Ethical dilema - cancer pain

[mlew]

Recently I was at clinical and was assigned a 50 something patient with cancer. She had increased weakness and didn't speak much at all. Her facial expressions and vital signs showed she was in obvious pain. She had pain medication ordered for every hour PRN. What really frustrated me was that everyone looked to her son and asked his permission when to give her pain medication, when she could have something to drink etc. It was frustrating to me to see this patient in pain and the son not wanting us to give her pain medication because he didn't want her to be "out of it" all the time. When is it appropriate to go above the families wishes and care for the patient? No where in her record did it state that the son was the power of attorney or in charge of her medical care. Has anyone else been in this situation? What was done regarding the situation? What would you do in this situation?

[Batman24]

These scenarios grate on my last nerve and we see them here all too often. I can't even explain how upsetting I find this to be. If the pain medication is ordered you are free to give it. This patient is conscious and can still handle their own affairs so they make the decisions. If she said she didn't want it that's one thing and you wouldn't give it. Explain to the son the importance of comfort care, etc. The son isn't allowed to turn it down and if he is I would be going to your manager first and then getting the doctor, ethics committee, etc. involved. This is one instance where being a patient advocate is so vitally important. If you don't help her no one will. There is no reason for her to be dying in pain especially at someone else's hand.

[RNwilltraveltoo]

I have had this happen before on multiple occasions. What I try to do is educate the family members about signs of pain other than the patient's actual verbalization of pain (sounds like your patient was no too verbal). Once the family is educated, hopefully that will allow you to administer the medications to make the patient more comfortable. Sometimes if you at the nurse point out the signs you observed, family members lighten up and allow the nurse to do the best for the patient. I always stress the importance of patient comfort level is more important than having a patient be "out of it". I would also ask the family first of all if their loved one would want to be having their pain left untreated and also ask if HE or SHE was the patient, would HE or SHE like to be in pain? I would use as much tact as possible when dealing with this situation.

[truern]

If the son doesn't have power of attorney, I would treat my patient's pain.

You never know if there's some family dynamic at work here....maybe he's "punishing" her in some way.

[leslie :-D]

is this pt able to communicate her needs?

if so, does she speak english?

other than a communication or cultural barrier, there is no reason to be asking her son anything.

first thing i'd do, is to get this woman on a scheduled and effective pain regimen.

even if she has something scheduled, it is clearly not working and needs an increase/something stronger.

it is maddening when families override the pts wishes, and the md/hosp admin support the family's wishes.

doesn't matter that we as nurses, have every legal and ethical right to medicate the pt.

family dynamics often dictate the whats and whens of pt care.

and.it.sucks.

i'm not going to tell you to do what's right for the pt, as i understand that ea of us has different personalities and handle adversity in our own unique ways.

but i will tell you that since i have a quick temper and big mouth, i have never, ever denied my pts their right to die w/o pain and suffering.

and that has included butting heads w/families and staff.

but that's me.

they can all kiss my hiney.

my pt comes first.

so yes, this nonsense happens a lot.

if you're not up to confrontation, you could get your pt on a therapeutic, scheduled regimen.

that's the least you could do.

much luck to you!

and even more luck to your pt...

leslie

[HappyBunnyNurse]

I agree that education is important. Perhaps the son doesn't realize she is in pain. Once educated family members are often better at recognizing pain cues than the nurse because they are in the room all the time. Also it is about respect. If these are his last days with his mom it is understandable that he wants her not to be "out of it". And it is natural that he need some feeling of control when he feels out of control about her illness. It is respectful sometimes to ask the family's "permission" for something even if you plan on doing anyway. That said, when I worked oncology I did sometimes occasionally have to go against the family if the patient was suffering. I can remember a few times in particular when the family was afraid of addiction in a person who was actively dying. If you can't reason with them you just have to do what is right.

[merrywhiterose]

We've always been taught that unless the pt. is unconscience or unable to speak, they have the say over their pain relief.

[back2bRN]

Having experienced this with a family in denial about their mothers pain I was able to assess her in private, explain everything to her and give her the option of having analgesia or not. She ended up having some every once on a while, but she would never agree to it when her family was around. Eventually they took her home where she likely died in pain. But I gave her the analgesic she would agree to, not what I would want my mother to have, but what she was comfortable taking.

I guess assess the patient and do what they wish, not the family.

[dsgrandmarn]

It is my understanding that if you have a legal order for pain med then you are legally obligated to treat the pt's pain unless, of course, she refuses. I think this is true even if you have DPOA who disagrees. Any legal experts out there?

[Merlinsmom]

I have to say in my experience, if you educate the family so they understand the "clinical" signs of pain, most will agree to treat it. Educate them on signs of pain. I think that some familes think that if they are not writhing...they are not in pain. Once they have a better understanding I think they feel a little more empowered by being able to understand what is going on and help their loved one. Just my .

[CaseManager1947]

Do you have the option for a Palliative Care Consult at your facility?? We do, and they can be very useful with recommendations on pain control and sx management. Also, what about Hospice. We have an IP Hospice in our hospital, they are separate from us, lease space. But I would involve the docs for a more aggressive approach.

[Virgo_RN, BSN, RN]

What would you do in this situation?

I would explain to the son that cancer pain is the worst pain a person can endure, and while I understand his desire to avoid having her "out of it", that because the pain is so severe, there is no way to control it without affecting her level of consciousness. I would explain to him that it's an either/or proposition. Either her pain is controlled but she is sedated, or she is alert but in excruciating pain. It cannot be both ways.

I would document not only my observations of the mother and my professional nursing judgment of her comfort level, but also my education attempts and the son's responses to them.

If, even after explaining to him in no uncertain terms the severity of her suffering, he still insisted on inadequately medicating her, I would get a witness and document this. I know of similar situations where family members had nurses investigated by the BON for the family members' misperceptions about the nurses' intent.