Patient complaint - Did I mishandle this situation?

[lily8424]

So I got my first patient complaint. Without going into much detail, I had a patient who was on IV Morphine q 4 hours. Patient was reporting pain in middle of night. I administer medication to said pt. I check up on patient half an hour later and he is sleeping. 2 hours later, patient is reporting pain again. Patient has order for Tramadol q6 and I offer it to him. Patient states medication doesn't work for him but states they've been giving him Percocet q6h. I check the MAR again and the attending DC'd the order. I explain that to him that order was DC'd. Patient is upset about this but I tell him that I will reach out to Dr. I explain to Dr that patient states tramadol doesn't work for him and had been on Percocet q 6h. On call Dr states they are trying to wean him off the Percocet and told me to have him wait for the morphine. I check on patient again to explain the situation but patient is asleep again. I rounded on patient again when morphine dose was due but pt was still asleep and I didn't even know if he'd want it instead of Percocet so I decide to let him sleep. When patient woke up in morning, I offered morphine again to him but he refused, stating he didn't have pain and didn't want it. I apologized and told him they were trying to wean him off the Percocet, but he told me he was going to write a complaint about me and wants another nurse and refused care from me. I had to get oncoming nurse to administer his morning med and vitals since he refused to allow me to do it. I documented my interaction with the Dr and pt but can't stop feeling like I failed this pt.

[Letisha Hamilton]

We all have an occasional complaint, especially when it comes to demanding patients.  The only problem there could be for you is if the Morphine was ordered around the clock, not as needed.  
Sometimes, pain meds are changed without taking the opioid equivalence into consideration.  For example,   Tramadol 50mg po  is equal to about 5 Oral morphine. oxycodone po 5mg is equivalent to around morphine po 7.5mg.   It’s different for IV Morphine.  
These are all IR dosages and amounts vary per facility policy and patient response.  I’ve had to remind doctors of prior dosages and ask they believe the dosage will be enough.  Be prepared with total dosage for day of all pain meds given. It’s not your role to calculate the dose, but you can be prepared with number of dosages and strengths given.  Help the on call make an informed decision. 
Now, dealing with an patient who has been abusing their drug of choice, there are going to be problems.  But we are responsible for attempting to assess their pain level.   Document to cover your actions and decisions.  Keep in mind the onset, peak and duration of the meds in patients with pain.  Allowing meds to totally wear off can then take longer to get patient relief.  Patients do not want to hear excuses, they want the problem fixed.  If he wants Md called, be proactive and ask right if he wants to be woke up and informed.  Telling the truth that the Md refused the order is appropriate, you tried,  offer a solution for now, even an apology that they are not satisfied.  Inform you will pass on report that there is a complaint and offer what you can do.  Sir, I cannot give you that Med without an order.  I can check on you when medication is due. I agree, offer to wake him.  If his pain is real, he knows the med will wear off and appreciate the offer. 
Have a complaint, pass it on to your direct supervisor, left them be proactive in addressing his threats and a dreaded bad review to survey.  I rather deal with it right away, not weeks from now when no one remembers and his complaint is exaggerated.   
try not to take this home with you.   Not the last difficult patient you will face.  
 

[Guest1157066]

If the morphine is scheduled q4h then yes you should have given it to him.  If it is PRN, he has to ask for it.  If he was asleep, he is comfortable.  A pt in true pain won't be able to sleep very well.  I hear many pts tell me a certain pain meds don't work.  We have to at least call and ask Dr as it isn't our place to determine which pain meds the pt can have.  Sometimes it doesn't matter what we do because not all pts can be pleased all the time.  As a nurse, you advocate for your pts but sometimes drs get in the way and won't prescribe more meds.  All you can do is educate and offer what is available.

[JKL33]

30 minutes ago, TxBSN19 said:

As a nurse, you advocate for your pts but sometimes drs get in the way and won't prescribe more meds. 

And sometimes we are mistaken in how we advocate for our patients.

[Jan Arellano]

The points everyone said are right on. You will see a-lot of patients like this gentleman.  To take the blame off myself, I will tell the patient that I’ll reach out to the doctor for him. I would also check in with him often to let him know, I’m wanting to help him. Offering other than pain meds as alternatives.  It really sounds like he wanted the Percocet, and he couldn’t manipulate or bully you to give it to him. My bet is he did the same thing to the other nurses. My bet is he won’t fill out a grievance, because he wouldn’t want to bring attention to himself. 
 Lastly: I never wake a pt up, unless they ask , , if they are sleeping because if their pain is that bad, they wouldn’t be able to sleep. 
You sound like a very caring Nurse!! 

[Lunah, MSN, RN]

Those are some screwy med orders. Let's add some Dilaudid while we're at it, but heck no to the Percocet! ?

OP, you did NOTHING wrong. The fact that you agonized over this says you are a good person who encountered someone that was not going to be happy no matter what they got from whoever was in the vicinity. You just happened to draw the short straw in patient assignments! There will come a day when you will be relieved to be "fired" by a patient like this, you'll be like, "Deuces, let me see if anyone else is available, and did you want some AMA paperwork while we're at it?" ? The key to dealing with miserable people is to remember that your time with them is limited, but they have to live with themselves! Must be awful. 

[Guest1157066]

On 3/13/2021 at 12:45 PM, JKL33 said:

And sometimes we are mistaken in how we advocate for our patients.

I disagree.  Any time you advocate for your patient is not a mistake. Pain is what the patient says it is...remember nursing school?  I don't believe it is a mistake to ask the doctor for a different pain med because at least you are doing something.  If the doctor doesn't want to order anything else, you at least attempted to do something about it. As hard as it is sometimes to believe how much pain the patient is in, you are to treat it as the level they say it is.

[heron, ASN, RN]

I agree with sour lemon that the pt was being manipulative. Another previous poster pointed out that he specifically wanted Percocet. The opioid in Percocet is oxycodone. The trouble with oxycodone is that it passes the blood/brain barrier more readily that most other opioids. That makes the euphoric effects more intense than most other opioids as well. This is why OxyContin is called “hillbilly heroin” - it’s the high of choice among prescription opioid abusers. As a long-time night nurse, I have noticed that a favorite tactic for obtaining the preferred medication is to raise a ruckus in the middle of the night, when the patient’s primary MD is unlikely to be on duty. On my AIDS unit, we sometimes had to follow a strict policy with some patients that only the primary MD was to make any changes to the pain regimen precisely because of this behavior.

This is only one possible dynamic affected this patient’s behavior. Without more info on the patient (was he informed of the change in orders? Is this his first experience with opioids? Does he have a history of substance use or chronic pain or depression?) it’s impossible to say.

There is also a theory that the euphoric effects of opioids are an integral part of their analgesic effect. Maybe he really does get better pain relief from the Percocet. Or relief from the anxiety and depression that commonly go along with being unwell.

Does this mean that we label him a “drug-seeker” and dismiss his complaints of pain, with prejudice? Absolutely NOT - and nobody has suggested that. We do exactly as the OP did - the best we can. OP did nothing wrong -and possibly helped to slow down the beginnings of an addictive pattern of behavior.

 

 

[Wuzzie]

On ‎3‎/‎13‎/‎2021 at 1:14 PM, TxBSN19 said:

As a nurse, you advocate for your pts but sometimes drs get in the way and won't prescribe more meds.

I find this statement puzzling. How is a physician getting "in the way" and "in the way" of what?

[heron, ASN, RN]

9 minutes ago, Wuzzie said:

I find this statement puzzling. How is a physician getting "in the way" and "in the way" of what?

I can’t speak for that poster, of course. In my own experience, patients often get labeled “drug-seekers” which leads physicians - and nurses! - to dig in their heels and dismiss any complaints as a conscious quest to feed an addiction.

There’s also the current crusade against the opioid epidemic which encourages physicians to refuse to prescribe any pain meds at all other than NSAIDs. (Sometimes I gotta wonder if they own stock in dialysis companies!)

[Wuzzie]

6 minutes ago, heron said:

In my own experience, patients often get labeled “drug-seekers” which leads physicians - and nurses! - to dig in their heels and dismiss any complaints as a conscious quest to feed an addiction.

I'm in agreement with you on this but I found the poster's word choice kind of odd.

[Guest1157066]

6 hours ago, Wuzzie said:

I find this statement puzzling. How is a physician getting "in the way" and "in the way" of what?

I think you go looking for things that are not there.  I meant In the way of helping to control patient pain levels.  I have had a few doctors that say they are drug seekers and dismiss any concerns about pain levels not being properly treated.  While the patient was being weaned off percocet, maybe they should have added something else, decreased the dose and or the frequency of it. 

[Wuzzie]

10 minutes ago, TxBSN19 said:

I think you go looking for things that are not there

No, not really. If I was doing that I would have posted my assumption of what you meant. I just described my reaction to it. Being puzzled and finding something odd are pretty mild thoughts in the land of anonymous posters on forums and asking for clarification before passing judgment is pretty darn polite.