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

  1. 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??
  2. Visit BiohazardBetty profile page

    About BiohazardBetty, BSN, RN

    Joined: Dec '09; Posts: 185; Likes: 153
    Palliative Care Coordinator; from US
    Specialty: 4 year(s) of experience in Oncology, Palliative Care


  3. by   anotherone
    Do you have an ethics committee or a palliative care speciall
    ist where you work? Sometimes , I want to just say "ok we'll just let her suffer". Who knows what his true motives are. I see a few pwople lile this but even those who don't want "knocked out" family don't want their family member to suffer ...... The oncologist said , "[ then she'll just have to hurt"]? ...... Wow ...... the drs where I work would really talk to the spouse over and over and usually involve palliative medicine and legal department for options ( this is a teaching hospital with a lot of gung ho residents)
  4. by   loriangel14
    You need to get the doctor involved. Where I work our palliative patients have PCA pumps and the med is delivered continuously SC.
  5. by   BiohazardBetty
    Quote from loriangel14
    You need to get the doctor involved. Where I work our palliative patients have PCA pumps and the med is delivered continuously SC.
    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 :/
  6. by   benegesserit
    If he's open to oral meds, would SL morphine be an option?
  7. by   R!XTER
    Keep escalating! If you're manager won't address it, go to the director of nursing, or the ADN, or whoever is above her. Get ethics committee involved. This may very well be a legal issue as it can be considered abuse or neglect. If the spouse is causing the patient to suffer he may need to be removed from the situation. Find out who he respects on the medical team and try to have them explain to him why pain meds are necessary for his wife's comfort.
  8. by   Caffeine_IV
    What is she admitted for then? That is unacceptable.
  9. by   BiohazardBetty
    Quote from Lil'mama
    What is she admitted for then? That is unacceptable.
    I agree... She was admitted for something along the lines of altered mental status… which is to be expected with brain mets, but at home she was just laying in bed on her own for about a month. Still had intact skin, but ended up with an NG tube because she refused/was unable to eat. It's a sad, sad situation to see anyone in. I desperately want to be able to help her get comfortable.
  10. by   Altra
    Unacceptable. I would say something to the spouse along the lines of, "well, then she'll be suffering needlessly." Or even, "why do you want her to suffer?" Sometimes you have to slap people upside the head verbally.

    To allow an end-stage CA patient lie in bed calling out in pain? Not on my watch.
  11. by   AMR21
    Do you have a pain team who can consult and possibly educate the family?
    SL morphine, some sort of transdermal patch?
    If that doesn't work, I would call the ethics committee. ASAP.
  12. by   AMR21
    Wait? I just reread. She has an ng? Why can't that be utilized for pain med admin?
    Thanks for being such an advocate for this pt!
  13. by   SwansonRN
    Not justifying his behavior, but I do think its coming from a place of ignorance or false hope rather than malice. I know my family is full of compassionate and reasonable people, but when my grandma was dying of cancer, they would never want to give her any pain meds because of similar reasons. They wanted her awake, they wanted to have conversations with her for the short period of time they knew they had left. There was an element of denial, as if the meds are the reason that she's not herself rather than the brain mets, or that all those narcotics are going to make the dying process faster. The home hospice nurse finally stepped in and sort of gave everybody a wake up call...therapeutically of course. It seems like nursing staff have done a lot to try and educate this man, so maybe it's time to pull in palliative care (they deal with these situations all the time and are experts). Maybe even try getting a chaplain involved. He may also be grieving and feeling helpless therefore trying to feel like he's in control of something. Either way this problem is bigger than nursing and should be handled with a multi disciplinary approach.
  14. by   morte
    why would you need the doc to refer to the ethics com.????