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.

[Larry77, RN]

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.

EXACTLY....I will not lie to a patient intentionally and misleading them in this case would be just that...a lie!

Not that I don't think a placebo would be very affective in many cases...:)

[Straydandelion]

I have only seen something similar ordered once. The patient had been in the hospital numerous times and was noncompliant with medical regime at home and at the hospital. After consulting all that knew the patient from different specialities it was decided the patient was seeking attention/or drugs or both. The home/family life appeared to be fairly complicated also with a negative atmosphere. A regime of stopping in the room to speak to her regularly along with the placebo (only given in between times...her regular pain medication being every four hours and the placebo given if she asks after two..no sign of pain during that time) seemed to get her mind clearer and be able to learn steps to help herself. This was also with permission from her husband.

[travel50]

Oh, dear....I will be the dissenting view point here. Please don't everyone jump on me. Twice I have used a placebo with a doctor's order. The first time was in the hospital, young man comes in c/o severe pain (I forget where...was sev yrs ago). Everyone said he was drug seeking. He may have been a druggie, but I was certain he was in real pain. The doc refused to order any pain med. Just keeping him for observation. I worked the evening shift. By around 7pm, I could not stand it any longer, so I called the doc. He wouldn't budge. So I asked to give the man a placebo. If it worked, I would assume the doc was right and hush. If it did not work, the doc agreed I could call back and get an order for pain med. I gave the placebo shot. Nothing. Poor man continued to beg for pain meds. So after 30 min, I called the doc back and got an order for a pain shot (demerol I think, large dose). After a few min., the man began to relax. Next day he was taken to surgery to correct the problem. Maybe using the placebo was not ethical, but it seemed the only way I could get the doc to order real meds. I didn't think letting him lie there and suffer was ethical.

Second time was last year at the nsg home. 60 yo woman comes in, hypochondriac, anxiety, etc. She had taken so many pain meds at home that she was killing her kidneys and liver. She had pain meds ordered at the nsg home....lots and lots of strong pain meds. But she was addicted to shots. So the doc (in an effort to not further damage her kidneys and liver) ordered a NS placebo injection TID. Worked like a charm. She'd calm right down, take a nap (b/c those shots made her so sleepy), and she'd be alright until she knew the next one was due. I would think this was unethical, but she had so much pain med already ordered despite the absence of any diagnosis to cause pain (which does not always matter), it obviously worked, and the doc was really trying to salvage her organs.

So while I definitely agree that placeboes are not usually right, I have found them useful for unusual circumstances. Like I said, don't everyone throw frownie faces at me at once....please.

[Magsulfate, BSN, RN]

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Second time was last year at the nsg home. 60 yo woman comes in, hypochondriac, anxiety, etc. She had taken so many pain meds at home that she was killing her kidneys and liver. She had pain meds ordered at the nsg home....lots and lots of strong pain meds. But she was addicted to shots. So the doc (in an effort to not further damage her kidneys and liver) ordered a NS placebo injection TID. Worked like a charm. She'd calm right down, take a nap (b/c those shots made her so sleepy), and she'd be alright until she knew the next one was due. I would think this was unethical, but she had so much pain med already ordered despite the absence of any diagnosis to cause pain (which does not always matter), it obviously worked, and the doc was really trying to salvage her organs.

So while I definitely agree that placeboes are not usually right, I have found them useful for unusual circumstances. Like I said, don't everyone throw frownie faces at me at once....please.

I am going to agree with you that in extreme circumstances and for the safety/health of the patient... IF the placebo has the same effect as the actual narcotic, then what is the problem? The only problem I see is the consent of the patient. Why hold back a placebo if it does a good job at making the patient feel better at the same time not doing any more damage to the liver... and there are no risks for overdose/ over medicating.

[pagandeva2000, LPN]

This is unique, but with the examples provided by travel50 and Straydandelion, I guess there are some times that it may be worth a try, especially if there is organ damage. I would be questioning the rationale of why, however and reading the chart like it is a steamy novel...

[NursingtheHeart]

Your instincts are right. Placebos for pain are unethical. Even the facility at which I work believes this. Patients are the only ones who can feel their pain. It is no one's job to assume the pain isn't real or that a placebo can "cure" it.

[MAISY, RN-ER, BSN, RN]

Cut and dried, Pain is what the pateint says it is....PERIOD!

Unless anyone treating, and or medicating the patient is clairvoyant or an empath and can KNOW how that patient feels I am DISGUSTED that any medical professional would placate a physician and not treat a patient the way they DESERVE to be treated.

I am sorry if that language is strong to some who I am sure are good nurses, but there is never a reason to take a chance. What if you are wrong? While we know mind over matter works, it's criminal to pretend.

Makes me sick to think about it, especially the ICU patients.

M

[PeteyPie]

Ha ha, dose? route? The MD left that part out. :)

Your primary role as a nurse is patient advocate. And unfortunately there is no magic machine that monitors pain. If a patient says they are in pain, then I believe them, I have no choice. Standard practice demands a nursing intervention for pain, a placebo does nothing. Doing nothing for pain will get you in BIG BIG trouble with your state board of nursing. Would you consider doing nothing for a patient with a BP of 65/42?

But for the sake of the argument, let's say you decided to give the medication. The only ethical way to give the medication is to walk into the room, introduce yourself and say,

"This is a placebo the doctor has ordered you to take, it does nothing and has no side effects, do you have any questions?"

"WHY IS THE DOCTOR MAKING ME TAKE A PILL THAT DOES NOTHING!"

"I'm not certain, lets call him/her."

My first call would be to the physician to verify the order. MD chicken scratch can be so hard to decipher sometimes. Perhaps the MD means to give some narc pain med that starts with P and ends with O, and is a train wreck of spelling errors in between.

If the order is correct, then the MD and I are going to have a very frank and candid conversation about his rationale of treating pain with a placebo. I'm going to try and convince him for a new order. If he refuses, then I'm calling someone else. Nurse manager would be a good start.

You have to do more than simply refusing to give the medication, you actually have to look out for the patient.

[Elvish, BSN, DNP, RN, NP]

If the doc refused to write anything more I'd tell him I'm not giving that placebo but that if he would like to come explain what he's doing and administer said placebo himself, to go for it. And then I'd go up the chain of command. Attending (if it's a resident), and if I had to call the medical director, then so be it. I'm not giving a patient normal saline and telling them it's for their pain.

[travel50]

Cut and dried, Pain is what the pateint says it is....PERIOD!

Unless anyone treating, and or medicating the patient is clairvoyant or an empath and can KNOW how that patient feels I am DISGUSTED that any medical professional would placate a physician and not treat a patient the way they DESERVE to be treated.

I am sorry if that language is strong to some who I am sure are good nurses, but there is never a reason to take a chance. What if you are wrong? While we know mind over matter works, it's criminal to pretend.

Makes me sick to think about it, especially the ICU patients.

M

For Maisy or anyone...please see my original post on the 2nd page....when I called the doc about my young man who was hurting so bad...I believed my patient, but the doc would not order pain med. When I asked for the placebo as a bargaining chip, it was b/c it was the only way I could think of to get him to order a pain med. I wasn't meaning to placate him. I just wanted pain meds. He was not only this patient's attending, he was the chief of staff. So I could not have gone above him. He was the "above". So if I was wrong (and I don't mind admitting to being wrong), what else should I have done? I was much younger and much less experienced than now. If it were today, I would call and simply tell the doctor he was wrong and that he by golly would give me an order. I didn't have the guts to do that then, so just did the best I could think of to do.

[Magsulfate, BSN, RN]

Wait one minute. In the previous post where travel50 cared for a patient the placebo DID DO SOMETHING, IT RELIEVED HER PAIN. I have seen it myself with my mother. She is one of those extreme circumstances that placebos actually do work on. So, you can't scare me with strong words. I DO know that placebos have an affect on some extreme cases. However, I am still not saying it is right. But some people need to open their mind a little more. Jeeze.

[mskate]

there has to be an informed consent re: this on the chart, usually for research purposes. without the consent - it is illegal.