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.

[Magsulfate, BSN, RN]

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

I agree. But, still, sometimes it works on those extreme cases, and you can't deny that. The placebo does have an effect and it is called the "placebo effect"

[leslie :-D]

travel50, it is obvious that your intent for your pt, was to relieve his pain.

and, it worked out because he ended up getting some demerol.

but giving a placebo that is effective (your 60yo pt) is still not a reason to continue on.

it violates every ethical principle we were taught in school.

most of all, we are betraying the pt.

and that is reprehensible.

i get sick to my stomach, thinking of a pt's reaction to being told, "all this time, you were getting ns".

yep...hahahaha- joke's on you, lady.

i'm telling you, i'm sickened.

but doing it as a way to get an md to change his mind, is almost ok.

it certainly is forgivable.

but anything beyond that...:down:

leslie

[Thunderwolf, MSN, RN]

You may need to check with your state nursing and medical board to see if this practice is even permitted in your state.

Personally, being a nurse with some years, I do remember the days of placebos prescribed by docs. I am mixed on the practice. I have witnessed multiple occasions where relief was obtained (sometimes immediately) from PO, IV, and IM routes. And since pain is what the patient perceives it to be...if a placebo brought pain relief...is it not therapeutic? So, if relief was obtained...is this not ethical?....don't know. Is it unethical to prescribe a pain med (or any med for that matter) that the patient truly doesn't or may not even need?

So, I am mixed on the issue.

[BradleyRN]

I have personally used placebos once for pain relief. In LTC, i had a patient who always requested roxicet beyond it's limit. When we began using a placebo to go over the maximum dosage, he told me to my face that his pain was completely relieved. I believe that pain is what the patient say it is, and so is relief. Had the placebo been ineffective, i am certain our next course of action would have been stronger pain meds. And i would have pursued that order stat had the placebo not produced immediate results, as i would then feel the placebo to be torture. Thankfully, he didnt need them, and as an elderly person, his risk of falls did not have to increase. Were the actions of myself and the doctor unethical? After reading the opinions on this thread, i am at a loss for an answer.

But, the placebo effect is real, as has been demonstrated in Parkinson's patients, who under placebos, began producing more dopamine simply based on their belief that the treatment would work.

I am not a nurse that judges people. You may be a drug seeker or actually in pain, and either way, i will give you the maximum dose of your prescribed PRN doses 30 minutes ahead of schedule. (I am not a detective or psychic.) If you are still in pain, i will get orders for more. Nobody is going to be in pain on my watch if i can help it. But i did see the placebo work once, so i wouldnt be so fast as to judge such an order. I would however not wait around to demand something else if it didnt work just as effectively as the real medicine. I am going to have to think long on that position though, since there are members in this thread that i revere the most who do not agree.

[LilyBlue]

It would completely depend on the patient and the MD, to tell you the truth. If the MD had a good reason, I would probably attempt it, and if it brought the patient relief, may continue it. I have been a nurse for long enough now to know that for me personally, black and white are rare shades in the world of nursing.

[MAISY, RN-ER, BSN, RN]

I guess the word TRUST comes to mind when I see placebo, if that patient doesn't have you-they have no one!

Put yourself in their place, vulnerable, obviously in the hospital for a problem; in pain with no ability to even medicate themselves with advil or tylenol.

Placebos are proven, but medical ethics tell us they are not ethical. We are playing with quality of life, when you play with placebos. A damn slippery slope.

As for those of you who would say about drug seekers-WE MADE THEM! The truth is the daily meds these people take are crazy in their dosages, but they have worked up to those levels!(sicklers, intractable back pain, RA) The pain relief we offer in the ER is a drop in the bucket!

We all saw in the movie the Bird Cage, the "pirin" tablets given to Nathan Lane's character and laughed (aspirin with as rubbed off), and we all know hypochondriacs in our real lives. Perhaps someday our medical institutions will offer alternative medicines which we also know works for pain relief, or in conjuction to pain relief meds. Right now all we have is their word that "it hurts" and that needs to be good enough! If the doctor won't treat the pain he needs to be reported over and over until he does!

For the nurses who have given placebos, I am not judging you-I am just offering my opinion about something I feel very strongly about! I don't like seeing patients undermedicated and fight this daily with those with intractable pain and in pain management-they bring their meds to the ER then I have a struggle to provide equal amounts and then some if they are admitted for something else. They are often undermedicated post op too!

M

[Purple_Scrubs, BSN, RN]

No way would I give a placebo for pain. JCAHO would have a field day with that!

[Flare, ASN, BSN]

I would have been interested to see how the pharmacy interpreted an order simply calling for a placebo.

[chenoaspirit, ASN, RN]

omg, imagine if something were to happen and the patient sued the doc, read their chart and found that order. That would NOT look good on the doc OR the nurse if she carried it out. One time a doc told me to administer saline into the IV of a patient and to tell them it was a good pain med. I did NOT do that and I called the coordinator regarding this. Ive never been told to do that again.

[leslie :-D]

this is something i too, feel strongly about.

even if i wanted to, i just could not do it...

it's an emotional response, not intellectual.

even knowing/rationalizing that in many cases, we're helping these folks, trust is the most important element of any relationship.

not just in nsg, but in personal ones too.

i'm sure there's a reason, however, that these acts were outlawed.

while i was perusing this thread, i also wondered about those who sneak meds into your pts...

for whatever reason, shouldn't that too, be just as much of a violation as placebos?

to me, it should be, but it's not.

interesting disparity, yes?

leslie

[Magsulfate, BSN, RN]

While I completely understand that the placebo thing is BAD, and I know that it is unethical, I would never do anything unethical. What about those extreme cases where the patient is MAXED out on very strong pain relief meds and if you give her anything more she will pass out and quit breathing...

Yet, she is still begging for pain relief. All tests have been run, there are no new acute things going on and you are sure of it,, and the patient, as long as her eyes are open and she is conscious keeps begging for more pain meds. And you KNOW that you've given her enough to kill a horse.... then what? The doc wants you to try an IV placebo...... you can't give her any more pain meds because she might stop breathing and DIE. So, you tell the doc,,, hey doc,, you give it because that is unethical and I won't do it.......... Then guess what.........

The doc gives it,, ,and the patient finds relief.

You can't tell me that it did not work. It worked. It happens, and it works.

However,. only in those extreme circumstances where you know that the patient is already so full of narcotics that if she gets anymore she will have to be intubated. If the patient is wanting the pain med that bad, she is not thinking about anything else. Maybe her pain is really bad like she says, but I've seen people that are so narc'ed up that there's no way they can even feel their fingers and toes. They can barely talk because their lips and tongue are numb and their face is droopy... and THEY STILL WANT MORE.

Instead of telling them,, there is no more, you can't have any... why can't the doc give a NS IV Push? just to give the patient relief that we are trying something, instead of not doing anything, because we can't give her anymore?

I understand that if it is allowed in those extreme circumstances that it would eventually be abused and the people that really need pain relief would be denied, and that's where I have a problem. I have been in pain before, and so have every one of you. There's no way that I would be alright with someone giving me a placebo, UNLESS they have maxed me out so far on narcs that they are afraid to give anymore. At that point, if someone is still in such bad pain that they need more meds,,, they SHOULD BE INTUBATED AND PUT TO SLEEP for a while. dang..

[wooh, BSN, RN]

I have been a nurse for long enough now to know that for me personally, black and white are rare shades in the world of nursing.

Absolutely. I've learned to absolutely NEVER say "never." It would be rare that I'd go for it, but I'm not going to say I never would because it seems there's been times that it has worked. I have to agree that if "pain is what the patient says it is" then relief is that as well. And if some normal saline or a sugar pill is working, then who am I to question it. And if it doesn't work, well, there's times that "real" drugs don't work either.