NO, my husband is not in pain. Or is he?

[SoCalRN1970]

I admitted a patient last week with the dx of CHF. He was moving around in bed, and snf staff reported he was agitated and in pain. Patient wife at bedside.

I asked to speak with her to just get a better insight on the patient status. She openly stated he never has pain, this is his normal baseline. Patient can answer simple quesrions. " Hello Mr. Smith, are you in pain right now?" patient states "Yes, I am!!" Nothing on the chart except Tylenol which he has been getting around the clock. Spouse said " he never said that before!" She agreed to have another pain med orderd. Dr. ordered routine vicodin q6. ( giving this is a snf and well, we know how prn's are easily missed) Spouse agreed to this tx.

ONe week later. SNF calls. Patient spouse wan't to dc medicaitons! Only allow tylenol. I assess patient, he is in pain. I called spouse left message. We can dc medicaiton, but MD will be notified, and I have to document request to decline vicodin. I also said my findings are patient is uncomfortable.

Can you lend me a brick wall so I may hit my head against it. I sometimes wonder if family wishes to have their family suffer the last few months of life. SOOO FRUSTRATING.

I have my work cut out with this one. Utlimately the family's decision to allow proper symptom management.

[tewdles, RN]

Have a sit down with the spouse, you, and the MSW. Invite the other disciplines if you want...have a little IDT, if you will. You are, after-all, the case manager and you have addressed a problem which is impacting your ability to meet goals of care (comfort).

Be calm, kind, and professional. See if you can't find out what her fears are and address them.

Good Luck!

[tencat]

Is he cognitively impaired? If not, then it's HIS decision whether or not to have pain medication, no matter what wife says. If she's the POA and is officially making his decisions, then you've got another issue on your hands. You might try asking wife why she doesn't think he needs medications, or why she's afraid to give him any.

[SoCalRN1970]

Cognitively impaired, dementia. Wife is acting a bit clueless... btw? She never returned my calls.. so yes, I have my hands full.

[Whispera, MSN, RN]

Try not to ask the dreaded "why" question, because that puts people on the defensive. Instead, sit down with her and talk about what you see in her husband that indicates he's in pain. Maybe he puts on an un-pained act for her, so she won't worry about him so much, trying to not be a burden, yada yada. Maybe she hasn't seen behaviors or heard words that indicate he's in pain. Ask her what she's noticed that says to her that he's not in pain.

Assess him and ask him questions with her present, so she can see what he does and says to you, as opposed to what she sees and hears when you're not there. Talk about these things in his presence and even address your words to him. Maybe he can respond and indicate what he needs and wants if he hears the conversation and is part of it rather than having people talk about him. I firmly believe people with dementia can hear and process more than they can tell us they hear and understand. They are still there!

Also ask what worries she has about the medications. Maybe she has some (addiction, stopping breathing, making him just sleep the rest of his life).

You have a big sit-down needed here. That's part of being the nurse for a hospice patient quite often. You need to keep trying.

I have to say, also, that even if he is cognitively impaired by dementia, if he can say he wants medication, I'd be listening to him and doing my best to convince his wife that he should have the medication, whether she's POA or not.

[AtlantaRN, RN]

is her desire to stop vicodin because he is sleeping more or is more sedated?? I get that alot from family members....

[sharpeimom]

my mother and mil both died of breast ca. my mom also had liver, pancreas, and brain mets. she suffered from horrible n&v and, later, pain. my mil had mets to her spine and hips, and was in agonizing and unremitting pain.

i had hospice for my mom and they were fantastic and caring! they saw that my mom had what she needed to stay comfortable and pain free, but her twin sister who was there from out of state remained absolutely adamant that she would receive no narcotics of any kind. by then, my mom had severe dementia and i had poa, but my aunt made things extremely difficult, sometimes bordering on absolutely impossible. all trys at explaining that addiction was not a concern, fell on deaf ears. even attempts by the nun who ran the program failed. that was in 1987, and my aunt still tells people that i "tried to turn ___ into a drug addict!":banghead:

my mil, on the other hand, was a christian scientist. all attempts to convince her that regular doses of rx pain meds would be permissable, failed miserably.

different ideas. misconceptions? one woman died an agonizing death, and the other died as comfortable as was humanly possible. my relationship with my beloved aunt has never quite repaired itself, despite many attempts.

could she have addiction fears or maybe the idea that if your faith is strong enough, you will not suffer unendurably severe pain? or has he been like my husband? before recent very painful foot surgery, my husband had never taken tylenol. ever! he gladly swallowed vicoden prn for a week, but it took

reassurances from me that it really was ok.

you just never know.

[Whispera, MSN, RN]

Another thought held by some, to think about is...some believe a person must suffer to enter into their afterlife in all its heavenliness.... I've had some patients who believe that and that's a reason they refuse pain medications.

[SoCalRN1970]

well.. still no return phone call today. Will ask for a family meeting with our social worker.