[aimeee]

Jacel, best wishes for success, growth, and fulfillment in your new position.

[JacelRN]

Thank you everyone,

It's amazing what a few days perspective can bring to a clouded issue. I first wrote my post out of frustration, reaching out to other nurses who could relate and hoping that Hospice would not frustrate me in these ways nearly as much. I understand no place is perfect, but I believe my personality and my issues on pain control will be better suited in a hospice care setting.

After re-reading my post, I can definitely understand everyone's initial reaction. I wrote it in high emotion and not exactly explaining the answers I wanted from everyone. Work can do that to me. I find it so difficult at times to keep my sanity.

So in hindsight, I have learned a lot about myself in this time I have had to think over what the issue was and I am less anxious about my move. I will learn the knowledge needed to care for this new populace and I will strive to be the best hospice nurse possible.

Thank you for your candid answers that made me think and also thanks for supporting me even when you didn't agree.

JacelRN

[Hellllllo Nurse]

JacelRN,

I did not intend to come off sounding overly harsh and critical in my reply. However, the visual I had in my mind's eye after reading your initial post was of a dying pt asking for pain meds, and a nurse hesitating, skeptical, trying to decide if the pt was sincere or just drug seeking. That visual was alarming to me.

Everyone's experiences in nursing and otherwise are different. I have rarely encountered a true drug-seeker in my 12 years as a nurse. It has been much more frequently that I have encountered doctors, nurses, pt family members, and pt relatives who held pts' power of attny who tried to keep pain relief from pts who really needed it.

Quite a few times in hospice, I have dealt w/ pt family members who, due to ignorance, issues w/ power and control, or issues w/ their own substance abuse problems, have tried to prevent their loved ones from getting the pain meds they needed.

As a student, I was paired up w/ a nurse who was assigned a recent post c-section pt in need of pain meds. This nurse did everything in her power to prevent the pt from getting her ordered and needed pain meds. The pt was scared and tearful. When the nurse left the room, the pt grabbed my arm, her eyes wide, and said “please help me.” The nurse left before the end of the shift, and I was able to give the grateful pt her prescribed pain meds. I should have gone to the charge nurse right away, but as a student nurse, I did not have the courage to do so.

In LTC, I encountered two pts with fx from falls whom no surgeon would operate on and whom were only given Tylenol, as the doctor feared prescribing anything stronger due to the pts' ages. These pts suffered terribly. I struggled against the "powers that be" to try to get these pts adequate pain control. I really had to stick my neck out, and aroused the anger of powerful people over that situation.

I have witnessed a pt who was admitted to hospice for pain control denied pain meds by a nurse who did not want to give MS Contin rectally, once the pt could no longer take po meds, so she did not medicate him at all. The pt’s pain got out of control. He was semi-responsive, but moaning, grimacing and guarding. His V/S had undergone changes indicative of pain. I was an LPN (at the time) and had to step on the RN's toes and call the doc behind her back to get the pts' pain treated. I was not assigned to the pt, but was aware of what was going on. The RN was fired over the situation. She was popular at the facility, and a few people were angry with me after that.

Several years ago, I had a very botched oral surgery and was in indescribable pain, which my dentist refused to treat. I called another doc and got an Rx for pain meds. When I went to fill the script, the pharmacist took it upon herself to call my doc and have him cancel the script. I had been given the same script a couple of weeks earlier (for another extensive oral surgery) and this pharmacist decided that I was drug seeking. I was in total shock that a pharmacist who knew nothing of my medical condition or procedures I had had, could actually call a doc and have him D/C a script he had just written for me. I was in incredible pain. I ended up going to an ER, waiting four hours, and paying $300. for a shot of a local anesthetic. When I saw another dentist the next day, he told me that the other dentist had accidentally cut into the pulp cavity and dentin of my tooth, something known to be excruciatingly painful. I also had a severe infection, and had to have three more oral surgeries to correct the damage my original dentist had done.

Another situation that comes to mind-
When I was working as an RN consultant for an adult day care center, I observed a little Spanish-speaking lady who always hobbled to the back room to lay down, and did not participate in activities. I got a co-worker to translate, and learned that this lady had severe pain in her hip, for which her doc had prescribed Celebrex, which was having no effect. With further questioning, I learned this lady had been treated for colon CA the previous year and had been declared "cured".

I made some calls, and with her permission, got her in to see another doc for tests the next day. Turns out the CA had metastasized to the bone, specifically the hip. This lady’s metastatic CA bone pain was being treated with Celebrex! After receiving adequate pain control, the change in this lady’s affect, participation in activities, and life in general were remarkable. Although she had learned that her CA was back and had spread, she seemed to be a much happier person, because she was no longer in pain.

Many more stories come to mind, but I think this post is long enough. You see, I need to rest. I just had two complete tooth extractions, with sinus membrane displacement and a bone graft the day before yesterday. Luckily, I found an oral surgeon who prescribed Vico-prophen for me, which I am taking q 3.5 atc, wa. My surgery would not have been so extensive, had I sought treatment earlier. However, with the pain I went through last time, I have become very fearful of dental procedures, and put off seeking treatment too long.
A friend of mine also experienced a dental procedure where her dentin and pulp cavity were inadvertently cut. She said it "hurt more than having a baby." She has six children.

So, you can see why I reacted so strongly to your post. I have very strong opinions concerning issues of pain control. After reading your subsequent post, you sound like a very thoughtful and intelligent person, and that you will be an excellent hospice nurse.

People who have a hx of drug abuse often require higher than usual doses of pain meds to obtain adequate relief after a surgical procedure. I have found this to be true in hospice, as well.

As stated before, I have rarely witnessed drug seeking. What I have witnessed (and experienced) a great deal of is pain-relief seeking.

[Nemeth]

Originally Posted by JacelRN

Hello all,

I have finally worked it out to transfer to hospice. :hatparty: I'll be working part time hours there and still 12 hours at my current job on a heavy med-surg floor.

My question is regarding "pain med seeking" behavior in hospice. Do you get it often? I have the least amount of compassion for these types of patients. That is one of the main reasons I wanted to work at hospice-working with patients who have true need of pain relief, who need me to advocate for them in case they cannot, etc.

Please understand my term "pain med seeker" to be someone who is obviously timing their meds. I know we are to treat each patient as their pain is real to them, but in reality, much abuse is present in the current hospital setting.

Please tell me I won't encounter this as much in hospice. That is my true hope in transfering is that I can care for patients as I wish to-and their pain.

Thank you for any replies,
JacelRN

Hi I work in a hospice in Chicago, Illinois. Patients must have a terminal diagnosis of 6 months or less to be admitted this is the medicare guideline and most insurance companies guide line. Dying has many distressing s/s that need adequate pain and symptom control. Does it really matter if a patient is med seeking at this point in their care. Addiction becomes irrelevant what matters is comfort, and care. Death needs to be peaceful, meaningful, and with dignity and closure for all involved. My experience has not been with patients who seek drugs regardless of their past alcohol or drug problems. They are dying, they need them. I have seen family members and friends steal or take patient meds for the wrong reason and know of 2 RN's who have been fired for the same. Hope this helps. Thanks, KIM

[hospicenurse]

Hospice patients aren't so different than any other patients. It's just that they are dying. You'll probably find about the same percentage of people who have been drug users of one type or another. It might not always be pain meds, it might be sleeping meds or laxatives. Or heroin. Their drug tolerance tends to make symptom management more challenging. It can be frustrating to deal with them because it is harder to control their symptoms, and often they have already tried most of what we have to offer. And they have some learned behaviors that can be very irritating. It's evident by your post that you are beginning to examine and deal with your feelings about drug seeking behavior; hopefully you will find some kind of resolution in order to be an effective nurse to these patients. Some more experience and a good mentor will help you greatly. You'll do fine.

Btw, when these patients "push your buttons" it's helpful to ask yourself why - what about the situation is really making you angry. Is it because they called you for more medication, or is it because you were about to go to lunch and you don't want to delay another 10 minutes? Most of the time when I get frustrated with a patient, I eventually realize that it's because I wasn't able or willing to do what needed to be done at the time. Nursing is hard work mentally and emotionally, and it's difficult to maintain the level of energy and empathy needed at all times. One of the things I hope you learn early on is that there is great interdisciplinary team support in hospice. You can often call on another hospice nurse, social worker, home health aide, etc., to help you out when you are on your last nerve. And vice versa.

Another great lesson to learn in hospice is that you are not going to change people's personalities nor their behavior. Families are going to be dysfunctional in a million different ways. Don't drive yourself crazy trying to mold them into something they are not. People won't always die the way you want them to. You really have to let go of what you want for people, and adopt the Burger King motto: Have it your way. (This post paid for by the fast food industry. And now back to our regularly scheduled program )

[talaxandra]

Jacel, I appreciate that your posting about your experience with drug seeking behaviour was in the Med/Surg setting, and not in palliative care, and I agree that there are some patients (most often with a complex psych and/or medical and/or drug abuse history) that could be classed as pain seekers. However, I agree with previous posters who have expressed concern about patients being so classified.
In my second year as an RN I looked after a patient who was the younger sister of an old school friend - when I was allocated her I said that I knew her, and went to check if it was okay with her that I care for her, making it clear that I completely understood if she was uncomfortable with the idea; she said she'd rather I look after her than anyone else
She'd come in a few days earlier with diffuse, severe abdo pain. During handover the staff on were fed up - her partner was a medic on another unit and had written her up for (non-analgesic) meds; she ambulated apparently freely much of the time; all of her tests to date had come back NAD; and she 'clock-watched,' requesting meds right on the dot of when they were due, and she would specify that she wanted the maximum dose prescribed. She was also a nurse, who had trained at the same hospital we were working in, though not the same group as me, and not currently employed as a nurse.
As she'd been handed over for the last couple of days as being a suspected drug seeker, nursing staff were waiting for her to request pain relief, would try to give her less than the maximum prescribed dosage, and would leave her alone as much of the time as possible.
Though I didn't know her at all well, and hadn't seen her sister for several years, she didn't seem to me likely to be drug seeking. So, after checking that she was happy for me to provide her care, I spent as much of my shift with her as possible. I explained that the waking nightmares she'd had with her sleepers were a known side-effect, I reassured her that the fact that her tests were NAD didn't mean that she was making up her symptoms (including guarding), and included her in all decision making about her care, including analgesia.
Despite my handing all of this over to the night staff, the next morning she told me that they were tardy bringing her analgesia, and were reluctant to give her the full dose. She expressed frustration and anger at having this extra burden to handle on top of concern about the cause of her pain.
The next day she was discovered to have retrograde bleeding in to her Pouch of Douglas, and a week after discharge was diagnosed with lupus.
I don't know if I would have gone in to her room with an open mind after that handover if I didn't have a history with her, but I always do now. Being forewarned that there are issues with patients (or their family) are helpful, but now I never take for granted another nurses' assessment of a situation.
PS Be prepared to have your idea of what constitutes appropriate pain relief challenged. When I worked in Medical Oncology I had a young guy with metastatic osteosarcoma who was getting 1000mg (yep, 1 gram!) of morph an hour IV plus breakthrough relief of up to 200mg every twenty minutes. He was sitting up, talking to his visitors, alert and oriented.

[earle58]

Originally Posted by talaxandra

When I worked in Medical Oncology I had a young guy with metastatic osteosarcoma who was getting 1000mg (yep, 1 gram!) of morph an hour IV plus breakthrough relief of up to 200mg every twenty minutes. He was sitting up, talking to his visitors, alert and oriented.

it's true.
there is no ceiling for mso4 dosages.
it's what the patient needs.
i've given outrageous amts too with the same ms you speak of, a&o.

i wish more knew that.

[doodlemom]

[quote=JacelRN]First let me clarify.

Have any that have replied ever worked on the type of floor I currently work? Please don't tell me that you haven't seen these types of patients. There are abusive personalities and it dosen't stop in the hospital. I do not feel comfortable supporting drug habits of patients. Even when my patients ask to go out to smoke, I educate them on the importance of not smoking. I assess their needs to find alternatives.

I turned to this board for advice and from those of you who tried not to judge ME by my response, thank you. I intend to reasearch hospice, palliative care, etc. For those who are less patient to judge a vulnerable poster, please read this and know I was attempting to clarify and educate myself on an important move both in my career and in my beliefs. I was not presenting a case for debate.


I worked in Hospice for several years, then left because our Hospice was taken over by a large hospital corporation. During the 2 years that I was gone from Hospice (I am now working in Hospice again), I worked on an oncology/neurology floor. Most of our neurology patients were there for laminectomies or some other back/neck surgery. We had a contract with the federal prison and the county jail to do all of their surgeries. I can tell you that even though I tried not to be judgemental, there were times when some of the (prisoner and non prisoner patients) would try my patience. I would always give the patients pain medications and never questioned their pain and in fact, I would call the doctor and ask for an increase if the patient was "timing" their meds. I wasn't very popular with the neurosurgeons and many times they would not give me orders to increase the meds. I knew that some of the patients were seeking meds for other reasons than physical pain and because of the unbelievable busy schedule on a med-surg floor, I would find myself feeling very irritated by their constant requests. I was also taking care of cancer patients on the same floor and found myself being more compassionate towards them and angry at the patients who could walk and talk and would be going home to heal after a day or two. I don't think that I showed my anger towards the patients...at least I hope that I didn't. Many of the people we were taking care of on that floor had been abusing drugs prior to coming and I had learned during my hospice years that these people had pain just like anyone else, but require more pain meds to control their pain. Somehow, the MD's that were attending did not understand this principle.
When I worked in Hospice previously, I had a few addicts that came on to service and fortunately their doctors were good to them and would give them whatever they needed to be comfortable. I think that you will find it easier to control a patient's pain in Hospice because most of the time the docs are willing to medicate a patient with a long acting med and increase as necessary. The problems with pain control in the hospital setting are vast. Most of the patients are in there for a short period of time and the docs are just interested in getting them out ASAP and they don't want to think about long acting pain meds.
In the hospice setting, we know the patient is dying and we give them whatever they truly need to help their pain, whether it be physical, emotional, or spiritual. A patient with prior drug abuse history has just as much pain as someone that doesn't. Just remember that they will probably need a great deal more meds than most everyone else.
I hope this helps and does not sound judgmental.

[earle58]

Originally Posted by gianine

In the hospice setting, we know the patient is dying and we give them whatever they truly need to help their pain, whether it be physical, emotional, or spiritual. A patient with prior drug abuse history has just as much pain as someone that doesn't..

there you go, in a nutshell.
and it's not about being judgemental;
you would hope that it would be instinctive to feel these patients should get whatever they want. no debate about it.

[PediRN]

I had a CF patient once...he was 17 years old and couldn't have weighed much more than 75 lbs. The day before his death, he finally consented to a MS drip to control his pain. We started him at 6 mg/hr. We titrated that drip all the way up to 300 mg/hr. At 250, he stood up and peed in a urinal. I remember going to the pharmacy to get the bag and the pharmacist said she felt like Jack Kevorkian. Why should anyone live the end of their life in pain? When I go, I want to be drugged to the gills if I'm in pain.

I agree with the poster who said that they rarely have seen drug-seekers, only pain-relief seekers.

Good luck in hospice, Jacel. Let us know how it goes.