chronic pain, depression, and suicide attempts

[blackribbon]

I am very frustrated. I admitted a patient last week who was suffering from significant chronic pain issues (plus other health issues) related to an accident 5 years ago. He woke up in the middle of the night and was so frustrated by the pain that he just wanted to die so he overdosed on his pain meds. He was found in time and rushed to the ER. After he was stablized two days later, he was told he was being admitted to our hospital for "24 hour observation"...a lie, he was an involuntary admit. When he woke up from the overdose, he regretted the impulsive decision to kill himself and was adamant that he wanted to live (could recite several very positive things in his life he had to live for).

Complicating factor....by being in the psych hospital, he was forced to miss the pain clinic appointment that had taken him 7 months to get. Prior to the suicide attempt, he was asked if he could manage the pain for "just one more week" and he thought he could. Obviously, the pain was so bad that one night that he couldn't.

Anyway, I did my best to try to document the information that he provided and the evidence (behaviors and mannerisms) that validated his story in hopes that someone during the day shift would see his primary issue was "pain". Control the pain and then he won't be considering suicide anymore.

Instead, I found out that he was still on the floor one week later. His pain management was almost nil since we don't "do" medical issues on our unit. It took 5 days for a social worker to even bother with his case. She verified everything in his story as being truth. Still, no mention of his being discharged.

I am a full time med/surg nurse who is contingent on the psych floor. I am excessively frustrated that nobody is even addressing the cause of his suicide. He was already on anti-depressants and med compliant. He will continue to be a risk for suicide as long as his chronic pain is not being managed. His risk has a cause ... and being on the floor is not helping him address that cause and may mean he has to wait more months before getting into the pain clinic.

The system is broken and I don't know how to help this man. Based on the notes, he is doing a valiant job controlling his temper and frustated ... but it is being documented as "incongruent" mood...as they see the frustration in his face and words, but he is forcing himself to remain calm and cooperative.

Yes, by all definitions, he belongs on our floor because of the attempted suicide. But we are screwing up his life...messing with his personal relationships, his job, his pain management appointments, etc... He would be a better patient for outpatient treatment because he has a long history of being compliant even though his prior history (like 19 years ago) shows bad decisions that he appears to be overcoming.

I also had a patient I once admitted about a year ago who I believe had a paradoxal rage reaction to her first ever Xanax (prescribed to ween her off of oxodone for chronic pain). She was sane, upbeat, and rational from the day she was admitted. No one ever bother to pursue the fact that her daughter had just been diagnosed with stage 4 colon cancer (on top of losing both her husband and son (overdose) in the past 5 years). She didn't belong on our floor. She was older and her friends didn't drive anymore so no one visited her or brought her any personal items although they did clean up her apartment after her psychotic event.

I am losing faith in the system. Most people are helped by being admitted. But I am so frustrated by the people whose lives are being damaged by our admissions and how long it takes to prove that you are "sane" and "safe" to be handled as an outpatient. And I am so frustrated by how hardened psych nurses can be to "real" medical issues after caring for so many hypochondriacs. I caught a man going into alcohol withdrawal seizures one day and my charge nurse was so pissed at me for making such a fuss thinking he was faking it until she actually walked into the room.

[Jules A, MSN]

While I agree and have seen people who aren't treated as compassionately as they should these are very different cases and to be perfectly honest I can't say I agree with a the first two scenarios. I disagree that a person with chronic pain who intentionally overdoses life is being ruined by having to stay on an inpatient psych unit while things are sorted out. How exactly is it interfering with his personal relationships? To be perfectly honest your description sounds a bit over invested, imvho. To me there are a few red flags such as if his accident was 5 years ago why is he just now getting an appointment at a pain clinic? What medications did he over dose on? How did he get found in the nick of time? Did they confirm what medications he was filling? I would bet there were opiates involved and what does it mean he has been compliant or many years? In most cases an inpatient unit can often expedite an appointment for services at pain clinics upon discharge. My guess is this patient has more going on than you actually know.

As for someone who had a "rage reaction" from taking Xanax for Oxy detox? that was serious enough to be taken to the hospital raises huge red flags for me. Sadly I would also bet there are thousands of people's whose daughters get a cancer diagnosis who don't require Xanax for Oxy detox or have a "rage reaction" from it. Based only on what you have added here it sounds to me like she required an evaluation and inpatient hospitalization if only for an appropriate opiate detox.

[Davey Do]

Wow. What a discussion. blackribbon, your attention and devotion to your Patients is admirable. Jules, I really admire your cut to the chase approach. You two are exemplary in the reason why I am a Nurse and also why I enjoy seriously involving myself in AN.com.

blackribbon, being proactively involved in our Patients' welfare is the essence of Nursing. You have done what you could for your Patients; you have shown your mettle. And once you've done all that you can, you have to let go and let God, the Fates, the Forces That Be, the Guardians of the Galaxy, or Whatever. Your job is done. But don't stop what you're doing- acting as an advocate for your Patient, or questioning the system.

I sense a sort of "going for the long haul" attitude in Jules: Get all the facts, and deal with the facts. Be empathetic, but don't waste any unnecessary energy.

A combined fact/philosophical approach helps me at times like this. First: Is the Patient safe and undergoing spontaneous respirations? Next, let's make the Patient and ourselves as comfortable about the situation as we are capable.

We are all the result of decisions we have made in our life and are where we are due to making the best decision we could at the time. And we each have to take responsibility for that; we have to accept that both for ourselves and others.

Otherwise, we're just going to be chasing our tails.

The very best to you both.

[Jules A, MSN]

Wow. What a discussion. blackribbon, your attention and devotion to your Patients is admirable. Jules, I really admire your cut to the chase approach. You two are exemplary in the reason why I am a Nurse and also why I enjoy seriously involving myself in AN.com.

blackribbon, being proactively involved in our Patients' welfare is the essence of Nursing. You have done what you could for your Patients; you have shown your mettle. And once you've done all that you can, you have to let go and let God, the Fates, the Forces That Be, the Guardians of the Galaxy, or Whatever. Your job is done. But don't stop what you're doing- acting as an advocate for your Patient, or questioning the system.

I sense a sort of "going for the long haul" attitude in Jules: Get all the facts, and deal with the facts. Be empathetic, but don't waste any unnecessary energy.

A combined fact/philosophical approach helps me at times like this. First: Is the Patient safe and undergoing spontaneous respirations? Next, let's make the Patient and ourselves as comfortable about the situation as we are capable.

We are all the result of decisions we have made in our life and are where we are due to making the best decision we could at the time. And we each have to take responsibility for that; we have to accept that both for ourselves and others.

Otherwise, we're just going to be chasing our tails.

The very best to you both.

Very well said and I also admire the OP's dedication to ensuring their patients are properly cared for. Probably because I have been around the block more than a few times I tend to prefer weeding out the cluster B from the Axis I before I proceed to any treatment course.

Parasuicidal gestures, addictions and eating disorders always raise the cluster B red flag for me. Although there is very little difference in their actual treatment for me being able to cut through the BS and attempt to deal with the present is crucial. This includes an excellent H&P as well as collateral from prior providers and family, searching online prescribing history and legal case search. These things help provide a clearer picture. For patients with multiple chronic life problems disorder from a NP standpoint while medication is a component intensive therapy, group therapy and family therapy is most likely to produce an improvement in function which is what I'm striving for in all my patients.

[blackribbon]

The patient in question had been waiting 8 months for this appointment at the pain clinic because he was on medicaid. I know this to be a realistic scenerio because I once had to wait 6 months to see a specialist and i had good private insurance. This is the reality of of specialized medicine. This wasn't a walky talky who had healed from his broken neck...he had difficulty walking and had even had a stroke two years prior while being hospitalize while being treated. He was still upbeat and very realistic about life. However, he probably will lose his new job over the absence and will also probably have to wait another 6 months before he can get another appointment at the pain clinic....they don't bump people, you just get the "next available"....that is what I mean about them screwing up his life. On our floor, he was getting one 5/325 norco q 12hrs....not even a shadow of what his home meds were and less than most people get for a root canal. It was a joke and cruel in my opinion as a med/surg nurse. I am sure the pain clinic would have put him on a weening program that was painful but then carefully reintroduced new meds to find out what would work now. This was ignoring his pain...both the mental torture knowing that he wasn't going to get treated now and the physical pain he was living with.

The people on the floor verified that Snobody in his life thought he was being non-compliant with his medications....they were surprised by this incident and only wanted him to get better. I personally think it must not have been his time to go because he had tried to hid to die...not sure why his father walked behind the garage that morning or why he didn't have more medical complications related to the overdose.

As for the person whom I believe had a pardoxical rage reaction...I didn't say that it was related to the cancer diagnoses...adverse side effects are biological and this is a documented potential adverse reaction...how be it, rare, side effect. I did say that I didn't think she was suffering from depression so much as grief. She wasn't admitted for depression or suicidal behavior...only for the psychotic state that brought her to the emergency room that night. I just don't think that keeping her on a locked down unit was appropriate for her individual case. For most of our admits, they do need the milieu environment....for these two specific cases, I honestly think they were "easy" patients and had insurance.

I don't get vested in every patient I admit...but these two patients are two that continue to haunt me because I think we did a disservice to them. At the very least, I feel we have the responsibility to "do no harm" and though I passionately believe in the importance of behavioral health medicine, I get tired of the assumption that everyone is crazy and tells lies. Nursing intuition has a place in psych nursing too.