Does she look in pain?

macawake, MSN · May 22, 2017

You're putting way more context and assumptions into this response then the original story ever gave.
As a cancer survivor I know what it's like to be in pain so I normally dose my cancer pts above average. All I was trying to put in perspective was the possible insight as to why the physician did what he/she did.

What I was responding to was the possible reason for why the on call doc might have been reluctant/unwilling to prescribe more analgesics for OP's patient. I wasn't making any assumptions whatsoever regarding how you personally would treat OP's patient, or any other cancer patient. My entire point was that I think that meeting an abundance of "malingerers" with negative abdominal work ups is an extremely poor excuse for not doing your job (nurse or physician), which would be to provide appropriate treatment to the patient with stage 4 cancer.

I understood that you were offering up this a possible rationale for the on call physician's behavior. My question to you was, do you actually think it's a valid excuse?

As far as what we know about OP's patient; we know that she has stage four breast cancer. We know that she takes a heavy-duty opioid at home, which does indicate that she experiences pain due to her pathology. She is now hospitalized for unknown reason. She tells her nurse that the iv pain meds administered at the hospital "were not touching her pain". (I'm gonna go out on a limb here and assume that the patient wasn't reporting to her nurse that the opioids weren't touching her barely noticable 2/10 pain, but that she actually had some sort of significant pain. She would likely not have used the term "not touching her pain" if the pain wasn't a problem in the first place).

We also know from OP's post that the on call physician never put in any new orders and that OP seems more bothered by the question asked by the doc, than the fact that no new orders were written. A lot of details are missing, but I do know enough to voice the opinion that I think that this was handled in a unsatisfactory manner.

Lastly, I'm happy to hear that you're alive and well!

Meeshie · May 22, 2017

... Did you say yes? I mean, pain is subjective. The patient says she is in pain. Therefor the patient is in pain. Please tell me you said yes?

Been there,done that, ASN, RN · May 22, 2017

This could be a fun topic. I floated to our sister hospital last night and it's got a total different culture there and honest the pt population is completely different and new to me. I was totally thrown off by this question. I called about my pt who is stage 4 breast cancer pt. The pts PTA meds included 4mg dilaudid I think it was q4hrs PO PRN. Not 100% on that. She had dilaudid 1mg q 3 hours IV which she said was not touching her pain.
All I got from the on call doc was "does she look like she's in pain?". She never did put any new orders in. This is bugging the heck out of me. Not so much that there were no new orders put in. I get it if you think the pt's a drug seeker and you don't want to prescribe, but since when are med orders determined by whether the nurse thinks the pt looks like they are in pain? This goes against everything that is taught on pain management. I have no problems with someone not giving more pain meds just because someone rates their pain at a 10 every single time you assess them if you the provider don't think it's appropriate or necessary for their condition, but it just bugs me that I'm expected to determine whether a pt is in pain or not by whether they look like they are in pain. Anyway, I guess this is a common question they ask over there if you call about pain meds and just thought I'd throw it out on the table for interesting nursing conversation. What's your thoughts on this question folks?

No fun involved here. The patient is complaining of pain, regardless if YOU have "experience" with their culture.

The doctor's question was inappropriate. Report the pain scale.. get an order to relieve their pain. Many patients are stoic and require advanced nursing assessment and intervention, in order to get them comfortable. There is NO ceiling to narcotic administration in Stage 4 cancer patients. I have administered 80 mgs of morphine to relieve pain.

This is NOT about you or the doctors interpretation. GET THEM COMFORTABLE.. whatever it takes.

kbrn2002, ADN, RN · May 24, 2017

Situations like this annoy the heck out of me. The pt has stage 4 cancer, this generally carries a very poor prognosis. While I understand MD's backing off on narcotics due to the "opioid crisis" why would any provider fail to provide adequate pain relief for a dying patient? Where is the addiction concern for this patient?

OP, you never did say how you responded to the question. Sure, I agree that asking if she looked like she was in pain is not the best decider on rather or not a patient gets pain meds but if that's what this MD is doing I hope you at least said a simple yes, she looks like she's in pain. Sometimes jumping through ridiculous hoops is the best thing we can do to advocate for the patient.