resident in pain, what to do?

[pansylvr523]

I have worked in nursing for 27 years and have never ran across this before. Hope you can help.

I work in a nursing home on nights. I have a resident called Ellen. She has a coccyx decub and back pain. She has a Fentynl 100 patch. Last night she was in so much pain all night long.The only med we have for overriding pain is Tylenol 2 every 4 hours and nothing stronger. The daughter who is POA doesn't want to "dope" her up. She won't let her have any a sleeper or sedative either.:angryfire

We have gotten orders from the doctor for a stronger med, but it gets taken away because of the daughter.

Any suggestions on what to do? Should I contact the Ombudsman for our region?

Thanks for your suggestions,

Kathy:nurse:

[nursedawn67, LPN]

The I would ask the daughter to come in and sit with mom to help comfort her through the pain...let her sit and see how much pain mom is in and how refusing stronger meds hurts mom.

[CoffeeRTC, BSN, RN]

Your facility has a responsibility to the patient first. Assessing and managing her pain is first and formost. The suggestion of upping the patch and trying NSAIDs is good, but if that doesn't help, you need to contact the ombudsman. Aside from having this pt suffer, the state would have a field day with this one. Been there, done that, have the t shirt.

[pansylvr523]

I talked with my counterpart last night. She said they had upped the patch to125, and put her on trazadone and she is doing better. Thank you for all your suggestions. I will keep up on this and if necessary will notify the Ombudsman.

Kathy

[leslie :-D]

i never, ever knew about contacting the ombudsman or public health for intervention.

even though i found it grossly unfair, i thought poa decisions were firm.

kripes, i've had doctors give an order but in the same breath, tell me not to give it because of pts' son, dtr, long lost cousin....

at the inpt hospice where i worked, there were so many family members that didn't want their loved one being doped up, or addicted, or "just because i said so".

often, i insisted they sit w/the dying pt, crying out in agony.

and all this time, all i had to do was call dept of public health? or jcaho???

leslie

[mcdonaldgirl]

It doesn't sound like the daughter is thinking about her mothers'best interests. Sounds like something else is going on there.....

'Mac'

[txspadequeenRN, BSN, RN]

What it sounds like is this daughter has been misinformed about pain medications. Has the Doc talked to this lady yet. This is the kind of families I hate , they bring their family member to you then refuse treatment. Why does this woman refuse additional pain medication, has someone sat with her and got into great detail with her. I hate the fact we have to go by the POA when you know darn well what the patient needs. This situation drives me crazy......:smiley_ab

[softstorms]

This is a social services issue. Some one needs to chat with the POA and see how realistic her ideas are. What are her goals here? As her nurse, your goal is to get your patient where she needs to be. You need to seek help from the other people around you. Her Dr. can be of help too. He can talk with her and the pt. No family member wants someone to be in pain. He needs to let them know the diffence between being in pain and being awake and alert. Sometimes is more for the family than the patient. Get help from the team you work with. Thats what they are there for.

[Kymmi]

Im interested as to whether the mother is coherent and able to make her own decisions. If the resident is able to make her own decisions then the issue of POA doesnt matter anyway.

[heron, ASN, RN]

Not to insult anyone's intelligence, you might also double check the placement of the patch ... it needs subcutaneous fat to work properly and if the patch is placed over a bone (the sternum, for instance) or if the pt is emaciated and has no subcu. fat, it may not be working in the first place.

Unfortunately the pt and staff may be taking the flak for past practices of heavily medicating pts to "decrease" workload or as a "quick fix" in place of addressing the problem. In hospice we've seen many situations in which a pt's family gets terribly upset at staff who are "overmedicating" the pt. They've heard stories, known a friend of a friend, etc., etc. There is no easy solution to this ... attempts to educate may or may not work and, although reporting is an option, becoming adversarial right off the bat may make the situation worse by polarizing the discussion. My first move is usually what has been suggested above ... ask the dtr to sit with mom when pain is bad. Also, the post above is right in pointing out that, if the pt is legally competent, the POA has no authority. Sometimes, nothing works. I once had a pt with an exquisitely painful open wound that was constantly being soiled due to its location. The family was in serious conflict over pain medication and in serious denial abt the pt's condition ... the pt's wife was convinced that the morphine was killing her terminally ill husband. (Oversimplified, but that's the gist) One night, the family member who was sitting with the pt. called me to do wound care but refused to allow any medication whatsoever. I told her that to do so would be abuse and I refused. Shocked the dickens out of her, but we were eventually allowed to premedicate for wound care, at least.

One last note, I want to reinforce that documentation is key. If the pt is non-verbal or too confused to use the pain scale, document non-verbal signs ... grimacing, crying, elevated VS, restlessness or inconsolability. It'll give you data to use with further discussions with dtr or regulators. Good luck!

[sasha2lady]

What about ultracet or tramadol? Non narcotics. But someone needs to get the picture to this dtr I had one who had a fx hip and her dtr wouldn't allow her to ask for vicodin so me and this pt made us a plan. We would wait for her dtr to come visit and then when shed leave I'd give her the vicodin. We did this til she was discharged.