This is my first time posting on allnurses.com. I am a final year nursing student at Napier University, Edinburgh.
Part of my coursework involves selecting one of the World Health Organisation palliative care principles. I have chosen 'intends neither to hasten or postpone death.' My essay will provide a literature review and analyse wether euthanasia has any place within palliative care - What are your views on this?
How does the above discussion relate to clinical practice?
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.
I disagree, too. I think many of us do.
I hope that when I am dying (if that is in my cards) of some terminal illness, I have a liberal nurse to whom I can frankly say, "Just assume I am in pain unless I tell you otherwise, and keep the pain meds coming around the clock--and don't be stingy with 'em, either. If I stop breathing, I guess that means it's time for me to go, so don't try waking me up. I've had a great life, and I haven't always played by the rules, and I don't intend to start, now."
Giving prn meds around the clock to prevent pain is poor pain mgmt. If the pt has that much pain, he needs to be on a long-acting agent, rather than having the peaks and valleys of relief that come with prns alone. The goal is for the pt to be as pain-free as possible, while hopefully allowing the pt to maintain alertness/mental clarity when feasible. PRN meds should be needed only for breakthrough pain, and if the pt is needing more frequent prns, then the long-acting med needs to be increased (as does the prn dose). Giving prns only to someone who is in chronic pain, particularly someone who is terminally ill, is simply unacceptable and is outside the standard of care.
HPNA advocates this approach, as does the National Hospice Organization, the American Society of Pain Mgmt. Nurses, and the International Pain Society. A good reference to read on pain mgmt. would be the pain mgmt. manual by Margo McCaffery.
Nowhere do I read in Katillac's posts that she allows her pts. to be in pain. She is precisely right that pts needing frequent prns should be placed on long-acting agents, with prns for breakthough. The whole point of giving a long-acting med is to prevent the pain to begin with.
Nowhere do I read in Katillac's posts that she allows her pts. to be in pain. She is precisely right that pts needing frequent prns should be placed on long-acting agents, with prns for breakthough. The whole point of giving a long-acting med is to prevent the pain to begin with.
what katillac said is she gives a prn when she sees the first sign of pain. there is absolutely no reason to wait until someone feels pain- the goal is to prevent it.
and of course if someone requires frequent prns, then the plan has to be reevaluated. but whether you're on oxycontin, fentanyl, dilaudid, oxyfast, methadone- whatever the regimen is, you do NOT want to wait until the pt starts exhibiting signs. if a prn is for q3h- i don't methodically give it q3h but i certainly don't wait sev'l hrs before the next prn. also depends what the pt. presents with- there are some that don't require alot of prns- i am referring to those festering ca's w/intractible pain; it's not as if i see a prn and give it just because it's there. it's called nsg judgement.
as for what i write for the prn, i write "pain" because i have to. but be rest assured, i am right on top of the mds if i think there should be a more appropriate regimen/longer-acting. and if the mds deny my recommendation, then i give the prn q3h or a/o. and i also let the md know that i am documenting pt.moaning, ineffective pain relief, or whatever the pt presents with- that will usually get them to modify the current plan.
and btw, i'm really surprised at you fab4. i thought you were a major proponent of aggressive pain mgmt. you believe that a pt. should show pain and then give the prn?????? i refuse to believe that.
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.
i answered your questions in my response to fab4- i thought this post was from fab4 and responded, now realizing it was you that wrote it.
you and i are just not communicating- majorly misunderstanding ea other. katillac- you do sound like a good, competent nurse; i just think there's a link missing where we're not connecting.
when i talk about aggressive pain mgmt.,i am referring only to those patients who have presented with scathing pain- those challenging pts that even on long acting opioids, the prns only help for a brief time. and yes, the regimen needs to be modified and you do what needs to be done to get this pain under control.
but if i know my patient and their patterns of pain, then yes, i am going to give the prns before the pain sets in. there is nothing random in the way i adminster narcotics. but there are medical directors and attendings that are still reluctant to increase dosages, change meds, titrate up/down to desire effect. being in hospice is not synonymous w/pain. the only pt population i was referring to were those with poorly controlled pain, knowing the pt and what they're experiencing, and ensuring that they get a prn before the pain sneaks up on them again. i do this when they're sleeping also. i consider myself adept at assessing pain. i will not give narcs to those who don't need it just because they're on hospice. i've seen many peaceful,drug-free deaths.
but i've also seen too many stingy, cya mds who just won't work w/you when you come up w/a recommendation. and as i've stated, the only way i get them to change their minds is when i tell them that i intend to document my conversation w/them, md's response, pt's response to current pain mgmt.,etc. then they get paranoid and typically will irritably ask "what is it that you want for this pt?" because the doctors know that they could get in a heap of trouble for undertreating pain.
perhaps you were talking on behalf of the gen'l hospice population and i was talking about those w/poorly controlled pain????
i answered your questions in my response to fab4- i thought this post was from fab4 and responded, now realizing it was you that wrote it.
you and i are just not communicating- majorly misunderstanding ea other. katillac- you do sound like a good, competent nurse; i just think there's a link missing where we're not connecting.
when i talk about aggressive pain mgmt.,i am referring only to those patients who have presented with scathing pain- those challenging pts that even on long acting opioids, the prns only help for a brief time. and yes, the regimen needs to be modified and you do what needs to be done to get this pain under control.
but if i know my patient and their patterns of pain, then yes, i am going to give the prns before the pain sets in. there is nothing random in the way i adminster narcotics. but there are medical directors and attendings that are still reluctant to increase dosages, change meds, titrate up/down to desire effect. being in hospice is not synonymous w/pain. the only pt population i was referring to were those with poorly controlled pain, knowing the pt and what they're experiencing, and ensuring that they get a prn before the pain sneaks up on them again. i do this when they're sleeping also. i consider myself adept at assessing pain. i will not give narcs to those who don't need it just because they're on hospice. i've seen many peaceful,drug-free deaths.
but i've also seen too many stingy, cya mds who just won't work w/you when you come up w/a recommendation. and as i've stated, the only way i get them to change their minds is when i tell them that i intend to document my conversation w/them, md's response, pt's response to current pain mgmt.,etc. then they get paranoid and typically will irritably ask "what is it that you want for this pt?" because the doctors know that they could get in a heap of trouble for undertreating pain.
perhaps you were talking on behalf of the gen'l hospice population and i was talking about those w/poorly controlled pain????
leslie
I think I am starting to see this from your side.
We are blessed at our hospice with a community of MDs who for the most part respond extremely well and quickly to our nurses' requests for changes in orders. There are a few who drag their heels, but our medical director takes care of them. So if I have a patient with poorly controlled pain I can quickly and easily get a routine order in place or changed. It must be so frustrating to have MDs who do not respond appropriately and who you need to basically strong arm to get what you need for your patients! And absolutely, if I couldn't get an appropriate routine order in place I would document the doc's refusal to give me the order and use PRNs until we could get an appropriate regimen in place.
I recognize that you have a passionate commitment to pain management for your patients, and that's wonderful. I believe there are shades of difference in the way that we go about manifesting that commitment, in part forged by the respective environments in which we practice. I don't think that you give meds randomly or to patients that don't need them. It sounds like you have sound nursing judgement and utilize it. It also sounds like our documentation is required to be tighter, and while I don't have the freedom to give PRNs based on pain I think my patient may have in the future, I can get routine orders to cover that.
We have gone far afield of the OPs topic, and I apologize for that. Perhaps if this side thread should be continued, it's time to start a new topic.
OK, let's try this scenario and see if I can explain myself better:
Mrs. Smith is on OxyContin 60mg BID. She has OxyIR 20mg which she can have q4h prn for breakthrough pain.
Now, I am not just going to go ahead and give the OxyIR if the pt is not having breakthrough pain. That kind of defeats the purpose of having a long-acting and short-acting agent. It doesn't give you a true picture of how well the pt pain is being managed. It makes it impossible to know if/when to titrate the long-acting med, and by how much it needs to be titrated. I have been fortunate in that most of our doctors allow us to go ahead and titrate long-actings based on prn use; we follow the algorithm for the particular med. No one is ever left in intractable pain.
So yes, I am a very strong proponent of pain control. If I have a pt who needs frequent prn meds, I am going to give them routinely until I can get an order for a long-acting agent. But I wouldn't routinely give a prn med if the pt is on a long-acting med and is comfortable. That just doesn't make sense.
As far as giving pain meds to "ease someone out of this world," that's not what hospice is about, either. Hospice does nothing to hasten or prolong life. The goal is to make what time the pt has left as comfortable as possible. Ultimately, it's the disease that kills the pt. If a pt happens to die shortly after getting a prn, I consider it a consequence of the disease. There's no intent to kill the pt; that would be unethical at the very least.
OK, let's try this scenario and see if I can explain myself better:
Mrs. Smith is on OxyContin 60mg BID. She has OxyIR 20mg which she can have q4h prn for breakthrough pain.
Now, I am not just going to go ahead and give the OxyIR if the pt is not having breakthrough pain. That kind of defeats the purpose of having a long-acting and short-acting agent. It doesn't give you a true picture of how well the pt pain is being managed. It makes it impossible to know if/when to titrate the long-acting med, and by how much it needs to be titrated. I have been fortunate in that most of our doctors allow us to go ahead and titrate long-actings based on prn use; we follow the algorithm for the particular med. No one is ever left in intractable pain.
what i'm saying is you need to get to know your patient and their patterns. if the oxy 60 mg bid isn't holding them and you end up having to give them a prn does of the oxyir, then i'm going to give a 2nd dose of the oxyir in 3.5 hrs, knowing that the long acting opioid did not sustain them the 1st time.
i won't wait until they get the next episode of breakthrough. and then i can report my findings to the md.
i don't know who you're referencing about easing one's way out of death, but that is certainly not my philosophy. i've seen death too many times that there is nothing scary about it....yet if the pt is fearful, then i'll get a prn ativan order along w/other interventions. but if it's in my control, should i witness only 1 episode of breakthrough pain, that is 1 too much, thus my rationales for giving out the prns until the regimen can be changed.
The original intent of this thread was a discussion about palliative care and euthanasia. I was not implying that you or anyone else are euthanizing pts.
I guess we'll have to disagree on the breakthrough med issue.
Just because a pt. has BTP once doesn't necessarily mean he'll continue to have it. Sometimes one dose of a short-acting agent is all the pt. needs.
The guideline as given by hospice and the manufacturers of long-acting agents
is that if a pt needs three prn doses in 24h, then the long-acting dose needs to be increased. If you just assume that a pt is going to continue to have BTP, then you really can't get a clear picture of what his med needs truly are.
I guess I'm going to continue to follow the above guideline, as there are numerous resources that concur with it.
i didn't know that's what the standard guidelines were.
i'll bite the bullet and wait for the 2nd episode of btp; after that i will assume there would be a 3rd episode.
sometimes i feel that our patients are used as guinnea pigs for research purposes. grrrrrr. very frustrating sometimes.
I don't get it. You said in an earlier post:
"to NOT stay ahead of pain is a cruel and abusive act of blatant neglect."
But now you're willing to wait until TWO episodes occurs? What happened to not allowing patients to suffer, even for a minute? And after that third dose which you give because you assume there will be pain, how long do you keep that up? If you neglect to give an available PRN dose, aren't you "allowing them to suffer needlessly" according to your philosophy? On the other hand, if you just keep pouring the PRNs to them, how are you ever going to know how much medication they really need?
The unfortunate reality is that in order to treat pain appropriately, we need to be able to assess it, which we can't do until it occurs. Pain changes. It's worse in the morning, or after a day of being up and around, with movement, with eating, with procedures or after bad news. It's better after a tub bath, a warm pack, repositioning, prayer, or during a visit from the grandkids. You just can't assume that pain will be the same all of the time.
As people who try so hard to relieve suffering it's hard for us to watch it occur. And it's a balancing act, a level of alertness and side effects acceptable to the patient versus a level of pain acceptable to the patient. So we get a good fix on a routine or long acting dose, and wince with them when breakthrough occurs, noting that carefully to determine whether changes in the routine order are needed.
Sometimes it does seem like we are experimenting on them, and in a way we are, trialing different regimens until we get one that works. But if we are to respect our patients' right to be unique and treated as unique individuals, we have no choice but to let them display that uniqueness and respond to it.
stevierae
1,085 Posts
I disagree, too. I think many of us do.
I hope that when I am dying (if that is in my cards) of some terminal illness, I have a liberal nurse to whom I can frankly say, "Just assume I am in pain unless I tell you otherwise, and keep the pain meds coming around the clock--and don't be stingy with 'em, either. If I stop breathing, I guess that means it's time for me to go, so don't try waking me up. I've had a great life, and I haven't always played by the rules, and I don't intend to start, now."