Is The 5th Vital Sign Valid?
by Tim Gieseke, MD, CMD

Over the last 15 years, all levels of medicine have emphasized the need for early recognition and appropriate management of pain.  One of the mantras of this campaign has been the dogma that only the patient can tell us the severity of their pain.  We have supported this construct with efforts to quantify pain severity using a variety of pain assessment tools including:   pain thermometers, faces, alphanumeric scales, and qualitative descriptors.  Using these tools, our nurses have put a # to this 5th vital sign.  This # has also become the key metric on our MARs for the success (or failure) of our interventions to control the identified pain.


I am amazed at how often nurses’ call or fax me to report a “10” in a patient with the implication that the pain care plan needs urgent modification.  Some of the pressure comes from the survey process that expects “10s” to be rare and urgently intolerable.  I don’t disagree with the nurse or surveyor about the need to manage severe pain well, however, as currently practiced, I can’t trust the accuracy of this pain reporting system.  I find that some patients over report the severity of their pain.  If I were to only use their self-report, I could easily overmedicate them and in so doing reduce their quality of life and function while put them at greater risk for falls, dehydration, delirium, aspiration pneumonia, and UTIs.

I propose that the 5th vital sign needs to be normalized.  After all, the reason we focus on pain care, has been to ensure that pain’s known adverse effects on function and quality of life are mitigated.  Patient centered care and good medical care demand that we pay more attention to how pain adversely affects a particular patient’s function and QOL. Pain commonly adversely affects:  sleep, meal intake, mobility, mood disorders, and rehabilitation and social engagement.  If a patient is sleeping and eating well, participating in social activities, and is progressing appropriately in rehab, a nurse should be permitted to normalize the alpha numeric pain report of 7-10 down to the 3-5 range, since those functions would rarely be possible if the patient were truly in severe pain.  Pain at this level still requires a detailed care plan, but it certainly doesn’t call for new potentially risky pain interventions.

I realize that functional and QoL metrics for pain have not been well defined, studied or validated.  However, I do believe that our patient care coordinators, attending physicians, and IDT should develop specific metrics in each patient so that our front line staff knows what good pain control looks like in each of their patients.

I welcome your thoughts on the reliability of the 5th vital sign.