When family refuses IV pain meds for cancer pt...? - page 8
by BiohazardBetty 10,842 Views | 87 Comments
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
- 0Jun 19, '13 by ElinorQuote from dudette10Doesn't a judge still have to legally determine that a patient is not able to make decisions, first?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.
- 1Jun 19, '13 by dudette10Quote from ElinorI 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.Doesn't a judge still have to legally determine that a patient is not able to make decisions, first?
- 2Jun 19, '13 by narcolepticnurseThese situations are awful when they arise. It's also intensely confusing as to whether or not to treat the patient for pain when they give very mixed messages as you've described. If she was telling you (confused or not) in a definite way that she is in pain and that she would like pain medicine, then I would say it doesn't matter what he wants. However, here... What I would do is, when I heard the patient crying out that she is in pain, I would ask, "Do you want medicine to help the pain?" If the patient says, "yes" then I would give her whatever ordered pain medicine that she can take safely because your obligation to treat her pain would surpass your obligation to make her family happy. If she says, "no" then I would not give it.
If that is not applicable or helpful here, other than what other people have suggested i.e. contacting the ethics committee, there may not be much you can do. Just be sure you're looking after yourself too and that documentation is tight (including the exact words of what the husband tells you regarding him not wanting her to have IV pain meds and all communications with the physicians, management, social worker, etc.) in case there's litigation later over inadequate pain control. You want all of your efforts to prevent her suffering to be recorded.
- 4Jun 20, '13 by R!XTERI was thinking about this thread at work yesterday. I had a pancreatic cancer patient yesterday with mets to multiple sites including bone. She came in because PO home meds were not relieving her pain. This poor woman was clearly suffering terribly. Her entire body was shaking from the pain and no matter what I tried to do for her she could not get comfortable. Her pain was barely relieved with Q1h dilaudid. She mentioned to me that her family has been telling her she takes too much pain meds. Luckily she was a&ox3 and able to speak for herself because I just looked at her straight and told her "you tell them that bone cancer is one of the most painful forms of cancer and you take whatever you need to to make yourself feel comfortable" she seemed so relieved after I told her that.
A separate issue is that there seems to be a severe lack of education when it comes to cancer patients. Maybe the docs are nervous to give it to the patients straight but this woman and her family did not seem to know that this was a terminal diagnosis. They had only discovered the cancer a few weeks ago and it had already metastasized everywhere yet she was on very aggressive chemo, the family was telling her to lay off pain meds, and she was telling me she can't wait for summer to be over because by then she'll be done with all these treatments etc. I guess it is possible that they decided to pursue aggressive treatment and try to remain positive by making future plans and all but I got the impression more that they were just clueless and that no one had had a serious conversation with them about likely outcomes. It just made me really sad because her chances of making it to the end of the summer are probably really really slim. My heart went out to her.
- 2Jun 25, '13 by GrnTeaQuote from dishesI doubt that no one had a serious conversation with the patient and family about the outcomes. I really believe that when all you've got left is hope, no one should try and take it away from you. If someone loses all hope what do they have left?
The hospice people will tell you that when we can no longer hope for cure, we can still hope for comfort, for someone to listen, for someone to look after your family after you're gone, for being able to live the days you have left in the best way possible. It is perfectly OK to say those words to patients. I have, and more than once, and it is heartwarming to see how it reassures and calms them and gives them permission to talk about what is important to them in their last days. I recommend it.
- 0Jun 25, '13 by dishesIn the situation that Rixter described, the patient had been newly diagnosed with pancreatic cancer within the last two weeks, and even though the chances of survival are slim, the patient was offered and accepted chemotherapy treatment. It sounds like standard practice to me, as the chemo may buy the patient a bit more time. Do you think it would be better to not offer chemo and just offer hospice care in newly diagnosed pancreatic CA patients?