Refued to give pain meds due to brady

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i am a new nurse half way through orientation and on the second day with a patient who has chronic pain found myself in a bit of a situation. overnight the pt's hr dropped to the upper 30's and 40's and was remaining there. with the full backing of my preceptor as well as the other nurse on the floor i did not administer the pt's prn oxycodone. i explained the reason why i wasn't giving the med to the pt in various ways several times but the med was still demanded. the pt states she wants to leave so ama paper work is brought to her. a hospitalist that is not treating the pt. explains the consequences of leaving ama and the pt decides to stay because the md said she could have the pain medication. (no new orders were written) hr is now at 38, clinical direction is notified who supports and confirms our decision to not administer the medication. long story short pt leaves ama.

would you have held the oxycodone? what other course of action could i have taken? is there a pain medication that i could have asked the hospitalist to write for that would not send us running with the code cart (that is still the "good stuff" the pt would have accepted)?

i just don't know....i have left the, question every step i make mind set and now am in the question 50% of what i do.

i'm sure anyone reading this can guess there is a ton of back story that i am leaving out.

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Why is the patient bradycardic?

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The "why" is what I wish I had a better answer for. Over night the HR dropped. The hospitalist who saw the pt. in the AM reduced her Coreg dose and gave more specific hold parameters. This lead me to holding the AM dose. The pt. was later dx with an 1st degree AV block.

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Specializes in ICU.

Were other avenues attempted to ease the patients pain, positioning, heat or ice? I guess my feeling are, if your hurting that bad are you physically able to leave AMA? I understand as nurses we always have to believe that the patient has the pain they say they have, but sounds like there are other dynamics involved. Does Oxy effect HR? I understand the patient might be more relaxed and pain free but I dont believe HR would be effected. Is this a normal dose for the patient if they have chronic pain. I guess I am more concerned about the HR and the block.

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From my drug guide: Potential cardiovascular adverse reactions to Oxycodone hcl are: orthostatic hypotension, circulatory depression, bradycardia, shock. I would have held it too and asked the MD if the pt could have a non-narcotic for pain relief or another type of narcotic that doesn't affect HR. What alternative pain relief was offered to the pt? Did the pt refuse those options? If the rationale for holding the medication was given, and the pt was offered alternatives, refused them and then signed out AMA...oh well. I believe in personal responsibility and if an A+OX3 adult wants to go AMA after being offered various options for pain relief and being counseled about the dangers of leaving AMA so be it. I'm your nurse not your mom.

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Yes, we offered the pt. all sorts of non pharmacological alternatives and they were refused. The previous day we offered Toradol for breakthrough pain and that was…..refused. The more I think about this, in my position I did all I could.

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Specializes in LTC, Medical, Telemetry.

Why wasn't the hospitalist addressing the bradycardia? Regardless of her pain level, wouldn't a consistent HR of 30's warrant an intervention? If she had a block, what were they doing for it.

Personally, I would have given her the oxy. Reason being, I would much rather her code in the hospital than on the drive home. Before I gave it to her though, I would get a great IV open, maybe ask hospitalist for a bolus, and put pacer pads on her in the instance that she does drop further. It may be what she needed to realize how serious the situation really is - place the pads and explain what cardioversion is, and why the pads go on before she gets the pain meds.

I tried looking it up but it appears that most pain meds have bradycardia listed as a potential side-effect; Anyone have input on what may have been safest in this circumstance? Did the hospitalist have any alternative ideas?

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Specializes in Certified Med/Surg tele, and other stuff.
Why wasn't the hospitalist addressing the bradycardia? Regardless of her pain level, wouldn't a consistent HR of 30's warrant an intervention? If she had a block, what were they doing for it.

Personally, I would have given her the oxy. Reason being, I would much rather her code in the hospital than on the drive home. Before I gave it to her though, I would get a great IV open, maybe ask hospitalist for a bolus, and put pacer pads on her in the instance that she does drop further. It may be what she needed to realize how serious the situation really is - place the pads and explain what cardioversion is, and why the pads go on before she gets the pain meds.

I tried looking it up but it appears that most pain meds have bradycardia listed as a potential side-effect; Anyone have input on what may have been safest in this circumstance? Did the hospitalist have any alternative ideas?

You are a brave soul. I think a court would have your hide in a second. If you knew there was that strong of a potential, and you still administered?

OP, I would have held the med, offered other pain meds like the toradol as you mentioned. My concern would have been with the heart block and getting it resolved.

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Why would you do this? Because the pt is having a tantrum and is whinging and whining about getting their Oxy?

Trust and believe if you gave that Oxy and something happened to that pt...the MD, your NM, administration and everyone else would throw you under the bus so quickly your head would spin. Why take the risk? The pt wasn't going to die from not getting their "fix." They were offered alternatives, refused, and they were obviously well enough to get out of their bed, sign AMA forms, and go home. On to the next one...hospital beds are at a premium.

The fact that you are willing to go through all of that just to make a point is crazy. Hello, don't we have other pts to take care of? People are ridiculous and out of control these days. They think the hospital is like Burger King and everything has to go their way. Well you know what? It can't always be like that. Sometimes we have to say we can't do this because it will harm or kill you and the pt just has to suck it up and DEAL with it already. If they don't like it then let them go! I bet it wasn't anyone under 30...society has turned into a bunch of over-sized, self-medicating babies. Also, trust me that MD knows what he was doing. Tell you one thing verbally but did he change the order? Nope because they will let you do whatever it is you're silly enough to do but they will make damn sure they cover their own rear end.

Why wasn't the hospitalist addressing the bradycardia? Regardless of her pain level, wouldn't a consistent HR of 30's warrant an intervention? If she had a block, what were they doing for it.

Personally, I would have given her the oxy. Reason being, I would much rather her code in the hospital than on the drive home. Before I gave it to her though, I would get a great IV open, maybe ask hospitalist for a bolus, and put pacer pads on her in the instance that she does drop further. It may be what she needed to realize how serious the situation really is - place the pads and explain what cardioversion is, and why the pads go on before she gets the pain meds.

I tried looking it up but it appears that most pain meds have bradycardia listed as a potential side-effect; Anyone have input on what may have been safest in this circumstance? Did the hospitalist have any alternative ideas?

Up Vote Up Vote ×
Specializes in ICU.
Why would you do this? Because the pt is having a tantrum and is whinging and whining about getting their Oxy?

Trust and believe if you gave that Oxy and something happened to that pt...the MD, your NM, administration and everyone else would throw you under the bus so quickly your head would spin. Why take the risk? The pt wasn't going to die from not getting their "fix." They were offered alternatives, refused, and they were obviously well enough to get out of their bed, sign AMA forms, and go home. On to the next one...hospital beds are at a premium.

The fact that you are willing to go through all of that just to make a point is crazy. Hello, don't we have other pts to take care of? People are ridiculous and out of control these days. They think the hospital is like Burger King and everything has to go their way. Well you know what? It can't always be like that. Sometimes we have to say we can't do this because it will harm or kill you and the pt just has to suck it up and DEAL with it already. If they don't like it then let them go! I bet it wasn't anyone under 30...society has turned into a bunch of over-sized, self-medicating babies. Also, trust me that MD knows what he was doing. Tell you one thing verbally but did he change the order? Nope because they will let you do whatever it is you're silly enough to do but they will make damn sure they cover their own rear end.

Thank you for saying this I 100% agree with your whole quote. We need to protect our patients but more importantly ourselves!!!

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Specializes in LTC, Medical, Telemetry.
Why would you do this? Because the pt is having a tantrum and is whinging and whining about getting their Oxy? .

Because the patient is obviously in pain. People do crazy things when pain pushes them over the edge; if you aren't even addressing their pain, they have every right to be upset. Yeah, they turned down the alternatives; can you really blame them? Unless they are drug seeking, they know this has worked for pain and they don't understand why they can't have it again. As my post stated, the bradycardia MUST be addressed first, and not sure why it wasn't. And besides, I am assuming they have recieved the oxy before - did it effect their heart rate then? You are hedging your bets on a POSSIBLE side effect, not a gauranteed side effect, and the end result is a very sick patient leaving and putting themselves and the community at a much higher risk. I am not generally one to jump to utilitarian conclusions, but in this case I feel that the possible outcomes to this situation are all terrible, and there are a lot of factors to consider.

Trust and believe if you gave that Oxy and something happened to that pt...the MD, your NM, administration and everyone else would throw you under the bus so quickly your head would spin. Why take the risk?

You may be thrown under the bus, but if you sit and do nothing you will also be thrown under the bus. I am guessing the OP was probably blamed for the patient going AMA by MD/Staff as well, especially being so brady. Its really a catch-22. I also don't think the oxy would push this pt over the edge and into coding - If she coded, she was probably destined to code before the oxy. Let's face it - if she is this adamant about the Oxy in the first place, the first thing she does when she makes it outside the hospital doors is spark a cigarette and find a more dangerous way to self-medicate. I would much rather she stay in a safe, observed environment. And if it is administered PO, the bio availability is limited (60%) and the time it takes to kick in buys me time to approach the bradycardia and figure out a plan. The oxy won't aggravate any dysrrhythmia if she does have one. Narcan at bedside if you are worried, ready her for cardioversion (which should be done anyway if you expect brady to worsen ).

At this point, you need to do something. You can step back and play it safe, but this is what I would have done. What happened with this patient anyway, OP?

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I agree to disagree. The patient was offered alternatives and declined them. Chances are nothing would have happened but if something did then what? I don't want to be responsible for someone who would force me to do something questionable.

Because the patient is obviously in pain. People do crazy things when pain pushes them over the edge; if you aren't even addressing their pain, they have every right to be upset. Yeah, they turned down the alternatives; can you really blame them? Unless they are drug seeking, they know this has worked for pain and they don't understand why they can't have it again. As my post stated, the bradycardia MUST be addressed first, and not sure why it wasn't. And besides, I am assuming they have recieved the oxy before - did it effect their heart rate then? You are hedging your bets on a POSSIBLE side effect, not a gauranteed side effect, and the end result is a very sick patient leaving and putting themselves and the community at a much higher risk. I am not generally one to jump to utilitarian conclusions, but in this case I feel that the possible outcomes to this situation are all terrible, and there are a lot of factors to consider.

You may be thrown under the bus, but if you sit and do nothing you will also be thrown under the bus. I am guessing the OP was probably blamed for the patient going AMA by MD/Staff as well, especially being so brady. Its really a catch-22. I also don't think the oxy would push this pt over the edge and into coding - If she coded, she was probably destined to code before the oxy. Let's face it - if she is this adamant about the Oxy in the first place, the first thing she does when she makes it outside the hospital doors is spark a cigarette and find a more dangerous way to self-medicate. I would much rather she stay in a safe, observed environment. And if it is administered PO, the bio availability is limited (60%) and the time it takes to kick in buys me

time to approach the bradycardia and figure out a plan. The oxy won't aggravate any dysrrhythmia if she does have one. Narcan at bedside if you are worried, ready her for cardioversion (which should be done anyway if you expect brady to worsen ).

At this point, you need to do something. You can step back and play it safe, but this is what I would have done. What happened with this patient anyway, OP?

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