A 65-year-old man who recently emigrated from the Dominican Republic is admitted to the hospital for surgery. He has multiple myeloma and a pathologic fracture of the right humerus. The surgery is completed without complications. Afterward, the patient is alert and oriented but grimaces frequently and appears uncomfortable. He is offered pain medication, but he politely declines. When asked through an interpreter whether he is in pain, the patient replies, "It hurts a lot, but I can bear it and don't wish to be a burden." Which of the following is the most appropriate response by the physician?

Question

A 65-year-old man who recently emigrated from the Dominican Republic is admitted to the hospital for surgery.  He has multiple myeloma and a pathologic fracture of the right humerus.  The surgery is completed without complications.  Afterward, the patient is alert and oriented but grimaces frequently and appears uncomfortable.  He is offered pain medication, but he politely declines.  When asked through an interpreter whether he is in pain, the patient replies, "It hurts a lot, but I can bear it and don't wish to be a burden."  Which of the following is the most appropriate response by the physician?

Quizplus · Accepted Answer

Patients who belong to ethnic minority groups experience significant health disparities in pain management. For example, Black and Hispanic patients are more likely to be undertreated for pain compared to nonminority patients. Disparities may arise from physician bias (eg, stereotyping) and suboptimal communication (eg, language barriers, incomplete pain assessment). A patient's cultural and social background can influence pain-related beliefs and behavior. Some patients value stoicism (eg, as a "test of faith") or emphasize respect toward healthcare workers (eg, avoid burdening providers by expressing discomfort). This patient has declined medication despite visible indications (eg, grimacing) and verbal confirmation of pain. The best next step is to nonjudgmentally explore the factors influencing the patient's decision, which reflects cross-cultural and patient-centered care. Objectives for discussion include: Clarifying the shared goal of patient well-being, which can address potential misconceptions that requesting pain medication burdens the physician Exploring the patient's preferences for increasing comfort, which may or may not include the use of medication (Choice A) Although the patient has the right to decline medication, the physician should first explore the reasoning behind his decision, which can clarify misunderstandings (eg, burdening the physician) and promote shared decision-making to improve his comfort. (Choice B) The patient's desire to avoid being a burden may reflect deference toward the physician rather than underlying depression. Exploration of the patient's emotional state is better achieved through an open-ended discussion of the values important to his comfort and well-being. (Choice C) This statement is physician centered; it focuses on the physician's perception of the patient's comfort. It also assumes that "feeling better" involves the use of medication and may be perceived as judgmental. (Choice E) Having a palliative care provider speak with the patient may ultimately be appropriate, but the physician should first attempt to explore the patient's values surrounding comfort and goals of pain management. Educational objective: Ethnic minorities are more likely to be undertreated for pain, potentially due to physician bias or suboptimal communication. Cross-cultural care can promote optimal pain management by establishing the shared goal of patient well-being. This can be facilitated by exploring the cultural values (eg, stoicism, deference) that influence patient perceptions of pain and comfort. __________ References: Defining racial and ethnic disparities in pain management. (http://www.ncbi.nlm.nih.gov/pubmed/21249483) Cultural influences on pain. (http://www.ncbi.nlm.nih.gov/pubmed/26525084)

A 65-Year-Old Man Who Recently Emigrated from the Dominican Republic