I didn't become a nurse to feed people's addictions. Do *nurses* have the right to refuse

  1. (Disclaimer: So this turned out to be longer than I thought it would, and a bit of a rant. Sorry! But I think this is something that's relevant to all of us).

    Some background: I work in a combined med surg ward, so we see a bit of everything. We have a young-ish girl, in her twenties, that has a VAC dressing in her leg following very deep self harm about two weeks ago. Her drug use has also given her 'meth mouth', and she's had at least one tooth removed about a week ago as well.

    The issue is that she has a personality disorder, a history of aggression, is a known drug seeker and has had to have her VAC replaced twice now because she keeps sabotaging it - picking at it, poking and playing with it. Before it was put in she was seen physically pulling the edges of the wound apart with her hands also. She demands morphine roughly every hour for "ten out of ten" pain even though you can clearly see that she's not distressed in any way. She is charted for PRN morph and fentanyl, subcut (not allowed to have a cannula).

    We always hear about the patients right to refuse; surely nurses have some way of objecting in a situation like this? Panadol (Tylenol), anti-inflammatories and endone all "don't do anything", even though it barely gets to two minutes after giving these before she buzzes and asks for "something better".

    It's ridiculous; the patient knows she's playing us for fools and has said as much. Surely there comes a point where enough is enough and we stop giving in to people, especially people who don't want to help themselves. No wonder the state health system I work in is broke; It frustrates me to no end when we can't even afford more then one obs machine on the ward between thirty two patients, yet we will hand out expensive treatments to people who clearly don't want to get 'better', and dole out morphine like it's soda.

    I know we need to cover pain relief somehow; I'm aware that vac dressings can be painful. But it's not like she can say we're not giving her anything at all. What are our options here? I'm not the only one with the same concern.

    Sincerely, nurse who didn't become a nurse to be a drug dealer.

    *edited for spelling.
    Last edit by Thankgodforativan on Feb 22
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  2. 113 Comments

  3. by   Oh'Ello
    I think it's ironic that your username is "Thank god for ativan" but you're apprehensive about giving prescribed controlled substances per order.

    You aren't a drug dealer because you aren't personally profiting from the dispense of drugs. She has pain meds ordered and they're indicated.If she is engaging in self-sabotage, self-harm, med-seeking, she will suffer the consequences of those destructive behaviors regardless of whether or not you attempt to control her pain. I think its important here to remember what our job IS and what it is not.
  4. by   Extra Pickles
    the short answer is no, you do not have the right to refuse to give medication that the provider has ordered and is appropriate for her diagnosis and condition. The longer answer is that if giving a medication isn't prudent for a specific reason, you need to address that reason. You can hold a narcotic, for instance, if the patient's vital signs, demeanor suggest that giving that medication would be dangerous. It is then your responsibility to notify the provider what the condition of this patient is, why you held the medication, and ask if he would like to change the current medication order. Sometimes decreasing the frequency is in order, sometimes lowering the dose or changing the medication entirely.

    You do not have the right to decide for yourself if the patient's pain warrants the medication that has been prescribed. Your job is to advocate for the best care for your patient, and that may mean a conversation with the provider on how to proceed going forward, but it is NOT to judge whether they "deserve" that medication.

    If you have concerns, address them with the prescribing provider, have your concerns heard, and then go from there.
  5. by   Thankgodforativan
    Quote from Oh'Ello
    I think it's ironic that your username is "Thank god for ativan" but you're apprehensive about giving prescribed controlled substances per order.

    You aren't a drug dealer because you aren't personally profiting from the dispense of drugs. She has pain meds ordered and they're indicated.If she is engaging in self-sabotage, self-harm, med-seeking, she will suffer the consequences of those destructive behaviors regardless of whether or not you attempt to control her pain. I think its important here to remember what our job IS and what it is not.
    But we are giving her pain relief. As I explained, nobody can say we're not doing anything for her, she just doesn't like what we give her (her words, not mine). She can do whatever she wants while she's out in the community, but surely as an inpatient giving in to her every demand (to the point where she's constantly drowsy) is doing her more harm than benefit.

    Where does it end? And why should my other patients suffer because I spend half my day (not an exaggeration, this is my actual hours as per allocation) dealing with her constant demands for pain relief?
  6. by   meanmaryjean
    And yet, your username.....
  7. by   AliNajaCat
    Strongly suggest you educate yourself about addiction, mental illness, and pain management for addicts and people who are dependent. Learn the difference between addiction, habituation, and tolerance.

    And while you're at it, repeat after me: "There but for the grace of God go I." A little compassion is in order here. Learn to feel sorry for people with screwed up lives; you'll see a lot of them the longer you're a nurse (new?) and it'll make you a better one.
  8. by   Thankgodforativan
    Quote from meanmaryjean
    And yet, your username.....
    It's just a username friend. Meant to be a joke, ya know? Humor?

    Incidentally, it comes from a framed picture we've had hanging in our nurses room for who knows how long now of Jesus that says 'and on the seventh day God created ativan'.
  9. by   SmilingBluEyes
    And yet *I* did not become a nurse to judge people. I dispense medication as ordered and let the doctor and patient sort it out. It saves my sanity many times. Use that brilliant sense of humor of yours and press on.
  10. by   Libby1987
    That's your example of a patient who makes you feel like a drug dealer? Can you come up with someone who isn't a self mutalating young-ish girl who has destroyed her life?

    How do you not fall over in gratitude?
  11. by   Been there,done that
    You do not have the "right" to refuse to carry out the physician's order. If the prescribed RX does not handle her pain, you have the right to notify the physician and the pain management team, and institute other therapies, such as heat or cold applications and repositioning.

    You do not have the right to judge her based on her psychiatric history.

    You CAN get her comfortable... perhaps, if you spent less time judging and more time thinking of alternative and adjunct therapies.
  12. by   KatieMI
    You cannot ethically refuse to give patient something that was prescribed by provider. Just as you cannot refuse to go into L&D room to assist a patient whose moral/social/sexual choices are in conflict with your own.

    As a nurse, you have right to refuse to work in a place which provides services you disagree with and find something else you like more. Under clearly dire circumstances (DIRECT threat to YOUR OWN health, physical or mental, such as sexual harrassment or death threats) you can refuse to care for a particular patient IF other caregivers are available and you do not work, say, in inpatient psych. This is it. You may want to go back to school, become practitioner and then enjoy your privileges to fire patients for abusive behavior.
  13. by   Sour Lemon
    You're not going to fix these individuals, so just do your job, then go home and count your money. I understand they can be frustrating, but they're really not making a fool of you ...it's their own lives that are sad.
    If it helps you feel better, there is a medical necessity- even for addicts. Have you seen what happens when they get a rare doctor who won't give them anything?
    The last hospital I worked at required anyone with Q1H orders to be switched to a PCA or sent to ICU, though ...fair enough, IMO. We simply don't have time to give Q1H anything for days at a time in med/surg.
  14. by   MPKH
    I work in a hospital that serves the majority of the inner city population. As a result, my medicine unit receives a lot of patients with drug use background. Most will want their prn morphine or dilaudid as soon as they can have it...they will watch the clock to ensure that they are receiving it at the frequency the doctor has prescribed.

    I don't judge them. It's not my business. I will hold narcotics if they are too drowsy to receive them. Same as I would any other patient.

    Ethically, nurses are to give out medications that are prescribed, provided that it is safe to do so. The treatment of drug users is complex, and it takes a team of healthcare workers to attend to the patient. You're not dealing drugs--you're medicating the patient as ordered.

    At the end of the day, you can't change people. Patients who are drug seeking will be drug seeking. All we can do is provide competent and safe nursing care...without the judging.

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