Patient denial of pain?

[AtlantaRN, RN]

I have a patient, end stage pancreatic cancer. Never complains of pain or discomfort since our first meeting. Initially, she did report nausea/dyspepsia that Reglan 4 times a day has relieved.

Patient is getting progressively weaker, but denies pain emphatically. Blood pressure nor heart rate is elevated.

Family called yesterday asking "the sitters say she is in greater pain than she leads on, can you evaluate her and put her on something for pain," I can evaluate, but i've sent .25mg Xanax for shortness of breath (it will come) and anxiety and the patient said "don't send me anymore pills--I won't take them". Now she does like lunesta, (she mentioned inability to maintain sleep, was tried on 2mg, but likes 3mg).

She is the stoic, matriarch of a large family and I believe she wants to put on a strong face. I have to remember not just use the term "pain", but discomfort, achiness, dull, sharp, etc... Start with nsaids. ((If she weren't diabetic, I would send dexamethasone for not only swelling, but pain))....

i see her this morning, I'll post with results

linda

[mc3, ASN, RN]

I see this all the time.....I go with the mantra "pain is whatever the patient says it is". I was taught to respect the patients wishes, no matter how much I may disagree. (and I have several times!) However, for pancreatic ca (or any cancer), I'd see if the MD (or hospice doc) will order MSIR and Ativan to keep on hand, just in case.... Pancreatic ca pain can come on quickly, and badly. Also, what are the family members seeing that you're not?

mc3:nurse:

[Hospice Nurse LPN, BSN, RN]

It's hard seeing someone in pain (you KNOW it) and they refuse to ask for anything. I like to have something on hand (just in case). I once had a pt. with cervical CA. You could just look at this woman and know she was hurting, but she kept insisting she had to be a "soldier for Jesus". I know she died in pain. For me, it wasn't a good death, but the family was very happy with all we did and what we tried to do. I agree with what mc3 says, "pain is what the pt. says the pain is", but darn it's hard sometimes.

[CANRN, MSN, RN]

It's hard seeing someone in pain (you KNOW it) and they refuse to ask for anything. I like to have something on hand (just in case). I once had a pt. with cervical CA. You could just look at this woman and know she was hurting, but she kept insisting she had to be a "soldier for Jesus". I know she died in pain. For me, it wasn't a good death, but the family was very happy with all we did and what we tried to do. I agree with what mc3 says, "pain is what the pt. says the pain is", but darn it's hard sometimes.

I agree, pain is what the patient says it is. But, darn it, when you see perperation over the upper lip, and lips quivering, elevated B/P, and resistance to movement, it makes it so hard to ignore. What I have done, is have Roxanol on hand in the home, when the patient gets closer and the family reports pain, they have been able to give Roxanol without much reistance.

[mc3, ASN, RN]

i once did a supervisory visit for a patient in terrible pain and respiratory distress. the crisis care nurse that was on insisted on giving her morphine, in spite of the patient and family's request. to them, morphine was "the end". they told me that patient had specifically told them she did not want morphine because she'd working in a nursing home and that's what "killed people". i actually had to ask the crisis care nurse to leave and get a replacement because she was upsetting the family (and pt) so much.

i thought of another thing you can do. use your chaplain! i've found sometimes that if you can address spiritual needs, the rest will follow...

mc3

[leslie :-D]

i have encountered so many pts who deny pain.

people (especially elderly) have a lot of misconceptions about narcotics.

i have found that:

a. once we (me/pt) have built a trusting relationship, and

b. i address their 'delusions', they almost always will try something at least once.

and that's how i go about it:

try it once.

we negotiate.

if, after the one time dose, they refuse a 2nd dose, i find out why and adjust the hopeful, 2nd dose.

eventually i do get them on a routine that they can tolerate.

i don't give up and will try and persuade them in my own, non aggressive way.

leslie