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Patient‐controlled analgesia — who benefits?

The technique of patient-controlled analgesia (PCA) was first described a quarter of a century ago [1] but its enthusiastic and unquestioned adoption for analgesia after major surgery has only occurred in the current decade. Its main advantage is said to be that patients have control over their own pain relief [2]. There has been evidence for many years that patients’ choice and participation in medical decisions can enhance the effectiveness of treatment [3]. The recent increased emphasis on patient involvement in health care reflects convergence between this view and contemporary cultural and political dogma. Currently, PCA provides the archetypal example of patient involvement in their own treatment. The popularity of PCA with patients is reflected in evidence of greatly improved satisfaction compared with intramuscular opioids [4]. However, PCA only marginally enhances pain relief [2, 4] and it is usually assumed that the improved satisfaction reflects the control that this technique affords patients over their postoperative analgesia [5]. The belief that patients recognise, and value, the control that PCA provides merits critical appraisal. This belief is challenged by our recent studies of 26 patients who had received PCA for postoperative analgesia [6, 7]. We found that control was not important; patients rarely mentioned it until questioned directly. Indeed, patients saw certain aspects of PCA as restricting the control they could exert over their own pain relief: the need to avoid nausea and vomiting, fears of overdose and realisation that analgesia depended on a complex machine working within limits determined by remote experts. Two main reasons for valuing PCA both concerned its effects on patients’ interactions with nurses. Not surprisingly it was seen as better than waiting for nursing staff to provide intramuscular opioids, even when qualified staff were readily available. An unexpected ‘benefit’ was that PCA was seen as protecting the patient from having to show distress to busy nursing staff. These two factors may help to explain why PCA improves satisfaction in comparison with intramuscular opioids. Perhaps the reasons why nursing and medical staff value PCA so highly should also be scrutinised carefully. Consider the interests, other than the patients’, that PCA serves. Apart from the obvious commercial considerations, there are important professional implications, not all of which are immediately apparent. First, there is the formation of acute pain teams from senior nursing staff and anaesthetists who are freed from routine duties. Their application of modern technology to an emotive and universal problem has resulted in this new means of enhancing professional status within the hospital. At first sight there are corresponding advantages for the nursing staff who remain on the ward and who are freed from the time-consuming task of administering intramuscular opioids. However, an unexpected consequence could be to promote the deprofessionalisation of nursing. Thus, senior nursing staff on the ward, who no longer have responsibility for pain relief, will find themselves replaced by less skilled staff with little more than domestic responsibilities. In this way PCA could eventually serve management objectives in reducing wage costs and the power of this august profession. Our own results suggest other subtle and important reasons for the popularity of PCA. Just as our patients appreciated the facility of not displaying their distress to nurses, perhaps their nurses viewed PCA as protection from involvement with patients’ pain and distress. We propose that PCA may be a modern example of the techniques which nurses have long been known to use to distance themselves from patients’ suffering [8, 9]. Specifically, it allows nurses to have less contact with the suffering patient and to escape responsibility for inadequate pain relief. It is central to PCA that the primary responsibility for pain relief is shifted from the nurse to the patient. However, it is not clear at present whether patients either wish, or indeed are competent, to be given this responsibility. Previous work has shown that patients prescribed intramuscular opioids fail to ask for adequate analgesia because of fears (such as addiction) and beliefs (such as some pain is beneficial) [10, 11]. We found similar constraints on the use of PCA, indicating that this new technique has not overcome these old fears [6, 7]. It was worrying to find that, when pain relief was inadequate, this was viewed as a failure of the patient to use the machine correctly, rather than of the nursing and medical staff to provide adequate postoperative care. This attribution of blame may be an inevitable consequence of devolving key decisions about treatment to patients. Therefore, modern anaesthesia may have provided unwittingly a poignant example of the consequences of a change in medical practice which reflects the current political and cultural climate more than the views of patients [12].