PCA BY proxy

UM Review RN, ASN, RN · Jan 19, 2005

It's called Patient Controlled Analgesia for a reason. Only the patient may use it. If the patient is unable to use it, the patient needs a different type of analgesia.

Family members and visitors need to be educated to refrain from playing with ANY buttons. (For that matter, so do patients. A coworker had a patient who was tired of the light from the pump in her face so she turned the pump off. She was getting Heparin. :uhoh21: )

Jolie, BSN · Jan 19, 2005

Hello all - I was wondering if any of you have heard of a policy covering PCA by proxy (meaning someone else, Nurse or family pushes button) - It seems to be a problem when well meaning staff or family think grandma is in pain and pushes the button then 10 mins later do the same and now grandma is getting Narcan. Now I have pushed the button for patients WHEN THEY ASK ME, but I have never just pushed the button without being asked - Has anyone heard of anything covering this or have thoughts on it - Thanks for any and all help - and GOD BLESS

I'm a NICU nurse, so forgive me if I sound stupid. I've never worked with adults. Why bother placing a patient on PCA if they are not capable of evaluating their own pain or pressing the button to deliver the needed medicine? Wouldn't they be better off with a regular order for pain meds say every 2 or 3 hours, and a prn in between to be given when warranted per the nurse's assessment?

JHUBRAIN · Jan 19, 2005

I'm a NICU nurse, so forgive me if I sound stupid. I've never worked with adults. Why bother placing a patient on PCA if they are not capable of evaluating their own pain or pressing the button to deliver the needed medicine? Wouldn't they be better off with a regular order for pain meds say every 2 or 3 hours, and a prn in between to be given when warranted per the nurse's assessment?

Hi - Thanks for the reaponses - You are right. We assess all of that, however, it is usually someone well meaning. We are looking at maybe doing a policy that would protect the nurse if she pushed the button for someone, however, I don't think it will fly for many reasons Thanks so much - GP

talaxandra · Jan 19, 2005

It's firm policy at my hospital that nobody, including staff, press a PCA button but the patient. If they can ask they can press and if they are physically unable to press the buttin then a PCA's the worng analgesic option for them.

Goofyfoot · Jan 19, 2005

If the PCA can deliver so much painkiller that you need to Narcan someone, the settings are wrong and the MD should change it. The dosing and lockout should be such that no matter who pushes the button however many times, the patient only gets a safe dose of medication.

On our floor (oncology), we sometimes encourage families to push the button when the patient is unable to do so. These folks are on such high doses of painkiller that there are no other ways to deliver the meds than a PCA ... I can't imagine trying to give IV PRN painkillers to someone who is on 12-16mg of Dilaudid an hour, for example.

nursemike, ASN, RN · Jan 19, 2005

If the PCA can deliver so much painkiller that you need to Narcan someone, the settings are wrong and the MD should change it. The dosing and lockout should be such that no matter who pushes the button however many times, the patient only gets a safe dose of medication.
On our floor (oncology), we sometimes encourage families to push the button when the patient is unable to do so. These folks are on such high doses of painkiller that there are no other ways to deliver the meds than a PCA ... I can't imagine trying to give IV PRN painkillers to someone who is on 12-16mg of Dilaudid an hour, for example.

Doesn't a safe dose depend somewhat on the amount of pain, though? My cousin says her oncology patients often get very large doses of morphine with no sedation, and sometimes little relief. I've seen a med-surg pt get narcan because his family zonked him. My understanding of PCA has been that if you give yourself enough to sedate yourself--which will vary from person to person--you won't give yourself more, because you'll be asleep.

I've had to warn visitors that we would not permit them to interfere with a patient's treatment (the controlled substance in that case was water).

ICUsleep · Jan 19, 2005

If the PCA can deliver so much painkiller that you need to Narcan someone, the settings are wrong and the MD should change it. The dosing and lockout should be such that no matter who pushes the button however many times, the patient only gets a safe dose of medication.
On our floor (oncology), we sometimes encourage families to push the button when the patient is unable to do so. These folks are on such high doses of painkiller that there are no other ways to deliver the meds than a PCA ... I can't imagine trying to give IV PRN painkillers to someone who is on 12-16mg of Dilaudid an hour, for example.

Yeah, I thought that, too. There are lockouts so that only a certain amount can be dispensed by the patient, much less a family member. Somone could easily kill your patient (and the patient could kill themselves) with no lockout.

bobnurse · Jan 19, 2005

I believe JACHO has addressed this issue in detail. You should have a policy covering this, and if you dont, you need to get one. We provide education to the family and clinical staff in regards to PCA...IF we find a family member pushing the PCA, we remove the button and place them on a basal rate only, with nursing providing the boluses.......There have been many deaths associated with family members pushing the PCA and administering pain medication without the patient requesting it, thinking they are helping the patient out. We also document the patients ability to use the PCA and difficulities or ease in using it (pushing the button). If the patient cannot push it, then theres no need of having it there.

bobnurse · Jan 19, 2005

If the PCA can deliver so much painkiller that you need to Narcan someone, the settings are wrong and the MD should change it. The dosing and lockout should be such that no matter who pushes the button however many times, the patient only gets a safe dose of medication.
On our floor (oncology), we sometimes encourage families to push the button when the patient is unable to do so. These folks are on such high doses of painkiller that there are no other ways to deliver the meds than a PCA ... I can't imagine trying to give IV PRN painkillers to someone who is on 12-16mg of Dilaudid an hour, for example.

Its best you visit the newest sentinal event alert in regards to PCA use, and the JACHO standards...Encouraging families to push the button is a violation and clearly addressed. Your practice of encouraging families to do this is outdated and dangerous. Also your liability in this case is sky high.

SmilingBluEyes · Jan 19, 2005

Our policy is no one presses the button BUT the patient herself. It's a sound policy if you ask me.

palesarah · Jan 19, 2005

This issue was addressed in the Institute for Safe Medication Practise's January '05 nursing edition newsletter. It doesn't look like the text is available online but subscription to the email newsletter is free: http://www.ismp.org/NursingArticles/index.htm

Hopefully I can copy/paste this snippet from the article without breaking any copyright laws or allnurses rules!

Patient-controlled analgesia (PCA) has great potential to improve pain management, allowing patients to self-administer a more frequent but smaller dose of an analgesic when in pain. When used as intended, PCA actually reduces the risk of oversedation, which is an unintended consequence of the traditional nurse-controlled analgesia in larger, less frequent doses. However, it's clear from anecdotal reports in the literature and events reported to ISMP that errors happen frequently, sometimes with tragic consequences. The following factors have often contributed to PCA errors. PCA by proxy. A crucial built-in safety feature with PCA that's often
overlooked is that the device is intended to be activated by the patient.
A sedated patient will not press the button to deliver more opiate, thus
avoiding toxicity. More opiate is required to produce respiratory
depression than to produce sedation. However, family members and health
professionals have administered doses for the patient, by proxy, hoping to keep them comfortable. This well-intentioned effort has resulted in respiratory depression and even death. (This problem was a topic in the December 20, 2004, Joint Commission Sentinel Event Alert.) For example:
A postoperative patient asked her husband to press the button on her meperidine PCA if she moved or made any noise as she slept during the night. Sadly, he complied, and by morning, the patient suffered a respiratory arrest and could not be successfully resuscitated.
A nurse consistently woke her elderly patient, assessed his pain, and pressed the button on his morphine PCA, believing she was helping this "stoic" patient. Extreme oversedation resulted by morning, which eventually
contributed to the patient's death.
Improper patient selection. Since an important safety feature with PCA is
that the patient delivers each dose, candidates for PCA should have the
mental alertness and cognitive, physical, and psychological ability to manage
their own pain. However, the benefits and convenience of PCA have led providers to extend its use to less than ideal candidates such as infants, young children, and confused patients. This facilitates the dangerous
practice of PCA by proxy. For example:
A previously alert elderly patient was prescribed morphine PCA postoperatively, but she became obtunded and confused, and unable to
verbalize pain or press the button. To keep her comfortable, nurses delivered PCA doses when the patient exhibited restlessness. Within 48 hours, the patient experienced respiratory depression and seizures, resulting in hypoxic
encephalopathy, and death 2 months later.
Oversedation has also occurred in less than ideal candidates at risk for respiratory depression due to comorbid conditions such as obesity, asthma, or sleep apnea, or use of concurrent drugs that potentiate opiates (e.g., benzodiazepines, barbiturates). PCA use in unsuitable patients may also result
in undertreatment due their inability to clearly communicate pain.