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.

Relaciones interpersonales en el nuevo modelo de atención sanitarista al niño con dolor / Interpersonal relationships within the new model of health care for children with pain

Introducción: el alivio del dolor debe considerase un derecho fundamental de la persona, porque el respeto a la dignidad humana exige que nadie sufra dolor innecesario. Objetivo: valorar cómo se establecía la relación de los profesionales con el paciente y representantes válidos, en la atención a niños con dolor, y si se ajustaban a un modelo de afrontamiento ético de las relaciones interpersonales y las valoraciones sobre virtudes y cualidades presentes en los profesionales que atienden niños con dolor. Métodos: se realizó una investigación descriptiva-transversal utilizando métodos cualitativos. Se realizaron encuestas a tutores válidos de niños que padecían dolor ingresados en el Hospital Pediátrico Juan Manuel Márquez, y a profesionales de ese hospital de diferentes servicios que atienden a niños con dolor. Las valoraciones de los profesionales sobre estas relaciones se contrastaron con las que hicieron los representantes legales de los niños con dolor atendidos en el hospital. Resultados: el personal de salud considera generalmente (casi siempre) correctas las valoraciones bioéticas en la relación médica con los enfermos y familiares. Los tutores válidos de los niños ingresados escogieron la alternativa siempre correcta en los procederes orientados desde la Bioética por parte del personal de salud. Las cualidades que caracterizan al personal médico y de enfermería son apreciadas en el rango de suficiente, y estas, con relación a cómo deberían estar presentes, las frecuencias no fueron lo suficientemente elevadas para esta profesión. Conclusiones: se constató que la ponderación de valores deseados para la profesión no alcanza las expectativas necesarias para considerar que se estén formando profesionales virtuosos. Los profesionales valoraron que no siempre se cumplen los procederes orientados desde la bioética, sin embargo los padres consideran que estos son cumplidos siempre(AU)

Introduction: pain relief should be considered a fundamental right of a person since the respect to human dignity demands that no one suffer from unnecessary pain. Objective: to find out how the relationship between the health professionals and the patient and his/her legal representative was developed in the care of children with pain, and whether they adapted to a model of ethical coping with interpersonal relationship, and the assessment on virtues and qualities present in those professionals who treat children with pain. Methods: a descriptive cross-sectional research study using qualitative methods was carried out. Guardians of children suffering pain and admitted to Juan Manuel Márquez pediatric hospital, and health professionals in different hospital services, who treat children with pain, were surveyed. The professionals' assessment on these relationships was compared with those of the legal representatives of children with pain, who were seen at the hospital. Results: the health staff considered that almost all the bioethical assessments in terms of the medical relationships with patients and relatives were correct. The guardians of hospitalized children chose the alternative always correct to qualify the procedures which were oriented from a bioethical viewpoint by the health staff. The qualities of the medical and nursing staffs were regarded as sufficient, but when comparing them with the way they should present themselves, then the frequencies were not high enough for this profession. Conclusions: it was proved that weighing of wanted values for this profession did not reach the required expectations to consider that virtuous professionals are being formed. The professionals stated that not always the bioethically oriented procedures are complied with; however, the parents think that they are always implemented(AU)

Ronald Melzack and Patrick Wall. La teoría de la compuerta. Más allá del concepto científico dos universos científicos dedicados al entendimiento del dolor / No disponible

La evolución histórica para el conocimiento del dolor ha tenido momentos cruciales en los que el curso evolutivo se modificó. Esos momentos son situaciones relevantes que cambiaron los conceptos previamente aceptados y abrieron nuevos horizontes de investigación, de entendimiento y de tratamiento. Cuando Melzack y Wall desarrollaron la “Teoría de la Compuerta” lograron aclarar fenómenos básicos del entendimiento del dolor pero igualmente abrieron múltiples tópicos de futuras investigaciones básicas y clínicas. Dieron sustento, con su teoría, a múltiples tratamientos del dolor que son la base de procedimientos que en la actualidad realizamos. Los aspectos psicológicos, el componente clínico y la base estructural anatomofisiológica fueron poco a poco conformando una de las teorías más completas de la ciencia médica y por supuesto principio básico para el mejor tratamiento del dolor. Son 50 años que se cumplen de la publicación de aquel artículo en la revista Science (Pain Mechanism: a new theory. A gate control system modulates sensory input from the skin before it evoques pain perception and response. Ronald Melzack and Patrick Wall. Science. 19 november 1965, volumen 150, number 3699), el cual ha sido reconocido hasta la actualidad como la referencia bibliográfica más utilizada en la ciencia médica en los últimos 50 años. Este artículo se escribió en un contexto científico particular y a la luz de dos vidas diferentes que ilustran un proceso ejemplar de desarrollo de la ciencia. El análisis es no solo científico sino humano de lo que ha sido este artículo para el entendimiento de las ciencias del dolor (AU)

The quest to acquire knowledge and understanding of pain has had crucial moments in which the evolution of the process has been dramatically changed. These moments have been revelations that have opened the path to rethinking previously accepted knowledge and created new horizons of research, understanding and treatment. When Melzack and Wall first described what would come to be known as the “Gate Control theory” they were able not only to clarify basic aspects of pain development but to lead the way to further basic and clinical research studies. They psychological aspects, the clinical basis and the structural anatomical and physiological components created one of the most complete theories in medical sciences and the ground for the basic management of pain. It has been fifty years since the original article was published in Science magazine (Pain Mechanism: a new theory. A gate control system modulates sensory input from the skin before it evokes pain perception and response. Ronald Melzack and Patrick Wall. Science. November 19, 1965 volume 150, number 3699). It has been recognized even until today as the most cited reference in medical journals in the past 50 years. The paper was written during a very particular moment in scientific history and the context of two very different lives, which illustrates the incredible process that leads to scientific development. The analysis of what this paper has symbolized to pain science must be done not only from a purely scientific view point but from a human one as well (AU)

Identificación y priorización de episodios adversos y fallos relacionados con la seguridad del paciente en las Unidades de Tratamiento del Dolor / Identifying and prioritising adverse episodes and failures related to patient safety in Pain Treatment Units

Objetivos. Un grupo de expertos coordinado por la Escuela Andaluza de Salud Pública identificó los episodios adversos (EA) más graves y frecuentes en las Unidades de Tratamiento del Dolor (UTD), así como los fallos y las causas subyacentes, como paso previo a la elaboración de acciones preventivas. Los objetivos del proyecto fueron identificar los episodios adversos potenciales en las UTD, identificar sus fallos y las causas que pueden originarlos y, priorizar dichos fallos según la herramienta análisis de modos de fallos y de sus efectos (AMFE). Material y métodos. La metodología empleada consistió en realizar una búsqueda bibliográfica, selección de un grupo de expertos con experiencia en UTD, creación de un catálogo de episodios adversos mediante la técnica de generación de ideas y, puesta en práctica de las herramientas AMFE e índice de prioridad de riesgo. Resultados. Se identificaron hasta 66 tipos de episodios adversos relacionados con medicación (30), técnicas invasivas (15), proceso asistencial (10), información y educación del paciente (6), práctica clínica (5). Se localizó que hasta 101 fallos pueden desencadenar esos EA y, que 242 causas pueden provocar esos fallos. Conclusiones. Los resultados indican la necesidad de trabajar principalmente en 2 sentidos: la mejora del proceso asistencial en las UTD (la organización de la asistencia), y el trabajo profesional; este último en 2 aspectos, mejora de la práctica clínica y aumento de las competencias profesionales mediante formación específica. La comunicación, ya sea interprofesional o interservicios o con el paciente y su familia, se identifica como un aspecto clave para la mejora(AU)

Objectives. An expert group coordinated by the Andalusian School of Public Health identified the most serious and frequent adverse events in Pain Treatment Units (PTU), as well the failures and underlying causes, as a prior step to preparing preventive actions. The aims of the project were to identify potential adverse events in Pain Treatment Units, identify failures and their underlying causes, and prioritise these failures according to a failure modes and effects analysis (FMEA) tool. Material and methods. The method employed consisted of a literature search, the selection of an expert group with experience in PTU, creating a catalogue of adverse events using the generation of ideas technique, and putting the FMEA and Risk Priority Index tools into practice. Results. Up to 66 types of adverse events were identified associated with; medication (30), invasive techniques (15), care process (10), patient information and education (6), and clinical practice (5). It was found that up to 101 failures could be triggered by these adverse events, and that 242 causes could lead to these failures. Conclusions. The results indicated the need to work principally in two directions, improving the care process in the PTU (the health care organisation), and the professional work, this latter having two aspects, improving the clinical practice, and increase professional skills by means of specific training. Communication, whether inter-professional or inter-department, or with the patient and their family, is identified as a key aspect for improvement(AU)

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)

Mejora de la calidad asistencial a los pacientes de la unidad de dolor torácico de un hospital comarcal / Improvement in health care quality for patients from the thoracic/chest pain unit in a regional hospital

Objetivos. Evaluar un ciclo de mejora en pacientes con dolor torácico en urgencias hospitalarias, especialmente los que se benefician de la realización de test de isquemia precoz en nuestro entorno. Material y métodos. Se diseñó un protocolo de atención por grupo multidisciplinario que identifica oportunidades de mejora y prioriza abordar que «la realización de test de isquemia de forma precoz era menor que lo recomendado». Se analizan las causas (diagrama de Ishikawa) y se definen seis criterios de calidad. Se evaluaron estos en una muestra aleatoria de 30 pacientes del total a los que se realizó ergometría en el hospital en el primer semestre de 2007 (n=180) y con encuesta a facultativos. Se introdujeron medidas correctivas: difusión, accesibilidad en intranet, información explícita a nuevos facultativos. La segunda evaluación se realizó durante el primer semestre de 2008 en otra muestra similar de 30 pacientes (n=120). Resultados. En la primera evaluación la clasificación de riesgo según protocolo fue muy baja (incumplimiento del 100%) y se derivaba a consultas de cardiología a pacientes subsidiarios de ingreso en la unidad de dolor torácico y test de isquemia precoz (incumplimiento del criterio del 74%). Tras medidas correctivas, se obtiene una mejora general, pero muy significativa en los anteriores, reduciendo incumplimientos al 17% en clasificación y el 23% en derivaciones. Conclusiones. El ciclo estructurado ha facilitado la solución del problema priorizado en un plazo corto. Las medidas adoptadas han sido fundamentalmente organizativas, dependientes de los profesionales y con coste muy bajo. Enfoques sencillos pero con metodología ordenada deben valorarse antes de la incorporación de tecnologías de mayor coste(AU)

Objectives. The evaluation of an improvement cycle in patients suffering thoracic/chest pain in hospital emergencies, especially in those who could benefit from the early Bruce Treadmill Test. Material and methods. A multidisciplinary group care protocol was designed, which identified improvement opportunities and gave priority to the fact that «an early Bruce Treadmill Test was carried out on fewer occasions than recommended». Causes were analysed (Ishikawa diagram) and six quality criteria were defined. These criteria were evaluated in a random sample of 30 patients out of the total of 180 who used the ergometer at the Hospital in the first six months of 2007, as well as questionnaire for the doctors. Corrective measures were introduced: circulation, accessibility through intranet and explicit information for new employees (doctors). The second evaluation was carried out during the first six-months of 2008 using another random sample of 30 patients from a total of 120. Results. In the first evaluation, the classification of the risk according to the protocol was very low (100% non-compliance) and patients whose admission to the Chest Pain Unit was recommended and an early Bruce Treadmill Test (74% criteria failure) were referred to cardiology clinics. After implementation of the corrective measures, we obtain a general improvement in all the criteria, but very significant from the previous ones, with non-compliances being reduced to 17% in classification and to the 23% in referrals. Conclusions. The structured cycle has helped resolve the priority problem in the short-term. The adopted measures have mainly been organisational, dependent on the professionals involved, and at a very low cost. Simple but organised methodological approaches should be taken into account before the incorporation of higher cost technologies(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.

Organización de una Unidad de Dolor Agudo en un Hospital Regional / Organization of an Acute Pain Unit in a Regional Hospital

Exponemos nuestra experiencia, en el desarrollo y gestiónde una U.D.A., en un Hospital Regional, que proporciona unaatención integral al dolor agudo y con unos costes reducidosy por ello, asumibles por el Sistema Público de Salud.Aunque habitualmente se tiende a identificar el dolor agudocon el dolor postoperatorio, bueno será constatar, que talapreciación puede conducir a un grave error: restringir el ámbitode actuación de una Unidad de Tratamiento del DolorAgudo (UDA.), a la atención del dolor consecutivo a una intervenciónquirúrgica. En el medio hospitalario coexisten otrosmodelos de dolor que pueden tener la misma importancia cualitativae incluso cuantitativa, que el DPO y que de forma idealdeberían recibir la atención especializada que proporcionala UDA, tal es el caso de: del dolor obstétrico, el dolor en lasunidades de cuidados críticos (de adultos o pediátricos), el dolorisquémico (Cirugía Vascular), el dolor en Urgencias y undolor agudo de cualquier origen.Sobre estos supuestos se basa el diseño y los protocolosde actuación de nuestra U.D.A., dado que se integra en elServicio de Anestesiología del Hospital Universitario “Puertadel Mar”, de Cádiz, que posee unas condiciones privilegiadaspara abarcar un proyecto de tal magnitud, ya que a pesar deser el hospital de referencia para más de 1.250.000 personas,no tiene segregado ni el Hospital Materno-Infantil, ni elHospital Traumatológico. Es decir, que posibilita el tratamientodel dolor agudo procedente de cualquier servicio quirúrgico(AU)

We expose our experience on the development and managementof and Acute Pain Service (APS), on a regional hospital,that provides an integral care of acute pain, with a lowcost model, sustainable by the Public Health Care System.Though, there is a common tendency to identify acutepain with postoperative pain, it’s essential to remark thatthis supposition contains a big mistake: to reduce the scopeof the Acute Pain Unit, to the treatment of the pain consecutiveto a surgical procedure. At hospital, coexists otheracute pain models, with the same or more significance, inqualitative and quantitative terms, than postoperative pain,and so, must receive the specialized care of an Acute PainService; good examples are: obstetric pain, vascular ischemicpain, pain at Intensive Care Units (adult and paediatric),Emergency Room’s pain and any other acute pain independentof it’s origin.Our APS, integrated on the Department of Anaesthesiafrom “Puerta del Mar” University Hospital, on Cádiz, has beendesigned with the purpose to offer guidelines and analgesicprotocols, in order to achieve a whole coverage for anytype of acute pain. This huge medical project, exploits thespecial privileged characteristics of a reference hospital formore than 1.250.000 persons, but nevertheless, still includeson a single functional unit, all surgical services and hasnot suffered the segregation of the maternal, paediatric andorthopaedic units, as any other great hospital on ourcountry(AU)

Organización asistencial de una Unidad del Dolor en Extremadura / Attendance organisation of a pain unit

Las Unidades del Dolor se establecieron en España desde1966 siendo en su mayoría, servicios hospitalarios en los quese realiza el estudio y tratamiento del dolor. En Extremaduraestas Unidades comenzaron en el año 2002 adecuándolas alas necesidades de nuestra región y realizando un programaformativo hacia Atención Primaria y Servicios Hospitalarioscon establecimiento de criterios derivativos tanto clínicos comode funcionalidad. Transcurridos cinco años exponemosnuestra experiencia en este modelo organizativo(AU)

Pain Units are set in Spain since 1966, being most ofthem hospitable services in which pain study and treatmentare developed. This Units first started in Extremadura in 2002and were made suitable for our region´s necessities, makinga formative program towards Primary Attention and HospitableServices, establishing clinical and functional derivativecriteria.Five years after we set forth our experience in this organisationmodel(AU)

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.