Palliative Care and Euthanasia - page 5

Hi everyone, This is my first time posting on allnurses.com. I am a final year nursing student at Napier University, Edinburgh. Part of my coursework involves selecting one of the World Health... Read More

  1. by   leslie :-D
    Quote from Katillac



    In an attempt to understand your perspective, I will ask how you document these PRNs that you give before you see any evidence of pain. What do you list as your objective reasons for giving them? Perhaps it comes down to our facilities have different documentation standards. Our staff must list the specific reason they give PRNs, and we've been told by the state that the old "to enhance comfort" or similar vague and subjective reasons aren't appropriate. Catchy phrases like, "You have to stay ahead of the pain" won't do for indications, either.

    Quite frankly, I think that a nurse who goes ahead and gives PRNs routinely without any indication that there is a need for them may be serving her own desires to see herself in a good light and trying to save herself the trouble of assessing rather than practicing in her patients best interests. But I am sure you will disagree.
    i answered your questions in my response to fab4- i thought this post was from fab4 and responded, now realizing it was you that wrote it.

    you and i are just not communicating- majorly misunderstanding ea other. katillac- you do sound like a good, competent nurse; i just think there's a link missing where we're not connecting.

    when i talk about aggressive pain mgmt.,i am referring only to those patients who have presented with scathing pain- those challenging pts that even on long acting opioids, the prns only help for a brief time. and yes, the regimen needs to be modified and you do what needs to be done to get this pain under control.
    but if i know my patient and their patterns of pain, then yes, i am going to give the prns before the pain sets in. there is nothing random in the way i adminster narcotics. but there are medical directors and attendings that are still reluctant to increase dosages, change meds, titrate up/down to desire effect. being in hospice is not synonymous w/pain. the only pt population i was referring to were those with poorly controlled pain, knowing the pt and what they're experiencing, and ensuring that they get a prn before the pain sneaks up on them again. i do this when they're sleeping also. i consider myself adept at assessing pain. i will not give narcs to those who don't need it just because they're on hospice. i've seen many peaceful,drug-free deaths.
    but i've also seen too many stingy, cya mds who just won't work w/you when you come up w/a recommendation. and as i've stated, the only way i get them to change their minds is when i tell them that i intend to document my conversation w/them, md's response, pt's response to current pain mgmt.,etc. then they get paranoid and typically will irritably ask "what is it that you want for this pt?" because the doctors know that they could get in a heap of trouble for undertreating pain.
    perhaps you were talking on behalf of the gen'l hospice population and i was talking about those w/poorly controlled pain????

    leslie
  2. by   Katillac
    Quote from earle58
    i answered your questions in my response to fab4- i thought this post was from fab4 and responded, now realizing it was you that wrote it.

    you and i are just not communicating- majorly misunderstanding ea other. katillac- you do sound like a good, competent nurse; i just think there's a link missing where we're not connecting.

    when i talk about aggressive pain mgmt.,i am referring only to those patients who have presented with scathing pain- those challenging pts that even on long acting opioids, the prns only help for a brief time. and yes, the regimen needs to be modified and you do what needs to be done to get this pain under control.
    but if i know my patient and their patterns of pain, then yes, i am going to give the prns before the pain sets in. there is nothing random in the way i adminster narcotics. but there are medical directors and attendings that are still reluctant to increase dosages, change meds, titrate up/down to desire effect. being in hospice is not synonymous w/pain. the only pt population i was referring to were those with poorly controlled pain, knowing the pt and what they're experiencing, and ensuring that they get a prn before the pain sneaks up on them again. i do this when they're sleeping also. i consider myself adept at assessing pain. i will not give narcs to those who don't need it just because they're on hospice. i've seen many peaceful,drug-free deaths.
    but i've also seen too many stingy, cya mds who just won't work w/you when you come up w/a recommendation. and as i've stated, the only way i get them to change their minds is when i tell them that i intend to document my conversation w/them, md's response, pt's response to current pain mgmt.,etc. then they get paranoid and typically will irritably ask "what is it that you want for this pt?" because the doctors know that they could get in a heap of trouble for undertreating pain.
    perhaps you were talking on behalf of the gen'l hospice population and i was talking about those w/poorly controlled pain????

    leslie
    I think I am starting to see this from your side.

    We are blessed at our hospice with a community of MDs who for the most part respond extremely well and quickly to our nurses' requests for changes in orders. There are a few who drag their heels, but our medical director takes care of them. So if I have a patient with poorly controlled pain I can quickly and easily get a routine order in place or changed. It must be so frustrating to have MDs who do not respond appropriately and who you need to basically strong arm to get what you need for your patients! And absolutely, if I couldn't get an appropriate routine order in place I would document the doc's refusal to give me the order and use PRNs until we could get an appropriate regimen in place.

    I recognize that you have a passionate commitment to pain management for your patients, and that's wonderful. I believe there are shades of difference in the way that we go about manifesting that commitment, in part forged by the respective environments in which we practice. I don't think that you give meds randomly or to patients that don't need them. It sounds like you have sound nursing judgement and utilize it. It also sounds like our documentation is required to be tighter, and while I don't have the freedom to give PRNs based on pain I think my patient may have in the future, I can get routine orders to cover that.

    We have gone far afield of the OPs topic, and I apologize for that. Perhaps if this side thread should be continued, it's time to start a new topic.
  3. by   fab4fan
    OK, let's try this scenario and see if I can explain myself better:

    Mrs. Smith is on OxyContin 60mg BID. She has OxyIR 20mg which she can have q4h prn for breakthrough pain.

    Now, I am not just going to go ahead and give the OxyIR if the pt is not having breakthrough pain. That kind of defeats the purpose of having a long-acting and short-acting agent. It doesn't give you a true picture of how well the pt pain is being managed. It makes it impossible to know if/when to titrate the long-acting med, and by how much it needs to be titrated. I have been fortunate in that most of our doctors allow us to go ahead and titrate long-actings based on prn use; we follow the algorithm for the particular med. No one is ever left in intractable pain.

    So yes, I am a very strong proponent of pain control. If I have a pt who needs frequent prn meds, I am going to give them routinely until I can get an order for a long-acting agent. But I wouldn't routinely give a prn med if the pt is on a long-acting med and is comfortable. That just doesn't make sense.

    As far as giving pain meds to "ease someone out of this world," that's not what hospice is about, either. Hospice does nothing to hasten or prolong life. The goal is to make what time the pt has left as comfortable as possible. Ultimately, it's the disease that kills the pt. If a pt happens to die shortly after getting a prn, I consider it a consequence of the disease. There's no intent to kill the pt; that would be unethical at the very least.
    Last edit by fab4fan on Jun 24, '05
  4. by   leslie :-D
    Quote from fab4fan
    OK, let's try this scenario and see if I can explain myself better:

    Mrs. Smith is on OxyContin 60mg BID. She has OxyIR 20mg which she can have q4h prn for breakthrough pain.

    Now, I am not just going to go ahead and give the OxyIR if the pt is not having breakthrough pain. That kind of defeats the purpose of having a long-acting and short-acting agent. It doesn't give you a true picture of how well the pt pain is being managed. It makes it impossible to know if/when to titrate the long-acting med, and by how much it needs to be titrated. I have been fortunate in that most of our doctors allow us to go ahead and titrate long-actings based on prn use; we follow the algorithm for the particular med. No one is ever left in intractable pain.

    what i'm saying is you need to get to know your patient and their patterns. if the oxy 60 mg bid isn't holding them and you end up having to give them a prn does of the oxyir, then i'm going to give a 2nd dose of the oxyir in 3.5 hrs, knowing that the long acting opioid did not sustain them the 1st time.
    i won't wait until they get the next episode of breakthrough. and then i can report my findings to the md.

    i don't know who you're referencing about easing one's way out of death, but that is certainly not my philosophy. i've seen death too many times that there is nothing scary about it....yet if the pt is fearful, then i'll get a prn ativan order along w/other interventions. but if it's in my control, should i witness only 1 episode of breakthrough pain, that is 1 too much, thus my rationales for giving out the prns until the regimen can be changed.

    leslie
  5. by   fab4fan
    The original intent of this thread was a discussion about palliative care and euthanasia. I was not implying that you or anyone else are euthanizing pts.
  6. by   fab4fan
    I guess we'll have to disagree on the breakthrough med issue.

    Just because a pt. has BTP once doesn't necessarily mean he'll continue to have it. Sometimes one dose of a short-acting agent is all the pt. needs.

    The guideline as given by hospice and the manufacturers of long-acting agents
    is that if a pt needs three prn doses in 24h, then the long-acting dose needs to be increased. If you just assume that a pt is going to continue to have BTP, then you really can't get a clear picture of what his med needs truly are.

    I guess I'm going to continue to follow the above guideline, as there are numerous resources that concur with it.
  7. by   leslie :-D
    i didn't know that's what the standard guidelines were.
    i'll bite the bullet and wait for the 2nd episode of btp; after that i will assume there would be a 3rd episode.
    sometimes i feel that our patients are used as guinnea pigs for research purposes. grrrrrr. very frustrating sometimes.
  8. by   Katillac
    Quote from earle58
    i didn't know that's what the standard guidelines were.
    i'll bite the bullet and wait for the 2nd episode of btp; after that i will assume there would be a 3rd episode.
    sometimes i feel that our patients are used as guinnea pigs for research purposes. grrrrrr. very frustrating sometimes.

    I don't get it. You said in an earlier post:

    "to NOT stay ahead of pain is a cruel and abusive act of blatant neglect."

    But now you're willing to wait until TWO episodes occurs? What happened to not allowing patients to suffer, even for a minute? And after that third dose which you give because you assume there will be pain, how long do you keep that up? If you neglect to give an available PRN dose, aren't you "allowing them to suffer needlessly" according to your philosophy? On the other hand, if you just keep pouring the PRNs to them, how are you ever going to know how much medication they really need?

    The unfortunate reality is that in order to treat pain appropriately, we need to be able to assess it, which we can't do until it occurs. Pain changes. It's worse in the morning, or after a day of being up and around, with movement, with eating, with procedures or after bad news. It's better after a tub bath, a warm pack, repositioning, prayer, or during a visit from the grandkids. You just can't assume that pain will be the same all of the time.

    As people who try so hard to relieve suffering it's hard for us to watch it occur. And it's a balancing act, a level of alertness and side effects acceptable to the patient versus a level of pain acceptable to the patient. So we get a good fix on a routine or long acting dose, and wince with them when breakthrough occurs, noting that carefully to determine whether changes in the routine order are needed.

    Sometimes it does seem like we are experimenting on them, and in a way we are, trialing different regimens until we get one that works. But if we are to respect our patients' right to be unique and treated as unique individuals, we have no choice but to let them display that uniqueness and respond to it.
  9. by   leslie :-D
    Quote from Katillac
    I don't get it. You said in an earlier post:

    "to NOT stay ahead of pain is a cruel and abusive act of blatant neglect."

    But now you're willing to wait until TWO episodes occurs? What happened to not allowing patients to suffer, even for a minute? And after that third dose which you give because you assume there will be pain, how long do you keep that up? If you neglect to give an available PRN dose, aren't you "allowing them to suffer needlessly" according to your philosophy? On the other hand, if you just keep pouring the PRNs to them, how are you ever going to know how much medication they really need?

    granted, it is contradictive as my ambivalence is now evident.
    i was merely going by fab4's stated guidelines of 3 prn doses/24 hrs= need for differernt regimen. the intellectual part of me is stating that makes sense. yet if i have to give 1 prn dose of a narc for btp, then i assume there will be a 2nd episode of btp......i anticipate it and treat it accordingly. as stated, i was not aware of these guidelines and that's why i compromised my values to 2 prn doses. i'm not sure if i'll still do it, but probably will. if a pt. needs a 2nd breakthrough dose, i'd feel safer in assuming that a 3rd one would follow. so that's why i expanded my thought process to r/o the notion that it might just happen 1 time. learning is a perpetual process and even i can push my emotions aside and make an unbiased, clinical judgement.
    nothing written in concrete however, lol. i said i'll try it.

    leslie
  10. by   fab4fan
    But the thing is, you can't just assume that the pt is going to have a second or third episode of pain.

    If you were taking care of a pt who was having chest pain, would you continue to give prn nitro sl, assuming that since the pt had chest pain once he will continue to have it?
  11. by   leslie :-D
    Quote from fab4fan
    But the thing is, you can't just assume that the pt is going to have a second or third episode of pain.

    If you were taking care of a pt who was having chest pain, would you continue to give prn nitro sl, assuming that since the pt had chest pain once he will continue to have it?
    well if the ntg didn't work after the 3rd dose, there are definitive protocols to be followed.
    and when it comes to a dying person with evident intractable pain, yes, i would err on the side of caution......w/o a doubt.
  12. by   fab4fan
    No, I mean if you gave it to the pt once, would you just give it again because you assume since he had it once, he'll have it again?

    The whole point of pain mgmt. is for the pt to not have intractable pain, which is why pts. need to be on long-acting agents with prn meds if the pt has BTP.

    As I said before, I am following established standards which have been proven thus far to be the most effective way to manage pain.

    I think I am going to bow out; I'm just repeating myself at this point.
  13. by   leslie :-D
    Quote from fab4fan
    No, I mean if you gave it to the pt once, would you just give it again because you assume since he had it once, he'll have it again?

    The whole point of pain mgmt. is for the pt to not have intractable pain, which is why pts. need to be on long-acting agents with prn meds if the pt has BTP.

    As I said before, I am following established standards which have been proven thus far to be the most effective way to manage pain.

    I think I am going to bow out; I'm just repeating myself at this point.
    ok.
    i'll repeat myself one last time then i'll bow out.
    i am only referring to these pts that ARE on long acting agtswith prns for btp. the long actings aren't holding them....more often than not,i am dealing w/uncoop doctors. i know the pt and their hx, get input from family,records, my own assessments. it is obvious there needs to be a modification.i know them well enough to know that yes, the pain WILL reoccur until a change is implemented. so normally it takes 2 episodes of btp for me to realize that this isn't working-i don't care if the guidelines say 3 in 24 hrs. once i realize that a change is in order, i will give the prn narcs until said change is implemented. this is a *******' dying person in pain. and until the docs get rid of their paranoid ideations of overprescribing, i will give and give within the legal guidelines and presume that there will be another episode of btp.i don't give a rat's asss what the literature says. i go on my personal observations and ethical guidelines. if i can prevent any dying pt from suffering, then i shall proceed and give it before the btp reoccurs. i am not rubberstamping this for all pts but for those that have mds that are ridiculously stingy in prescribing narcs-i will do what i have to until change has been instituted. period. end of conversation.

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