Uncontrolled pain- how to approach the Doc?

[Sam J.]

We've all seen patients with uncontrolled pain, and many have stated the physician failed to act. Any insider tips that have worked to alleviate this issue, to advocate for the patient, even if the physician is obstinate?

Assuming the physician knows the patient personally (I'm not talking about calling anyone on call to ask for pain meds), and really is aware the patient is still in pain, and still the problem continues, what are some ways to get past this road block, without alienating the physician, of course? Begging? Pleading? Fresh-baked cookies? Suggest the family contact the doc? It can probably be tricky with some physicians, for a variety of reasons (liability claims, being offended by a nurse assuming to know more than the physician, personality differences, etc.).

Any unusual (or even simple, tried and true) success stories?

[wooh, BSN, RN]

I stand corrected: Great idea to tell them what "isn't" working. I'll leave it at that point. Sorry I wasn't wearing my spectacles.

Suit yourself. My patients get the pain control they need. Apparently yours don't.

[Sam J.]

Suit yourself. My patients get the pain control they need. Apparently yours don't.

Read my posts- you'll find I've 'never' had a patient that a physician that did not keep comfortable.

[wooh, BSN, RN]

Read my posts- you'll find I've 'never' had a patient that a physician that did not keep comfortable.

Yeah, but I was advised not to believe everything I read on an anonymous forum. For all I know, you're simply a drug-seeking patient looking to trick someone into giving you prescription medications to get high.

[Esme12, ASN, BSN, RN]

To add.....Medicare makes a BIG deal out of pain. Its the 5th vital sign and MUST be addressed.

Like I said.....find a doctor who will listen and treat pain accordingly. Its not that hard to do....

Which the FDA makes increasingly difficult to obtain and take these drugs making it difficult for truly disabled patients to have relief.

[Gabby-RN]

Maybe try going to your unit manager with the concerns. Bring a printout of the MAR showing how often the patient is being medicated over a period of a couple of days and let the manager know the MD has been approached about the patients pain control and has not addressed it. Say you wanted to bring it to their attention because the patient is unhappy and could make a complaint. Make sure you add your objective assessments regarding the patients pain. If you have a decent unit manager they will hopefully look in to it.

[Sam J.]

Maybe try going to your unit manager with the concerns. Bring a printout of the MAR showing how often the patient is being medicated over a period of a couple of days and let the manager know the MD has been approached about the patients pain control and has not addressed it. Say you wanted to bring it to their attention because the patient is unhappy and could make a complaint. Make sure you add your objective assessments regarding the patients pain. If you have a decent unit manager they will hopefully look in to it.

Good idea- more so since the MAR speaks for itself. And if the physician sees that MAR and that nurses are documenting ineffective pain control (rather than just telling him/her about it) it might give him/her pause to reflect on his/her plan of treatment.

[guest2210]

Which the FDA makes increasingly difficult to obtain and take these drugs making it difficult for truly disabled patients to have relief.

I have dealt with chronic back pain from a work-related injury for 25 years. He was bought out by a major healthcare system and insists this is their "rule" to try other avenues for pain management. I have done the pain management route, with PT, caudal blocks, etc over the past 25 years. Due to other issues, I cannot take NSAIDS. My PCP, after going to him for 15 years, decided I am not having as much pain as my recent MRI would indicate. He has been weening me off of my pain med, regardless of the amount of pain I am still having. I am having surgery tomorrow for severe spinal stenosis. It's the last thing I wanted to have done, having known so many other colleagues who have had surgery and are worse off now then they were beforehand.

I am in the process of changing PCPs after 15 years.

[Sam J.]

I have dealt with chronic back pain from a work-related injury for 25 years. He was bought out by a major healthcare system and insists this is their "rule" to try other avenues for pain management. I have done the pain management route, with PT, caudal blocks, etc over the past 25 years. Due to other issues, I cannot take NSAIDS. My PCP, after going to him for 15 years, decided I am not having as much pain as my recent MRI would indicate. He has been weening me off of my pain med, regardless of the amount of pain I am still having. I am having surgery tomorrow for severe spinal stenosis. It's the last thing I wanted to have done, having known so many other colleagues who have had surgery and are worse off now then they were beforehand.

I am in the process of changing PCPs after 15 years.

This is a good illustration of how so many things are taken to one extreme, or another. Another is a sign I just saw posted on the front of an urgent care center, visible from the street: WE DO NOT HAVE ANY NARCOTICS IN THIS CLINIC AND WE DO NOT PRESCRIBE NARCOTICS- IF YOU ARE IN PAIN YOU NEED TO GO TO AN EMERGENCY ROOM. Makes me wonder what sort of urgent services they provide. Also, I wonder if your PCP, if he had your medical history, would opt for alternative options for his own pain control?

[annie.rn]

Don't know if these are "tried and true" but here are some ideas that were discussed at our recent mandatory nursing staff meeting. The purpose of the meeting was to discuss how to improve our HCAPS scores, one of which is pain control, as we all know.

1.) Collaborate w/ a pharmacist and get a recommendation from him/her that we can then suggest to the MD.

2.) Have the pharmacist call the MD and have them discuss pain control options. We have been told by management that this should work b/c based on similar levels of education, they are "colleagues" and the MD's should therefore take their suggestions better than the suggestion of a nurse. (I know, know) The pharmacists are allowed to take orders from the docs or so they say. I've personally not seen any that do that and we were not told logistically how they would enter the order. I guess it could be true, though, since the pharmacists are allowed to dose Vanco if the doctor writes an order as such. Have any of you seen pharmacists take orders for pain control from MD's?

3.) I have had luck with some stubborn doctors by first talking to the pt. about their past experiences w/ pain and what has worked for them. If they are a chronic pain pt., they can usually give you pretty specific ideas. If I start off the conversation with the doctor with "I spoke to the patient and he/she has had (fill in type of pain, location) for (fill in length of time) and she sees (pain management doctor) and this is what he/she was taking at home that works for him/her and do you think we could try that?" I have much better luck and they usually go along with it. Or something close to it.

4.) I used to work hospice and still have some books that were given to us as references for trouble shooting chronic pain. They contain really good decision trees and equalanalgesic dosing charts that can come in handy for having suggestions for the doctor when you call him/her. Maybe you could get your hands on something like that. Maybe online or from the pharmacist.

5.) This is more of a long term fix but maybe find a conference in your area on pain management. I am not at all trying to suggest you don't know about pain control. I know that I, for one, even after doing hospice could always learn more. This helps b/c the more you know, the more confident you will feel w/ making suggestions to the doc and the more you might get what you need for the pt. I still have room to grow in this area.

Sorry so long. I have an issue w/ expressing myself succinctly. :-(

[Sam J.]

Don't know if these are "tried and true" but here are some ideas that were discussed at our recent mandatory nursing staff meeting. The purpose of the meeting was to discuss how to improve our HCAPS scores, one of which is pain control, as we all know.

1.) Collaborate w/ a pharmacist and get a recommendation from him/her that we can then suggest to the MD.

2.) Have the pharmacist call the MD and have them discuss pain control options. We have been told by management that this should work b/c based on similar levels of education, they are "colleagues" and the MD's should therefore take their suggestions better than the suggestion of a nurse. (I know, know) The pharmacists are allowed to take orders from the docs or so they say. I've personally not seen any that do that and we were not told logistically how they would enter the order. I guess it could be true, though, since the pharmacists are allowed to dose Vanco if the doctor writes an order as such. Have any of you seen pharmacists take orders for pain control from MD's?

3.) I have had luck with some stubborn doctors by first talking to the pt. about their past experiences w/ pain and what has worked for them. If they are a chronic pain pt., they can usually give you pretty specific ideas. If I start off the conversation with the doctor with "I spoke to the patient and he/she has had (fill in type of pain, location) for (fill in length of time) and she sees (pain management doctor) and this is what he/she was taking at home that works for him/her and do you think we could try that?" I have much better luck and they usually go along with it. Or something close to it.

4.) I used to work hospice and still have some books that were given to us as references for trouble shooting chronic pain. They contain really good decision trees and equalanalgesic dosing charts that can come in handy for having suggestions for the doctor when you call him/her. Maybe you could get your hands on something like that. Maybe online or from the pharmacist.

5.) This is more of a long term fix but maybe find a conference in your area on pain management. I am not at all trying to suggest you don't know about pain control. I know that I, for one, even after doing hospice could always learn more. This helps b/c the more you know, the more confident you will feel w/ making suggestions to the doc and the more you might get what you need for the pt. I still have room to grow in this area.

Sorry so long. I have an issue w/ expressing myself succinctly. :-(

Interesting and not wordy at all in my view, starting with your mandatory pain conference. With all the varied advice in these replies it's apparent more than a nurse or two has dealt with difficult physicians. Mandatory meetings that bring all staff onto the same page might be the best idea yet to clear the air. As far as pharmacists, I've encountered more than a few physicians that had little, if any, regard for their opinions, and have always thought that to be curious, as though those physicians felt intimidated by pharmacists? But recently I heard talk of the scope of pharmacy to possibly be expanded to include expansive prescribing authority- if that happens, it'll be fun to watch how the dynamics change between those professions.

[JustMe]

Just attended a pain management conference with speaker Chris Pasero. It was wonderful!! I learned so much! Chris is published in numberous journals. Pain relief is not as complicated as it sounds. Ask if your Education Dept can get her to come and speak at your facility. Even the Docs don't know as much about pain relief as she does!

[Kooky Korky, BSN, RN]

Doctors fear having a reputation for prescribing "too much" pain Rx. The DEA makes a big deal of tracking the doctors' prescribing habits. They are not treating particular patients, of course, just monitoring doctors.

Best solution might be to get the patient or family call in a Pain Management specialist.