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

Nurses General Nursing

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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??

Specializes in ICU, step down, dialysis.

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.

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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.

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Specializes in Neuro ICU and Med Surg.

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.

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Specializes in Emergency, ICU.

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.

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Specializes in Emergency & Trauma/Adult ICU.

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.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

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.

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Specializes in Med-Surg/Neuro/Oncology floor nursing..

As others have pointed out as long as the spouse hasn't been appointed power of attorney he really doesn't have a say. Of course he can yell at you till he's blue in the face for giving pain meds..but that's a price I'd be willing to be pay. UNTIL and WHEN HE is the one with the power of attorney he can't legally do anything to you(being yelled at of course is not what you want but the spouse is not your patient). I would DEFINITELY go to the MD for an order for a fentanyl patch...when my father was dying of pancreatic cancer(and I don't need to tell a bunch of people in medical profession how painful and NASTY pancreatic cancer is) those fentanyl patches kept him more comfortable than anything given through an IV. For BTP we would mash up 30mg oxycodone pills in applesauce(which he didn't need that often as the Fent patch did a great job). Of course every patient is different and what worked for my dad may not work for your patient.

As for your patient's doctor..go to the chair of oncology if you need a pain management/palliative care consult. It sounds like you're patient really could benefit from a daily visit from pain management/palliative care...it also sounds like she needs a long acting narcotic on board.

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Specializes in Med Surg.
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.

Not only worthwhile, but mandatory where I come from.

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devil's advocate....he will out live her, and he will be filling out the press ganey form. also, the dead don't sue, but the living do.

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Specializes in Oncology, Palliative Care.
devil's advocate....he will out live her and he will be filling out the press ganey form. also, the dead don't sue, but the living do.[/quote']

His survey is the least of my concerns...

What do you feel he could he sue for?

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Specializes in Hospital Education Coordinator.

does the spouse have the legal right to speak for the patient? You need to get others involved and STAT. There is no reason to allow someone to die in agony

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
His survey is the least of my concerns...

What do you feel he could he sue for?

morte was being facetious.....hospitals press ganey surveys are the facilities bible these days.....sad.

He could sue for anything that will cost the hospital time and money....not that he would win. Forcing a patient to take a med she doesn't want...(her saying no no no no all the time) is assault. Now we all know she is confused and is in pain but that doesn't mean he can't sue later just to cause a stink.

People are crazy....and do weird things.

For example.....I had a patient that survived a horrible fire and lengthy hospital stay and sued for a breakdown over the right ear for O2 tubing.....it wasn't bad never needed plastic surgery like their burns...but it did get red and blister. He got a settlement from the facility. It never went to court.

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