Denentia, pain, and ckd

[Shubbell]

I have a resident with dementia in a nursing home with idiopathic pain in the lower back/abdomen/lady parts (DNR-A2) that started a month ago. Advanced directive states "no matter my condition, give me the medicine or treatment necessary to treat my pain". Limited tests have been performed including X-ray and CT pelvis only. PA assigned to the case is notorious for refusing to prescribe opiate analgesics and benzodiazepines (they'll find any reason to refuse) based on poor kidney function (BUN and creatinine barely out of range 23 and 1.8 respectively). RP has stated they'd rather have the resident treated for pain (even though we don't know the cause) regardless of kidney function and resident's own AD states the same. PA and unit manager insists it is behavioral (r/t anxiety) but we have all learned "pain is subjective!". Resident is declining, (was once walking with a walker and continent. No longer able to walk on her own and completely incontinent x 2weeks). Prescriber still refuses stronger pain meds. Fentynil is non-nephrotpxic yet PA states she won't go from tramadol to fentynil, however she won't prescribe anything in between! I need help! This resident is suffering and having episodes of screaming and crying in pain for several hours at least twice a day. I'm a new RN and I'm so close to reporting the facility I work for. It's inhumane and she is suffering. Please help!

[KatieMI, BSN, MSN, RN]

Is the gal still "full code"?

The PA works under M.D. licence... did you contact the doctor?

Does family know about patient declining? What do they think about hospice? Can your LTC do hospice care? If yes, can you actually PROVIDE hospice care, and at what level? What if patient needs morphine drip for pain control?

Is it possible to send her inpatient for a few days for workup so he could be seen by pain specialist and the cause of pain/way to treat it can be figured out?

What you need to do is to organize care conference including family, case management, nurse(s) and parovider(s) and get everybody on the same page re. goals and ways they can be achieved. If the family feels that the only one goal is comfort, that's one thing. If they still want "fixin'g 'er up" somehow, that's completely another one.