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Causing Pain to Conscious Patients - Dr Mark Burgin

Dr. Mark Burgin BM BCh (oxon) MRCGP discusses the ethical issue of how much pain it is reasonable to inflict on a conscious patient.

Many procedures involve short lived discomfort such as using needles, examination of painful areas and passing tubes where anaesthesia is unnecessary.

Before anaesthesia it was acceptable to amputate a leg or remove a tooth as this was necessary and proportionate to reduce the pain and save the patient’s life.

ERCP is a procedure where a camera is passed into the duodenum and instruments are passed through the sphincter of Oddi to operate in the bile ducts.

Whereas no surgeon would attempt a laparoscopy under conscious sedation many interventional gastroenterologists still use opiates and benzos to sedate for ERCP.

Painful experience

Most patients who are sedated become restless during ERCP and about 10% suffer moderate to severe mental health problems following ERCP under sedation. (1)

The use of a short acting anaesthetic (Propofol) can almost completely prevent this but due to organisational issues few UK patients are offered this option.

Many who suffer pain will not remember that pain due to the effect of benzos on the memory so some would argue that their pain is not an issue.

There is a possibility that even unremembered pain may have negative effects upon the recovery of a patient e.g. increased cortisol, but there are other problems.

Failed procedure

ERCP is more likely to be effective if the patient has had an anaesthetic than if they are undergoing conscious sedation as they will be less restless.

This improved outcome had led to most other countries moving to using anaesthetic as standard in all cases when performing ERCP rather than sedation.

The UK is lagging behind in part due to gastroenterologists not being trained as surgeons and partly because pain and discomfort can be difficult to differentiate.

It is not possible with current technology to prevent every short-lived discomfort but using a local or general anaesthetic before a prolonged operative procedure is good medical care.

Psychological Complications

A memory of a prolonged painful experience may not appear to be too high a price to pay for relief from the severe pain from gallstones.

Traumatising 10% of patients undergoing ERCP will decrease their ability to undergo further treatments and they may become hypersensitive to even discomfort.

GPs are familiar with patients who having suffered a painful procedure who are difficult to engage in any health discussion and become distrustful of doctors.

This can cause later delays in presentation with medical problems, difficulty in agreeing treatment strategies and even disabling psychological symptoms.

Conclusions

Gastroenterologists in the UK have lagged behind other countries in providing anaesthesia when conducting painful and prolonged surgical procedures on their patients.

This is perhaps the best example of an issue that is pervasive throughout the medical establishment and has led to complaints even where the discomfort was necessary.

From a Bolam perspective there is a responsible body of UK gastroenterologists who consider anaesthesia unnecessary but Bolitho and Montgomery should also be considered.

Most patients are not even offered the option to have anaesthetic which is “a lacuna in professional practice… by which risks of grave danger are knowingly taken”. (2)

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register and audits medical expert reports.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

1. Jeurnink, S.M., Steyerberg, E.W., Kuipers, E.J. et al. The burden of endoscopic retrograde cholangiopancreatography (ERCP) performed with the patient under conscious sedation. Surg Endosc 26, 2213–2219 (2012). https://doi.org/10.1007/s00464-012-2162-2

2. Bolitho v. City and Hackney Health Authority [1996] 4 All ER 771

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