Patches: My Non-Compliance Patient

Pain management is a very tedious part of the hospice nurses' lives. It takes a lot of time to titrate medications, figure out which adjuvant meds will work best for each patient and provided continual assessments for each patient to ensure you're ahead of the pain (or whatever symptom you are palliating)!

In hospice, pain has multiple definitions. We've all been taught, or at least I hope we have, that pain is what the patient says it is. Which is why Mr. H was such a challenge. His descriptions of his pain were very nondescript which meant that I had to pretty much try to figure out on my own what Mr. H was feeling.

With his diagnosis of COPD, but multiple co-morbid disease processes going on, Mr. H's physician and I were working hard to come up with a plan we thought we provide Mr. H the best pain control. The second part of the equation was Mr. H-he was very noncompliant.

Every time I made a visit I was educating him on his medications and how to take them and why he should take them the way I told him. Mr. H was in his 70s. He was a retired veteran. And he was always in control, no matter what.

So I was reluctant to ask the physician to start him on long-acting pain medications because I was certain that Mr. H would not be compliant and it would be that much harder to try to tackle his pain issues. I talked at length with his doctor on several occasions.

We were surprised that it wasn't so much the COPD that was his biggest issue, but his pain from all of the other abuse his body had endured over the past years. Mr. H would call his doctor several times a week about his pain as well, so the physician was eager to try something different.

Taking into consideration Mr. H's long history of non-compliance, we discussed the option of starting the patient on fentanyl patches to try to get his pain under control. We decided that the patches would be the most effective way to control pain while keeping the patient compliant.

I obtained the prescription for the patches at the beginning of the week so we could see how the patient was responding toward the middle to late week. I made a visit to the patient on Monday, assisted him in applying the patch, I explained to him and his wife what it was for, how it was used, the potential side effects and everything else I could think of that the patient would need to know. He was one that needed to know everything.

On Tuesday I received a message that Mr. H had called to let me know he needed a refill on his patches. Knowing I had visited the patient the day before and what had occurred, I was sure the person who had taken the message had gotten the message confused. So I called Mr. H. And sure enough, he told me he was out of patches and needed a refill.

Not completely understanding what was happening, I decided I better make a visit again that day. When I arrived at the patient's home, I asked him for the box the patches had come in and he gave it to me.

It was empty.

I began questioning Mr. H as to what had happened to the rest of the patches that had been in the box. He replied I was still hurting so I put one on each of the places I was hurting. I asked Mr. H to show me where he had placed the patches and sure enough, he had the one I had placed on his chest, two on different areas of his back and one on his abdomen and one on his knee. I quickly removed the patches which I can tell you, did not go over well with Mr. H. I finally got him to understand how to use the patches and why he needed to give them time to begin working,

I never in a million years would have guessed that instead of worrying about non-compliance I should have been concerned about over-compliance!

Mr. H and I had several months together after that. He always listened to what I told him and I always made sure to follow up with him. He was more than happy to adopt my nickname for him. Patches.