I didn't become a nurse to feed people's addictions. Do *nurses* have the right to refuse

[Thankgodforativan]

(Disclaimer: So this turned out to be longer than I thought it would, and a bit of a rant. Sorry! But I think this is something that's relevant to all of us).

Some background: I work in a combined med surg ward, so we see a bit of everything. We have a young-ish girl, in her twenties, that has a VAC dressing in her leg following very deep self harm about two weeks ago. Her drug use has also given her 'meth mouth', and she's had at least one tooth removed about a week ago as well.

The issue is that she has a personality disorder, a history of aggression, is a known drug seeker and has had to have her VAC replaced twice now because she keeps sabotaging it - picking at it, poking and playing with it. Before it was put in she was seen physically pulling the edges of the wound apart with her hands also. She demands morphine roughly every hour for "ten out of ten" pain even though you can clearly see that she's not distressed in any way. She is charted for PRN morph and fentanyl, subcut (not allowed to have a cannula).

We always hear about the patients right to refuse; surely nurses have some way of objecting in a situation like this? Panadol (Tylenol), anti-inflammatories and endone all "don't do anything", even though it barely gets to two minutes after giving these before she buzzes and asks for "something better".

It's ridiculous; the patient knows she's playing us for fools and has said as much. Surely there comes a point where enough is enough and we stop giving in to people, especially people who don't want to help themselves. No wonder the state health system I work in is broke; It frustrates me to no end when we can't even afford more then one obs machine on the ward between thirty two patients, yet we will hand out expensive treatments to people who clearly don't want to get 'better', and dole out morphine like it's soda.

I know we need to cover pain relief somehow; I'm aware that vac dressings can be painful. But it's not like she can say we're not giving her anything at all. What are our options here? I'm not the only one with the same concern.

Sincerely, nurse who didn't become a nurse to be a drug dealer.

*edited for spelling.

[MPKH, BSN, RN]

I work in a hospital that serves the majority of the inner city population. As a result, my medicine unit receives a lot of patients with drug use background. Most will want their prn morphine or dilaudid as soon as they can have it...they will watch the clock to ensure that they are receiving it at the frequency the doctor has prescribed.

I don't judge them. It's not my business. I will hold narcotics if they are too drowsy to receive them. Same as I would any other patient.

Ethically, nurses are to give out medications that are prescribed, provided that it is safe to do so. The treatment of drug users is complex, and it takes a team of healthcare workers to attend to the patient. You're not dealing drugs--you're medicating the patient as ordered.

At the end of the day, you can't change people. Patients who are drug seeking will be drug seeking. All we can do is provide competent and safe nursing care...without the judging.

[KatieMI, BSN, MSN, RN]

If it helps you feel better, there is a medical necessity- even for addicts. Have you seen what happens when they get a rare doctor who won't give them anything? .

When they finally hit the line of waiting time in pain clinic with nobody giving them even a single new script, they go one of three ways:

- go on street drugs (approximately half of them)

- wean themselves off (yep... believe me or not)

- or hit one ER after another, move doctor shop, etc., till they are fed-flagged in state pharm surveillance, after what they go one of ways above.

I had to observe recently what happened with about 600 patients seen by one incredibly "caring and understanding" doctor who was caught red-handed by DEA. Pretty much all of them were addicted to certain level to opioids and /or benzos; they all were purposefully left on cold air by all local providers for at least 3 months, and local ERs were put on alert not to give these people anything without clear clinical indications such as withdrawal. When after that they started to be re-distributed among local providers, half of them found that their "nerves", "debilitating anxiety" and such disappeared most mysterious way. They just self-weaned Xanax, and were put on much more reasonable doses of pain meds. Honestly, I was feeling angry on those conspiring providers for letting the poor souls to suffer, but once I saw the results of it, I kinda changed my opinion.

I do not want to say that all of chronic addicts are simulating or something, but sometimes REASONABLE limits are everything that is needed.

[martymoose, BSN, RN]

But we are giving her pain relief. As I explained, nobody can say we're not doing anything for her, she just doesn't like what we give her (her words, not mine). She can do whatever she wants while she's out in the community, but surely as an inpatient giving in to her every demand (to the point where she's constantly drowsy) is doing her more harm than benefit.

Where does it end? And why should my other patients suffer because I spend half my day (not an exaggeration, this is my actual hours as per allocation) dealing with her constant demands for pain relief?

This is what she wants. My opinion, but a lot of these " drug seekers" want a way to not know reality. If we are snowed into oblivion, we dont care what is going on in the world, life, etc.

I swear the 10/10pain is mental- as in mental pain of reality.

I dont blame them one bit.Its too bad mental health in the USA is broken and not supportive

But I could see where someone would not want to perpetuate this by " giving in"

we arent going to be the ones to fix things. If its ordered, and they are safe ( ie breathing > 10 resps) and state 10/10, I give it.

[Thankgodforativan]

You do not have the "right" to refuse to carry out the physician's order. If the prescribed RX does not handle her pain, you have the right to notify the physician and the pain management team, and institute other therapies, such as heat or cold applications and repositioning.

You do not have the right to judge her based on her psychiatric history.

You CAN get her comfortable... perhaps, if you spent less time judging and more time thinking of alternative and adjunct therapies.

Oh oh get off your high horse. God forbid we ever question anything in nursing huh? It's not my judgement, her addiction and drug seeking are well documented. But hey, far be it from me to question your knowledge.

[Thankgodforativan]

I do not want to say that all of chronic addicts are simulating or something, but sometimes REASONABLE limits are everything that is needed.

Or any limits at all. I see so much waste in my work. It's God damn shameful when our ward can't even afford to put buzzers or oxygen connections on the walls, but we'll indulge every addict within 100 miles without question.

[Ruas61, BSN, RN]

But we are giving her pain relief. As I explained, nobody can say we're not doing anything for her, she just doesn't like what we give her (her words, not mine). She can do whatever she wants while she's out in the community, but surely as an inpatient giving in to her every demand (to the point where she's constantly drowsy) is doing her more harm than benefit.

Where does it end? And why should my other patients suffer because I spend half my day (not an exaggeration, this is my actual hours as per allocation) dealing with her constant demands for pain relief?

Perhaps you should get another employment opportunity.

[SmilingBluEyes]

It's not indulgence to give an addict medication for pain. Just because they are an addict does not mean they don't have pain. And yes, addicts are clock-watchers. Yes they are challenging to care for. Yes, they can be aggravating/whiney/annoying/frustrating/hard to deal with. Yes, they *do* need more pain meds for their pain than the non-addict does. These are facts. Addicts do feel pain like anyone else when they have had surgery or are sick, however. They still need medication, even if they are addicted, particularly to opioids.

Addicts are not "bad" people. They are not "dirty". They are not "beneath" you. They are human beings with a brain disease that causes daily misery in their lives. They are not criminals, unless they committed a crime to support their addiction. And even if so, you still are charged with giving them quality and timely care when they are in your charge. If this brain disease were diabetes would you withhold insulin?

It's not your job to judge them to the point it affects how you care for them or makes you want to withhold their medication because you feel like a drug dealer. Your feelings really are immaterial in this. It IS your job to give them what is ordered when it's indicated, as long as it's safe. You have your opinion and your right to it. Keep it to yourself and just do your job. You are not being a "drug dealer" in medicating an addict as ordered by the MD. You are doing your job. If you can't do that, and care for them like you would a non-addict, please, just find another job. Simple as that.

It is because 10-12% of the population in the USA (including nurses) are substance-addicted and struggle daily, I believe everyone in nursing should have to take CEUs in addiction. It's poorly understood by so many of us.

So, the answer to your question: "do you have the right to refuse?" When it comes to caring for the patient and giving them the medication as ordered? No! You do Not!

[Meriwhen, ASN, BSN, MSN, RN]

If the medication is ordered and it is appropriate to give it (i.e., it's at the right time, she's reporting pain, her respirations aren't 7/min, et al.), then no, you don't have the right to withhold ordered medication from a patient.

If you feel the medication isn't managing her symptoms well-enough, the patient is requesting/using medications inappropriately and/or the patient is constantly complaining about not getting the "right" medications, then notify her PCP so they can evaluate her and her medications. The PCP will decide if medication changes are necessary.

You can certainly question it, but ultimately it's the PCP's place--and not yours--to decide if medications are appropriate.

[Been there,done that, ASN, RN]

Oh oh get off your high horse. God forbid we ever question anything in nursing huh? It's not my judgement, her addiction and drug seeking are well documented. But hey, far be it from me to question your knowledge.

Many references made recently to high horses , are you friends with Philly85?

You ARE making a judgement.

I am acutely aware of pain issues. My father had a brain enzyme that caused morphine to metabolize rapidly. It took 80 mg. of morphine an hour to manage his pain. I saw him suffer greatly, because many judgemental nurses, could not deal with such an unusual issue. But, you don't need to learn from my experiences, you seem to know it all.

[ItsThatJenGirl, CNA]

I thought addiction was a disease. Therefore, should be treated as any other disease regardless of your personal feelings about it.

[Double Dunker]

I don't understand why so many are giving the OP such a hard time. Anyone who has worked med-surg for any length of time has cared for many of these types of patients and knows how exhausting they can be, especially with Q1 hour pain meds. Being frustrated with the state of affairs does not mean she is judging. She asked a clinically relevant question. Honestly, I thought she asked the question in a reasonably detached, impartial manner. It's the same question many of us have asked ourselves, and our coworkers, before.

As others have said, you can't refuse to give an ordered med without documented justification. Does your charting system have an opioid sedation scale that you have to chart on before giving pain meds? If the patient is schnockered, document and call the physician. Otherwise, dilute the heck out of the morphine and push it really slow. Your patient will still get pain relief, but less of any type of "high" she might be getting.

[beckysue920]

With tongue in cheek...isn't it all about PATIENT SATISFACTION????