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

[BiohazardBetty]

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??

[dishes, BSN, RN]

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.

[BiohazardBetty]

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.[/quote']

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?

[martymoose, BSN, RN]

maybe he's finally coming to terms. Good for you for sticking it out for the pt.

[jadelpn, LPN, EMT-B]

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.

[Esme12, ASN, BSN, RN]

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.

[dudette10, MSN, RN]

People are strage.....and can sue for anything. I would NOT take this on myself.

And I am curious as to why all of the concern about the husband when he is not your patient? He has no power as of yet (or if at all per a POA or HCP deems someone else) and I just don't understand that part of the equation at all.

In some states like mine, absence of a legal document specifying POA then follows kinship rules with the spouse at the top of the list. If she is not able to make a decision, then yes, the husband can make decisions on her behalf in my state.

[tainted1972, ASN, RN]

I have been in this situation and I have given IV pain medicine despite what the family wants. If the pain medicine is ordered the patient is in pain I give it to them. I take advantage of the moments when the family is gone, because at that time I get to make the choice to give or not give the medicine... and I pretty much do not care if the family gets mad at me. My patient comes first. It makes me angry and sad when I see people deny others much needed paid medication. As far as the oral pain medicine, what about making it into a slurrie, and administering it SL. Most of my hospice patients are given oxy this way, even when they are unresponsive. the percocet is too big to make into slurry so maybe you can get the order changed to oxycodone.. the tabs are small enough to slurry.

[dishes, BSN, RN]

helloberry, in situations where a patient's rights are in conflict, I address the right that I believe is the most important first. In this case, I would address the patient's right to self determination and full informed consent first, because I believe it's more important then the patient's right to pain treatment.

Since the patient does not have a formal POA and the admitting diagnosis is altered mental state/confusion, I would clarify whether or not her husband is the designated subsitute decision maker.

I would listen carefully to the patient's and husband's descriptions of their experience at home and about the events that occurred prior to the patient's admission, my guess is, something happened that has caused them to be concerned about the side effects of pain medication and that is why they are declining the medication now. I would tell the patient she does not have to take any medication that she does not want to, but if she is uncomfortable, there is medication available and although there can be some side effects they are usually mild compared to the problems associated with severe pain. I would give the patient and husband time to come around to the idea of trying the medication. If they chose not to, I would respect their choice and tell them if she changes her mind at anytime to let any of her nurses know.

[Caffeine_IV]

I'm glad you took action and I'm sure the patient is too if she could verbalized. Sometimes families think we want to sedate their family member with pain meds and that is not generally the case.

[Elinor]

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.

This. He doesn't have power of attorney, so it's not up to him. Explain this to him. Do what you would do for any other patient. I don't understand why this patient hasn't been getting her meds.

To me it seems like a clear violation of this patient's rights and the law to allow her husband to prevent administration of ordered meds. If she refuses, that's another matter entirely. But to not give ordered meds because her husband says so? This is unethical and sounds illegal.

ETA: Oops, this is a little outdated because I only read the first half of the thread, sorry.

[Elinor]

In some states like mine, absence of a legal document specifying POA then follows kinship rules with the spouse at the top of the list. If she is not able to make a decision, then yes, the husband can make decisions on her behalf in my state.

Doesn't a judge still have to legally determine that a patient is not able to make decisions, first?

[dudette10, MSN, RN]

Doesn't a judge still have to legally determine that a patient is not able to make decisions, first?

I think there is a difference between someone being declared incompetent (a legal term) and someone who, in a team's professional judgement, has impaired judgement. In practical terms, we can't wait for a judge to determine if a patient, lets say, can sign a consent, but we would look for a spouse or whomever is next of kin to sign in the absence of a POA. There are have lots of dementia patients with no POA in place. Whether this is legally right or wrong, I don't know, but it is what we must do, practically speaking.