A sudden chill was sent through the Utah medical community recently. Physicians from Logan to St. George are refusing to prescribe pain medicine. Patients are afraid to take appropriate medicine because of fears of undesirable side effects, including death.
This situation is due to a criminal court case involving Dr. Robert Weitzel, who was prosecuted in Davis County. He was convicted on two counts of manslaughter and three counts of medical negligence in a much-publicized case involving the deaths of five elderly people suffering from end-stage dementia. The patients were hospitalized in a Davis County hospital and were being treated by Dr. Weitzel. He alleged he was providing comfort care by giving the patients morphine injections as well as other medications. The jury found his care inappropriate and criminal.
The unfortunate fact is that pain is an underdiagnosed and undertreated condition, not only in Utah, but across the United States. Numerous studies that have shown this to be true attribute the problem to medical professionals, who are often poorly trained in pain management, and to patients, who fear the side effects of medications, who underreport their pain, or who are unwilling to take prescribed medications.
The Weitzel case has compounded the situation. Now health care professionals fear criminal prosecution for medical treatment decisions, and the public has been shown that their advanced medical directives are not legally binding in Utah.
I am a physician whose practice is limited to palliative care and pain medicine. I am the medical director for a Salt Lake and Ogden hospice, and I see patients exclusively in their homes. I can speak from experience that excellent end-of-life care demands a comprehensive interdisciplinary care plan.
In at least 90 percent of my cases, pain medication must be utilized to maximize quality of life. The decision to use these treatments is guided by the patient's or care surrogate's documented wishes and instructions for care. Physicians are bound morally and ethically to respect these instructions. I am concerned that my physician peers will ignore these advanced directives as a result of the Dr. Weitzel case, for fear of criminal prosecution for use of pain medication.
I have observed the chilling effect this case has had on my professional colleagues. Doctors are now refusing to prescribe morphine for patients with intractable pain. Nursing homes have stopped giving pain medicine when ordered on an "as-needed" basis.
The week after the completion of the case, a physician in Logan informed a hospice nurse who was requesting morphine for a dying patient in pain, "No, and I mean . . . no!" During the same week, physicians in Richfield informed me they were forced by the case to rethink their care practices because they feared criminal prosecution for quality care!
This is a disturbing atmosphere in which to practice medicine at a time when the profession is trying to improve end-of-life care.
The Partnership to Improve End-of-Life Care in Utah (www.carefordying.org) is a partnership of state and community organizations and individuals that was created to improve end-of-life care. The partnership has been funded by a three-year grant from the Robert Wood Johnson Foundation and is one of 23 such demonstration projects nationwide
Recently, the partnership met with representatives from the Utah State Department of Professional Licensing (DOPL) to discuss the issues involved. DOPL's bottom line is that appropriate pain management is necessary and is the expected standard of care. The Dr. Weitzel case, in DOPL's opinion, should not be a deterrent to good care and cannot justify undertreatment of symptoms.
No physician needs to be concerned about a "witch hunt" or other intrusive investigations into their practice. Physicians are not targeted by review of drug prescriptions or other means, and DOPL only initiates investigations after public complaints. DOPL should be regarded a partner in the process of improving end-of-life care in Utah.
Dr. Weitzel's case has also had an unfortunate and undesirable impact on the care of people suffering from pain in the state of Utah. I have been asked if the medicine I am prescribing will "kill me like those patients in Davis County?" Patients have gotten the message that morphine or other pain medication is bad medicine!
Pain medications have minimal side effects that are predictable and easily treated. People should not fear that the use of pain medication will make them "addicts."
Physicians and other health care professionals must feel comfortable prescribing these well-known analgesic medications and are encouraged to consult palliative care and pain medicine specialists if they have concerns. Guidelines for the care of the elderly and for patients suffering in pain exist and are recognized by the leading medical specialty groups in the United States. I personally have no reservations about utilizing medications to control pain, and DOPL has reassured me that good, well-documented care will not be penalized.
I encourage Utah physicians to be guided by the principles of good medical care, recognizing the importance of patients' autonomy and of doing no harm. A patient-physician bond is a gift and makes the practice of medicine a most rewarding career. Please continue to do what is best for your patients. They expect and deserve it.
Dr. Gregory Miller is a physician who specializes in pain medicine and palliative care among terminally ill patients.