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.
Where this gets tricky is, the pt. has their right to know what they are being given. If they ask you, while adminitering the med. what it is, and it is the placebo (NS or something) and you claim it is a pain med, you are in trouble.
There are places that do this sort of thing, but not a hospital. I'd have refused the order, responded to the physician that he must give the placebo if he wishes for it to be done.
This is one of those things, hospital administration will cover their eyes and hope for the best. If things get outta hand though, people will be saying "Hey, what's Beetlebailey doing under that bus wheel?".
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?
Absolutey we would be at fault.
PRNs are ordered under the assumption that the nurse is assessing the patient and knows when something would be a danger.
Many docs do write "hold for sedation" for this reason. We all hold meds if our assessment deems it necessary - for example, we don't give a scheduled digoxin if the patient has a HR of 50, we don't give Lopressor if the systolic B/P is 80, we immediately d/c a cardizem drip and seek physician input if the patient experiences sudden bradycardia. We certainly wouldn't give a scheduled Cipro if the patient has broken out in hives after the previous dose.
Narcotics are no different - if your patient is hard to rouse, as a respiratary rate of 10 and still lethargically moans for a pain med, I would hope that his/her nurse wouldn't give a narcotic just because it was due and the patient asked for it. He/She should hold it and contact the physician.
The right to be free of pain is important but except in cases of active, anticipated death process, narcotics are subject to the same "do no harm" standards that any other pain med is.
I have help PRN narcotics many times and noted it and paged a physician.
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.
i've seen it work really well, too. "i'm going to give you your sleeping pill (not available, giving a tylenol) but stay in bed because it's really strong and i don't want you to have any falls". fast forward 15 min., the patient is knocked out and slept the rest of the night.
Well, that is a placebo if the desired effect is getting high. It's not really a placebo if the desired effect is pain relief - ultram IS a pain medication.
Ultram's not a placebo for pain relief. And there have been cases of people becoming addicted to Ultram. It's less likely to be abused than narcs but shouldn't be used as a placebo. And for me personally I prefer Ultram over narcs because narcs make me extremely ill most of the time.
Again, my issue is that pain relief would even be an area in which any nurse or physician would take a chance. A flexeril can stop spasms: spasms= pain, but we wouldn't classify it as a pain reliever, but that simple pill can make the difference between comfort and discomfort.
Fluids can stop a headache, so can ice packs, darkness and sleep. HOWEVER, WHY MAKE ANYONE SUFFER NEEDLESSLY? If they need a medication give it to them !
Some people are lucky, one tylenol PM and I am out! Others need alot of medicine to touch their pain.
I maintain that placebos should never be used to treat patients who say they are in pain.
I work as an Acute Pain Sister in the UK. This topic really annoys me. I have encountered it a few times in my career. If the physician, obviously feels that there is no pain and that the patient is asking for unnecessary analgesics, whether it's for attention or addiction, then it should be the physician that speaks to the patient and tells them that analgesia is being discontinued. They should never expect the RN to lie or deceive the patient in any way, shape or form! Although we know that they do. Pharmacy should be speaking to the physician also if they received this order. But certainly, the RN should never, ever give a placebo, unless it is in a clinical trial and the patient has consented. It is completely unethical. The RN should tell the patient, if asked for analgesia, that the physician does not want them to have anything and that they can speak to the physician if required. Someone further up the ladder should be involved with this. If the patient complains of pain and opioids are to be avoided then alternatives can/should always be offered. :)
With drug companies thrilled when their outrageously expensive drug is 2% better than placebo in a study funded by and weighted in favor of the drug I don't know why there is such a negative connotation to placebo. Personally I would have no problem taking a placebo as long as it produced a positive effect. No doubt the adverse and side effect profile will be much better.
I think I would want more information before deciding.
I'm only first year RN, but in our pharmacology class we have discussed that a placebo may be administered to clients; however, the ethical aspect of this treatment is that the client must first know and agree that a placebo is to be administered.
There is even the possibility that the client requested a placebo due to personal beliefs and ideologies in which case the physician should respect the client.
So maybe I would contact the physician and ask why they prescribed a placebo, and consider the client's knowledge and feelings on the situation before jumping to the conclusion that this treatment is unethical...
One thing about your account however really shocked me. I was very surprised to find that a secretary would ask a nurse to "decipher" a physician's order. As far as I have been taught, any time a physician's order is illegible it is the responsibility of the nurse to contact the physician and confirm the order or request a more legible order before administering the drug to reduce drug administration error. This policy is taught by the College of Nurses of Ontario and is supported by the Registered Nurses Association of Ontario as the standard practice.
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eriksoln, BSN, RN
2,636 Posts
Where this gets tricky is, the pt. has their right to know what they are being given. If they ask you, while adminitering the med. what it is, and it is the placebo (NS or something) and you claim it is a pain med, you are in trouble.
There are places that do this sort of thing, but not a hospital. I'd have refused the order, responded to the physician that he must give the placebo if he wishes for it to be done.
This is one of those things, hospital administration will cover their eyes and hope for the best. If things get outta hand though, people will be saying "Hey, what's Beetlebailey doing under that bus wheel?".