pain management for bone ca

kmchugh · Sep 5, 2005

Dinkymouse

STICK BY YOUR GUNS! You are absolutely correct in your assessment of this lady's pain. Even if the other nurses are correct that this lady might become addicted, SO WHAT?? She has cancer with widespread mets, and her potential for recovery is nonexistant.

Your co-workers are completely out of touch with current thoughts and practices on pain management. When given for real pain (and there is no pain more real than the pain of bone cancer), narcotics are not addictive. They treat the pain, and nothing more. Further, current thought is that if a patient with cancer does become addicted, that is less of a problem than failure to adequately treat pain.

Frankly, these nurses are living in the 30's. Their attitude towards pain is barbaric, and the thought of this woman spending her last days in this kind of pain is hideous. Inadequate pain management has become a reportable issue, and unless I am grossly mistaken, these nurses could all be reported to the BON for malpractice.

As I said, stick to your guns. You are doing exactly what you, as a nurse, should be doing. You are advocating for your patient.

Kevin McHugh, CRNA

fab4fan · Sep 5, 2005

Bone cancer ususally responds best to a multi-drug approach; opioids alone are not usually enough to control the pain.

I've found that using a combo of an NSAID (usually Trilisate, since it's less irritating to the stomach and comes in elixer if swallowing becomes an issue), a long acting opioid like MS Contin/OxyContin (in an appropriate dose, not just a small dose), as well as dexamethasone gives pts. better relief.

Can someone from your hospice depart./a local hospice come and give an inservice on pain mgmt? Do you have a pain mgmt. team in your hosp? Are these nurses aware that by denying this pt. adequate relief they are operating below the standard of care? Ask them if this pt were their mother/wife/sister...would they want her to suffer?

Good luck; sometimes it takes a maverick to get things going!

Home Health Columnist / Guide · Sep 5, 2005

from: challenges in pain management at the end of life - october 1, 2001 ...

bone pain typically cannot be completely controlled with narcotics. therefore, adjuvant agents are added to the narcotic regimen.8 first-line adjuvant therapies for bone pain include nsaids and corticosteroids such as prednisone (30 to 60 mg per day taken orally), dexamethasone (decadron; 16 mg per day taken orally) and methylprednisolone (medrol; 120 mg per day taken orally).

bisphosphonates, calcitonin-salmon (calcimar) or palliative radiotherapy may be used as adjuvant treatment in patients whose pain does not respond to nsaids or corticosteroids. bisphosphonates have been shown to reduce pain from bony metastasis.9,10 the bisphosphonate pamidronate (aredia) has been used in the treatment of bone pain; the currently recommended dosage is 90 mg given intravenously over two to four hours once a month. www.aafp.org/afp/20011001/1227.html

you have never heard such complaining. "well she'll get addicted, she od on it at home." "she needs to take as little meds as possible."

:angryfire :angryfire :angryfire

bone cancer one of the most difficult types of pain to treat and the most painful. from my experience in hospice and homecare, overdose is extremely but may occur if pain is unrelieved, especially if docs are not current in pain mgmt practices and don't prescribe adjunctive meds. addiction should not be an issue here or at any time then a patient has cancer pain!!!

a. she's in a nursing home. is goal long term placement here or short term rehab?

b. do you have a pain mgmt flowsheet that you use for patients with chronic pain to show your doing all you can to releive it?

c. can your medical director help intervene if this doc unwilling to provide effective relief?

see these resources:

the management of cancer pain

clinicians have recently discovered that a group of drugs called bisphosphonates (pamidronate is the most commonly used) halt bone corrosion and even reverse bone loss in some cases. these drugs also have shown potency in controlling pain.

discovery health :: cancer and bone pain

Home Health Columnist / Guide · Sep 5, 2005

PS: I agree that Trilasate great drug as NSAID for cancer patients with lower GI SE.

renerian, BSN, RN · Sep 5, 2005

Good Lord percocet for bone pain vs addiction. Is hospice the controller of the meds? Very sad....poor lady.

renerian

bargainhound, RN · Sep 5, 2005

Hospice can provide services even though she is in nursing home.

Make sure this suggestion is heard....either by the patient or her

family....they will make sure she has available pain meds that

will work.

renerian, BSN, RN · Sep 5, 2005

This is very true about hospice. I think the original post said something about hospice....is this patient a house patient or a hospice primary doc patient?

renerian

CardioTrans, BSN, RN · Sep 5, 2005

With bone cancer the percocet is probably not going to do much. If your facility has a contract with a hospice agency and the family and MD agree, the hospice can come into the facility and help manage this patients pain. The hospice agencies are a wealth of knowledge when it comes to pain management. I work for an agency that does both home care and hospice. We see MDs who are afraid of ordering the "hard pain meds" due to the fear of law suits. Unfortunately, some MDs dont understand pain management either.

Stick to your instincts and fight for this patient and her comfort. See if your DON or if you know a local company, see if they can come in and offer a class on pain management. The information that they learn from that class, will change their minds.

When I went back to working flexi in a hospital as a 2nd job, I was in ICU, had a nurse talking about 4 mg of Morphine for a patient. They made the comment that "the new nurse (me) may think we are trying to knock the patient out or kill her with that much pain med". I smiled looked at them, and said 4 mg is nothing when you are talking to a nurse who helps patients manage pain and breathing and has patients that take Ativan 2mg q 4 hr and Roxanol (liquid form of Morphine) 1 mg q 1hr..........and oh btw..... they are more coherent than I am in the mornings.

Needless to say their mouths hit the floor and couldnt believe that patients were given that much.

And if a pt with bone ca gets "addicted"........ who cares....... bone ca doesnt get better.

CritterLover, BSN, RN · Sep 5, 2005

i am not a hospice nurse, but i recently replaced a picc line in a patient getting hospice services at home.

know how much morphine he was getting? 150 mg/hr. seriously. quite alert and oriented. not the least bit drowsy. is he addicted to his morphine? i don't think so. habituated to it? most definatly. god help him if he ever has to go to the er for some odd reason (and i work er, too; we do get hospice pts on occasion) because he will never get that kind of dose there, and he will go into withdrawls.

dinkymouse · Sep 6, 2005

We do have hospice come in to our LTC. The family, since it has the DPOA, has to agree and they won't. I agree that morphine and and NSAID would be more helpful. I try and get things ordered but I only work weekends and sometimes when I get back someone has superceded my orders. I also agree that who cares if she gets addicted. I talked to the nurse who is charge on this unit on Monday, I am the only RN who is not management, and so holidays are going to be mostly mine. She is concerned about her tolerance when she does need stronger pain meds but she is also the one who recommended that we only give her the ASAP instead of the Percocet. I think some of the problem is the staff gets tired of her crying and consider her a problem patient. I can't get them to realize she wouldn't be so bad if her pain was controlled. She was taking her entire dose of Percocet in the am when she was at home. She is in a controlled situation here and that isn't a problem. I know I haven't worked in this facility more than 2 months but I have a broader knowledge than the staff here as I have worked home care and with hospice. The doctor here has no problem ordering what hospice says they feel the patient needs but we can't bring hospice in until we get family permission. I am having the hospice nurse I know fax me info on ca pain management. I also have doctors every weekend who say, "why did no one inform me this was going on." It seems I often have to take care of health issues that others either don't notice or leave for someone else to do. Like a pt. with nausea and vomiting intermittently for over 3 weeks. Boy was that doctor upset.

CoffeeRTC, BSN, RN · Sep 6, 2005

We do have hospice come in to our LTC. The family, since it has the DPOA, has to agree and they won't. I agree that morphine and and NSAID would be more helpful. I try and get things ordered but I only work weekends and sometimes when I get back someone has superceded my orders. I also agree that who cares if she gets addicted. I talked to the nurse who is charge on this unit on Monday, I am the only RN who is not management, and so holidays are going to be mostly mine. She is concerned about her tolerance when she does need stronger pain meds but she is also the one who recommended that we only give her the ASAP instead of the Percocet. I think some of the problem is the staff gets tired of her crying and consider her a problem patient. I can't get them to realize she wouldn't be so bad if her pain was controlled. She was taking her entire dose of Percocet in the am when she was at home. She is in a controlled situation here and that isn't a problem. I know I haven't worked in this facility more than 2 months but I have a broader knowledge than the staff here as I have worked home care and with hospice. The doctor here has no problem ordering what hospice says they feel the patient needs but we can't bring hospice in until we get family permission. I am having the hospice nurse I know fax me info on ca pain management. I also have doctors every weekend who say, "why did no one inform me this was going on." It seems I often have to take care of health issues that others either don't notice or leave for someone else to do. Like a pt. with nausea and vomiting intermittently for over 3 weeks. Boy was that doctor upset.

I'm the weekender too. I can't tell you how many times I come in to problems like these. It helps that we have a new DON who becomes involved in these situations. These nurses are extremely uneducated on pain issues (and I bet alot more) I would and have raised heck on matters like this. Of course she's "whiney" ...she is in pain. What I end up doing is recomending pain meds to the doc and get an order for it. When the rest of staff complains..Tell them...its what the doctor ordered.

What about a long acting pain med and Roxinal for break thru. Of course you can taper or increase them as needed.