When family refuses IV pain meds for cancer pt...?

morte, LPN, LVN · Jun 14, 2013

why would you need the doc to refer to the ethics com.????

Tait, MSN, RN · Jun 14, 2013

Check your policies but there should be no need for a doctors order to talk to the ethics committee. That would negate the purpose if the doc had control over it. Ethics committees are like any other admin in the hospital. Just as you don't need an order to talk to a manager, you should not need one for ethics. They are there to help you in JUST these kinds of situations. If an order is needed then there needs to be a policy rewrite! I would definitely fight for that palliative care consult as well.

BiohazardBetty · Jun 14, 2013

Not justifying his behavior but I do think its coming from a place of ignorance or false hope rather than malice. I know my family is full of compassionate and reasonable people, but when my grandma was dying of cancer, they would never want to give her any pain meds because of similar reasons. They wanted her awake, they wanted to have conversations with her for the short period of time they knew they had left. There was an element of denial, as if the meds are the reason that she's not herself rather than the brain mets, or that all those narcotics are going to make the dying process faster. The home hospice nurse finally stepped in and sort of gave everybody a wake up call...therapeutically of course. It seems like nursing staff have done a lot to try and educate this man, so maybe it's time to pull in palliative care (they deal with these situations all the time and are experts). Maybe even try getting a chaplain involved. He may also be grieving and feeling helpless therefore trying to feel like he's in control of something. Either way this problem is bigger than nursing and should be handled with a multi disciplinary approach.[/quote']
I think you are absolutely right on all counts... A couple of the problems I'm facing are:
1) spouse won't allow anyone to spiritually counsel the pt but him (they're baptist & here in the south, this is unusual for all of our pts, regardless of faith)
2) I have to have a doctor's order to consult palliative care/hospice... I realize that's strange for most of you, but I have to follow policy :/ and as you can tell, her doctor isn't the most compassionate guy around. The other oncologists are afraid to step on this doctor's toes, so they've all refused to put in consults about this.
Since the spouse is rarely there, I believe it is a control issue... Way more than I first realized. If he's not around much, I don't understand why he wouldn't want her comfortable rather than in pain... She can't visit if he's not there- let her rest comfortably! Unfortunately the spouse's schedule is unpredictable so I couldn't be sure she wouldn't be a little sedated if he showed up... It feels like I'm a little kid waiting on my dad to come home & spank me after I got in trouble at school!!! Insane!!!
I think I will call the hospice unit today & get some tips on what exactly they say to families in situations like this & continue trying to educate the spouse. Maybe it will eventually click.
As long as I document her pain level & administer meds accordingly, without a POA- other than pitching a fit- what's the worst he could do??

Jory, MSN, APRN, CNM · Jun 14, 2013

What do you do when a pt's spouse refuses to allow you to administer IV pain medications as ordered? Pt has end stage cancer w/ brain mets. DNR. Confused most of the time. Has not been deemed incompetent, has no power of attorney. Says "no" when you ask her if she's in pain, all the while she's yelling out that she's in pain. Spouse tries to console her if he's in the room, but is often gone... But has an unpredictable schedule.
Spouse said he doesn't want pt "knocked out" & she "isn't herself" after she's had IV pain meds. (Like rolling around in pain IS her??) He will allow PO Percocet 10, but pt has swallowing difficulties r/t confusion. Spouse has been educated many times by many different nurses regarding pain associated w/ pt's type of cancer.
Talked to the doctor during rounds, but he offered no guidance and the spouse wasn't present. Went to the charge nurse who said to talk to the nurse manager who said to address it with the social worker who said to contact the oncologist (again) who said that if the pt can't swallow then "she'll just have to hurt." Seriously??!!??
What would you do?? It feels ABUSIVE to allow her to be in such awful pain for so long, but the spouse will cause a HUGE scene if he thought the pt had received IV pain meds. What are my options to protect my pt & keep her at least reasonably comfortable??

As a nurse, you have the right to call for a consult with the ethics committee.

Do it today. The patient doesn't need to be in hospice to receive HUMANE care and pain control. That applies for any patient in your facility.

BiohazardBetty · Jun 14, 2013

Wait? I just reread. She has an ng? Why can't that be utilized for pain med admin?
Thanks for being such an advocate for this pt!

She HAD an NG tube... It's since been pulled, at the spouse's request :/

Tait, MSN, RN · Jun 14, 2013

I think you are absolutely right on all counts... A couple of the problems I'm facing are:
1) spouse won't allow anyone to spiritually counsel the pt but him (they're baptist & here in the south, this is unusual for all of our pts, regardless of faith)
2) I have to have a doctor's order to consult palliative care/hospice... I realize that's strange for most of you, but I have to follow policy :/ and as you can tell, her doctor isn't the most compassionate guy around. The other oncologists are afraid to step on this doctor's toes, so they've all refused to put in consults about this.
Since the spouse is rarely there, I believe it is a control issue... Way more than I first realized. If he's not around much, I don't understand why he wouldn't want her comfortable rather than in pain... She can't visit if he's not there- let her rest comfortably! Unfortunately the spouse's schedule is unpredictable so I couldn't be sure she wouldn't be a little sedated if he showed up... It feels like I'm a little kid waiting on my dad to come home & spank me after I got in trouble at school!!! Insane!!!
I think I will call the hospice unit today & get some tips on what exactly they say to families in situations like this & continue trying to educate the spouse. Maybe it will eventually click.
As long as I document her pain level & administer meds accordingly, without a POA- other than pitching a fit- what's the worst he could do??

The palliative care consult order is not foreign, but I do believe that has changed in a lot of places recently. Two years ago when I was still bedside you didn't need an order. Recently during my practicum I learned that has changed.

jadelpn, LPN, EMT-B · Jun 14, 2013

If the patient has not been deemed incompetent, has no power of attorney, and even a HCP doesn't "kick in" until the patient can no longer communicate, then you need to go with what a patient wants. And this patient clearly is saying "no" to being medicated for pain. The patient needs the consults. Not the family. They have not a thing to do with a patient's decision making process until the patient can not make her own choices. If the patient has an NG tube for the purpose of nourishment, the percocets can not be crushed and put in the tube? NOT that a couple of percocets are the answer to this pain, however, her swallowing should not be a contraindication if a tube is in place. This is all heartbreaking, however, most often patients with terminal illness need and want to maintain control. Negotiate where you can, and attempt to get MD orders (ie: I am thinking a patch is a viable option. Would you be willing to try that so only food goes into the tube?)

I am confused as to your palliative care consults. Are they done with a palliative care nurse? Or just the care nurse discussing these issues? That is a concern.

I would approach social work to discuss deeming incompetency or talking to the patient about a POA or HCP, along with setting up a family meeting to discuss plan of care once patient is agreeable to a POA. I would also have them speak with her while she is still not confused 100% of the time about a HCP, and what exactly her wishes are. In the meantime, I would again have conversation with the patient that she has the right to have pain control. If she is agreeable to percocet, then perhaps she would be agreeable to some other type of relief. The husband and/or family have no say in the matter until deemed in charge of the patient's care, and if they are "mad" so what? You are a patient advocate, and not the family's advocate. Interestingly, sometimes patients decide on Aunt Sue, my cousin Tom or some other person as their HCP and/or POA. That could get interesting, so have the conversation with the patient.

Patients have the right to refuse just about anything. It is in your best interest to have this conversation with the patient alone. I would tell your charge nurse/NM that this is continuing to be a significant issue, and that you would like her there with you when this conversation takes place.

The end result will be that even if the patient is incompetent or chooses a POA, she will continue to not receive relief from pain, unless she decides that some other relative/friend make those decisions. Brain mets is nasty business, and of course will change a patient into "not themselves". That also needs to be explained.

Bottom line is that I would bring this to the higher powers of your unit. Another option would be to respectfully decline to take this patient assignment, as you may be ethically opposed to how the patient is choosing to deal with her terminal illness.

Document everything, even when you suggest a palliative care consult, and the MD declines same. That you have suggested alternate pain control, and the MD declines same. And I find it exceedingly difficult to understand how a primary care nurse is responsible for the palliative care consults. Do you not have a palliative care unit?

This situation goes deeper than just you. I would certainly not hesitate to hand this off to someone who has the "power" to take over this case and can try and make changes. Seems like you are just running in circles. This should not fall on just your shoulders.

No matter how this plays out, your patient is in charge unless deemed otherwise. We may not agree with the decisions that a patient makes, however, she certainly has the right to make them. But they need to be informed decisions. And I see no evidence that the patient has been informed of her choices, only the family. Which is incorrect. Well meaning, but incorrect.

jadelpn, LPN, EMT-B · Jun 14, 2013

OOOPs, NG tube pulled. If the spouse is calling the shots, this is where it can get really, really sticky for you. The patient should have these choices. But you need to have the back up or decline the assignment.

PMFB-RN, RN · Jun 14, 2013

First I don't understand how he CAN refuse for her. I would have NO problem giving pain meds regardless of his objection. In my hospital he could not refuse for her.

I agree with some others. Time to be brutally frank with him. Ask him things like "Why do you want her to suffer in pain?" and similar questions. If he tried to prevent me from administering the meds I would ask him to leave the room. In my hospital ALL visitors MUST comply with an RNs request to step out. This can be (and often has) been enforced by our on-site police officers. I would aslo question if he should be allowed to be at the bedside at all if he is compromising her care.

Lucky724 · Jun 14, 2013

If the doctor won't address the problem than he is NOT involved..he is passing the buck and has, from the sounds of it, no backbone. Go to the MD, the charge nurse, the DON of the facility, the Risk Manager and the SW - bug them until one of them stands ground here. ASK the doctor of a Pallative Care Consult - or contact the Palliative Care Nurse yourself, explain what the situation is and maybe he/she will offer to be proactive and contact that doc, etc. In the meantime, if you assess the patient is in pain and the patient is stating they are in pain - give the pain meds - the husband can't stay in the room 24/7 w/o having to use the bathroom, shower, etc. Also, some pain meds come in liquid form - the doc can order the pills changed to liquid. What a terrible situation for the patient and the staff.

Rhi007 · Jun 14, 2013

A court order of intervention is needed to over ride the spouse, although she has no enduring power of attorney so technically the spouse has no rights to say whether or not the pain meds are given. Morally we know that it's unacceptable to deny a person in pain..pain meds but its even more morally unacceptable for a pt's spouse to deny pain relief! Yes the law is needed here.

CrunchRN, ADN, RN · Jun 14, 2013

If nothing else maybe slip an anonymous note to the ethics team?