Patients in pain: it's a big problem

A door opens behind me, causing my shifting heel to land on a socked foot just as the resident warns me to watch out.

“Hey!” an irate voice protests. “First you keep me in pain and now you are trying to kill me.”

I whip around with a sincere apology, but a veteran nurse grabs me by the arm and drags me away.

“Listen, he is really unhappy with you.”

My heart skips a beat. “Why?”

“All I know is he’s been in pain all night.”

He was admitted to hospital recently with advanced cancer and frailty. One of the idiosyncrasies of working as a doctor in the public health system is finding yourself having some of life’s most difficult conversations with complete strangers. You didn’t see them at diagnosis, or at any of the points where one treatment failed and another commenced. You haven’t a clue about their journey, their hopes or desires. But now, they are too sick to go to their oncologist; their oncologist can’t come to see them; and your job is to pull up a chair, introduce yourself and build enough rapport fast enough to learn the answers to some pressing questions that will determine the direction of care at the end of life. Before doing this, you piece together correspondence to decipher who said what. You study serial scans to understand what was happening inside the body when those conversations were had. Then, with this piecemeal knowledge about the disease and no knowledge about the person, you approach your task, praying it will go well.

It can be a recipe for disaster but this time, it isn’t. The patient is accepting of his impending death – he just wants a quiet place to contemplate his final days and to be kept out of pain. The simplicity of his request moves me. I reassure him that a first-world hospital has many options for pain relief.

“Why did you lie to me?” he now demands, fighting back tears. “I was in pain all night and they wouldn’t give me an injection.”

“Can I get you something before we talk?”

“The nurse just did.”

“But that’s the morphine that has been on your chart all along”, I exclaim, showing him the order I wrote.

Just then his nurse walks in. Sympathetically, she says, “You wrote two sorts but he only got oral morphine overnight.”

“It didn’t work, and I kept asking for an injection but they said I had to wait for you to come.”

I feel sick thinking of the 24-hour interval between my rounds. How much pain had he endured in that time? What had he made of my promise? How much trust had been eroded?

My remorse is too little and too late for him. As he finally drifts into a tired sleep, I realise how little I can do to erase his memory of a night of pain and terror in a place he put his faith in.

Later, I talk to his nurse. “His night nurse wasn’t sure about an injection, so she asked the resident who said no.”

Next, I track down the junior doctor, who says she was worried about causing respiratory depression. A dying man needed relief from pain. Surely, that’s what injectable morphine was for, I gently observe.

“I didn’t get the full story on the phone”, she says contritely, before adding, “I guess I could have seen him.”

I withhold these bleak explanations from my patient, but they play on my mind. Unfortunately, my patient’s story is hardly unique. Every day in every hospital, there is a patient with uncontrolled and poorly managed pain, not necessarily associated with the end of life. As the recent harrowing account of a patient (who happens to be a professional medical advocate with an anaesthetist for a husband) shows, delayed, inadequate or inappropriate relief of pain transcends boundaries of disease, socioeconomic status, language, level of education and insurance status. Recalling her experience, the patient advocate says, “It is a terrifying thing to be in extreme pain, know your condition is deteriorating, be confined to bed, diminished by narcotics and then be mismanaged by the people who have a duty of care to you.” Her words singe me. My patient would agree that the final step to disempowering already vulnerable patients is to neglect their pain.

Why does this happen? After all, every medical student rote learns the “pain questions”: Where is the pain? Does it go anywhere? What does it feel like? What makes it better? What makes it worse? Neither these important questions nor the answers have shed their clinical utility.

While pain specialists would contend that the subject isn’t taught well enough, medical education and training covers pain management as much (or as little) as it covers many other important areas of patient care including communication, confidentiality and consent. These days, there is no excuse for inadequate pain management. It seems ridiculous but conceivable that good pain management is somehow perceived as a “soft skill” when it ought to be a tenet of good medicine.

But here is something else we might wish to dwell on. When faced with shortcomings in healthcare delivery, it is common for healthcare professionals to lament “the system”. True enough, the system is burdened. Doctors face a continuous onslaught of complex and sick patients, and there is a growing tendency to own responsibility for an organ rather than a person. Nurses can find themselves justly overwhelmed by the needs of just one or two such patients, and the demands of bureaucracy and meaningless checklists hijack everyone’s time. For each omission in patient care, it’s tempting to summon some such aspect of our working environment as an explanation.

But much as I hate to admit it, I think that the failure to manage the pain of our patients speaks to something more elemental: our failure to listen. When a patient is in pain, nothing beats taking a history and conducting a thorough examination. Merely skimming the notes or getting second-hand information is no substitute for the laying of hands and should not buy reassurance for doctor or patient.

My patient found his quiet place in hospice. After the first mishap, he thankfully didn’t have further reason for distress. He died exhibiting the same calm and grace that I came to appreciate.

While it hardly seems so on some days, the task of medicine is to be accountable, above all, to our patients. To practice good medicine is to harness the power of listening and pair it with a capacity for empathy, two of the oldest tools of medicine. Without them, even the most modern and sophisticated advances will come to naught. The ability to sit quietly and listen attentively to the patient’s story seems like a quaint detail from a bygone era but as the physician Thomas McCrae observed to his students a hundred years ago, “More is missed by not looking than not knowing”. I think my patient would agree.

• Ranjana Srivastava is a Guardian Australia columnist and oncologist