Order that says "Don't call MD for pain meds"?

Kooky Korky, BSN, RN · Dec 28, 2016

You must be leaving out some other context of the story. Most physicians don't just write orders saying "don't call me for xyz." Read the notes on the patient, their injury, their history, etc and see if there's something more to that order. Physicians generally aren't in the business of letting patients suffer.

Perhaps not intentionally. But they are very much, in my experience, especially those who do LTC, in the business of not answering their calls.

kaydensmom · Dec 28, 2016

We have a group of hospitalists where a standard order for every patient is "do not call for sedatives, pain medications, or anti anxiety meds, these will be addressed on morning rounds". I still call if it really seems like the patient is in pain, can't sleep, etc and it is really interfering with their comfort. I usually preface with "I'm very sorry to bother you with this but I did not feel that it could wait until morning". Now if this was just an individual order for one patient I would look into the patients past (pain management Doctor, hx drug abuse, etc) to see if maybe there was a reason for the order.

If if the patient seems to be in distress due to the pain (elevated bp, tachycardia, etc) then I would call regardless and let the on-call know about the order and let them decide. Then at least you did what you could and advocated for your patient.

allnurses Guide · Dec 28, 2016

Most physicians don't just write orders saying "don't call me for xyz."

The title of the post is misleading "don't call MD" but that's not what the note said, it says "don't call the on-call MD". There is a big difference there.

Boomer MS, RN · Dec 28, 2016

We have a group of hospitalists where a standard order for every patient is "do not call for sedatives, pain medications, or anti anxiety meds, these will be addressed on morning rounds". I still call if it really seems like the patient is in pain, can't sleep, etc and it is really interfering with their comfort. I usually preface with "I'm very sorry to bother you with this but I did not feel that it could wait until morning". Now if this was just an individual order for one patient I would look into the patients past (pain management Doctor, hx drug abuse, etc) to see if maybe there was a reason for the order.
If if the patient seems to be in distress due to the pain (elevated bp, tachycardia, etc) then I would call regardless and let the on-call know about the order and let them decide. Then at least you did what you could and advocated for your patient.

This is outrageous. Since you mentioned a "group of hospitalists", I assume you're referring to an acute care hospital. I am married to a surgeon who was on call for 43 years (every other or every third night) and got called all the time at night. He was never angry about night calls and was able to fall back to sleep quickly.(me not as well.) The cure would be to have this hospitalist sick and admitted and to need an order that cannot wait til "morning rounds." It's their JOB as a hospitalist. Maybe I'm a COB, but I never apologized when calling the MD on call. And some were nasty, but I didn't care.

BeenThere2012, ASN, RN · Dec 28, 2016

Doctor-shopping is a common strategy for many drug abusers. Typically, when hospitalized, they will wait until "after hours" to insist on calling the md in the hopes that a substitute unfamiliar with their behaviors will give them what they want.
This is why pain specialists insist that their patients get pain prescriptions exclusively from their practice. It's part of the contract they sign and is intended to control drug-seeking and manipulative behaviors. If your patient is known to abuse pain medication, the order is a reasonable one.

I agree with all of your statements except for the last sentence. Addicts with justifiable pain deserve some attempt to control their pain as much as anyone else. And, because of tolerance, they REQUIRE larger doses to achieve the same level of pain control. Of course, you need to have limits, but to say that because a patient is an addict, they should only receive Tylenol for mod-to severe pain is very debatable.

BeenThere2012, ASN, RN · Dec 28, 2016

Actually, NSAIDs inhibit the healing process according to the latest research.
Look, just because Tylenol has worked for certain people on here with a fracture dies not mean it works for everyone. We are not to judge people's pain.
There is a reason that order was written. Just call and clarify who you are supposed to call. No big deal. Why is it assumed they are a drug seeker or doctor shopper? There could be numerous reasons.

True. It would have been better to say who you should call for pain control issues or be more clear in general as to why, if it is a patient related issue.

heron, ASN, RN · Dec 28, 2016

I agree with all of your statements except for the last sentence. Addicts with justifiable pain deserve some attempt to control their pain as much as anyone else. And, because of tolerance, they REQUIRE larger doses to achieve the same level of pain control. Of course, you need to have limits, but to say that because a patient is an addict, they should only receive Tylenol for mod-to severe pain is very debatable.

You misunderstood my post. I did not say what you think I said. Finish reading the thread and you'll see it.

BeenThere2012, ASN, RN · Dec 28, 2016

There was an interesting article a year or so ago in the JEN about the efficacy of one gram IV acetaminophen; on the analgesia scale pts reported the same amount of relief as 2 mg of morphine, with placebo way below. Large scale study. My only problem using it in the ER is that you have to infuse it over an hour.
Long time ago at a pain management seminar, 650 mg of po tylenol was rated as equivalent to 30 mg of po codeine.
People just don't want it because it is OTC so it must not be "as strong as I need".

The assumption that OTC meds are not as effective is not always true, but yes, sometimes, the psychological factor comes into play. I have seen IV Acetaminophen work wonders for some....but not ALWAYS...Nothing is "always" with humans.

BeenThere2012, ASN, RN · Dec 28, 2016

Are we now giving Tylenol instead of MS04 for MI?
I would really have to question that study. And I wonder how long Tylenol's pain relief endures for someone with severe pain or even just sub-severe. And how long for the onset of action and of noticeable relief? Again, thinking of severe pain - such as MI, bad fractures, bad burns, and the sickle cell I used to see in ER.
Codeine - so not equivalent to oxycodone, hydrocodone, oxymorphone, the big guns.
Perhaps if this whole mess we now face hadn't been couched as Big Brother is going to come down on abusers, with the side effect of negatively impacting ordinary people who do not abuse drugs but who happen to have real and serious pain, either chronic or acute, I would have a more positive attitude.
Maybe if someone had referenced the study and article you cite here, this latest swing of the pendulum would be a less bitter pill to swallow.
I guess military in war scenarios will have to love that Tylenol instead of their Morphine. So what if their legs were just blown off? After all, we don't want them to get addicted and abuse the stuff. Sorry, couldn't resist.

I feel the same as you regarding this subject...I just have to add something. Morphine for MI's is not just for pain, but also reduces after load which lessons the "stress" on the heart. (At least that is what I was taught many moons ago). All the Cardiac nurses out there, please correct me if I am wrong. So, pain meds work in different ways for different reasons and some good Critical thinking goes a long way...if only more would do so. We don't have enough info on this to make ANY assumptions regarding the patient or doctor's reasoning for writing this order. I wish the OP would chime in and give us an update.

BeenThere2012, ASN, RN · Dec 28, 2016

The issue of pain control need not be approached as if it were a secret or worse yet a matter of conjecture.
The physician is being a provacateur in this instance by not defining the specific reasons why, I will assume opioids, are out of the question.
Until this issue is resolved it relagates the nurse into a snivelling errand boy/girl and an ineffective, incompetent caregiver in the eyes of the patient whether a drug seeker or not.
After all isn't the issue of pain control and mitigation a HEDIS measure that sooner or later must be addressed and reviewed in the light of day?

Thank you for this....yet another potential aspect of this post...doctor provocateur!

BeenThere2012, ASN, RN · Dec 28, 2016

The OP provided no information other than the order in question and the diagnosis ... then asked why such an order would be written. How does one not make assumptions?
My answer to her reflected my experience working with addicts with end-stage AIDS on an inpatient unit during the nineties. That work required that we treat pain effectively and control addiction behaviors at the same time.
Other posters, with different experience, posted different possibilities.
I've been fighting for compassionate and effective pain management since the early 70's. What's striking to me is the fact that these discussions always deteriorate into a big, polarized battle, with one side addressing only addiction and the other addressing only pain. The one thing both sides share is self-righteous outrage.
Of course, the only thing neither side mentions is caring for an active or recovering addict having pain.
Where is the OP, btw?

Asking the same question re OP....and have another.

Heron... In a case where a patient with a terminal illness, who is NOT actively working to remain sober, is in severe pain, why would you treat addiction at that point?

I'll give you an example, and please let me know your opinion on this...During that same period in time, I worked in a Family Practice clinic and had a patient who had a history of opioid addiction and was in the end-stages of HIV. One of his chronic infections included one of the diseases that cause diarrhea. He wore a diaper, had skin breakdown and an anal fissure. He could barely walk with weakness and pain and had to take a bus to get to our clinic. His primary, was sooooooooo concerned about his history of addiction, that he was only willing to prescribe 10 Tyco tabs every week. Made him come in weekly to check in and get the Rx. Would that seem overboard to you? I felt it was COMPLETLY devoid of compassion and common sense. If anything, the opioids might help the diarrhea, and if anyone would be in pain, this man was. No doubt...not a faker. He died a couple weeks later.

BeenThere2012, ASN, RN · Dec 28, 2016

You misunderstood my post. I did not say what you think I said. Finish reading the thread and you'll see it.

Okay. Apologies if I misunderstood.