In need of some feedback

Published

Specializes in LTC, Psych, Hospice.

I have pt who weight approx 90 lbs and has been on services for a couple of weeks. She is currently taking MSContin 60 mg BID, Lortab 10/500 mg QID, Lyrica 50 mg BID, diazepam 5 mg BID, lorazepam 2 mg BID. She's also taking a couple of meds for B/P and thyroid. We had been given a "head up" from the daughter who stated that "mama loves her pain meds". I counted the narcs and ordered what was needed at the first visit. When I made my first couple of visits the CNA was giving her a bed bath at the time and I listened at the closed door for a couple of minutes and heard laughter and chatting between the two of them. I knocked and entered the room. The pt is still laughing and telling stories to both the CNA and myself. When the bath is over I get V/S, which are all WLN. When I asked about pain, she states, "Oh! I'm hurting so bad!" This is accompanied by moaning and crying out. Now keep in mind that this happened on two visits in a row.

Second week comes around and the CNA isn't there at the time of my visit, but the pt is very friendly and laughing, telling me stories that had me laughing. When I get to the pain part of my assessment, she begins the moaning and crying out again. This lady could win an Accademy Award for her performance! When I counted the narcs this time (one week later) the count is WAY off! She's taken 10 days of Lortab in 7, MSContin was short by 10, diazepam was also short by 12 or 14. I called my DON immediately and spoke to the son (PCG). He said she whines so much about wanting a pill that it's easier to just give in than to tell her it isn't time. I explained to the pt and PCG that I was only leaving enough medicine in the house to last her to my next visit. The pt wasn't happy, but the son sure was. I had him get me a pill box which I filled for Thursday, Friday, Sat, Sun, and Mon till noon. I took the rest of the narcs and locked them up at the office. Today, I filled the pill box to last until Thursday pm when I'll be making another visit.

I don't like having to carry the meds in my car and locking them at the office, but pt is so manipulative and the son gives in. I'm really at a loss! The pt's speech isn't slurred---she's very A&O. I don't know how in the world she's taking that much medicine. She fussed with me today about keeping her meds from her, but I told her that it was for her good. Anyone else ever have this problem? I've been doing hospice for more than 10 years and when the family know I'm counting narcs the count is always right.

Thanks!

Up Vote Up Vote ×
Specializes in ICU, Hospice.

I feel your pain...been there. However, what I instituted was having the family purchase a locked box, such as for money. I would fill the drug box for a week, then lock up the rest. That way you leave the drugs in the home and take the key. The liability of caring drugs vs your license is not worth the risk!

Up Vote Up Vote ×
Specializes in LTC, Psych, Hospice.

Thanks, riverwink! I'm seeing the pt in the morning. I'm going to have the son purchase a lock box and have it there in time for my next visit.

Up Vote Up Vote ×

I questioned lack of accountability (count sheets for the nurses/family members) with my latest employers, and each of the agencies do not use them, do not plan to use them, and do not want to be bothered with accountability of controlled medications. What does that tell you?

Up Vote Up Vote ×
Specializes in PICU, NICU, L&D, Public Health, Hospice.

ok...I have to admit that I am a bit confused.

You are quite certain that the patient is taking the meds and they are not being diverted? If so, why are you advocating for a lock box?

You did not say what the diagnosis was on this case, but you did say basically that you thought this woman was feigning distress from pain. However, she is not on very significant doses of meds...and they are available to her infrequently. Does she have a fast acting opioid in place for breakthrough? Is that the Lortab? ativan BID?? How long has she been on these doses?

I cannot imagine a worse situation for this woman...she is in pain and wants medications to be comfortable. She makes an effort to be pleasant and nice to people inspite of her discomfort. Her family thinks that she takes too many "pain meds" and communicates this to others. Now her hospice nurse has limited her access further to her medications.

My basic questions are...if you do not believe this woman's report of pain and do not honor her medication requests how do you ever accomplish an appropriate titration of her medication POC to actually provide comfort and quality of life? If your patient is A&O why do you not believe her pain reports? Are you comfortable with the thought that this woman (who presumably has only months to live) will spend her remaining life in pain because you (and her family) restricted her access to the medications which could help?

My apologies if I sound irritable about this...but as a hospice nurse I frequently deal with families who are scared to death of opioids and are certain that their loved one will become an addict, or that they will OD, or that ... you fill in the blank. I have had to lock up and hide meds from family members but I have never had to restrict my patient's access to comfort meds.

I recently had a patient with intractable pain. The evidence of her pain was obvious, but she was always pleasant and kind. She actually tried to keep her family and friends thinking that she had less pain than she actually did, they thought she took too many pain meds. She would occasionally have an exacerbation and take more of her meds than she should....once she took 2 weeks of vicodin in 4 days! Did I restrict her access to the meds? Heck no...I rotated agents, tried different combinations and adjuvant therapies, even got her a nerve block. At one point the adult daughter called my company and complained about the amount of meds her mom was taking (she lived an hour away and visited a couple times a month)...the higher ups got a little nervous and put some heat on me...until they actually spoke to the A & Q patient and considered her diagnosis and situation. They reviewed the documentation and there was no problem.

The bottom line for me is this...hospice is for people at end of life, the dying...it is all about quality of life, dignity, and comfort. Restricting a hospice patient's access to pain relief is not providing for quality, dignity, or comfort. I would be focusing on education with the family...their mother's pain should be what she says it is.

Up Vote Up Vote ×

Yes, I wondered about this case too. Not to say limiting her meds is the wrong action, because I didn't see the patient and don't want to backseat-drive my colleague's instincts and decisions. But I wonder:

What about increasing the MS Contin to 90 mg q12h (compensating for the QID Lortab), and tweaking the anxiolytic to either Valium 5 mg q 6-8h, or lorazepam 1 mg q4h (depending on pt preference)? I agree, if she's asking for it, and is terminally ill, she needs it. Try to manage it in a way that gives her what she needs in medically appropriate dosage and schedule.

Nobody on hospice should have to watch the clock. Not that we should turn a blind eye to abuse, but we have to be willing to give pts the benefit of the doubt.

Up Vote Up Vote ×
Specializes in LTC, Psych, Hospice.

I forgot to mention in my OP that this pt has been hospitalized twice for suicide attempts. It is not my intention to limit her access to meds if she has physical pain, but I don't want to be responsible for allowing her the access to check out early. SW is making daily visits with pt.

Since my original post, the pts MSContin was increased to 90 mg BID and she continued taking the Lortab 10/500 2 pills QID. Her diazepam was also increased to TID and the Lyrica was upped to 100mg. She is sleeping more (the son reported her sleeping approx 12 to 16 hrs a day). I called to check on her the day after increasing the meds and she was sleeping. When I made my scheduled visit on Thursday, she stated that the new medicine was really helping her. When asked her to rate her pain, she replied "10. When are we going to get me some more meds?"

Thanks to all who replied.

Up Vote Up Vote ×

Well, hmm. What to do?

I think I would be sure to document very carefully... especially about the contradictions in her self-rating of pain and her behavior, such as reporting her pain is better, she's sleeping more, she laughs with caregivers, etc. I would also be noting the adjustments made in her pain meds and dosages. I'd get the lock box and count the pills.

I think I would have a straightforward conversation with the patient about all of the above. I would tell her I want to act as her advocate and do everything I can to make her comfortable, but I also have to rely on my own experience and judgment and assessment skills, and that I won't participate in providing her with more meds than needed to control her pain. I would keep the SW coming!

After all that if she continued to report pain of 10, I would increase her dosages.

What is her dx, BTW?

Good luck. What a vexing case.

Up Vote Up Vote ×

while your pt's physical pain is better controlled, please don't discount her mental pain...which can be a 10.

there is nothing wrong in addressing that part of her pain...hopefully this is exactly what the sw is doing.

...something to brainstorm at your next meeting.

leslie

Up Vote Up Vote ×
Specializes in L&D, Hospice.

where I work we are always told "pain is what the patient says it is"

I have a pt now and then who will tell me his pain is a 7 or 8, however shows no signs of pain, walking, talking....

I feel if my pain was a 7 or 8 I would be curled up... then again, I also feel one can get used to pain and live with it; we deal with hospice patients, we are trying to make them comfortable in their last days/ months and some times hours; does it really matter how much pain med they take to be comfortable?

may be the conversations take your patient's mind off her pain, then when you ask- oh yes i have terrible pain- and some people will always play us, so be it; ultimately it is still her responsibility if she takes too much, then again I guess she does have a terminal diagnosis! we do not know when our pts are to leave this world, we are not in charge! and i have encountered many by now, on such a high dose of IV meds - i would have bet my license it was going to kill an elephant, however the pts are barely pain controlled; who is to say? :twocents:

Up Vote Up Vote ×
Specializes in CICU, radiology, psych.
I forgot to mention in my OP that this pt has been hospitalized twice for suicide attempts. It is not my intention to limit her access to meds if she has physical pain, but I don't want to be responsible for allowing her the access to check out early. SW is making daily visits with pt.

Since my original post, the pts MSContin was increased to 90 mg BID and she continued taking the Lortab 10/500 2 pills QID. Her diazepam was also increased to TID and the Lyrica was upped to 100mg. She is sleeping more (the son reported her sleeping approx 12 to 16 hrs a day). I called to check on her the day after increasing the meds and she was sleeping. When I made my scheduled visit on Thursday, she stated that the new medicine was really helping her. When asked her to rate her pain, she replied "10. When are we going to get me some more meds?"

Thanks to all who replied.

I went to an all day pain management class that helped me with issues like this, it really gave me better understanding. Distraction is a method of pain management, maybe while someone is talking with her it helps a little or maybe she doesn't want people to know until they ask because she is afraid they will end their visit if she complains without being asked. I also wonder if some patient's have been trained to act out because in the past they just told nurse or Md they hurt but were stoic about the pain and subsequently got nothing. I used to be afraid to give someone who had been on pain meds a long time what seemed like a huge dose. I was afraid I'd be the last person to give a dose of med and the patient would die. Someone in the pain management class stated, "would you rather be the last person to give a person medicine to decrease their pain or the person who made them suffer till they died because you were afraid to give that dose". Some point will come where there will be a last dose. I think I've probably been played plenty of times because of this philosophy I adopted but so be it, if it's ordered and they say they hurt and want something I give it. Sticky situation, glad I work in a hospital not hospice, sounds like there are loads of factors your dealing with there that I can't even comprehend from my perspective.:twocents:

Up Vote Up Vote ×
+ Join the Discussion