomas on her chest. Respiratory examination reveals regular breathing with bilateral crackles at the bases of both lungs that do not clear with cough. Cardiovascular examination discloses a regular heartbeat at a rate of 90 beats per minute. Ms. C.'s lower extremities are well perfused and noted to have 2+ pitting edema at her ankles bilaterally. Abdominal examination reveals distention. The liver is easily palpable, measuring 10 cm below the costal margin at the midline. The consistency is hard and somewhat nodular. The remainder of the physical examination is unremarkable.
In addition to receiving care from her primary care team, with whom she has a pain contract, Ms. C. sees a gastroenterologist for treatment of her hepatitis. She had a pain contract with a private pain clinic but has left their care. On recent visits to the community clinic, she has occasionally become very verbally abusive to the PA and staff, with the result that the clinic is considering making her ineligible for care.
The ethical question
As the medical provider, the PA must determine if and when Ms. C. truly needs pharmacologic pain therapy. Is she using the PA to obtain narcotics for her personal addiction? Is she selling the medication to obtain illegal narcotics?
Discussion
Medical indications (beneficence and nonmaleficence) The major medical issues in this case are Ms. C.'s liver disease, which is life threatening, and her pain secondary to cirrhosis. The prognosis of cirrhosis is quite variable and depends on a number of factors, including etiology, comorbid disease, complications, and severity of disease. Ms. C.'s prognosis is poor, and she is not expected to live more than 2 years.
The goals of treatment in this case are to reduce pain and to maintain the patient's ability to have a functional and meaningful life. Treatment of pain in the 21st century continues to rely on opioids for severe, unremitting pain from malignant disease or chronic nonmalignant pain, though controversy in this area remains. Patients with liver disease can be treated in the same way as other patients with chronic pain; however, careful observation of the patient's liver function is vital.1 Ms. C. should not take NSAIDs because they increase the risk of variceal hemorrhage and adversely affect renal function.2 She may take acetaminophen, 2 g daily.3 The most effective pain medications are opioid derivatives, but because opioids are metabolized in the liver, the dosage must be monitored and adjusted. Methadone's pharmacokinetics appear least affected by liver dysfunction, and this agent appears to be safe if the dosage is reduced as liver damage increases.4