I am a Hospice RN/Case Manager who just recently assumed care of an elderly Nursing home Pt who has a son who is an ER Doctor. This man is completely involved in the care of his mother...can't blame him for that,.....except that we can't do a single thing with his mother without clearing it with him. I mean, I can't even have the mattress changed without running it past him.
THe issue that I have a real problem with is that this lady has a Stage III wound on her heel which requires daily wound care. It is very painful to her. I can tell, even if the lady is aphasic, because she pulls her foot away, and starts breathig heavy and "sputters", and moaning. When I first took care of her, I called this son, and asked him if I could PLEASE order up some Roxanol liquid Morphine for her to have 1/2 hour before wound care, to ease her pain. I got an earful about how "I don't want anybody doping my Mom up, my mom doesn't do well on morphine, she received it post-op, and it just knocked her out." I told him that I wasn't going to give her a large dose (POst-op doses are much higher and usually given IV, are they not??) but he cut me off, saying, that "I know how nursing homes operate, if they have it, they'll give it, and pretty soon, she'll be a zombie." Getting nowhere with him, I next consulted with the lady's husband who is her next POC. I told him that I was concerned about her pain, but that their son said no, and we have to go by his decision. Ten minutes later, I got a callback from this same son chewing me out for "trying to go behind his back." I told him of course that I did no such thing, that I was talking to his dad at his request, and was reporting on my observations as her new Case Manager. But again, his mind was made up, don't confuse him with facts. He said that his decision was final and under no circumstances, was his mother to receive any narcotic medicines.
A couple of days later, I was taking care of this lady at the same time as her husband was there, and I did her wound care. He would not stay in the rom while I did it, but waited in outside. When I was done, I wheeled her out to him, and of course she was still showing s/s pain. I told him "Do you see, sir, that she hurts? THat would care is very painful to her, see she still hurts." HIs answer was "Look, she is just going to have to hurt. MY son and I have made our decision, she is not going to get any narcotics of any kind, and that's all I am going to say about it, so I'd appreciate it if you din't bring it up again." I of course documented everything that was said, and reported same to the facility nurses who basically just shook their heads and said "we've all dealt with that son!"
THis lady has actually been with several different hospice providers before us, and was d/c'd from the last one for long-term prognosis, or as the son said "she wasn't sick enough." I feel very stymied by all this. My first instinct is to recommend that this lady be discharged, and tell the son, you want to take care of her, well here she is, have at it, since we can't do anything without his sayso anyways. THis lady has a past history of seizures and Tegretol was ordered, and the next day this son cancelled the order. Anybody got any thoughts on how to deal with this unfortunate situation?
does the medical director go along with everything the son says? talk with head of hospice, maybe they feel she is in such a coma that she doesn't feel anything but the nurse who attends her might have a different view
i think that the husband here is so over-powered by son that he can not make an in telligent decision if the attending gives in to the son as a colleague then this nurse may be the only voice that this patient has
I've heard family members of hospice patients voice concern that their loved ones may become dependent or addicted to pain meds. I ask "Where is the education"? God forbid I'm ever a hospice patient you may refer to me as "happily addicted".
Have you thought about what you are going to do?! I still don't understand how the son can override her doctor. Isn't her physician angry?! Couldn't you as the nurse get in trouble for not giving meds even though the son says no?! I like the suggestion of getting the doctor involved and then going to Administration. If that doesn't work then call Social Services. Someone needs to help this poor woman out.
I still don't understand how the son can override her doctor. Isn't her physician angry?!
I'm not understanding this situation. The son is a doctor but surely he is not her primary doctor? How can he override what the primary doctor orders? How can he cancel orders written by the primary doctor?
This is what I thought as well. I was under the impression that MD's cannot prescribe to family members. My first thought upon reading your story is that it is not legal for him to deny his mother pain meds if they are ordered by the primary. Does this primary doctor know of what is going on? S/he needs to step in and speak to the woman's son if he continues to stand in the way of her pain management.
We had a very similar situation where I worked. A lol was suffering from advanced bone cancer.
The family adamantly refused that she recieve narcotic pain meds. I have a feeling that cultural reason were cited as the reason for this (strange that we have come up against this cultre again and again with no objections to pain relief). This poor lady suffered a long time until nearly the very end when the family had to come to terms with this poor ladies imminent demise.
My guess is it's the sons fear of losing his mother (you know the common belief that it hastens the process/ addiction etc). He may be the doc he claims to be but is his fear for his mom clouding his judgement as a professional.
Take the issue higher if you need, but be diplomatic with the son, engage in conversation determine his fears, ask if there is an alternative he would agree to. I have done this myself and succeded. Families and docs included.
Has anyone ever tried to report this as elder abuse? I'm just curious. I can't imagine someone would be allowed to force an elderly person to suffer regular pain.
Absolutely. As a nurse, the OP is a mandated reporter. I wouldn't hesitate to do so.
Call the ombudsman. The number should be posted in your facility or you can check online. They are an excellent support for you. This is something that can be cited under quality of life, abuse and a whole bunch of other things.
Why is she there...wound care and adls? Missing the part about maintaining a quality of life during end of life care?
I don't work in LTC, but can't you give something like versed IM/oral? Try discussing this with the son, as we use it in the ED prior to certain procedures. Perhaps the son would be more willing to use something like this since it is "in his realm".
In the ED we almost always use versed IV, but I used versed IM once in a patient who had severe cerebral palsy and had continuous bleeding from an oral surgical site (wisdom teeth) - we had to "relax" him a bit before attempting to stop the bleeding, and an IV line would have been very difficult and traumatic to the patient; therefore, versed IM worked beautifully .
Versed doesn't help with the pain, but it does make the patient more "comfortable" and helps them to forget the procedure. And from what I understand, it has a shorter duration of action when compared to other medications of the same class.
The son has probably seen the effects of pain meds in the elderly while working as an ED doc, and this probably has tainted any open-mindedness on using pain medication in his mother (seriously, some people go WAY OFF the deep end on small doses of opioids). But there are multiple options and he should know better! I believe that the care he gives to his mom is probably similar to the care that he gives his patients (scary thought). I work with many ED docs who do a great job with ordering adequate pain medication and I can't imagine these same docs withholding pain meds from their own family members.
Just because the son says "no" doesn't make it right. A conference between you, the ordering MD, and others (ethics committee?) needs to take place. Pain is pain. Also, is there a WOC (wound, ostomy, continence) nurse that can come by and recommend an effective dressing that could be changed less frequently?
[:devil:On a side note, similar theme; I ALWAYS report facilities that sent patients with known fractures (or "suspected" fractures) who fail to provide pain medication prior to ED arrival. I've had patients sent 3 hrs after xray confirmation of a fracture (8 hours post-injury) that receive no pain medication (even though oxycodone q 4-6 hrs prn is ordered). Recently, I also had someone with a shattered elbow come to the ED, with documentation over 2 days that there was swelling to the site. The patient was in his 50's and had a hx of massive stroke, A/O x 0. He was holding his injured arm, and would grimace when it was touched (he would yell "Stan, why you gotta go down to the store, take me for a drive man!). Even though he wasn't saying "ouch", it was obvious he was in pain. And when I asked the EMT's if pain meds were given, they said "the RN's stated that the ED can take care of pain meds" :angryfire . He was aggitated, and the ordered ativan prn aggitation wasn't given prior to transport. Sorry for the rant, but my point is this: everyone deserves adequate pain relief, whether the person can articulate it or not.]
I wonder what the underlying issue is with the son's problem with narcotic pain relief for his mother...
Anyway, back to the patient. Is there anything else that can be given? Can anything topical be used such as lidocaine jelly, 4% lidocaine liquid, etc. prior to wound care? I know this has worked when we've cleaned up "road rash" in the ED.
(Forgive me if that's a dumb question. My knowledge of chronic wound care is limited.)
the son is not necessarily acting as a physician when he refuses to allow his mother to have a med....that is with in his realm as POA
as it would be her right to refuse a med, he is making that decision in his role as POA. That said...just because the woman is aphasic does dont make her incompetent...has she been ajudged incompetent? are you able to communicate with her? is she both expressive and receptive aphasic? is her aphasia mechanical or brain damage?....having her evalved for communication capicity and competence to make her own dec. would seem to be in order.....good luck
CHATSDALE
4,177 Posts
does the medical director go along with everything the son says? talk with head of hospice, maybe they feel she is in such a coma that she doesn't feel anything but the nurse who attends her might have a different view
i think that the husband here is so over-powered by son that he can not make an in telligent decision if the attending gives in to the son as a colleague then this nurse may be the only voice that this patient has