When family refuses IV pain meds for cancer pt...? - page 5

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... Read More

  1. Visit  Altra profile page
    1
    So OP ... how are you planning to change your approach to care of this patient?
    DizzyLizzyNurse likes this.
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  3. Visit  GrnTea profile page
    6
    Quote from helloberry
    The doctor IS involved, he just won't address the problem. She would be a great candidate for a continuous PCA, but I also think the PRN dilaudid that she has ordered would keep her comfortable if I was allowed to give it to her. She isn't a hospice pt or even a palliative care pt at this point... The family just recently agreed among themselves on a DNR status.

    I'd need the doctor to order a palliative care consult, & even then it's just a nurse who counsels the family on end of life issues. I'd also have to have a doctors order to consult the ethics committee :/
    If she has a prn Dilaudid prescription, then you are within your rights and obligations as a registered nurse to give it as you assess appropriate. You are a patient advocate by licensure. Whether anyone believes it or not, if the husband does not have legal guardianship (not just medical POA) he cannot legally stop you from giving appropriate care as prescribed already by the physician. Also, it is legal and appropriate under the terms of your RN license to consult an ethics committee in a situation like this. You are her advocate. She cannot speak for herself. That is why RNs are who we are.

    Beyond that, all you can say to the husband is how terribly upsetting it must be to have this terminal diagnosis for his wife and see her in such a distressing condition. Sometime when he comes in and she's peaceful, you can tell him that, and then mention that she is peaceful and resting comfortably because she has pain medication prescribed via a safe route, subq or IM or IV, whatever it is, so she won't choke.
    nrsang97, PMFB-RN, wooh, and 3 others like this.
  4. Visit  BiohazardBetty profile page
    16
    Quote from Altra
    So OP ... how are you planning to change your approach to care of this patient?
    Starting yesterday afternoon, when I honestly felt she was suffering I asked her if she was comfortable. She said no & I said okay I'm going to help you get comfortable... & pushed dilaudid as ordered. She was a totally different person. Even smiled a time or 2! Spouse said oh she's doing so much better... Said, "Keep up the good work & you'll get to go home!" I never said a word about the med to him. Just did what I knew was the right thing & charted accordingly. One of the hardest choices I've had to make so far in my short nursing career, but I'm proud that I finally chose to care for her like she deserved. Thanks to all of y'all for your advice & support!!!!!!!
    klone, canoehead, antania31, and 13 others like this.
  5. Visit  blondebabe0625 profile page
    2
    Quote from helloberry

    Starting yesterday afternoon, when I honestly felt she was suffering I asked her if she was comfortable. She said no & I said okay I'm going to help you get comfortable... & pushed dilaudid as ordered. She was a totally different person. Even smiled a time or 2! Spouse said oh she's doing so much better... Said, "Keep up the good work & you'll get to go home!" I never said a word about the med to him. Just did what I knew was the right thing & charted accordingly. One of the hardest choices I've had to make so far in my short nursing career, but I'm proud that I finally chose to care for her like she deserved. Thanks to all of y'all for your advice & support!!!!!!!
    Great news!!!! :-) you're a great nurse! I'm glad everything's working out now.
    PMFB-RN and GrnTea like this.
  6. Visit  GrnTea profile page
    4
    Now make sure everyone else knows to do that, and in a few days you can let her spouse know why she's better. Pain relief is, well, a relief.
  7. Visit  november17 profile page
    0
    This is just wrong, wrong, wrong.
  8. Visit  november17 profile page
    2
    Quote from dishes

    Maybe the husband is frightened about his wife dying, maybe his wife expressed a strong fear of being too confused by the side effects of the medication to talk before she goes into a coma and dies, maybe the way he sees it, he is just trying to keep a promise he made to his dying wife.
    She probably wasn't in horrible pain when/if they made such a promise either.
    DizzyLizzyNurse and PMFB-RN like this.
  9. Visit  november17 profile page
    3
    Quote from helloberry
    Starting yesterday afternoon, when I honestly felt she was suffering I asked her if she was comfortable. She said no & I said okay I'm going to help you get comfortable... & pushed dilaudid as ordered. She was a totally different person. Even smiled a time or 2! Spouse said oh she's doing so much better... Said, "Keep up the good work & you'll get to go home!" I never said a word about the med to him. Just did what I knew was the right thing & charted accordingly. One of the hardest choices I've had to make so far in my short nursing career, but I'm proud that I finally chose to care for her like she deserved. Thanks to all of y'all for your advice & support!!!!!!!
    I know they really stress treating the family as well as the patient as holistic care but I'm glad you did what you did. If he finds out and makes a fuss, stand your ground.
    GrnTea, DizzyLizzyNurse, and nrsang97 like this.
  10. Visit  dishes profile page
    1
    Since the patient can speak for herself and agreed to receiving medication to make her more comfortable, she should be informed what medication she was given, as purposely omitting this information violates the ethical principle of veracity.
    canoehead likes this.
  11. Visit  BiohazardBetty profile page
    10
    Quote from dishes
    Since the patient can speak for herself and agreed to receiving medication to make her more comfortable, she should be informed what medication she was given, as purposely omitting this information violates the ethical principle of veracity.
    Make no mistake, I would absolutely never purposefully withhold or omit information from a patient- that would be just as unethical as letting her lay there in pain, if not more so. Neither the pt or spouse, who was present, asked what the med was & they both watched me give it. Without a doubt I would have told them if they had asked- i was prepared for the repercussions. I passed the info along to the night nurse when i left that night, but she said she was too afraid to give the meds b/c of the spouse.

    But get this: I was off yesterday & back w/ this pt today. 630 this AM I'm coming on the floor & see the spouse. He says how the pt has been "acting up" ever since I left & asked what I did for her that afternoon. I was kinda scare but I told him I had given her dilaudid like the doctor ordered. Guess what he said... "THANK YOU. Can you give her some more?" 😮 Whoa. Of course it took some education on the purpose of pain meds vs. helping her calm down, but by the end of the day he was saying how much better she must feel (she's not very verbal at all now, mostly just yells out) & thanking me for making her comfortable.

    dishes, I like the way you think & I'm curious- what would you have done in this situation?
    Mandychelle79, klone, canoehead, and 7 others like this.
  12. Visit  jrwest profile page
    2
    maybe he's finally coming to terms. Good for you for sticking it out for the pt.
    nrsang97 and GrnTea like this.
  13. Visit  jadelpn profile page
    7
    In my opinion, there's still a huge disconnect here.

    Going forward, I think that the unit could benefit from education regarding patient rights. All of this hoopla could have been avioded straight away if the patient was properly educated on pain control from the get go and she was lucid at times. And the fact that the other nurses who took care of this patient declined to give her the medication that was ordered and needed is inexcusable. All on the assumption of what the husband would do (and really, what could he do?) on his say so. Borders on unethical. I can not stress enough that patients, especially patients who are dying of metastatic cancer, have the right to speak for themselves, have the right to hear and understand all options for pain control, and have the right to receive such pain control based on their perception of pain, your assessment of pain, when they ask in the confines of your MD order. If it is not working, you need an alternate order and to speak with the patient on said order.

    While you all fussed around at the whims of a husband, you had a patient who was in excrutiating pain. I am not sure how any nurse can believe that to be correct. Patients have the right to decline medication. Then there needs to be a plan "B" discussed. However, at no time is it good practice to base your nursing interventions on the say so of the husband when a patient is very capable of speaking for herself.

    This does need to be brought to your ethics committee as a case review, and some education needs to happen so that this situation doesn't repeat itself.
    antania31, LibraSunCNM, Elinor, and 4 others like this.
  14. Visit  Esme12 profile page
    3
    Quote from helloberry
    That's good info... I was worried that I had already done something that may invite a law suit! The spouse is kinda crazy... SUPER attentive when staff are present- rubbing her feet & talking sweet, singing to her- but when we aren't in the room he sits in the corner & ignores her. We have observation type windows where we can see into the room without disturbing the pt, so I've noticed this frequently. Now that I think about it, I've actually never seen him showing her any attention when we weren't in the room... But then again, my 4 seconds 4 times an hour is hardly a good judge of what they do the rest of the time.

    I don't feel like its a cultural/religious thing- they're southern baptist just like most of the staff. Even used to go to church with one of our CNAs. It feels more like a control issue to me, sadly.
    Creep ...or he was abusive to her at home and this is one final way to make her suffer.
    PMFB-RN, monkeybug, and GrnTea like this.


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