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.
I had to chuckle a bit at this post because I can't tell you how many times myself and my colleagues would jokingly say "Can't we just get some placebos ordered?" when dealing with our needy prn seekers in the acute emergency inpt setting. This of course after they have gone through every prn available and we have called the dr. asking for more. I have said on certain occasions, I wouldn't be a good nurse if I gave you any more medication. Usually this was to a person who was slurring their speech, falling asleep at the med window and still asking for a sleeper. Obviously though, we never thought that placebos were actually being ordered in the medical hospital!
Just because someone appears unconscious does not mean they can't feel pain. Ask you peers who have cancer patients. Some cancers are so insidious that unless artificial coma was induced and perhaps even then (we really don't know), pain exists, and is very real to the sufferer.
That's why morphine is used...no ceiling.
Again, we all know mind over matter. God help any of us, if we are in that spot. I want the nurse caring for me to push, push, push.
M
So what you are saying, if you are in the position of suffering to no end and wanted it to just go away, you would want your nurse caring for you to push morphine until you go off peacufully. Though I don't disagree and would want the same, it is also viewed as unethical and if I recall correctly (correct me if Im wrong because Im not positive) its also illegal... so why is it OK to condone this practice but not the use of placebos if and when the Dr feels that it would medically benefit the patient?
Not trying to start an argument or anything, I truly want to know. I dont work in an area where I would face such things, but we never know what the future may bring.
I dont see the problem, if the patient has had their Rx'd pain meds and are still wanting something extra. If you give them the placebo and it works, then why not? Their pain is being controlled and as long as you dont say "hey here is a pain pill" you arent lying to them? As for informed consent, a lot of the people that this would work on, in my opinion at least, would be people that dont have the mental capacity to make informed consent for themselves. Say an elderly alzheimers patient in LTC... and really... do you get informed consent on every single medication that is given? Before the Dr writes an RX does he sit the patient down and say, OK this is what I'm giving you, now you have to sign this paper saying that its OK for me to give it to you...? Maybe it would help if when admitted to the hospital, or LTC, or wherever, part of the paperwork states that you are under the care of a physician and that he will treat you as deemed necassary? Something like that?
I dont know, just my thoughts on it. Like I said, I dont work where I have to deal with these situations...
...as for informed consent, a lot of the people that this would work on, in my opinion at least, would be people that dont have the mental capacity to make informed consent for themselves. say an elderly alzheimers patient in ltc...
as with any other patient, someone with alzheimer's must be assessed for pain. just because they cannot tell you with words about their pain does not mean you cannot assess them for heaven's sake. would you give a placebo to all children? sorry, the example just rubbed me the wrong way.
i personally would hesitate to give a placebo. in the circumstances as described, i would not give it because there is not enough info. my other question is why is there no instructor present? in my state, an instructor is required at every clinical site for just this reason.
Specializes in Home Care, Primary care NP, QI, Nsg Adm.
Years ago I saw placebos given by injection, usually saline, but only on rare occasion and I think I gave an injection once in the ER. If I recall it was stopped because of the limited benefit. Frankly, I don;'t remember much more about it because it did not come up often.
It is a legitimate order and has its place however, I believe it is quite limited because patients tend to figure out quickly that a medication is fake.
As to refusing to give it, I would clarify the order from the physician and ask him to explain his reasoning in order to understand the use of placebo in this patient as well as knowing how to deal with the patient if the patient questions the medication.
Could you give a bit of history about this patient which might clarify why the placebo was given. Is the patient drug seeking or malingering?
as with any other patient, someone with alzheimer's must be assessed for pain. just because they cannot tell you with words about their pain does not mean you cannot assess them for heaven's sake. would you give a placebo to all children? sorry, the example just rubbed me the wrong way.
i personally would hesitate to give a placebo. in the circumstances as described, i would not give it because there is not enough info. my other question is why is there no instructor present? in my state, an instructor is required at every clinical site for just this reason.
sorry, i think you took my example the wrong way... i was using them as an example of someone not being able to give informed consent. i guess i should have also said maybe someone in the advanced stages.
i totally agree, people with alzheimers do have pain, i know this very well. my grandmother had alzheimers. she could not speak but she could definately communicate her pain in other ways! but there would be no way that she would have been able to give her consent to anything. just as someone who is already maxed out on pain medication, they cannot give informed consent really, they are in an altered state of mind.
i never said dont assess for pain, i think pain assessment is a vital part of patient care. i said, if the patient has already had their meds, what does it hurt to give them something else that wont hurt them, especially if just the thought of having it makes them feel better? no i would not give a placebo to all children just as i would not give a placebo to "all" of any form of patient.
my thoughts on no instructor being present is that maybe she is in the end stages and doing preceptoring. at that point you are pretty much on your own with your preceptor.
Specializes in Critical Care, ED, End of Life, Pain.
As stated earlier, the AMA has come out vehemently against the use of placebos as being an unethical practice requiring the patient's consent. It's experimental, not treatment.
learned about Placebo during traing and saw it used on occasion to determin whither a pt. was actually having pain or just attention seeking. If the placebo worked then the pain was not real and beats having the pt. addicted to pain meds for no reason. If the pain is real then it was treated in short order. I am a firm believer in placebo especially in this age of "Pills fix all" and having a drug addict on my hands! They have to get the drugs somewhere!
The only thing that I can possibly think of, is if the patient were a participating member as part of a pain-study.
They sign a release stating that they may receive the medication or a placebo...but which, they won't know...but they understand this.
The doctor would need to be questioned...that is the only time it would be ethical to give a placebo if the patient were complaining of pain b/c the patient understands that is a possibility.
I know this is unethical. But there are some situations where you would want to give placebo for pain. For pts who are addicted to pain meds. That no matter how much morphine you give they are still claiming that there pain rate 10/10. If a Doctor order placebo for pain for sure there is a reason behind it.But again, i know placebo meds are not legal to use now.
I'm with the majority in saying I wouldn't give it. I actually had a patient who was a drug seeker hit me because he thought I was giving him a placebo pill. And to whoever had the orders to narcan the pt until family makes them a DNR that doctor shouldn't be practicing in my opinion.
PsychRN98, ASN
31 Posts
I had to chuckle a bit at this post because I can't tell you how many times myself and my colleagues would jokingly say "Can't we just get some placebos ordered?" when dealing with our needy prn seekers in the acute emergency inpt setting. This of course after they have gone through every prn available and we have called the dr. asking for more. I have said on certain occasions, I wouldn't be a good nurse if I gave you any more medication. Usually this was to a person who was slurring their speech, falling asleep at the med window and still asking for a sleeper. Obviously though, we never thought that placebos were actually being ordered in the medical hospital!