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.

[Valerie Salva, BSN, RN]

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.

Very thoughtful post.

[Valerie Salva, BSN, RN]

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.

Excellent post!

Your first anecdote is a great example of unethical, inappropriate use of a placebo, and your second story is a perfect example of ethical, appropriate and effective use of placebo!

[rn/writer, RN]

I've been given an Rx for Ultram twice- it really doesn't do a damn thing. I've never met a single person who said it helped them.

Some meds don't work for some people. I have a family member, a young boy, who has histamine reactions to many narcotic meds. He needs the narcs after ortho surgeries, but his step-down med is Ultram. It really works well for him and allows him to taper off the morphine and dilaudid much sooner than anything else we've tried. Believe me, if it wasn't giving him relief, we'd hear about it.

On a similar note, in postpartum I have had a number of c-section patients on PCA dilaudid who just did not get the relief they should have. Even with a basal dose (which we don't often do) or periodic extra boluses, these poor women were still suffering. I learned from co-workers that people can have "blind spots" for certain meds. They flat out don't work. Now when I have such a patient, I switch her to oral pain meds and get rid of the PCA. It's amazing what a difference this makes.

The above situation is sort of an anti-placebo. Instead of a false "medication" giving a measure of relief, you have a real medication that doesn't help at all.

[Scubadiver]

You say you know this is unethical yet can find times when it's okay to give a placebo. It is never okay to be unethical. If a doctor doesn't want to give someone an opiate for pain he/she always has the option to offer the patient something else and tell the patient what that is. Likewise, the patient has the option to seek legal recourse for un/undertreated pain.

[Scubadiver]

I've been given an Rx for Ultram twice- it really doesn't do a damn thing. I've never met a single person who said it helped them.

Tramadol binds to mu receptors just like opiates do. It inhibits norepinephrine and serotonin reuptake so it is far from being a placebo. However, we all react differently to drugs. If it doesn't work for you then it just means you need something else for your pain.

[Tom123]

This is a difficult problem. I would really have to know the patient's history before I made the decision. I would hope the physician discussed it with the patient. I would ask if there is anything in the chart showing the patient is really drug seeking. What is the patient's diagnosis? I would really like to see a physician, who is not sure about pain medication, to seek a pain management referral for the patient.

Regretfully, there are doctors who think the patient is faking. I always fall back to this:

If the patient says he/she has pain -- he/she does.

The pain is as bad as the patient tells me.

On the other side -- While I was a Navy Nurse, I saw the use of placebos used in amputee patients, well past the post-operative phase. They were usually given for phantom pain, and it worked the majority of time. The doctor then told the patient what we had been giving him, and that he - the patient - had been controlling the pain all along.

Some patients think that a pain med should completely eliminate the pain. That is not the purpose of a pain med. The pain med, brings the pain down to a tolerable level.

Hope this helps.

[TiredMD]

Tramadol binds to mu receptors just like opiates do. It inhibits norepinephrine and serotonin reuptake so it is far from being a placebo. However, we all react differently to drugs. If it doesn't work for you then it just means you need something else for your pain.

Yeah, it binds to mu receptors just like opiates . . . just at 1/6000th the strength.

Personally, I think it's a crap drug, a throw-away to pawn off on your chronic back pain patients in the hope that the weak anti-depressant effect will improve their overall pain scores (since they all absolutely refuse to believe they have any kind of depression and don't want to be labeled as "crazy"). But that's just me.

For those who think it's okay to give a placebo (and I'm kind of amazed that it's taught in schools that it's an ethical thing to do), when you patient asks you what they're getting, what do you say?

[pearlrose57]

I would not give the placebo either. I just wonder what the motivation was for ordering it in the first place. What is the patient's history and diagnosis? Is there an emotional or psych component here? Pain can be perceived due to many reasons. If pain is not expected for the diagnosis, further evaluation is warranted. Maybe something was missed. If the physician still feels that pain should not be expected, maybe a psych eval should be suggested. This is just another train of thought to help in advocating for the patient. What do you all think?

[pearlrose57]

Thanks for your answer. I forgot to also consider/evaluate for drug seeking behavior.

[pearlrose57]

I'm still learning how to use this sight and I am not very computer savvy! My last response was to Tom123.

[Valerie Salva, BSN, RN]

Tramadol binds to mu receptors just like opiates do. It inhibits norepinephrine and serotonin reuptake so it is far from being a placebo. However, we all react differently to drugs. If it doesn't work for you then it just means you need something else for your pain.

I know all of that- I just know that it has never helped me at all- or my mother, or my mil, several friends, pts and so on. I know a lot of people who have full bottles of ineffective Ultram in their cupboards.

[Valerie Salva, BSN, RN]

Yeah, it binds to mu receptors just like opiates . . . just at 1/6000th the strength.

Personally, I think it's a crap drug, a throw-away to pawn off on your chronic back pain patients in the hope that the weak anti-depressant effect will improve their overall pain scores (since they all absolutely refuse to believe they have any kind of depression and don't want to be labeled as "crazy"). But that's just me.

For those who think it's okay to give a placebo (and I'm kind of amazed that it's taught in schools that it's an ethical thing to do), when you patient asks you what they're getting, what do you say?

Finally someone admits that Ultram is a crap drug!

It is very often prescribed for people who are already on Prozac and so on- so what's the point?

To me, an Ultram Rx = "I don't want to deal with you- so take this script and go away."