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Margo McCaffery: Resolute and Visionary

      Mary Margo McCaffery, a pioneer in the care of people with pain, died of pneumonia and myocardial infarction on January 8, 2018, at the age of 79 in Marina Del Rey, California. Margo (her preferred name) was born and raised in Corsicana, Texas. She received a bachelor of science degree in nursing from Baylor University and a master of science degree in nursing from Vanderbilt University and spent the first part of her nursing career as a professor in nursing at the University of California at Los Angeles (UCLA). In 1970, Margo became self-employed as a consultant and educator on the nursing care of patients with pain, conducting lectures and consultations throughout the world, until she retired in 2011. By the time I met Margo in 1992, she had collaborated with Dr. Betty Ferrell to develop their famous knowledge and attitude questionnaire (
      • McCaffery M.
      • Ferrell B.R.
      How would you respond to these patients in pain?.
      ), written three books and several articles on pain, and was considered by many to be the ultimate nursing authority on pain management. During her career, Margo became a Fellow in the American Academy of Nursing and received numerous prestigious awards and appointments, but she is best known for her widely embraced definition of pain, “Pain is whatever the experiencing person says it is, existing whenever he says it does,” which she first expressed in her 1968 UCLA class syllabus (
      • McCaffery M.
      Nursing practice theories related to cognition, bodily pain, and man-environment interactions.
      ).
      To appreciate Margo McCaffery's profound contribution to pain management, it is important to consider the state of health care at the beginning of her career. Until the mid-1990s, patient care was guided primarily by the experiences and opinions of those who provided the care. When I met Margo in 1992, pain management was dictated by what seemed to work, whether or not it was supported by research. The concept of evidence-based practice was on the horizon, but the term was rarely used. Dr. Gordon Guyatt and his colleagues are credited with introducing the term to the medical world in 1992 to shift the emphasis in decision making about patient care from “intuition, unsystematic clinical experience, and pathophysiologic rationale” to clinically relevant research (
      • Guyatt G.
      • Cairns J.
      • Churchill D.
      • Cook D.
      • Haynes B.
      • Hirsh J.
      • Irvine J.
      • Levine M.
      • Levine M.
      • Nishikawa J.
      • Sackett D.
      • Brill-Edwards P.
      • Gernstein H.
      • Gibson J.
      • Jaeschke R.
      • Kerigan A.
      • Neville A.
      • Panju A.
      • Detsky A.
      • Enkin M.
      • Frid P.
      • Gerrity M.
      • Laupacis A.
      • Lawrence V.
      • Menard J.
      • Moyer V.
      • Mulrow C.
      • Links P.
      • Oxman A.
      • Sinclair J.
      • Tugwell P.
      Evidence-based medicine: A new approach to teaching the practice of medicine.
      ).
      My first “meeting” with Margo was via telephone in 1992 when I was the clinical coordinator of a large acute pain service in Louisiana. Margo heard about my hospital's focus on empowering nurses to provide individualized pain management and called to learn more about it. As we talked, I realized she was most interested in understanding how to apply research to clinical practice. She asked me several times about how to calculate a basal rate for intravenous patient-controlled anesthesia (IV PCA) and kept quoting a formula she found in the literature. I told her repeatedly that our pain service was not using any formula, but what we were doing was resulting in good pain relief for our patients. She said she appreciated our experience in managing pain, but it was difficult to accept that we would rely on opinion and anecdotal evidence more than a formula derived from research. We finally agreed that ideally there should be a blending of research and clinical experience. After my conversation with Margo ended, I remember saying to my co-worker that I was not exactly sure who Margo McCaffery was, but I found her to be relentless and irritating! (Margo always described my first impression of her as “insightful” and said it was better to be relentless and irritating than milquetoast!)
      A month later, Margo called me again and asked if I had any experience managing pain in patients with addiction issues. I thought it was odd that she was surprised and thrilled when I told her we used IV PCA to manage postoperative pain in patients with addiction and never had any problems with diversion. It was clear that she had spent the last month thinking about our previous conversation and how to apply a combination of research and clinical experience to manage patients who were at risk for undertreated pain. (I would learn in time that improving pain management in vulnerable populations was an underlying passion of hers.) She asked if I would be interested in writing an article on IV PCA with her. I agreed and sent her an outline for what would become our first publication together, “Unconventional PCA: Making It Work for Your Patient” (
      • Pasero C.
      • McCaffery M.
      Unconventional PCA: Making it work for your patient.
      ). That first article led to another (
      • Pasero C.
      • McCaffery M.
      Avoiding opioid-induced respiratory depression.
      ), and over the next 20 years, we co-authored and collaborated on hundreds of articles, editorials, guidelines, position papers, educational videos, and lectures and two textbooks on pain management.
      Margo firmly believed that misconceptions and lack of knowledge were at the root of suboptimal pain treatment and the best way to improve the situation was through the presentation of evidence. Over the years, I watched Margo use her name and reputation to introduce or reinforce the need for evidence-based decision making to nurses in all settings. For example, the American Journal of Nursing (AJN), like most of the other nursing journals in the early 1990s, did not routinely provide references in its articles. However, when we wrote our first article together in 1993, Margo insisted AJN include “Suggested References” at the end of the article. She required this of every journal in which we published, well before including references became standard journalistic practice. If a journal would not allow us to provide references, we would publish elsewhere.
      Another example of how Margo advanced evidence-based nursing could be found in her lecture syllabus. Margo required the distribution of a unique 1-inch (or more) syllabus to every audience member at her daylong conferences. Those who attended a McCaffery conference may remember that nearly every page of the syllabus was footnoted with references to support her lecture.
      Not only did Margo pursue the evidence to support her assertions about pain, but she also expected others to do the same. Absolutely no one got a free pass. She was outspoken, fearless, and unapologetic when confronting misconceptions and bias against people with pain. Many readers may recall when she stood up at a national pain conference to ask a well-credentialed speaker to provide references for his particularly disrespectful and inaccurate statements about people with pain. I remember looking around the room at the faces of my peers and realizing that Margo's actions and words had changed forever the way they and the organization would treat and talk about people with pain. She also introduced the possibility to many in the audience that they could and should have the strength and courage to do the same when they returned home.
      Having said all of this, it would be inaccurate to present Margo as one who was focused purely on the evidence. Margo had tremendous respect for frontline health care team members and often said that she wished she had “just a shred” of the clinical experience they had. Although she preferred lecturing to consulting, her most enjoyable consultations were those that included nursing and medicine rounds at patients’ bedsides. She loved being able to touch and talk with patients and watch them interact with the health care team. This afforded her another opportunity to promote the concept that clinical experience is at its strongest when it is combined with evidence and vice versa. She told me that her proudest achievement was that her clinical definition of pain had been researched and applied to patient care worldwide.
      I think it was a determination to blend research with clinical experience that made the relationship between Margo and me so productive. Our 20-year partnership was often intense and exhausting. The moment we completed one publication or project, she would present an idea for the next (“no rest for the weary”). Because she was a perfectionist, she sometimes set unrealistic goals, creating frustration for both of us. She often worked around the clock for days and expected others to do the same. While writing our first book, I remember my husband calling Margo at 11 p.m. one night and telling her, “Most normal people sleep once in a while, so I'm going to disconnect the telephone after this conversation. Go to bed, Margo!”
      At the same time, working with Margo was exhilarating and immensely rewarding. She made me a better educator than I ever would have been had I never met her. Once when I expressed my frustration with a misinformed member of a recent audience, she advised, “When you're confronted by a naysayer in the future, always fall back on the evidence. It's hard for people to argue against it.” That was a bit of wisdom that got me through 25 years of lecturing to countless naysayers.
      She was an incredible author and even better editor. She taught me to think about all possible ramifications of a statement. For example, when writing an article on pain in older adults, I wrote that nurses are obligated to provide safe pain management, especially in the elderly. Margo edited out, “especially in the elderly” and told me that there can be no qualifiers for that type of statement; no population of patients is more deserving of safe pain management than another. That lesson had a tremendous impact on how I thought about issues and influenced the way I wrote and lectured from that day forward.
      A month or so before she died, I told Margo she was uniquely resolute and visionary and that I knew I would never meet anyone like her again. She already knew I thought she was one of the bravest people I had ever met after going on to write several articles and another book after surviving the tragic losses of both her only child and her husband within an 18-month period. I said I could never repay her for the once-in-a-lifetime opportunity of working with someone like her. Typical of her, she quickly turned the tables and thanked me for sticking with her all those years. Like so many other duos at the end of their careers, we were able to enjoy reminiscing about all the challenges we faced together.
      Margo will be deeply missed, but it is most gratifying to know she leaves behind nurses, pharmacists, physicians, and researchers who dedicate themselves every day to the pursuit of the best possible pain relief for people with pain, thanks in large part to her pioneering work. Margo was one of those impossible people you read or hear about who had a genius IQ with an incomparable stubborn streak when it came to her cause. She could never be turned off or distracted from the singular goal of finding a solution to the epidemic of unrelieved pain. She was driven by what she described as the image of a suffering person behind every example of suboptimal pain treatment. She would be elated to know that the work to erase that image continues because of her example as a brilliant, strong-willed champion for people with pain and the practitioners who care for them.

      References

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