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.

[abeni]

Ithink I am mixed on this as well.I have witnessed a similar situation in which the patient verbalized relief from pain after placebo was administered.Yes Pain is what the patient says it is and patients have a right to be duly anfd fully informed about their care meds inclusive.However being patient advocates would we advocate pain medications for a patient who is clearly drug-seeking knowing fully well the consequences of overdose.....Would we indirectly be responsible for doing harm in this circumstance all in the name of pain relief? We all know how relentlessly this category of patients ask for pain meds.

Penny for your thoughts anybody?

[dotherightthing]

I guess I'd want to know a couple of things such as, if the patient had a power of attorney or if he/she was signing his/her own consent for treatment. Also whether the patient has a psyche diagnosis, problems in the past with over medicating, etc. What's the patient's stated reason for pain medication?

What could be the reason for a doctor substituting a pain med with a placebo? And yeah, I would kick it above my pay grade and hope it would land in the lap of someone who could handle something like that on an adminstrative level.

[Tweety, BSN, RN]

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.

I'm not sure their position is as you say "vehemently against it", although some physicians are.

"Survey: U.S. Doctors Regularly Prescribe Placebos"

http://www.npr.org/templates/story/story.php?storyId=96063076

Aparently AMA's position on "informed consent" is not saying "I'm giving you a placebo......." but kind of dances around it a little bit.

[Eaglelady]

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.

I totally agree I think the main issue here in my opinion is that if it is ethical to give a placebo pain medication then have the patient to sign a consent form okaying it or go into the room and tell them thats what they are getting --don't go in and let them believe that what they are getting is the real thing--thats deceitful and illegal just my opinion

[jadelpn, LPN, EMT-B]

I can't get over that there would ever be such an order, as even if it were a medication, the order as you wrote it would still not be complete. (and never, ever give a medication on an incomplete order....) However, you can't give a "placebo"

[Eaglelady]

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.

If there are situations where placebos are given then tell the patient other wise it is wrong and illegal---you as the pt advocate have to inform the client what they are getting---would we as patient's like getting a placebo when we are believing we are getting the real thing? I know I wouldn't---and as far as saying a patient is a drug seeker thats not our call---pain is what a patient says it is when they say they have it---thats their call not ours--again just my opinion :)

[BabyLady, BSN, RN]

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.

The Joint Commission states that this is unethical.

"Pain is what the patient says it is".

Even for drug addicts. The reason is, pain is actually, undertreated, especially in ER facilities.

Yes, doctors do it, but they are risking getting sued, if in fact, the patient has pain.

A patient that is morphine addicted is going to be able to tolerate much higher doses to get their pain under control than you or me.

I would personally, refuse to administer it.

[rn/writer, RN]

I think most of us are in agreement that under current rules and guidelines it would not be right to administer a placebo (apart from research studies where patients know this is a possibility).

I just want to comment on a couple of confusing aspects of this discussion.

Administering a placebo to "see if the pain is real" is an exercise in contradiction. Patients who benefit from the placebo effect do indeed get some measure of relief from their pain, probably connected with the body's release of endorphins (naturally-produced neuro-chemicals similar to morphine). This does not mean that they weren't having pain. So using a placebo to scope out whether or not someone's pain is genuine is an invalid "test."

The practice of giving a placebo--because of the ethical considerations and the many problems involved--should not be done.

The concept of giving a placebo--when used within a very narrow framework--has been shown to help a small subset of patients whose belief that it would medicate them triggered physiological reactions that did indeed give them pain relief.

Giving a placebo now is wrong because we have decided that the risks substantially outweigh the benefits, not because there are no benefits to be had.

[Valerie Salva, BSN, RN]

A placebo would never cut it in place of a pain med, but here is a situation in which I saw one work in place of a sleeper.

I worked in a nursing home where there was a pt whom the doc felt was becoming dependent on her narcotic sleeping pill, so he D/C it.

The pt was really anxious about it, and was sure she'd never sleep again.

I asked the doc several times if there was something else he could give her. He refused. The pt had no familiy that I could get involved. She'd lay awake at noc and ask for her sleeper over and over again.

When the doc wrote an Rx for a MVI qd, I put the time on the MAR as 9pm.

The first night I gave her the MVI, I told her it was her new "really strong" sleeping pill. She slept well that noc, and almost every noc after that as long as I worked there. The other nurses and I agreed to never tell her that the pill was really a vitamin.

In this case, when I could not get an order for anything, a "placebo" did work.

I did work in an LTC years ago where one pt actually had a script for a placebo. The pills came in the usual bubble med card, and said "Placebo" on the label. It was a very colorful capsule.

The was a day shift med and I worked nocs, so I never gave it. I do not know what it was placebo for. The pt was demented with short term memory loss, and asked for pills all the time.

[stellina615]

I feel fortunate that I have not come across a situation like this in my practice. If I did, I would take serious issue with either 1) telling a pt that they're getting, say, a narcotic, when in fact it was saline, OR 2) skirting the issue and saying that I've got "a little something" to help them feel better without telling them exactly what's in the pill cup/syringe/IVPB. Don't forget that patients can request itemized bills for hospital stays that spell out every little charge, right down to the last pill. The case is not necessarily closed when your shift is over, nor even when the pt is discharged!

[TiredMD]

Ultram is my placebo of choice.

[BabyLady, BSN, RN]

When the doc wrote an Rx for a MVI qd, I put the time on the MAR as 9pm.

The first night I gave her the MVI, I told her it was her new "really strong" sleeping pill. She slept well that noc, and almost every noc after that as long as I worked there. The other nurses and I agreed to never tell her that the pill was really a vitamin

This is still an unethical practice.

The patient has a legal right to know what medication they are or are not receiving...because they have the right to refuse to seek a second opinion.

I don't think anyone is debating that placebo's do work in some cases, or that doctors don't occasionally prescribe them.

I think the question is whether it's ethical to give it to the patient.

There is no question that it violates the patient's rights if you don't tell them the truth.