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?
"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?
granted, it is contradictive as my ambivalence is now evident.
i was merely going by fab4's stated guidelines of 3 prn doses/24 hrs= need for differernt regimen. the intellectual part of me is stating that makes sense. yet if i have to give 1 prn dose of a narc for btp, then i assume there will be a 2nd episode of btp......i anticipate it and treat it accordingly. as stated, i was not aware of these guidelines and that's why i compromised my values to 2 prn doses. i'm not sure if i'll still do it, but probably will. if a pt. needs a 2nd breakthrough dose, i'd feel safer in assuming that a 3rd one would follow. so that's why i expanded my thought process to r/o the notion that it might just happen 1 time. learning is a perpetual process and even i can push my emotions aside and make an unbiased, clinical judgement.
nothing written in concrete however, lol. i said i'll try it.
But the thing is, you can't just assume that the pt is going to have a second or third episode of pain.
If you were taking care of a pt who was having chest pain, would you continue to give prn nitro sl, assuming that since the pt had chest pain once he will continue to have it?
But the thing is, you can't just assume that the pt is going to have a second or third episode of pain.
If you were taking care of a pt who was having chest pain, would you continue to give prn nitro sl, assuming that since the pt had chest pain once he will continue to have it?
well if the ntg didn't work after the 3rd dose, there are definitive protocols to be followed.
and when it comes to a dying person with evident intractable pain, yes, i would err on the side of caution......w/o a doubt.
No, I mean if you gave it to the pt once, would you just give it again because you assume since he had it once, he'll have it again?
The whole point of pain mgmt. is for the pt to not have intractable pain, which is why pts. need to be on long-acting agents with prn meds if the pt has BTP.
As I said before, I am following established standards which have been proven thus far to be the most effective way to manage pain.
I think I am going to bow out; I'm just repeating myself at this point.
No, I mean if you gave it to the pt once, would you just give it again because you assume since he had it once, he'll have it again?
The whole point of pain mgmt. is for the pt to not have intractable pain, which is why pts. need to be on long-acting agents with prn meds if the pt has BTP.
As I said before, I am following established standards which have been proven thus far to be the most effective way to manage pain.
I think I am going to bow out; I'm just repeating myself at this point.
ok.
i'll repeat myself one last time then i'll bow out.
i am only referring to these pts that ARE on long acting agtswith prns for btp. the long actings aren't holding them....more often than not,i am dealing w/uncoop doctors. i know the pt and their hx, get input from family,records, my own assessments. it is obvious there needs to be a modification.i know them well enough to know that yes, the pain WILL reoccur until a change is implemented. so normally it takes 2 episodes of btp for me to realize that this isn't working-i don't care if the guidelines say 3 in 24 hrs. once i realize that a change is in order, i will give the prn narcs until said change is implemented. this is a friggin' dying person in pain. and until the docs get rid of their paranoid ideations of overprescribing, i will give and give within the legal guidelines and presume that there will be another episode of btp.i don't give a rat's asss what the literature says. i go on my personal observations and ethical guidelines. if i can prevent any dying pt from suffering, then i shall proceed and give it before the btp reoccurs. i am not rubberstamping this for all pts but for those that have mds that are ridiculously stingy in prescribing narcs-i will do what i have to until change has been instituted. period. end of conversation.
i'll repeat myself one last time then i'll bow out.
i am only referring to these pts that ARE on long acting agtswith prns for btp. the long actings aren't holding them....more often than not,i am dealing w/uncoop doctors. i know the pt and their hx, get input from family,records, my own assessments. it is obvious there needs to be a modification.i know them well enough to know that yes, the pain WILL reoccur until a change is implemented. so normally it takes 2 episodes of btp for me to realize that this isn't working-i don't care if the guidelines say 3 in 24 hrs. once i realize that a change is in order, i will give the prn narcs until said change is implemented. this is a friggin' dying person in pain. and until the docs get rid of their paranoid ideations of overprescribing, i will give and give within the legal guidelines and presume that there will be another episode of btp.i don't give a rat's asss what the literature says. i go on my personal observations and ethical guidelines. if i can prevent any dying pt from suffering, then i shall proceed and give it before the btp reoccurs. i am not rubberstamping this for all pts but for those that have mds that are ridiculously stingy in prescribing narcs-i will do what i have to until change has been instituted. period. end of conversation.
You are so right earle58. Strong nursing advocacy is the only way to provide
the care that these pts needs is delivered. As you said before we have a more abstract way of thinking and different beliefs on pain managment and rely on our instinct instead of arachic guidlines.
i don't care if those guidelines were hot off the press this morning.
and i don't know if you're referring to a specific pt. population (hospice) or the gen'l population that endure pain.
i would probably follow those guidelines for those w/chronic pain, neuropathies or any neuro pathology, pre/post-ops, etc. as these people are not terminal. i strongly believe that end of life care should be exempt from these guidelines and ensure that they never have to experience any undue suffering because it's recommended to see if they need 3 prns over a 24 hr period. leaving this life should be pain free, physically, emotionally/mentally, spiritually- the goal being at total peace. and this is the only population i am taking issue with and firmly stand behind my beliefs. trust me when i say that my pts have appreciated my interventions greatly, as their families have too.
You are obviously not understanding me; I never let someone experience needless pain just to see what dose he/she needs.
Those are the same guidelines hospice follows. Again, if you want to deviate from the standard of care as defined by countless reputable authorities, including those in hospice, fine. But don't even think of accusing me of allowing people to suffer. :angryfire You do not know me, you don't know my practice; you are way out of bounds to insinuate that I would not advocate for my patients' best interests.
If you want to say, "to heck with what research/standards say," that's fine; it won't serve you too well if something happens and you're involoved in a malpractice situation, however. There's a reason we have standards.
Nursing is an evidence-based practice profession. While I very much believe in intuition (and in fact, am very much a "listen to your gut" type person), I also believe there needs to be data to back up what we do, too.
Now I am really done, before I say something I'll get in trouble for.
You are obviously not understanding me; I never let someone experience needless pain just to see what dose he/she needs.
Those are the same guidelines hospice follows. Again, if you want to deviate from the standard of care as defined by countless reputable authorities, including those in hospice, fine. But don't even think of accusing me of allowing people to suffer. :angryfire You do not know me, you don't know my practice; you are way out of bounds to insinuate that I would not advocate for my patients' best interests.
If you want to say, "to heck with what research/standards say," that's fine; it won't serve you too well if something happens and you're involoved in a malpractice situation, however. There's a reason we have standards.
Nursing is an evidence-based practice profession. While I very much believe in intuition (and in fact, am very much a "listen to your gut" type person), I also believe there needs to be data to back up what we do, too.
Now I am really done, before I say something I'll get in trouble for.
i don't know where you felt accused as i merely just repeated what you told me about 3x in 24 hr protocol. you can get as pissed as you want. if you would rather follow a guidleline (an assistive tool,not the bible) and listen to your pt's 1st moan before you give that prn, that that's your choice.
my "data" is sensible. i have a pt that has been on opioids for yrs which no longer work. he is now in hospice for advanced prostate ca. the doctor automatically puts him on 50mcg of duragesic with orders for prns q2-3hfor the 1st 48 hrs,then decreased to q 4-6 hrs. on the 3rd day this man is still requiring prns, even knowing that the fentanyl has been absorbed into his system. of course i'm going to get an order for more frequent prns or a stronger prn or an increase in his duragesic. once i KNOW the fentanyl has been absorbed and i note that he's in pain, i give him his prn and call the md stat to change his orders. if the 50 mcg hasn't been effective, i'll be damned if i wait 24 hrs to see if he needs more than 3 prns. to me that is downright shabby.
and again, i would like to know where i insinuated anything about you. i am saying to hell with the guidelines in the hospice population. just remember guidelines are only that but are not written in stone. nsg judgement holds more credence, for those who choose to use it.
btw, i am 1000% confident that my 'data' would hold up in any given court if one is worried about malpractice.
At the risk of being controversial, I do believe in euthenasia and wish there was more acceptance of this need and the appropriate legislation and protections for providers to support it. In 1974, For a nursing class, I wrote a paper on this subject and all heck broke loose.
Having had some experience in ther hospice setting, I think passive euthenasia, if you will, occurs. For example, in a case of end-stage COPD, MS in used in nebulizers extensively as well as oral administration PRN. We all know the respiratory impact of Morphine. Hospice physicians are really incredible. Their point of view about pain control, comfort, medication dosage and administration is unique to the profession.
leslie :-D
11,191 Posts
granted, it is contradictive as my ambivalence is now evident.
i was merely going by fab4's stated guidelines of 3 prn doses/24 hrs= need for differernt regimen. the intellectual part of me is stating that makes sense. yet if i have to give 1 prn dose of a narc for btp, then i assume there will be a 2nd episode of btp......i anticipate it and treat it accordingly. as stated, i was not aware of these guidelines and that's why i compromised my values to 2 prn doses. i'm not sure if i'll still do it, but probably will. if a pt. needs a 2nd breakthrough dose, i'd feel safer in assuming that a 3rd one would follow. so that's why i expanded my thought process to r/o the notion that it might just happen 1 time. learning is a perpetual process and even i can push my emotions aside and make an unbiased, clinical judgement.
nothing written in concrete however, lol. i said i'll try it.
leslie