When family refuses IV pain meds for cancer pt...? - page 3

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... Read More

  1. 22
    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.
    klone, canoehead, Elinor, and 19 others like this.

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  2. 0
    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.
  3. 2
    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.
    Jory and sharpeimom like this.
  4. 0
    If nothing else maybe slip an anonymous note to the ethics team?
  5. 5
    Do you guys think contacting Adult Protective Services would be worthwhile? I'm not real familiar with all that they do, but wondered if this would be an option.
  6. 8
    Easy. Chart her as having an altered mental status. Describe in detail your assessment of her pain and her behavior: "Pt appears to be uncomfortable AEB restlessness, grimacing, guarding" or whatever s/s she's presenting with.

    Do a full mental assessment--ask her the time and date and all that jazz. If she's that altered, she won't pass. That frees you to give medication to alleviate suffering per your nursing judgement based on your assessment and within the confines of the physician's order.
    Last edit by SoldierNurse22 on Jun 14, '13
  7. 2
    You can consult ethics without an MD order. I would medicate her appropriately if she is in pain regardless of what the spouse says. Would roxanol be an option since it isn't IV and can be given SL? How about a fentanyl patch? I would keep bringing this to the attention of the NM.
    canoehead and SoldierNurse22 like this.
  8. 2
    OP, this is a tough scenario. Personally, if the patient is the one who still legally in charge (you stated she is confused but has not been deemed incompetent), I would talk to the patient when the husband isn't there and ask her if she needs pain medications. If she says yes, I will push whatever is ordered. If she says no, I'll chart accordingly and not give her meds. It is her decision and no one else's.

    Now, if the spouse does become the legal decision maker and he refuses medications for an end stage cancer patient with obvious signs of pain, I will document that clearly in my charting and call adult protective services. As a mandated reporter in my state, any signs of abuse have to be called in. This to me is clearly abuse.

    Also, I agree with other posters who expressed that if the chain of command is not listening to your worries, you need to call the ethics department of your place of work. You don't need an order for that. (I understand that you said you need an order for a hospice referral and people misunderstood that as meaning an order for ethics...). Call them. Worst thing that will happen is they won't be able to do anything because the patient is still competent.
    antania31 and NurseDirtyBird like this.
  9. 18
    I'd like to point out ... the OP indicates that there are orders for pain meds. In that, the MD has done his job, now it's time for nursing to do the same. Objective signs of pain present in your patient? Medicate per orders. Spouse is interfering with that? Deal with spouse according to policy, involving unit management, security staff, etc.

    I cannot wrap my head around not medicating a patient because spouse might show up and be upset.
    klone, nuangel1, redhead_NURSE98!, and 15 others like this.
  10. 2
    I think it is time to continue up the food chain. Get a pain consult. Find your hospital policy on how to get to the ethics committee. Make sure your documentation describe all the physiological symptoms of pain and the family members refusal for to provide relief for the patient. A meeting with the family and/or clergy is needed to get the family on the same page and emphasize that the patient is suffering unnecessarily....and that the confusion is from the cancer not the meds. Ask the MD for a social services consult (if you even need an order) to have some honest conversations with the family on how to go forward from here.

    Bless you for caring for your patient.
    nuangel1 and wooh like this.

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