Palliative Care and Euthanasia

ladybird1292 · Jun 12, 2005

Thanks for the posts on this thread, a very interesting subject. I am very interested in Pallative care/Oncology work and I will remember what has been said. I have just completed a Wound and Pain subject, being in my final year, and the focus has been to prevent breakthrough pain from occurring. That we are NOT creating addicts, we are relieving pain. Addiction is the pursuit of drugs for recreational use, not pain relief. Yes, tolerance can be built up over time, but that is not addiction when pain relief is the aim of treatment. Congrats on being advocates for your patients, and I hope when it is my turn that I will do the same.

leslie :-D · Jun 12, 2005

Too many nurses are afraid of making waves, let alone bypassing the chain of command or even approaching a physican directly to effect a change in orders that would better serve the patient. Those nurses have no place in end of life care, where a patient is absolutely dependent on his nurse to advocate for him--as is our role in the first place, in ANY patient care situation. Too many nurses, sadly, seem to have forgotten or never learned that.

taking it one step further, too many nurses will protect their own (when something happens w/a patient) rather than do what is needed to prevent harm from the patient again.

obviously pts not getting the care they deserve is a sore spot of mine; i even wrote a letter to the ama, BEGGING tptb to implement a course of pain mgmt/palliative care as a requirement for their core curriculum. sometimes my passions get the best (or worst) of me.

i think i must have been a wild one in another life. :chuckle

(and it carried over into my current one)

leslie

HospiceNurseDawn · Jun 23, 2005

Leslie -

I just wanted to say I really enjoyed your posts and totally agree with you. Apparently some of us have been at the bedside of a patient sweating and struggling for every agonizing breath who could not "verbalize" pain. What I may think is pain - another nurse may not. Lesson one in nursing is that pain is SUBJECTIVE. No matter how good your assessment skills are - a nurse can never truly assess a patients pain level unless thay hear it from the patient themselves. I can use my education and experience to know if a patient has liver ca with bone mets for example - they ARE in pain whether they can let me know or not. Causing a patient to reach breakthrough pain when it can be avoided is almost criminal.

I loved your thoughts on this subject.

Dawn RN

Katillac, RN · Jun 23, 2005

Leslie -
I just wanted to say I really enjoyed your posts and totally agree with you. Apparently some of us have been at the bedside of a patient sweating and struggling for every agonizing breath who could not "verbalize" pain. What I may think is pain - another nurse may not. Lesson one in nursing is that pain is SUBJECTIVE. No matter how good your assessment skills are - a nurse can never truly assess a patients pain level unless thay hear it from the patient themselves. I can use my education and experience to know if a patient has liver ca with bone mets for example - they ARE in pain whether they can let me know or not. Causing a patient to reach breakthrough pain when it can be avoided is almost criminal.
I loved your thoughts on this subject.
Dawn RN

I don't think you'll get much argument from anyone that it's poor nursing judgement to fail to take action with a patient who is "sweating and struggling for every agonizing breath (because they) could not verbalize pain". However, there is a huge difference between allowing that and presuming that you know, based on a patients' diagnosis, who has pain and who does not. My education and experience have taught me that all patients are different, that I need to assess carefully using both nonverbal and verbal signs and symptoms. If my serial assessments show that my patient has persistent pain, I often approach the MD for a routine order or a long acting med. Until I get it, I continue to treat the first sign of breakthrough pain.

By your logic, if I have a patient that gets a PRN order, I should start giving it then and give it to the max perameter routinely to eliminate the possibility that they might have pain. With opioids especially, the consequences of that can be dangerous, and I think it shows poor nursing judgement. You say that "pain is subjective" but then go on to say that you know based on diagnosis whether a patient has pain or not. So if someone with liver CA with bony mets says he has no pain, you give him the PRN anyway? Your education and experience have taught you that you know best, it seems.

This board is read by both laypeople and professionals. I'd like to assure those reading that few nurses take this "one size fits all" approach to pain management, and few allow pain to go untreated.

stevierae · Jun 23, 2005

I don't think you'll get much argument from anyone that it's poor nursing judgement to fail to take action with a patient who is "sweating and struggling for every agonizing breath (because they) could not verbalize pain". However, there is a huge difference between allowing that and presuming that you know, based on a patients' diagnosis, who has pain and who does not. My education and experience have taught me that all patients are different, that I need to assess carefully using both nonverbal and verbal signs and symptoms. If my serial assessments show that my patient has persistent pain, I often approach the MD for a routine order or a long acting med. Until I get it, I continue to treat the first sign of breakthrough pain.
By your logic, if I have a patient that gets a PRN order, I should start giving it then and give it to the max perameter routinely to eliminate the possibility that they might have pain. With opioids especially, the consequences of that can be dangerous, and I think it shows poor nursing judgement. You say that "pain is subjective" but then go on to say that you know based on diagnosis whether a patient has pain or not. So if someone with liver CA with bony mets says he has no pain, you give him the PRN anyway? Your education and experience have taught you that you know best, it seems.
This board is read by both laypeople and professionals. I'd like to assure those reading that few nurses take this "one size fits all" approach to pain management, and few allow pain to go untreated.

Kat, maybe I am an "old fashioned" nurse, but I don't think that ANY patient should have to ASK for pain medication---let alone a dying patient.

I was taught to round frequently on my patients (not wait for them to summon me via call bell, asking for their pain meds--at that point, I would feel I have failed them) ask open ended questions, OFFER the prn pain meds, and encourage them to take what's ordered--in other words, not to wait until pain is at a point where they are suffering, and have to ASK for pain relief.

We didn't have a numeric "pain scale" in the '70s when I was a corpsman, or in the early 80's when I was in nursing school, but we were always taught--and I still practice this way--that no patient should have to advocate for himself--EVER. That's a NURSING responsibility.

Too many people, particularly older men, are stoic and won't ask for pain meds. Why not offer them, so that they don't have to be put in a position of doing so? Why not be liberal with the use of pain meds, particularly with the terminally ill?

I don't work in hospice, but I sure think that's a place where independent decision making on the part of the nurse is critical, and I think perhaps it's not a place where everything must be done "by the book." THese people are dying, and they are suffering intractable pain----and I'm sure that pain, on a scale of 1-10, is more like a 25. I think it would be criminal to not treat that pain early and liberally, with everything I have available.

hollyster · Jun 23, 2005

Kat, maybe I am an "old fashioned" nurse, but I don't think that ANY patient should have to ASK for pain medication---let alone a dying patient.
I was taught to round frequently on my patients (not wait for them to summon me via call bell, asking for their pain meds--at that point, I would feel I have failed them) ask open ended questions, OFFER the prn pain meds, and encourage them to take what's ordered--in other words, not to wait until pain is at a point where they are suffering, and have to ASK for pain relief.
We didn't have a numeric "pain scale" in the '70s when I was a corpsman, or in the early 80's when I was in nursing school, but we were always taught--and I still practice this way--that no patient should have to advocate for himself--EVER. That's a NURSING responsibility.
Too many people, particularly older men, are stoic and won't ask for pain meds. Why not offer them, so that they don't have to be put in a position of doing so? Why not be liberal with the use of pain meds, particularly with the terminally ill?
I don't work in hospice, but I sure think that's a place where independent decision making on the part of the nurse is critical, and I think perhaps it's not a place where everything must be done "by the book." THese people are dying, and they are suffering intractable pain----and I'm sure that pain, on a scale of 1-10, is more like a 25. I think it would be criminal to not treat that pain early and liberally, with everything I have available.

I agree completely, Stevierae. No one should suffer. If a nurse is uncomfortable with properly medicating pts they need to further education on pain management. It is nonsense that a pt will get addicted on a short hsp stay, if a pt comes in addicted we are not going to fix them in an acute setting and if they are terminal it is cruel to the point of criminal,IMO, if they are not medicated properly.

Katillac, RN · Jun 23, 2005

You said, "Kat, maybe I am an "old fashioned" nurse, but I don't think that ANY patient should have to ASK for pain medication---let alone a dying patient."

I was taught to round frequently on my patients (not wait for them to summon me via call bell, asking for their pain meds--at that point, I would feel I have failed them) ask open ended questions, OFFER the prn pain meds, and encourage them to take what's ordered--in other words, not to wait until pain is at a point where they are suffering, and have to ASK for pain relief.

I think I'm not communicating clearly. It's not my practice to require that my patients ASK for pain meds. I round and assess frequently and offer PRNs when there is any indication that they are needed. What I don't do is assume that they are having pain based on diagnosis, and routinely give medications that are ordered PRN because I assume that the individual is in pain.

And here's the thing that has caused much of the response here: I don't give PRN pain meds routinely to people who I think may have pain in the future if I don't give them; I confirm pain with the patient using either verbal or non-verbal means. There have been a lot of emotional statements made in this thread, including references to the "criminality of allowing a patient to suffer for even one minute", but if you engage in the legal practice of nursing, you don't give PRN meds routinely and prophylactically. "Pain med PRN to prevent pain" wouldn't be a legal order; it would be impossible for a nurse to predict how much pain a person would have and how often.

Obviously, all cases are different. If someone has come to our facility with a medication that the doctor ordered "just in case", the family indicates that they have never taken it and they deny pain, I'm not going to offer it. If I have someone who has been struggling with pain, I try to establish an appropriate long acting dose based on the number of PRNs that they have required to get comfortable, get that ordered and started, and then continue to reassess for breakthrough pain, all the while giving breakthrough meds when I see any signs or symptoms of pain. Note I didn't say, "Wait for them to tell me they are in pain."

We didn't have a numeric "pain scale" in the '70s when I was a corpsman, or in the early 80's when I was in nursing school, but we were always taught--and I still practice this way--that no patient should have to advocate for himself--EVER. That's a NURSING responsibility.

I don't necessarily use the pain scale, either. But I guess I'm not sure what you mean here. I agree that advocating for patients is a nursing responsibility. And I fulfill that role in response to my assessments, not from assuming that because a patient has a certain medication ordered that it needs to be offered frequently without any indication that it's needed.

Too many people, particularly older men, are stoic and won't ask for pain meds. Why not offer them, so that they don't have to be put in a position of doing so? Why not be liberal with the use of pain meds, particularly with the terminally ill?

My approach would be very different with someone who I suspected was being stoic. And I'm all in favor of being liberal with the use of pain meds, and I have no problem offering them. But pain meds, especially the opioids we use in hospice, have side effects that are significant and can be dangerous. I'm completely justified in my patients having those side effects if the end result is that they are relieved of pain, but I need to see evidence of pain to relieve (and yes, that can come in the form of a verbal or non-verbal). My practice is to keep all patients, dying or not, comfortable to the extent I can. I do that by assessing and offering and giving meds where they are indicated.

I don't work in hospice, but I sure think that's a place where independent decision making on the part of the nurse is critical, and I think perhaps it's not a place where everything must be done "by the book." THese people are dying, and they are suffering intractable pain----and I'm sure that pain, on a scale of 1-10, is more like a 25. I think it would be criminal to not treat that pain early and liberally, with everything I have available.

You have some misunderstandings about hospice patients. Anywhere from 40 - 60% of my patients at any one time have non-cancer diagnoses. And of them many, even cancer patients, have no pain at all, never mind intractable pain. How are you, "sure that there pain is more like a 25"? Beyond that, nurses in hospice are under the same standards of practice that any other nurse is. Every PRN dose that I give must be documented with what I gave, why I gave it and what the effect was. It's not acceptable for me to write, "Gave Roxanol 10mg @ 1800 to keep patient from having any pain as it had been four hours since previous dose." That's why it's my facility's policy as well as that of the board that certified me to look for either a long acting med or an increase in the long acting med if a patient has more than three episodes of breakthrough pain in 24 hours. Nurses in hospice need to go by the book, too, and get the book changed if it doesn't meet the needs of their patients. Of course there are those who don't feel a need to go by the rules, but I think they risk their licenses and the wellbeing of their patients.

I have a patient right now who, while being on high doses of pain meds had declined to the point that she was much less responsive. However, for reasons nobody understands, she improved dramatically to the point that she is now up and about, interacting with family and friends, wandering in our gardens and has taken up her former habit of smoking. Along with her improvement came a decrease in pain. While it's is slowly escalating, her pain is very well controlled on less pain med than she was on when she was declining weeks ago. If we had simply kept pouring the pain meds to her instead of assessing her and realizing that she was no longer needing as much, we would have denied her the past two weeks with family and friends. Had we continued to routinely offer her the same doses, instead of seeing if we could taper her for more alertness, I believe she would have taken them. She trusts us and would have thought we knew what was best, I suspect. And giving those levels of meds when there was less pain would have sedated her, I believe to the point that she would not have "come around" for these weeks.

I will not compromise the quality of the remaining time my patients have based on the fact that I am afraid that they MIGHT experience pain. I will continue to assess and give pain meds in the way I feel appropriate, including offering meds when I have any reason to suspect that pain is an issue.

leslie :-D · Jun 23, 2005

and stevierae, ESPECIALLY when it could be prevented altogether. waiting for the 1st sign of pain not only makes the pain more difficult to handle, but it invokes much undue anxiety and fear for the pt. anticipating when the pain is going to return.

and for those stoic and reluctant patients, educate, educate and educate. i've had several pts who refused pain meds but once a therapeutic relationship was established, they trusted me and my recommendations. i never just took no for an answer, esp when i knew they were in pain.

to NOT stay ahead of pain is a cruel and abusive act of blatant neglect.

leslie

hollyster · Jun 24, 2005

and stevierae, ESPECIALLY when it could be prevented altogether. waiting for the 1st sign of pain not only makes the pain more difficult to handle, but it invokes much undue anxiety and fear for the pt. anticipating when the pain is going to return.
and for those stoic and reluctant patients, educate, educate and educate. i've had several pts who refused pain meds but once a therapeutic relationship was established, they trusted me and my recommendations. i never just took no for an answer, esp when i knew they were in pain.
to NOT stay ahead of pain is a cruel and abusive act of blatant neglect.
leslie

Earle58,

I agree. In some pts the fear and anxiety of the pain overwhelming. If a pt knows they will be medicated properly they are more relaxed and able to move around more easily, DB/C and heal faster (IMO more people die because of pain then properly assessed and medicated for pain.) You are so right about having therapeutic relationships with pts they are putting their faith in our skills we owe them the best care possible so we do not violate that trust.

leslie :-D · Jun 24, 2005

Earle58,
I agree. In some pts the fear and anxiety of the pain overwhelming. If a pt knows they will be medicated properly they are more relaxed and able to move around more easily, DB/C and heal faster (IMO more people die because of pain then properly assessed and medicated for pain.) You are so right about having therapeutic relationships with pts they are putting their faith in our skills we owe them the best care possible so we do not violate that trust.

you know, it's obvious i'm incredibly impassioned re proper pain mgmt., esp in eol care. as horrified as i was at katillac's philosophy, i have tried to understand it over and over. her concept of prn is when she sees a sign of pain, then a pain med is needed....a rather concrete perspective. whereas our views of prn are perhaps more abstract, in that in order to prevent pain, we give prns, which are needed to attain that goal. but whatever the etiology is, there is no reason in this day and age, to allow anyone to suffer silently or otherwise.....there should be a hell of alot more classes in proper pain mgmt.jcaho shouldn't be calling pain the 6th vital sign w/o implementing a plan where all healthcare providers are educated enough to appreciate their policy.

leslie

stevierae · Jun 24, 2005

Earle58,
I agree. In some pts the fear and anxiety of the pain overwhelming. If a pt knows they will be medicated properly they are more relaxed and able to move around more easily, DB/C and heal faster (IMO more people die because of pain then properly assessed and medicated for pain.) You are so right about having therapeutic relationships with pts they are putting their faith in our skills we owe them the best care possible so we do not violate that trust.

I wonder how many, also, are embarrassed to ask for pain meds (opiates, I mean) because they know that severe constipation may result and they would feel humiliated by the thought of having to receive an enema or, worse, being disimpacted. Imagine how powerless that would make a vulnerable patient feel, and it seems to me that dying patients, particularly the ones who have intractable pain, are already feeling pretty powerless--and vulnerable.

I guess there has to be some really open communication and teaching, and a finely established sense of trust between patient and caregiver in a sensitive situation such as this. If I was a hospice patient, I'd have a really hard time communicating openly (and even perhaps trusting) a caregiver who let me even GET to the point of pain--ANY pain; even pain described as a "1" on a scale of 1-10.

If I was dying, I sure wouldn't care about respiratory depression from liberal use of narcotics--in fact, I would think the individual givng me those narcotics was an angel to "err" (a better word would be, I guess, "decide" since I don't consider this decision an "error") on the side of not letting me suffer for even one minute.

I saw a form that hospital patients had filled out that talked about whether their pain needs had been assessed and addressed while hospitalized.

I could not believe the number of older patients, both men and women, who said that they had significant pain, not treated AT ALL, because:

---They didn't want to bother their nurse

or

---"Pain is to be expected, it's part of being hospitalized"

So very sad that these patients had no nurse teaching or advocating for them, and that they had to suffer

Katillac, RN · Jun 24, 2005

you know, it's obvious i'm incredibly impassioned re:proper pain mgmt., esp in eol care. as horrified as i was at katillac's philosophy, i have tried to understand it over and over. her concept of prn is when she sees a sign of pain, then a pain med is needed....a rather concrete perspective. whereas our views of prn are perhaps more abstract, in that in order to prevent pain, we give prns, which are needed to attain that goal. but whatever the etiology is, there is no reason in this day and age, to allow anyone to suffer silently or otherwise.....there should be a hell of alot more classes in proper pain mgmt.jcaho shouldn't be calling pain the 6th vital sign w/o implementing a plan where all healthcare providers are educated enough to appreciate their policy.
leslie

JCAHO is calling for a 6th vital sign? Good heavens, I'm way behind. I thought the five they advocate for were B/P, temp, pulse, respirations and pain. What is the sixth?

You and I disagree on this one, leslie. I understand your perspective, I just disagree. Calling my practice abusive and criminal won't change that, and neither will more "education". In all of the many presentations I have seen, including the latest information I got today from JCAHO which I will be posting as soon as I have permission, nowhere does it indicate that it is appropriate for a nurse to look into her crystal ball, determine how much pain a patient is going to have and when, and give a PRN prophylactically. That's why we have doctors; they order routine meds to cover expected pain and PRNs for breakthrough.

In an attempt to understand your perspective, I will ask how you document these PRNs that you give before you see any evidence of pain. What do you list as your objective reasons for giving them? Perhaps it comes down to our facilities have different documentation standards. Our staff must list the specific reason they give PRNs, and we've been told by the state that the old "to enhance comfort" or similar vague and subjective reasons aren't appropriate. Catchy phrases like, "You have to stay ahead of the pain" won't do for indications, either.

Quite frankly, I think that a nurse who goes ahead and gives PRNs routinely without any indication that there is a need for them may be serving her own desires to see herself in a good light and trying to save herself the trouble of assessing rather than practicing in her patients best interests. But I am sure you will disagree.