Every visit, pain is 7?

[AtlantaRN, RN]

Have a case mgr with a frustrating situation. She has a pt w breast cancer. Pt nor family ever call the on call service. Nurse will call Monday, Wednesday, and Friday before visiting.... It isn't until nurse arrives n does her nursing assessment that pt will say pain is a "7", and an acceptable level is less than or equal to "4". Pt went from 100-175 mcg fentanyl last week, she can have 6 lortab a day (she may take 2/day), and she has an ekit with morphine sulfate elixir 20mg/ml that she can have hourly if she needs it (she rarely takes). Also scheduled motrin was ordered last week (but she will only use prn).

Case mgr is at her wits end. Pt a&0x3, angry that she is ill. She won't let chaplain or social worker visit. She has a Dtr that visits daily. PTs sister moved in with her to help pt with her care. A Dtr in law committed suicide a few months ago. She needs Sw n chaplain involvement, but she n family are draining case mgr in that capacity. Case mgr spending 1.25-2hrs each visit.

Pt will state "slept all weekend", then report pain"7" all weekend n pain is 7 now. So, then pt will take a lortab n cm has to stay until pain less than or equal to 4.... Pt keeps up taking bp meds as scheduled but for the life of us we don't understand why pt isn't keeping up w her own prn meds. One weekend fam said pt "cried all weekend" bc she was I'm severe pain- yet no call to on call service to report.

Pt has Xanax for anxiety but stopped taking 2 weeks ago bc she was "sleeping" too much.

We just don't understAnd why pt isn't utilizing on call service or meds in the home. Cm has asked pt and she says "I don't know.". I'm believing her pain is more depression n pain related to family issues. It is frustrating for cm bc it looks like we aren't keeping her pain at a 4.

Thoughts? Thank you.

[Whispera, MSN, RN]

A few thoughts/questions come to mind:

--Does she have a belief that pain is required to atone for sins before dying?

--Why don't family members give her the pain medications when she cries all weekend because she's been in severe pain?

--Is she getting some secondary gain by having pain or by rating it a 7 whenever hospice staff is present? Is she getting attention she doesn't get otherwise?

--Why does the CM have to stay after the patient is medicated, until pain is less than 4? Can't the CM go on with her work and the pt. could call the agency if the med isn't working enough? Or family could?

--You can educate until you're blue in the face but you can't force people to do what would help them. Just document, document, document.

[Hospice Nurse LPN, BSN, RN]

Personally, I'm thinking spiritual or emotional pain. However, pt is refusing MSW and chaplain visits. Will she visit w/ her own minister? Have you thought about antidepressants?

I had a pt like this once....very draining emotionally for me. Pt did not stay on service long as family decided to seek agressive tx.

[tewdles, RN]

yep, these patients can be difficult and time consuming.

You are doing all the right things. Make sure you document her pain, a good pain assessment, her level of acceptable pain, and her preferences for controlling her pain.

Is she on a long acting opiate? Would she be a candidate for an infusion to control her discomfort. As you know, the type of pain will help you to determine what her options might be. In a case such as this, where the patient/family is not compliant with prn meds but the pt reports unacceptable pain levels, I like to increase long acting meds or switch to infusions. The goal is to get the pt comfortable, not to get her compliant with the POC.

Good luck!

[LMTRN]

What kind of pain is she complaining about? mets to bone? My organization uses a ketamine gel that works great for that.

And as above, document your education, especially to family.

Good luck, don't let the energy vampires get you down.

[Hospice Nurse LPN, BSN, RN]

What kind of pain is she complaining about? mets to bone? My organization uses a ketamine gel that works great for that.

I've never used ketamine. What kind of dosage and what is it compounded with? thanks!

[hikerellie]

I agree a long acting opiate like mscontin or a cadd pump. What is her dx?

Is she on a long acting opiate? Would she be a candidate for an infusion to control her discomfort. As you know, the type of pain will help you to determine what her options might be. In a case such as this, where the patient/family is not compliant with prn meds but the pt reports unacceptable pain levels, I like to increase long acting meds or switch to infusions. The goal is to get the pt comfortable, not to get her compliant with the POC.

Good luck!

[leslie :-D]

after working hospice many years, please consider the following:

when you ask a pt their pain level, they often are responding to their mental and physical pain.

it's their way of saying that even if the physical pain has improved, the 'other' pain is just too much.

that is why you often get unchanging numbers on the pain scale.

not always, but certainly worth noting.

leslie