Contested a Doctor's Order Psych ?

[mhadvrn34, BSN, RN]

Hello all,

I am a psychiatric nurse who has been working in the field for about a year now. Today, I had a patient who complained of severe abdominal pain and had a history of endometriosis which had gotten so bad to the point where they recommended she have a hysterectomy. She was currently being medicated on Ibuprofen and Tylenol which had no effect. I knew that these would not even touch her. 

Come on Tylenol and Ibuprofen for endometriotic pain? 

I then contacted the psychiatrist to see if I could get an order for breakthrough pain to which she declined. Narcotics are typically not prescribed in the psychiatric setting due to how common opioid addiction is within this population. The only patient I have even had who was on opioids was my patient who was post op ORIF after having jumped off a two story building.

There is a common misconception in the psychiatric field that many patients are "faking it." I believe that pain is subjective and try to give my patients the benefit of the doubt. That being said, as a psych nurse I am not oblivious to the fact that some patients are "medication seeking."

I typically am a good judge of character, but this was not one of those moments. She was wrenching in pain to the point of tears. If she was "faking it" she was doing a really good job at it.

At this point, I decided to advocate for my patient and escalate the situation. I asked again and she [psychiatrist] continued to refuse. I then relayed this to my charge nurse and she recommended getting an order from the hospitalist because all medical issues are under the jurisdiction of the medical doctor.

The hospitalist agreed to order a one time breakthrough pain med. I told the psychiatrist what I had done and then she proceeded to berate me over the phone spurting profanities, saying I was insubordinate and said "I was being played by [my] patient."

I then escalated the issue to my nurse manager who recommended I follow the psychiatrist orders and let it go. When I asked if I did the right thing, he praised my efforts in advocating for my patient, but believed at the end of the day, the doctor's orders should be respected and followed.

I followed his advise and after all was said and done, the patient had to bear through the pain and eventually it subsided. Nursing community, did I do the right thing? Should I have done more?

[NurseBlaq]

I'm confused. You asked the hospitalist who ordered the pain meds but you didn't give them to the patient because the psych doctor threw a tantrum? Or you did medicate the patient per hospitalist's orders and the psych doctor threw a tantrum because you did? Also, why not call the hospitalist in the first place? And your nurse manager agreed but didn't agree? Too much going on here.

[JKL33]

Narcotics are a last resort for endometriosis. NSAIDs are the first line pain treatment.

I am glad that your goal was to advocate for your patient. ?? 

That said,

Quote

Come on Tylenol and Ibuprofen for endometriotic pain? 

^ This is not a well-researched train of thought. It is what a lay person would say and nurses should understand the way medications work, not just think in terms of whether or not they are "the good stuff," or available over the counter, etc. NSAIDs have a very good chance of being effective in problems that revolve around inflammation, as they are antiinflammatories. Endometriosis is a condition in which inflammation is a major factor. It isn't uncommon to have NSAIDs provide a sort of amazing degree of pain relief in conditions that revolve around the degree of inflammation present. It's true they don't provide fully adequate pain relief for every patient or every condition (even in a setting of inflammation), but then we would move to the next step in the process, not the last resort step.

On 10/20/2020 at 3:36 AM, mhadvrn34 said:

Today, I had a patient who complained of severe abdominal pain and had a history of endometriosis which had gotten so bad to the point where they recommended she have a hysterectomy.

The symptoms of endometriosis (I.e. the pain, etc.) are generally all over the place in relation to extent of disease. While I believe this is neither here nor there in the overall discussion because we are talking about a patient's pain experience, it is important to understand that the presence or severity of pain itself is not easily predictable based on the extent of disease or vice versa.

On 10/20/2020 at 3:36 AM, mhadvrn34 said:

There is a common misconception in the psychiatric field that many patients are "faking it." I believe that pain is subjective and try to give my patients the benefit of the doubt. That being said, as a psych nurse I am not oblivious to the fact that some patients are "medication seeking." I typically am a good judge of character, but this was not one of those moments. She was wrenching in pain to the point of tears. If she was "faking it" she was doing a really good job at it.

Try to move beyond thinking in these terms. It isn't necessary to decide whether a patient is so-called faking it. It's good to start with the idea that they are having a very distressing situation and then fully assess what that is and what its factors are in order to provide best help. Fully accepting a patient's report of pain severity still doesn't dictate what must be done about it or determine the best course of action. There are several types of meds and modalities of pain treatment that are preferred (or should possibility be tried) before narcotics in the pain setting you are describing.

On 10/20/2020 at 3:36 AM, mhadvrn34 said:

I then relayed this to my charge nurse and she recommended getting an order from the hospitalist because all medical issues are under the jurisdiction of the medical doctor. The hospitalist agreed to order a one time breakthrough pain med.

I do think this action is very problematic even though the hospitalist is in charge of medical issues. Did you inform the hospitalist that the specialist involved in the condition for which the patient was admitted had assessed the situation differently than you and had already declined to order the type of medication for which you were seeking an order?

Even when it is necessary to advocate for a patient by "going over" a provider to seek help from another provider, part of the assessment of when/whether you need to do this depends heavily upon you understanding, as very best you can, the condition in question, the patient's overall picture, the spectrum of options available (and which of those may be contraindicated for various reasons), the rationales for the recommended treatments and in general the risks and benefits of what you are advocating as well as the risks and benefits of other options. Etc. That's a lot to know, and that's why we proceed with caution in demanding (advocating for) what we think is best.

On 10/20/2020 at 3:36 AM, mhadvrn34 said:

Nursing community, did I do the right thing?

I think you had the right general idea and good intentions. You included some steps that are very important, such as informing the physician, consulting your charge nurse, etc.

[Guest219794]

JKL gave a great and informed answer, but I'll chime in.

5 hours ago, mhadvrn34 said:

Nursing community, did I do the right thing? 

No.  

Though you did have the right intentions, and did try to do the right thing, which is commendable.  

The patient is being managed by two services- psych and medicine.  You would not have gone to the hospitalist service for a psychiatric med.  Going to psych for a medical condition is the equivalent.

Once you went to the hospitalist, you basically got "no" from mom, and were hoping to get "yes" from dad, which you did.  Now mom is ticked off, and apparently, had a temper tantrum.

5 hours ago, mhadvrn34 said:

There is a common misconception in the psychiatric field that many patients are "faking it." I believe that pain is subjective and try to give my patients the benefit of the doubt.

The psychiatrist probably does not share this misconception, and, hopefully knows a bit about psych patients.

I believe that your manager was commending you for advocating, but realized that you created a bad situation, and recommended a course, that, in the end, would yield the best overall outcomes, despite the limited impact on one patient.

There is a bit of a problem.  Seems like you disregarded an appropriate order.  Hospitalist ordered a med you advocated for, and you held it.  Because of a tantrum?  Honestly a bit hard to stand behind that.

Chalk it up to learning.  If you want any credibility at all with the psychiatrist, I would recommend a discussion, the focus of which is you acknowledging you handled it wrong.  (You did).

In the future, don't go to mom for a dad request.  If you do, listen to mom.  If you plan on running over mom- so be it.  But be prepared for the consequences.

Good luck.

"Good judgment comes from experience, and experience comes from bad judgment."  

[Wuzzie]

I would think any provider being asked to manage a patient's acute pain should maybe actually, oh I don't know, assess the patient. ?

[Jedrnurse, BSN, RN]

26 minutes ago, Wuzzie said:

I would think any provider being asked to manage a patient's acute pain should maybe actually, oh I don't know, assess the patient. ?

What is this strange word "assess" of which you speak...?

Anyone else not impressed by the psychiatrist spewing obscenities over the phone?

Somebody needs to have a time out...

[Davey Do]

At Wrongway Regional Medical Center, the psychiatrists dealt with the psych issues and the hospitalists dealt with the medical issues.

Kept everything simple.

[JKL33]

32 minutes ago, Davey Do said:

At Wrongway Regional Medical Center, the psychiatrists dealt with the psych issues and the hospitalists dealt with the medical issues.

It seems reasonable except for all those situations where the condition in question is not exclusively one or the other. Without any judgment whatsoever, I think it is correct to say that pain itself is one such issue.

39 minutes ago, Jedrnurse said:

Anyone else not impressed by the psychiatrist spewing obscenities over the phone?

Not impressed with the specific reaction, no. Do understand the frustration over the inappropriateness of what happened.

[Sour Lemon]

8 hours ago, mhadvrn34 said:

 Nursing community, did I do the right thing? Should I have done more?

That's impossible to judge with only one side of the story.

[Guest219794]

On 10/20/2020 at 12:01 PM, Sour Lemon said:

That's impossible to judge with only one side of the story.

Nope.

Even with the one side, it should have been handled differently.

We have all mismanaged an interaction, and hopefully learned from it.  I sure have.

[Sour Lemon]

On 10/20/2020 at 3:41 PM, hherrn said:

Nope.

Even with the one side, it should have been handled differently.

We have all mismanaged an interaction, and hopefully learned from it.  I sure have.

Thank you for your opinion of my opinion. ??

[Lunah, MSN, RN]

15 hours ago, mhadvrn34 said:

Come on Tylenol and Ibuprofen for endometriotic pain? 

Oh yes, all day long. When given properly as far as scheduling and dose, NSAIDs and acetaminophen are very effective for many kinds of pain. That was the first thing that our trauma docs did for our patients - schedule those types of meds to decrease the need for narcotics, especially in our older population. Heck, I only had acetaminophen and ibuprofen after my c-section, I refused narcs because I wanted to be awake to revel in my new baby. ?