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.

[Spidey's mom, ADN, BSN, RN]

Actually not funny at all and no such poster would be up in our hospital anywhere!

Hppy

I guess I won't invite you into our break room.

Nursing humor . . . aka Gallow's Humor is what gets us through the day sometimes. Never in front of patients but just between us.

[hppygr8ful, ASN, RN, EMT-I]

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.

But she's not there to be treated for her addiction or psych which is why I suggested consults from both specialties. Contrary to what you may believe addicts are not bad people anymore than non-compliant diabetics are bad people. Best to think of them as sick people who need to get well. I drank alcoholically for 30 years and were it not for some extremely compassionate and informed nurses and doctors I doubt very much I would be alive and sober today.

Hppy

[Simonesays, BSN, RN]

Ok. I didn't read all of the comments. To a certain extent, I get your frustration. Health care can be a downer sometimes (i.e. the CHF patient who is aggressively diuresed and then proceeds to sneak in an x-large sodium-laden fast food meal). Sigh. However, I would try and think of this situation from the patient's perspective.

In order to deeply self-mutilate, she would have to be very unhappy. And now this patient is stuck in a hospital where she is away from her friends/family/community. She likely feels a loss of control and disempowered. And, on top of this, she isn't able to "cope" with the situation through drug use. So she picks at her dressing. And she uses her call bell frequently. And asks for her PRN narcotics around the clock.

As I said, I get that this can be frustrating. But, it's not about you. It's about your patient. So what can you do as her advocate?

What types of resources are available at your hospital? Do you addictions specialists? What about psych support? Hopefully they are already on board. If not, ask and advocate! What about spiritual health? Or a music therapist? Or even a volunteer visitor?

Hopefully your manager is aware of the patient's needs already has some strategies in place (i.e. weighing assignments accordingly, switching up staff, etc). If not, talk to your manager too.

I would also talk to your patient and try to work together to come up with a plan. This might give her back some of her power.

I get where you are coming from, though. I have worked with lots of similar patients before and remember one in particular who pulled off a complex VAC dressing less than one hour after it was completed because she "wasn't allowed to leave the floor for a cigarette." Again, sigh.

Last piece of advice: remember to take care of yourself. I don't know if you're burnt out or not but I usually find that if I'm not able to approach a patient compassionately, it's more about my mental state than theirs (not saying you weren't compassionate to this patient to her face or that you didn't provide her with good care).

Go out with a few coworkers and order a few drinks. No one understands your job better than someone else who is doing it so vent together.

[hppygr8ful, ASN, RN, EMT-I]

I get the humor I do actually especially in some cases addiction humor Last week We were attempting to medicate with a standard PO cocktail Haldol/Ativan/Benadryl and the patient said they would spit it back in my face. The thought ran through my head to catch that Ativan like a thrown piece of popcorn if you get my drift - such a shame to let 2 mg of perfectly good Ativan go to waste. Still our management is into posters with puppies and kittens and inspirational quotes. I mostly take my breaks outside.

Hppy

[missmollie, ADN, BSN, RN]

I think this is a legit question from the op, even if she is venting her frustrations. Often I have several different medications ordered PRN, but just because it's ordered doesn't mean I'm going to give all 10mg of oxy, 4mg of morphine, 650mg of Tylenol, or the 2 fiorcet they might have available. It is up to us to judge and decide how to best relieve pain while also being safe.

For me, that means coming up with a plan for the patient, with the patient's knowledge. I'll explain what I'd like to do, ask what they'd like to do, and go from there. If Dilaudid is ordered PRN, I'm not going to mention that to the patient. It's my hail mary when the patient isn't responding to other pain medication.

If the patient is watching the clock and claiming that the pain is a 10/10 and they have regularly been receiving morphine, then it's time to talk to the doctor. Obviously it's not working. Maybe add some tylenol or try a different pain medication altogether. But OP, if you are spending the majority of your time fighting pain with the patient, then you're not doing what's best for your other patients. Give it and be done.

[Spidey's mom, ADN, BSN, RN]

Ok. I didn't read all of the comments. To a certain extent, I get your frustration. Health care can be a downer sometimes (i.e. the CHF patient who is aggressively diuresed and then proceeds to sneak in an x-large sodium-laden fast food meal). Sigh. However, I would try and think of this situation from the patient's perspective.

In order to deeply self-mutilate, she would have to be very unhappy. And now this patient is stuck in a hospital where she is away from her friends/family/community. She likely feels a loss of control and disempowered. And, on top of this, she isn't able to "cope" with the situation through drug use. So she picks at her dressing. And she uses her call bell frequently. And asks for her PRN narcotics around the clock.

As I said, I get that this can be frustrating. But, it's not about you. It's about your patient. So what can you do as her advocate?

What types of resources are available at your hospital? Do you addictions specialists? What about psych support? Hopefully they are already on board. If not, ask and advocate! What about spiritual health? Or a music therapist? Or even a volunteer visitor?

Hopefully your manager is aware of the patient's needs already has some strategies in place (i.e. weighing assignments accordingly, switching up staff, etc). If not, talk to your manager too.

I would also talk to your patient and try to work together to come up with a plan. This might give her back some of her power.

I get where you are coming from, though. I have worked with lots of similar patients before and remember one in particular who pulled off a complex VAC dressing less than one hour after it was completed because she "wasn't allowed to leave the floor for a cigarette." Again, sigh.

Last piece of advice: remember to take care of yourself. I don't know if you're burnt out or not but I usually find that if I'm not able to approach a patient compassionately, it's more about my mental state than theirs (not saying you weren't compassionate to this patient to her face or that you didn't provide her with good care).

Go out with a few coworkers and order a few drinks. No one understands your job better than someone else who is doing it so vent together.

This is excellent and I think is what the OP was looking for.

Thank you for sharing.

[cocoa_puff]

I agree with your perspective.

Also, the OP didn't say she wanted to refuse to give pain medication but was asking if there was another way to handle this complicated issue.

I think that is a legitimate question.

And I'm outing myself as a member of a family with many drug addicts.

I didn't intend for my post to sound like I thought the OP would refuse to give the patient pain medication. I have struggled with similar things to the OP, and often feel the same way. That I'm just fueling the addictions of my many manipulative, drug-seeking, alcoholic non-compliant patients, and once they leave, they will go right back to doing what they were before (same with my non-compliant diabetics, CHF, and COPD patients). On several of my previous threads I have been accused of being judgmental as well (being told "you have no right to judge these patients! I would never want you caring for me!! How would you feel to be judged like that!). I wrote about how refusing to give pain meds to an addict won't fix their addiction in a general way, not in reference to the OP. I apologize to Thankgodforativan (love the username!) if it came across that way.

I also come from a family of addicts.

[Spidey's mom, ADN, BSN, RN]

I didn't intend for my post to sound like I thought the OP would refuse to give the patient pain medication. I have struggled with similar things to the OP, and often feel the same way. That I'm just fueling the addictions of my many manipulative, drug-seeking, alcoholic non-compliant patients, and once they leave, they will go right back to doing what they were before (same with my non-compliant diabetics, CHF, and COPD patients). On several of my previous threads I have been accused of being judgmental as well (being told "you have no right to judge these patients! I would never want you caring for me!! How would you feel to be judged like that!). I wrote about how refusing to give pain meds to an addict won't fix their addiction in a general way, not in reference to the OP. I apologize to Thankgodforativan (love the username!) if it came across that way.

I also come from a family of addicts.

I was agreeing with you.

And making a general statement.

No criticism at all from me with what you said.

[LuckyMoon]

Strongly suggest you educate yourself about addiction, mental illness, and pain management for addicts and people who are dependent. Learn the difference between addiction, habituation, and tolerance.

And while you're at it, repeat after me: "There but for the grace of God go I." A little compassion is in order here. Learn to feel sorry for people with screwed up lives; you'll see a lot of them the longer you're a nurse (new?) and it'll make you a better one.

While I understand how the situation described by the OP might be frustrating, I finished the post feeling quite sorry for the young woman causing the OP grief. What a sad and miserable situation. I appreciated the above post by AliNajaCat.

[Guest219794]

Thanks to everyone who replied, but I'm done with this thread. I hoped to actually have a reasonable discussion, but I can see that just isn't possible here.

This is actually a surprisingly reasonable discussion.

The subject comes up frequently, and often elicits emotional responses.

In this case, several folks have explained your responsibilities and your options. Some have sympathized, some have been critical. That would be a reasonable discussion.

Was it a real question? I see you are new to nursing, but did you really not know the answer?

Were you expecting: "Yes- you have the right to disregard MD orders on admitted patients under your care. Just make a list, let administration know, and somebody will come in and take care of any orders to which you have moral objections".

Do some searching on this site, and you will see that this issue frustrates many of us, including me. But, I like my job in the ER, and this is one of the aspects that keeps it from being perfect.

[Tenebrae, BSN, 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.

I recall from way back in my student days a young bloke who had a vac dressing in place and it caused him so much pain he had to be taken back to the OR and every dressing change had to be done under a GA

[BostonFNP, APRN]

Thanks to everyone who replied, but I'm done with this thread. I hoped to actually have a reasonable discussion, but I can see that just isn't possible here.

Did you want to have a discussion about the topic or just have people validate your feelings on the issue? After all that is the purpose of ranting in the first place.

I think we all understand the patient is frustrating; most here seem to also agree that regardless of that frustration, punishing the patient by refusing prescribed care is both unethical and malpractice.

This patient needs long-term out-patient care; you are not going to "fix" her by refusing her morphine during her inpatient stay.