MD ordered placebo for pain PRN~would you give it?

[beetlebailey524]

I am an RN student who will graduate in May. I ran across a situation during my clinical the other day that I wanted to seek some experienced advice on. This was my 3rd or 4th day of clinical at this hospital so I was still getting oriented to everything and trying to familiarize myself with all the "policies and procedures."

I do not have an instructor with me but my preceptor is great and always answers my questions but even she seemed to be at a loss of explanation for this one.

The secretary for the floor asked my preceptor to try and decipher an order for a new med scribbled out on the pts chart so it could be ordered. It was determined to read "Placebo for pain PRN" and scanned to the pharmacy. So of course I had to ask my preceptor if this was normally done at this hospital and what exactly would be given to the patient.

She did not seem to surprised by the order and said she had not ever had this ordered for any of her patients so she did not know what would be given. (she was acting as charge nurse so we had to view the chart)

Being new and a student and not knowing the entire situation I did not say anything else to her but I did ask another nurse what her opinion of giving a placebo for pain was. She seemed surprised that this was actually written on an order and scanned to the pharmacy but also said she had never had this ordered for any of her patients before so she really did not know what to tell me.

All I want to know is this something that goes on and nurses are doing? I would not give a placebo pain med to a patient, ordered or not. It is not honest and goes against all I have been taught in school about an RN being a patient advocate, practicing with fidelity and non-maleficence. Am I just being naive?

If the patient were to find out they had been mislead and wanted to press charges against the MD, the hospital and the nurse wouldn't that qualify as an intentional tort on my part-as my instructor always says "a prudent nurse would have known otherwise!"

I do not know if the order was ever carried out but I was told the doctor had discussed this with the patient's nurse. Whatever that meant? I have chosen to use this as an ethical dilemma I encountered during clinical to write a short paper on so any feedback would be appreciated, pro or con.

Thanks.

[Valerie Salva, BSN, RN]

I worked in a nursing home where the med director approved policy said that staff is to use "disctraction (play music, turn on the TV, sit and talk w/ pt, etc...) "provide diversional activities" and a whole bunch of other bs before a prescribed prn pain med could be given.

In front of every narc sheet in the med book is a form where you check off all the other "interventions" you tried, their effect and so on.

Okay, my 60+ other LTC pts, and my hours long med pass have to wait- I have to drop everything and play patty-cake with this contracted, tube fed, bed-sored, chronic loose stools 75-year-old pt to try and stop her moaning, grimacing, and tachycardia.

Here is what the good nurses really did- take about five seconds to fill out that bs form (without doing any of those bs interventions), crush up the Lortabs and give them to her in her g-tube ASAP. The relief on this poor pt's face about 45 mins later was obvious- every time.

This pt really should have been on scheduled, sustained release pain meds, but you can't force people to do their jobs.

[MAISY, RN-ER, BSN, RN]

OH NO! I guess the placebo effect does work! I have taken Ultram with relief, then again 1/2 flexeril knocks me out!

M:wink2:

[TiredMD]

Finally someone admits that Ultram is a crap drug!

It is very often prescribed for people who are already on Prozac and so on- so what's the point?

To me, an Ultram Rx = "I don't want to deal with you- so take this script and go away."

I've met people who swear by it, but as the above poster notes, it tends to be people who are highly medication-sensitive to begin with. For most patients, I don't find much use for the drug, and I am personally of the opinion that it is no more effective than ibuprofen, naproxen, or any other NSAID.

That being said, I do prescribe it. Usually it's under two circumstances:

1) Patient has been on Percocet or Vicodin for a few weeks after an acute injury, and is really convinced they need more because they still hurt. I deliver my standard "Narcotics are not intended to be used indefinitely, and it's time to get you off them." Then I explain that I will give them Tramadol, which is believed to act similarly to narcotics but without the same dependence/addiction profile.

2) Patient is young, shows signs of developing chronic pain from a musculoskeletal condition (almost always low back pain or PFS), has cycled through all the NSAIDs and Tylenol, but I really don't want to send them down the narcotic pathway. Tramadol is offered as an "intermediate" solution.

In truth, the only real benefit of Ultram is that people aren't all that familiar with it. If someone is sore, and you offer them Tylenol or Motrin, they think you're not taking them seriously, and don't expect it to work. But if you offer them Ultram, they assume it's a "real" pain medicine, and so it tends to work better.

[Valerie Salva, BSN, RN]

To me it seems like this is still like prescribing a placebo, to a degree.

If it works for some, that's fine.

I finally did get a real med prescribed for me, and I only take it when I need pain relief to keep functioning. The rest of the time, I just suffer.

[Babs0512]

Knowingly giving a patient a placebo is unethical - and I wouldn't do it. HOWEVER - I accidentally gave .08mg of Morphine instead of the 8mg that was ordered for an adult male with a fx mandible and maxillary bones - and it worked!!! Yes, I wrote myself up for the error and reported it appropriately. But I basically gave the patient a placebo with good effect - I was amazed when I realized what happened. I had taken a 2mg/ml Morphine syringe instead of a 10mg/ml morphine syringe.

The patient (and I) thought he was getting 2mg per dose, when he was actually getting .02 mg/dose. Anyway, he saw me doting on him and giving him pain meds, and dammed if he didn't feel better!!

I would NEVER knowingly give a placebo.

Blessings

[Katie82, RN]

Being new and a student and not knowing the entire situation I did not say anything else to her but I did ask another nurse what her opinion of giving a placebo for pain was. She seemed surprised that this was actually written on an order and scanned to the pharmacy but also said she had never had this ordered for any of her patients before so she really did not know what to tell me.

Thanks.

If the pharmacy sent medication, probably after clarifying with the doctor, I would have given it. In today's enviornemnt where docs pass out pain meds like candy, he must have had a good reason for prescribing a placebo. Many patients are med seekers who get themselves admitted for pain meds, I deal with folks like this every day. This could have been one of those patients. I think the doc took the easy way out, he should have had a discussion with the patient and told them he was not prescribing pain meds. I do remember a frequent admission patient I had back in my hospital days who was mildly MR and had a very low threshold for pain. His doc would order placebo pain meds and I would give them. He always slept like a baby for hours......

[Tom123]

I am assuming that you are a physician, based on your screen name. I agree with your assessment of Ultram. What continues to baffle me is why physicians will not refer their chronic pain patients to a Board Certified Pain Management Physician.

I have chronic back pain, post 3 spinal surgeries. My pain physician is a Board Certified Anestheologist and Board Certified in Pain Management. Chris is fantastic. He constantly monitors my pain, to ensure that I am receiving the best relief possible -- that is reducing my pain to a tolerable level.

As to the point about depression. Many people do not want to admit depression, because of the stigma. Regretfully, ALL chronic pain patients have depression -- from the pain. Again, this is a great teachable moment for the physician to explain to the patient about depression. Of course, we all know that it will be the nurse doing the explaining. I hope everyone involved in the care of pain patients do this type of education. In most states education by the RN is mandated in the Nurse Practice Act.

[morte, LPN, LVN]

Yeah, it binds to mu receptors just like opiates . . . just at 1/6000th the strength.

Personally, I think it's a crap drug, a throw-away to pawn off on your chronic back pain patients in the hope that the weak anti-depressant effect will improve their overall pain scores (since they all absolutely refuse to believe they have any kind of depression and don't want to be labeled as "crazy"). But that's just me.

now i am really, hm , ticked off.....now i know why the idiot orthopod asked me if it worked!...hm ED, middle aged woman=depression for sure, idiots!

[Vito Andolini]

I wouldn't give it. I'm not lying to a patient telling them I'm giving them something for pain when it's nothing.

Ah, but it is something. It is a psychological treatment and might actually do good.

I've never dealt with this in actual practice, so am just thinking aloud. Not sure what I'd do. In the case presented by the OP, we are not given the history of the patient or the patient's relationship with his doctor or what has been tried before. Too hard to judge the whole case without all the facts. Good ethics discussion.

[Vito Andolini]

Yeah, it binds to mu receptors just like opiates . . . just at 1/6000th the strength.

Personally, I think it's a crap drug, a throw-away to pawn off on your chronic back pain patients in the hope that the weak anti-depressant effect will improve their overall pain scores (since they all absolutely refuse to believe they have any kind of depression and don't want to be labeled as "crazy"). But that's just me.

For those who think it's okay to give a placebo (and I'm kind of amazed that it's taught in schools that it's an ethical thing to do), when you patient asks you what they're getting, what do you say?

Throw away? Pawn off? Do you try to sound so disrespectful?

[TiredMD]

Throw away? Pawn off? Do you try to sound so disrespectful?

Sorry, next time I'll lie so that you feel better.

Ultram is a wonderful drug! It works just like narcotics and I fully expect it to work every time I give it!! The mechanism of action is identical to morphine but you won't get addicted to it!

[TiredMD]

I am assuming that you are a physician, based on your screen name. I agree with your assessment of Ultram. What continues to baffle me is why physicians will not refer their chronic pain patients to a Board Certified Pain Management Physician.

I'm with you 100%.

In fact, I'll go a step further and say that many, if not most, chronic back pain patients should see Pain before they get sent to a surgeon. We are doing so many questionable lumbar lamis and decompressions, and so many recent papers have suggested that the outcomes w/ & w/o surgery are very very close . . . we could probably save a lot of people a surgery that really won't make them better in the long run.