Q: Do Joint Commission regulations require the patient’s pain to be reduced or treated with opioids?

A: No. The Joint Commission holds that all patients have a right to pain control. It specifically requires the hospital to conduct a comprehensive pain assessment and then either treat the patient’s pain or refer the patient for treatment. Thus, there is no obligation to treat the patient’s pain in the emergency department.⁹ The emergency physician may judge after the MSE that the patient’s pain, whether acute or chronic, is best managed by bed rest, heat/cold, physical therapy, or simple referral back to the patient’s private physician or a pain management specialist. There is no Joint Commission standard requiring the hospital or physician to provide pain medicines to the patient in the emergency department or via a prescription.

Q: At the time of discharge the patient’s pain scale number is the same as or higher than initially at triage; does this pain score mean the patient is being discharged in an unstable condition?

A: No. Discharging patients from the ED without relieving their pain is not a violation of EMTALA. Unrelieved pain is not an EMC and doesn’t mean the patient is unstable under the law. Throughout recorded history and for the foreseeable future, plenty of patients have left and will leave the ED without the physician relieving their pain to their satisfaction. As long as the emergency physician has performed an appropriate medical screening exam and determined that an EMC was not present, the EMTALA obligation was met. Thereafter, the treatment, discharge, transfer, or referral of the patient for pain management is not controlled by EMTALA in any way.

Summary

Severe pain by itself is not an EMC; it is only severe pain such that the lack of immediate medical attention would reasonably be anticipated to lead to life- or limb-threatening consequences. Emergency physicians have no EMTALA obligation to make any patient pain-free or even to improve the patient’s pain. Moreover, emergency physicians should never feel compelled to prescribe opioids for emergency department patients complaining of pain, either because of perceived EMTALA requirements or because the Joint Commission mandates pain control. The choice of type, modality, and amount of pain relief, if any is entirely up to the treating physician. We all must determine our own clinical approach to this difficult issue, but neither EMTALA nor Joint Commission standards are relevant to our medical decision-making.