Morality in clinical space: treatment of youngsters with functional somatic symptoms in a Western clinical context.

This paper explores the moral implications of treatment of young people with functional somatic symptoms. Based on an ethnographic field study at a Danish pain clinic for youngsters (age 8 to 18), the paper seeks to unearth the cultural, moral values that clinical practice steers by and upholds, and the implications this has for the assessment and management of ill body-selves. Through an exposition of the general practice of the clinic and an investigation of two specific cases of youngsters, it is found that the assessment of symptoms and selves and the goals of treatment are informed by cultural ideals of 'the good self' and 'the good life' in which agency and work ethic - both pertaining to the notion of individual responsibility - figure as prevalent virtues. The study underpins the findings of other researchers who have found that ideals of individual autonomy and responsibility for own life and health permeate the Western health care system and the discourses of ill individuals. The contribution of this article is to portray in ethnographic detail how such a cultural ethics manifests in practice and what implications this have for the treatment of young people with functional symptoms at a specific location and in specific cases. The two cases illustrate that the underlying norms and values can give rise to very different moral assessments of symptoms and selves within the same diagnostic category.

Valoración del dolor y aplicación de intervenciones terapéuticas enfermeras en el paciente neonatal y pediátrico, en contextos asistenciales hospitalarios / Pain assessment and implementation of nursing therapeutic interventions in neonatal and pediatric patients, in welfare hospital contexts

El dolor es una realidad, una experiencia subjetiva culturalmente construida y sociohistóricamente determinada desde la más tierna infancia. Con respecto a los cuidados proporcionados a niños y adolescentes un reto de vigente actualidad es el alivio del dolor tanto agudo como crónico. Los abordajes para su tratamiento han ido cambiando y mejorando a medida que aumentaban los conocimientos por lo que disponemos de una gran variedad de intervenciones terapéuticas tanto farmacológicas como no farmacológicas. El objetivo del trabajo es visibilizar cómo se lleva a cabo la valoración del dolor en ciertas técnicas, procedimientos y procesos patológicos, así como los conocimientos que sobre intervenciones terapéuticas enfermeras para el alivio del dolor y su grado de aplicación en contextos asistenciales hospitalarios. En este artículo exclusivamente se muestran los resultados relativos a la valoración del dolor. Pude concluirse que existen algunos procesos patológicos en los que no se apuntaba la pertinencia de valorar el dolor., posiblemente no se trate de una inadecuada valoración del dolor sino por el motivo de ingreso en las unidades estudiadas. Con respecto a técnicas y procedimientos apuntan en el mismo sentido, aunque se cree importante profundizar en las causas que subyacen en aquellos casos en los que no se valora en ningún momento del procedimiento el dolor del paciente pediátrico(AU)

Pain is a reality, a subjective experience culturally built and socio-historically determined from the earliest childhood. With regard to the care provided to children and adolescents, a challenge of a present validity is the pain relief, both acute and chronic. Approaches for treatment have been changing and improving as knowledge increased so we have a wide variety of therapeutic interventions both pharmacological and non-pharmacological. The objective of this study is to demonstrate how to carry out the assessment of pain in certain techniques, procedures and pathological processes and as well as the knowledge on therapeutic interventions nursing for pain relief and its level of application in welfare hospital contexts. In this article exclusively is shown the results related to pain assessment. It may be concluded that there are some pathological processes that were not pointed out the relevance of evaluating the pain, possibly is not a case of an inadequate assessment of pain but the reason for admission in the studied units. With regard to techniques and procedures they pointed in the same direction, although it is believed important to look into the causes underlying those cases where the procedure of the pain of the pediatric patient is not valued at any moment(AU)

Circuloterapia: uma metáfora para o enfrentamento da dor crônica em duas clínicas de dor / Circle therapy: a metaphor for coping with chronic pains in two pain clinics

Este artigo descreve e analisa a dinâmica da clínica de dor enquanto um "artefato complexo" do sistema terapêutico biomédico, explorando as múltiplas vozes e as relações dialógicas sobre dor e a interdisciplinaridade no cotidiano clínico de duas clínicas de dor situadas em hospitais-escola nas cidades de Salvador e São Paulo. Foi realizado estudo etnográfico orientado pela antropologia interpretativa, na qual se buscou a descrição de situações singulares e expressivas da dinâmica da clínica de dor (considerada enquanto um serviço, constituído no interior da Biomedicina, destinado ao cuidado da dor crônica). Tais situações expressam tensões e soluções construídas a partir do enfrentamento da dor crônica enquanto objeto complexo que impõe, a todos, flexibilidade. Essa experiência etnográfica focalizou quatro espaços terapêuticos: a sala de espera, o corredor, a consulta médica e as discussões de caso clínico. A descrição produzida ilumina as múltiplas vozes sobre dor e interdisciplinaridade no cotidiano da clínica. Os sentidos da circulação nos espaços terapêuticos, representado no texto a partir da metáfora "circuloterapia", orientam essa discussão em torno dos limites e possibilidades da constituição e funcionamento deste serviço.

This paper describes and analyzes the pain clinic's dynamics as a "complex product" of the biomedical therapy system, exploring the many discussions about the meaning of pain and the interdisciplinary collaboration in the therapeutic daily routines of two pain clinics, located in university hospitals in the cities Salvador and São Paulo. An ethnographic approach guided by interpretative anthropology was used to search for the description of singular and expressive situations of the pain clinic's dynamics (considered as a service, established within Biomedicine, intended for care of chronic pain). Such situations express tensions and solutions created from the confrontation of the chronic pain as a complex object that imposes flexibility to all. This ethnography focuses on four therapeutic spaces: the waiting-room, the hall, the medical consultation and the clinical case discussion. The resulting description enlightens the multiple voices on pain and interdisciplinary collaboration in the clinic's daily routines. The directions of circulation within therapeutic spaces guided this reflection around the limits and possibilities of the establishment and operation of this service.

A perfect storm in interventional pain management: regulated, but unbalanced.

Interventional pain management now stands at the crossroads at what is described as "the perfect storm." The confluence of several factors has led to devastating results for interventional pain management. This article seeks to provide a perspective to various issues producing conditions conducive to creating a "perfect storm" such as use and abuse of interventional pain management techniques, and in the same context, use and abuse of various non-interventional techniques. The rapid increase in opioid drug prescribing, costs to health care, large increases in death rates, and random and rampant drug testing, can also lead to increases in health care utilization. Other important aspects that are seldom discussed include medico-legal and ethical perspectives of individual and professional societal opinions and the interpretation of diagnostic accuracy of controlled diagnostic blocks. The aim of this article is to discuss the impact of several factors on interventional pain management and overuse, abuse, waste, and fraud; inappropriate application without evidence-based literature support (sometimes leading to selective use or non-use of randomized or observational studies for proving biased viewpoints - post priori rather than a priori), and issues related to multiple professional societies having their own agendas to push rather than promulgating the science of interventional pain management. This perspective is based on a review of articles published in this issue of Pain Physician, information in the public domain, and other relevant articles. Based on the results of this review, various issues of relevance to modern interventional pain management are discussed and the viewpoints of several experts debated. In conclusion, supporters of interventional pain management disagree on multiple aspects for various reasons while detractors claim that interventional pain management should not exist as a speciality. Issues to be addressed include appropriate use of evidence-based medicine (EBM), overuse, overutilization, and abuse.

A primer of ethical issues involving opioid therapy for chronic nonmalignant pain in a multidisciplinary setting.

OBJECTIVE: This forum presents a clinical vignette of orofacial pain and expounds on ethical issues related to opioid therapy in the context of multidisciplinary treatment. The purpose of this forum is to assist health care providers from different disciplines in identifying ethical issues and conflicts regarding opioid therapy encountered in multidisciplinary clinical pain practices. DESIGN: We use the case vignette and opioid therapy as a backdrop for a discussion of 1) an overview of ethics terminology; 2) a presentation of key ethics principles; 3) our conceptualization of ethical obligations of patients regarding opioid therapy; and 4) the process of developing an appropriate treatment plan within the context of the discussed ethical principles.

Laços e nós: a comunicação na relação médico-paciente com câncer e dor crônica / Ties and knots: the communication between doctors and patients with cancer and chronic pain

É alta a prevalência de dor crônica em pacientes com câncer, que é comprovadamente associada ao sofrimento psicológico acentuado e muitas vezes não é adequadamente diagnosticada e tratada. Estudo que realizamos com 120 pacientes adultos em atendimento ambulatorial na Clínica de Dor do Instituto Nacional de Câncer, no Rio de Janeiro que demonstrou que os pacientes mesmo conhecendo o seu diagnóstico de câncer, não se sentiam informados sobre a doença e a dor oncológica a contento, o que trazia insatisfação com o tratamento recebido e maior exigência com os resultados do mesmo. Nosso estudo revelou, ainda, que o comportamento do profissional durante o atendimento pode ser percebido pelos pacientes como fator tanto de melhora como de piora da dor, sendo o comportamento atencioso do profissional muitas vezes mais valorizado pelos pacientes que a supressão da dor. Estes resultados suscitaram questões relativas à qualidade da interação entre médicos e pacientes, desenvolvidas nesta dissertação. Embora não sejam suficientemente investidas nem na relação médico-paciente, nem na educação e no treinamento profissional, as habilidades de comunicação do médico afetam diretamente o nível de informação e de satisfação do paciente, suas crenças e os resultados do tratamento. Ao longo do tempo a relação médico paciente vem mudando, deixando de ser tão centrada na doença e no médico, para centrar-se mais no doente como um ser integral, o que implica no reconhecimento, pelo médico, de saberes diferentes dos seus e de que o seu saber não constitui uma verdade absoluta a ser acatada pelos demais. Apesar de bem-vindas, estas mudanças trazem uma certa confusão nos papéis a serem desempenhados por médicos e pacientes e dificuldades aos médicos de lidarem com as diferenças, com as queixas subjetivas dos pacientes, com as emoções destes e as suas próprias...

A crisis in chronic pain care: an ethical analysis. Part three: Toward an integrative, multi-disciplinary pain medicine built around the needs of the patient.

A number of variables have contributed to the current crisis in chronic pain care and are affected by, and affect, the philosophies and politics that influence the socio-economic climate of the American healthcare system. Thus, we posit that managing the crisis in chronic pain care in the United States is contingent upon the development of a multi-focal healthcare paradigm that more thoroughly enables and fortifies research, its translation (in education and practice), and the implementation of, and support for, both the curative and healing approaches in medicine in general, and pain care specifically. These steps necessitate re-examination, if not revision of the health care system and its economics. The ethical imperative to consider and prudently employ cutting-edge diagnostic and therapeutic technologies in pain medicine is obligatory. However, "supply side prudence" is of little value if "demand side accessibility" is lacking. Revisions to health insurance plans advocated by the in-coming administration seek to create uniformity in basic health care services based upon re-assessment of the clinical effectiveness (versus merely cost) of treatments, including those that are "high tech." These plans attempt to allow every patient a more complete ability to deliberatively work with physicians to access those services and resources that maximize health functioning and goals. But even given these revisions, authentic pain care must take into account the interactive contexts of the painient individual. The biopsychosocial model of chronic pain management may have significant practical and ethical worth in this regard. A system of pain treatment operating from a biopsychosocial perspective necessitates integrative multi-disciplinarity. We propose a tiered, multi-disciplinary paradigm based upon the differing needs of each specific patient. But establishing such a system does not guarantee access, and distribution of these services and resources requires economic support to ensure that capabilities are more broadly available (i.e., supplied), and afforded as needed and wanted (i.e., demanded). Toward this end, we posit the need to focus upon, and more fully integrate 1) education, 2) multi-disciplinary care (including re-vivification of MPCs), 3) policies that allow financial subsidies that afford patients the latitude to access and utilize such expanded resources appropriately to meet identified medical needs, and 4) medico-legal initiatives and statutes that protect and enable patients and physicians. The proposed changes comport with a number of ethical systems in that they support the basic deontic structure of the profession and allow for a richer, more finely grained articulation of clinical and ethical responsibilities within the scope of particular general, specialty, and sub-specialty practices.

A crisis in chronic pain care: an ethical analysis. Part two: proposed structure and function of an ethics of pain medicine.

In this paper, we propose a constructive approach to an ethics of pain medicine that is animated by a core philosophy of medicine as specific and focal to the uniqueness of pain, the pain patient, and the pain clinician. This philosophy of pain medicine 1) defines the nature of pain, 2) recognizes the variability and subjectivity of its expression in the pain patient, 3) acknowledges and explicates the vulnerabilities rendered by pain, 4) describes the inherent characteristics and asymmetries of the patient-clinician relationship, and 5) defines the ends of pain care. That these ends entail the provision of "good" care links the epistemic domains of pain medicine to its anthropologic focus and ethically sound conduct. We posit that an ethics of pain medicine should define the profession and sustain the practice. Facts establish (the need for) certain duties and rules of pain medicine. These emphasize the duty to self and others, and an appreciation for relational asymmetries, and dictates that those who enter the profession of pain medicine should be generally aligned with this set of core practical and ethical affirmations and duties. To maintain contemporary relevance, rules, duties, and moral reasoning must adjust to changing conditions. Applied ethics shape the practice within the infrastructure of core rules and duties of the profession. An applied ethics of pain medicine must be pragmatic, and therefore, cannot rely upon, or be reduced to, a single principle or ethical system. A number of ethical systems (such as the use of principles, utilitarianism, casuistry, feminist/care orientations) all have relative merit and potential limitations. We argue that the obligation to recognize ethical issues, and utilize knowledge to best reflect appropriate moral values rests upon the clinician as a moral agent, and therefore advocate the relevance and importance of an agent-based virtue ethics, recognizing that virtue ethics cannot stand alone, but must be employed within a larger system of ethical intuition. Yet, if such a structure of normative and applied ethics is to be realized, moral consideration must guide evaluation of the current system of pain care, and provide direction for the development and implementation of therapeutically and ethically integrative pain medicine for the future.

Moral agency in pain medicine: philosophy, practice and virtue.

Although established as a field of specialization, pain medicine remains somewhat fractionated. Such lack of cohesion creates dissonance on multiple levels, and thus, impedes the provision of effective pain care. This paper asserts that there is a core philosophy of medicine that reflects the intellectual and moral quality of the healing relationship. I argue that pain medicine, in all its constituent disciplines, is bound to this philosophy. The intricate relationship between pain, the pain patient, and the pain physician creates pragmatic and moral dilemmas that may not be well served by the use of prima facie principles. It is argued that an agent-based, virtue ethics best enable the clinician to both apprehend the complexity of this relationship and appreciate other ethical approaches in the discourse arising from issues of care.