Knee pain is an immobilizing symptom from various of diseases and particularly important to treat in the elderly population. Knee pain accounts for 1.9 million visits to general practitioners and 1 million visits to emergency departments annually. Through history taking, focusing on red flags that the patients might present with, through physical examination, and understanding knee anatomy, physicians are able to make the diagnosis and formulate an appropriate management strategy (Gross & Ma, 2013).
The important part of management strategies is to identify realistic functional goals for therapy. A multidisciplinary approach that includes medications, counseling, physical therapy, …show more content…
nerve blocks, and surgery may be required to treat the pain and improve patient’s quality of life. There also other invasive treatments which involve, epidural injection of glucocorticoids for acute radicular pain, spinal cord stimulation to inhibit pain in the affected columns or implantation of intrathecal drug-delivery systems. Though a referral to the multidisciplinary pain clinic for a full evaluation should precede any invasive procedure. For some patients, pharmacologic management alone can provide adequate relief (Rathmell & Fields, 2015).
One of the pharmacological interventions that can be applied is analgesics which includes nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, COX-2 inhibitors, and opioids, which are used to ease pain and inflammation of arthritis. Besides that, corticosteroids which are quick-acting drugs, similar to the hormone cortisone, are used to control inflammation. Furthermore, disease-modifying anti-rheumatic drugs (DMARDs), decrease pain and inflammation, reduce or prevent joint damage, and reserve the structure and function of joints. Other than that, tricyclic antidepressants (TCAs) can be used to treat pain by inhibiting reuptake of serotonin and norepinephrine at the nerve endings in the spinal cord as well as in the brain (Reddy, Lopez & Elsayem, 2011).
In the case of VW, she received medications and physical therapy. She has been taking Buprenorphine (5mcg/hr), once a week, and Paracetamol (500mg), 2 tablets, four times daily. Buprenorphine is 25-50 times more potent than morphine, though it is considered to be a partial opioid agonist (limited intrinsic activity). Buprenorphine, produce its pharmacological actions, by acting on receptors located on neuronal cell membranes. The presynaptic action of Buprenorphine is to inhibit neurotransmitter release and blocks pain transmission (Yaksh & Wallace, 2011). Paracetamol on the other hand is a COX inhibitor that reduces concentrations of prostaglandin E2, which then lowers the hypothalamic set-point to reduce fevers. Paracetamol also activates the descending inhibitory serotonergic pathways to produce analgesia and thus reduces pain (Anderson, 2008). For most patient pharmacological interventions (especially combinations of drugs) works to reduce pain and help with rehabilitation of the injured joint.
List B: Ethical perspective on criteria for surgical intervention
In the case of VW, she reports of pain in knee and has been given pharmacological interventions in order for her to cope with pain and the physiological exercises that has been prescribed to her.
There is a guideline for surgeons to help them decide when it is necessary for surgical interventions and in this case is the total knee replacement. In VW’s case, the surgeons have decided to put off surgery as she has the ability to recover through rehabilitation with assistance of pain killers. One of the many ethical principles that physicians ought to adhere to is respecting patients; it is difficult to place values on health and medical care and weigh the benefits and risk of medical interventions (Lo & Grady, …show more content…
2015).
Autonomy
In VW’s case, where she has been informed but felt like her decision was made for her. The importance of informed choices can change the quality of a patient’s life, especially for a patient with bipolar affective disorder and depression, losing the feeling of control of one’s life can be detrimental. Determining cognitive ability and decision-making capacity is not easy but it is needed to decide the patient’s autonomy on treatment/management plans. Specific tests have been developed to determine patient’s decisional capacity, however, these are generally more difficult for the elderly to complete because they require consideration of hypothetical situations and complex abstract thinking (Kane, Ouslander, Abrass & Resnick, 2013).
The practical solution is to recheck with the patient after a period of time to be certain that they understand the situation and consistently states their preferences of treatment/management plans.
Beneficence
Physicians should promote what is best for the patients, by saying that, physicians are obligated to ensure that their patients understand what is best for them. Ideally, the decision-making process would allow the individual to review all possible options, understand the risks and benefits associated with each, and decide which outcomes they would like to achieve. In geriatrics, however, evidence-based information is typically less available and interventions are often not clear-cut in terms of risks/benefits (Kane, Ouslander, Abrass & Resnick, 2013). Physicians may also decide which studies to report to the individual in any given situation. In VW’s case, it is more important to her that her pain gets treated, she should be given the option of surgical intervention. Patients and clinicians have difficulty with quantitative expressions which means that people may misunderstand information. Qualitative expressions such as “rare,” can mean 1% to one person and 0.001% to another and such, biases often influence patient’s decisions as well as physicians’ communication of information (Karlawish & James, 2009).
Reflection
The elderly patients are quite different than the rest of the population when it comes to consideration of signs and symptoms, complications and medications.
In the geriatric wards the first thing we were thought is the importance of bowel movements which to me made a huge impact in how I see the importance of morning rounds. No bowel movements or BNO (bowels not open) could lead to delirium which results in poor treatment outcomes and danger to the patient, as well as other patients and members of staff.
I realized the importance of symptomatic treatments could better the patient’s quality of life and how it is more important than just prolonging life. It is true that when a physician sees a patient, they treat the patient and not the disease.
One of the issues I had was dealing with cognitively impaired patients. I felt like the history I would take sometimes is disconnected and patients tend to leave out things. I rose to solve this by seeking advice from the interns and their solution to my problem was that I should be seeing patients during family visits. This would allow me to gain collateral history and get a picture of the social support the patient has. I realized the importance of having the ability to empathize with patients in order to better understand their
situation.