Patients with drug issues vs. the doctor playing dumb about it!

[nursey07]

I recently had a patient who "fired" me (haha) because I refused to push his dilaudid when he had fluids running. Aside from the fact that he was getting it every hour on top of Fentanyl patch, Phenergan, Zofran, Ativan, Valium......you get the jist. The doctor absolutely refused to use a PCA pump and would not discuss addiction issues with said patient and or staff. He just decided to go with what the patient wanted! I calmy suggested to the patient that he ask the doctor himself for the PCA pump if he felt the doses we were giving him were not taking away the pain sufficiently because the pca can give him MORE! I also said at one point that I hoped the Fentanyl patch would help his pain more so he didn't have to use the Dilaudid as much! He took this as a direct attack from me and went to my charge nurse saying I made him feel like I was judging him for asking for pain meds. In my experience, I know this is his own guilt of knowing what he is doing and was happy when he decided I wasn't the nurse for him!

What ****** me off is this makes me look bad to charge, management and administration where I felt I was advocating for the patient!

The doctor won't listen and when a solution (pca pump) was suggested he would get mad about it! Number one: who has the time to make sure one out of 8 patients is properly doped every hour? On top of more frequent trips for his other PRNS?

Number two: If the doctor wants to put him on an hourly dosing, COME UP AND DO IT YOURSELF!!!!!!!!!!

This doctor is such a wuss to come up and look at the guy and say, "You're an addict and we're lowering your doses?" I'm also sick of the other nurses who "just go with it". How does this help the guy and why are we powerless over this?

Ughhhhhhh sorry for the rant, but it just ****** me off!!!!!!!!

[nursecass]

comfort measures s/p lami?:eek:

i'd take it personally too.:rotfl:

lordy.

leslie

I don't think this sounds quite as silly as you make it seem. Comfort measures can be used with pain meds for certain patients. It is clear from her previous posts that she is not expecting JUST comfort measures to help, but for some people that is the trick. I know we've all had that patient that lays in one place in the bed, clenching and focusing on their pain, and with pain meds, repositioning and distraction somehow their pain is reduced a little (when just meds didn't touch them before). It might not always work, but we learn those for a reason-and when pain meds aren't working and she can't get an order for an increased dose/delivery, then comfort measures may be the LAST measure.

OP-I wish I could give you advice, just be grateful that you no longer have to care for that patient...there are others that will appreciate your advocacy!

[leslie :-D]

Maybe its just me, but if after two weeks from a lami that had no complications, should he be needing all of this? Ok, theres tolerance and needing of higher doses, BUT AGAIN, the doctor won't agree to it, so what else is there to do?

limit setting.

that if the patient has any concerns, to take it up with the doc.

yes, he does sound med seeking.

try to stop taking it personally:

document all interventions, including those that have attempted to educate pt, pt response, pt demands....everything.

keep your cn/nm informed...

and truly, it sounds like this pt needs limit setting.

much luck to you.

I don't think this sounds quite as silly as you make it seem. Comfort measures can be used with pain meds for certain patients. It is clear from her previous posts that she is not expecting JUST comfort measures to help, but for some people that is the trick. I know we've all had that patient that lays in one place in the bed, clenching and focusing on their pain, and with pain meds, repositioning and distraction somehow their pain is reduced a little (when just meds didn't touch them before). It might not always work, but we learn those for a reason-and when pain meds aren't working and she can't get an order for an increased dose/delivery, then comfort measures may be the LAST measure.

i laughed and was shocked, r/t me being a hospice nurse.

so comfort measures to me, meant stopping all txs and keeping pt comfortable til they die.

misunderstanding, that's all.:)

leslie

[accessqueen]

It is extremely frustrating to deal with patients who SEEM to be displaying drug seeking behavior. Unfortunately, even if they are a raging drug addict, you are not going to cure them, not is it your job to do so. Changing the behaviour of an addict is a medical specialty in and of itself, and a when a patient is post-op it is not the time to try to change their behaviour. Your job is to do your nursing duties as properly and safely as possible. Give the dilaudid the way your're supposed to, over one minute or whatever. Explain to the patient calmly why you can't fast push it. That's it. You can suggest a pain management consult. Getting all bent out of shape because the doc is a "wuss" who won't order a PCA , is wasting a lot of energy. I have taken care of a fair amount of patients who were labeled as drug seeking, because no one could figure out what was wrong with them and their tests were normal. The next thing you know they're in emergency surgery to treat a condition that for some reason was very difficult to diagnose. You can't be judgemental with these types of patients.

[wooh, BSN, RN]

i laughed and was shocked, r/t me being a hospice nurse.

so comfort measures to me, meant stopping all txs and keeping pt comfortable til they die.

misunderstanding, that's all.:)

leslie

lmao!!:chuckle i too thought you didn't think comfort measures (like repositioning, etc) would be any good, but now that i see what you think of as comfort measures, for this patient, i'm about to fall out of my chair.:chuckle

[nerdtonurse?, BSN, RN]

It would be interesting to know what kind of pain meds he/she was on prior to the lami. I had a pt come in, hysterical about pain after a lap appy. I mean, 4mg morphine an HOUR weren't enough for this very uncomplicated straight in-straight out surgery. Turns out he'd been on demerol, MScontin, and half a dozen other pain meds prior surgery, so nothing touched his pain.

Oh, and the reason for all his pain meds? "Back Pain" and this guy's in better shape than I am.

[Katie82, RN]

He had a lami two weeks ago, and went home and fell. He came back and all xrays/mris/ctscans have shown no damage from his fall. If anything they have showed improvement. So he is technically two weeks post op with 2mg dilaudid being pushed every two hours or 1mg/hour. I see this as innopropriate and neglectful per the doctor!

.

You can bet that this guy was discharged after surgery with a grocery bag full of narcotics, which is probably why he fell, I have seen it happen. As a case manager, I pay a lot of attention to the amount of narcotics my patients use, and many of them are on pain meds from 3 or 4 docs. I have no problem messaging the PCP with a copy of the med profile and cc to the other providers. That usually slows the flow. State Medical Boards are really cracking down on inappropriate use of narcotics, they are tracking docs through Pharmacy Boards, and insurance companies are as well. Dilaudid is powerful stuff, that guy is already addicted, and it will be a tough one to kick. I think it will take a lot of malpractice suits against docs who overprescribe before we see a big change. Unfortunatly, you are going to see this guy again, every time the ER refuses to give his Dilaudid.

[wooh, BSN, RN]

State Medical Boards are really cracking down on inappropriate use of narcotics, they are tracking docs through Pharmacy Boards, and insurance companies are as well.

At the same time that Joint Commission is pushing the "Pain is what the patient says it is."

Basically we're stuck between a rock and a hard place, and there's no easy answer.

[BradleyRN]

I also said at one point that I hoped the Fentanyl patch would help his pain more so he didn't have to use the Dilaudid as much! He took this as a direct attack from me.

He had a lami two weeks ago, and went home and fell.

I have heard from numerous patients over the years that those patches barely help at all. Compared to Dilaudid qh, they probably barely make the radar. To say you hope the patch would cut down on the Dilaudid use could have been construed as you didnt want to have to give it to him qh. And that would have been correct.

If this guy had a lami, then that should be evidence enough for you that he actually is in pain, and not just a junkie. Many people with chronic pain are addicts through no fault of their own. It doesnt make their pain less real, and it is not your place to judge.

We follow guidelines for an iv push regardless of what anyone wants. I have also had many patients that would like the drug pushed faster for the rush, and it didnt always mean that they were a drug seeker. Pain is what the patient says it is, and the doctor has written orders to address it. We are here to implement those orders. Even if we are the best arm-chair detective in the state, and feel certain that someone is not in as much pain as they claim, we are not clairvoyant, and thus can not be 100% sure of something so subjective.

[Patti SW]

As a social worker I would like to know if as nurses you have ever experienced the fact people behave differently. My father died of lung cancer but, never needed oxygen or pain meds, however, I have known lots of other lung cancer pts who required both. They needed a lot of pain meds. Should I believe from my personal experience lung cancer pts are drug seekers? Should I believe they ask for oxygen because they think they deserve it?

MD's may make bad mistakes as we are do but, they also have more education and experience. Maybe they realize every individual is exactly that, an individual. If they had based their decisions on how my father handled his lung cancer then there would be a lot of lung cancer pts who suffered from pain and oxygen deprivation. That would be a shame. I am thankful my father never needed drugs or 02. He had a quick pleasant death. Please respect the experience of the MD. I know sometimes they prescribe narcotics when they are not necessary but, better safe than sorry.

[sheilagh]

just a quick comment:I am no big cheerleader for fentanyl patches.I learned while doing hospice work that it takes 12 hours for the blood level to be therapeutic after a patch is applied.Many Dr's thought I was nuts and trying to kill my pt's because I would ask for something to cover them until the patch became effective.

[Dolce, RN]

Personally I think the PCA is a BIG mistake. I can understand why a physician wouldn't want to order it. PCAs are for initial post-op pain, not 2 weeks post-op. Yes, he is still getting dilaudid frequently, and yes, it is a pain for you, but he really probably shouldn't be placed on a PCA. Whenever I have a patient who I suspect is drug seeking I try to remember that there may be a psych component to their illness. Many drug addictions co-exist with mental illness. Addiction, if indeed he is struggling with this, is very difficult for caregivers to deal with. You have every reason to be frustrated. But, you must remain professional with the patient and not convey that to him. Set limits and take the time to calmly discuss treatments and medications with him.

Sorry you're having a rough time. This probably won't be the last patient that you will deal with in your career who you suspect is drug seeking. Just remember, I have suspected this in the past about patients and have been wrong! Something to keep in mind.

[KBRN413]

i can't even begin to tell you how familiar this sounds! we have had a young girl on our floor for almost a month now. she is a frequent flyer for dysphagia and abdominal pain. she had a gastric pacemaker placed and is here for tube feeds and pain control. she has been here for a long time and is receiving iv dilaudid, zofran, ativan, anzemet and benadryl. we are in that room every hour medicating her with something. it is rediculous. the nursing staff feels that she is addicted. she is always complaining of a lot pain yet, she never shows it. she writes the times that her meds are due on her dry erase board. the nursing staff have talked with the mds, psych, social work and the nm. they are finally starting to have conversations with her regarding tapering her medication. but, before, she would complain and get what she wanted. it is not helping the patient. we as nurses are patient advocates and need to step up and make the necessary phone calls! we have to push for things to get done. she should have been tapered and home with services a long time ago! its amazing how the mds will give patients what they want so that they stop complaining!!! ughh so frustrating!