Pub. 2 2018 Issue 1

A wrongful death case was filed on behalf of the patient’s two children and his mother. Criticisms of the pa- tient’s care by plaintiff’s experts in- cluded initiating opioid therapy with- out documenting a complete physical and mental health exams; prescribing addictive, depressing and mind al- tering drugs for over three years in increasingly larger amounts without appropriate monitoring for depend- ence; concurrent prescribing of opi- oids and benzodiazepines; lack of informed consent; and negligent re- cord keeping. This case was settled in the low seven figure range. Problems with this case included: Inadequate documentation; Inadequate informed consent; Electronic record template that in- dicates patient was “advised caution w/ meds” without any additional infor- mation; No indication of the state’s prescription monitoring program was queried; No written pain management agree- ment; and Prescribing dosages of opi- oids exceeded clinical guidelines. Discussion: Several of the problems with defend- ing this case stemmed from incom- plete documentation. Electronic re- cord templates can be very helpful to ensure multiple aspects of the patient’s care are addressed, but the generic na- ture of the information captured may not provide a complete description of the care rendered or any specific discus- sions with the patient. In this case, the field “advised cautionw/ meds” was often checked, but there was no information regarding the specifics of the warning. Without a specific notation regarding the risks, benefits and alternatives to opioid therapy, there was no evidence that the patient was provided sufficient information to make an informed deci- sion. In addition, there was no written pain management agreement signed by the patient that would verify his under- standing of the risks, limitations and re- alistic expectations of chronic pain man- agement with opioid therapy. Another issue that proved problem- atic for the defense in this case was the disregard for accepted guidelines regarding opioid therapy. As early as 2012, the FDA was convening meet- ings to address the public health concerns related to the epidemic level of prescription opioid abuse and overdose. 2 It is important physi- cians and/or advanced healthcare professionals (AHP) are aware of the existence of practice guidelines and familiarize themselves with those per- tinent to their area of practice. If fol- lowed, practice guidelines developed or endorsed by nationally recognized organizations or agencies, such as the FDA or CDC, may provide a solid defense in a medical professional li- ability claim. In addition, document- ing the thought process prompting a variance from the practice guideline is important for two reasons. The documentation provides written com- munication to the healthcare team in- forming them of the unique needs of the patient and the rationale for the treatment plan. Secondly, it provides evidence the physician developed a treatment plan that tailored the prac- tice guidelines to meet the individual needs of the patient. During the four year period of the patient’s treatment, more and more information was being published regarding the dan- gers of concurrently prescribing opioids andbenzodiazepines. In their study, Calca- terra et al found the most common cause of polysubstance overdose fatality was the combined use of opioids and benzo- diazepines .3 One of the CDC’s guidelines for prescribing opioids for chronic pain cautions clinicians to avoid concurrent prescriptions for opioids and benzodiaz- epines whenever possible. 4  1. Fang WB, Lofwall MR, Walsh SL, Moody DE. Determinationof oxycodone, noroxydocone and oxymorphone by high-performance liquid chromatography – electrospray ionization-tan- demmass spectrometry in human matrices: in vivo and in vitro applications. Journal of Analyt- ical Toxicology. 2013; 37: 334-344. https://doi. org/10.1093/jat/bkt042 2. Korff MRV. Opioids for chronic noncancer pain: As the pendulum swings, who should set prescribing standards for primary care. An- nals of Family Medicine. 2012; 10(4): 302-303. Available from http://www.annfammed.org/ content/10/4/302.full 3. Calcatera S, Glanz J, Binswanger IA. Na- tional trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009. Drug and Alcohol Dependence. 2013; 131(3):263-70. Available from https://doi.org/10.1016/j.drugal- cdep.2012.11.018 4. Guideline for prescribing opioids for chronic pain. (U.S). Centers for Disease Control and Prevention (CDC). Available from https://www. cdc.gov/drugoverdose/pdf/Guidelines_Fact- sheet-a.pdf It is important physicians and/or advanced healthcare professionals (AHP) are aware of the existence of practice guidelines and familiarize themselves with those pertinent to their area of practice. www.UtahAFP.org | 34