VIP Patient Demanding His Drugs

[athey1999]

In our department, we have a very wealthy patient who is a frequent flier. He comes in every two weeks for either an EGD or a Flex Sig. But he wants and demands IM Demerol in prep and then again in recovery. He absolutely denies pain and he just tells the nurses, "They just give me the drugs". The two doctors involved in his care are aware that he does not have any pain issues, but they automatically write for the drug every time he shows up.

The problem (besides all of it) is that he is a major donor to the hospital and if anyone refuses the drug to him, the thought is that he will just call administration. He is receiving these procedures under anesthesia and is also non-compliant with the admonition not to drive after the procedure. He drives himself home immediately after getting Demerol IM in pre and post and anesthesia on top of it.

Talking to leadership has not helped. Many of the nurses are understandably uncomfortable with the idea of administering this medication to a patient who does not endorse any pain and clearly just wants the drug because he wants it. The issues are what if this person drives in their car under the influence of anesthesia and Demerol and gets into an accident, either harming himself or another innocent person? And what kind of influence would a wealthy donor have over a nurse's job (if any)? Would a hospital back the nurse against a wealthy donor or would the nurse's job be in jeopardy?

The nurses want this brought to the ethics committee, which will be done. But in the meantime, does anyone have any thoughts about this or maybe even prior experience with a situation like this?

[Closed Account 12345]

1. Patients who deny pain should not be given narcotics as a party favor for having a procedure. Personal life factors like income, spending and donation habits, or who a person knows should have ZERO impact on the nursing care you provide.

This is actually the only ethical issue I see here- nurses lacking the principles of justice and non-maleficence. Under justice, all patients should receive the same level of care regardless of socioeconomic status. Under non-maleficence, nurses should not be doing harm. Encouraging someone's social opioid habit, administering narcotics with no clinical indication, depressing someone's respiratory system and altering their mental status before allowing them to drive, despite hospital policy, are all harmful actions. There's no need for an ethics committee; there is a clear right answer.

2. Clearly communicate with the patient, and document your discussion. "Patient denied pain but requested Demerol. Patient stated 'They just give it to me.' RN explained to patient that Demerol is an opioid medication that can only be administered when there is a clinical indication. Patient once again stated that he has no pain but would like medicine. RN declined to administer medication since patient does not meet the criteria for the PRN order. Charge RN aware of the situation." Just because an order is placed does not mean it is safe or appropriate for a patient. You are the one administering the medication; you are the one who needs to use clinical judgment. In fact, your RN license requires you to use clinical judgment. If a charge RN or the MD pressure you to administer an opioid without a clinical indication, you still do the right thing. I'd file an incident report if you get any pushback about holding the medication. Create a paper trail.

Alternatively, after you say "I can't give this to you without pain," the patient lies and says "Then my pain is a 7." At that point, you could administer the medication. However, you are NOT required to discharge the patient until he has met your organization's written policy for discharging a patient after sedation/opioid administration. A responsible adult, whose presence is verified, needs to be present at the time of discharge and state that he/she is providing a ride home; document this. Otherwise, this patient can sit around for however many hours your written policy requires after sedation/opioid medications. If he chooses to drive himself, despite policy, or leave 30 minutes later, despite policy, he needs to leave AMA. Document your efforts to have the patient stay. If the doctor tells you "It's fine, just let him go," you refuse. (I don't mean falsely imprison the patient. He is free to go. I mean you don't willingly discharge him instead of AMA.) Let me tell you who's going down if that groggy patient runs someone over in the parking lot- YOU. Again, if you get pushback, you file an incident report and create a paper trail.

3. The pre-op or procedural nurse should verify that a responsible ride available before proceeding. The responsible person's contact information should be verified. Is this not happening? At my place of employment, no ride after sedation/opioids means no procedure. Cabs and ride shares are not permitted; there needs to be a responsible adult who is willing to accept care of the post-sedation patient. It's black and white.

4. Who cares if he calls administration? Administrators do not dictate patient care. Administrators will not fall on the sword if YOU cause harm with this practice. Administrators aren't responsible for protecting your license. If your hospital administrators try pressuring you into unethical or harmful practices, look for a new job. You don't want to work in a place like that. Then, report accordingly.

Only you are responsible for your nursing actions. Choose to do the right thing even if everyone else is doing wrong.

[MarkMyWords]

I agree with the ethical choice. But it is easy to tell someone to quit and find another job and quite another to be able and willing to do it. And stand up to administrators, if needed. Courage.

My answer: give the VIP placebos. If he/she asks about it, don't answer. Shrug, disappear.

[speedynurse, ADN, BSN, RN, EMT-P]

WOW!.....that’s....very unethical. I thought my hospital was bad but at least they won’t go that far. I would never allow a patient to drive home after IM or IV opioids. That is a huge licensure risk. I am really surprised that the physicians prescribe it with it being such a tremendous opioid crisis.

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

I’m curious as to how the order reads. If it’s “as needed”, then the physicians have shifted the burden to the nurse. If something happens to this patient, responsibility falls on the nurse for giving a medication that wasn’t needed.

[Nurse SMS, MSN, RN]

Even if it isn't written PRN, the nurse has a responsibility to refuse to administer. I have been known to say "I cannot follow this order based on the patient's denial of pain, but I am happy to care for the patient after you have given the drug yourself". If they then leave without someone to drive them, I document it as the patient leaving AMA, not as a discharge.

It DOES take courage to face this. I would rather face that fear than the one I would feel when a family whose loved one died because of this individual driving under the influence smashes into them and kills someone and I am on the stand trying to explain myself.

[Kooky Korky, BSN, RN]

On 7/19/2020 at 7:41 PM, FacultyRN said:

1. Patients who deny pain should not be given narcotics as a party favor for having a procedure. Personal life factors like income, spending and donation habits, or who a person knows should have ZERO impact on the nursing care you provide.

This is actually the only ethical issue I see here- nurses lacking the principles of justice and non-maleficence. Under justice, all patients should receive the same level of care regardless of socioeconomic status. Under non-maleficence, nurses should not be doing harm. Encouraging someone's social opioid habit, administering narcotics with no clinical indication, depressing someone's respiratory system and altering their mental status before allowing them to drive, despite hospital policy, are all harmful actions. There's no need for an ethics committee; there is a clear right answer.

2. Clearly communicate with the patient, and document your discussion. "Patient denied pain but requested Demerol. Patient stated 'They just give it to me.' RN explained to patient that Demerol is an opioid medication that can only be administered when there is a clinical indication. Patient once again stated that he has no pain but would like medicine. RN declined to administer medication since patient does not meet the criteria for the PRN order. Charge RN aware of the situation." Just because an order is placed does not mean it is safe or appropriate for a patient. You are the one administering the medication; you are the one who needs to use clinical judgment. In fact, your RN license requires you to use clinical judgment. If a charge RN or the MD pressure you to administer an opioid without a clinical indication, you still do the right thing. I'd file an incident report if you get any pushback about holding the medication. Create a paper trail.

Alternatively, after you say "I can't give this to you without pain," the patient lies and says "Then my pain is a 7." At that point, you could administer the medication. However, you are NOT required to discharge the patient until he has met your organization's written policy for discharging a patient after sedation/opioid administration. A responsible adult, whose presence is verified, needs to be present at the time of discharge and state that he/she is providing a ride home; document this. Otherwise, this patient can sit around for however many hours your written policy requires after sedation/opioid medications. If he chooses to drive himself, despite policy, or leave 30 minutes later, despite policy, he needs to leave AMA. Document your efforts to have the patient stay. If the doctor tells you "It's fine, just let him go," you refuse. (I don't mean falsely imprison the patient. He is free to go. I mean you don't willingly discharge him instead of AMA.) Let me tell you who's going down if that groggy patient runs someone over in the parking lot- YOU. Again, if you get pushback, you file an incident report and create a paper trail.

3. The pre-op or procedural nurse should verify that a responsible ride available before proceeding. The responsible person's contact information should be verified. Is this not happening? At my place of employment, no ride after sedation/opioids means no procedure. Cabs and ride shares are not permitted; there needs to be a responsible adult who is willing to accept care of the post-sedation patient. It's black and white.

4. Who cares if he calls administration? Administrators do not dictate patient care. Administrators will not fall on the sword if YOU cause harm with this practice. Administrators aren't responsible for protecting your license. If your hospital administrators try pressuring you into unethical or harmful practices, look for a new job. You don't want to work in a place like that. Then, report accordingly.

Only you are responsible for your nursing actions. Choose to do the right thing even if everyone else is doing wrong.

She will be canned about 2 minutes after doing the things you say, even though you are right to give the counsel you gave.

Always comes the advice to quit and go work elsewhere.

Getting creative here - how about calling the police to be ready to pull him over the instant he moves his car? They can do the breathalyzer, all the tests for DUI at their disposal.

If he's so rich, how come he doesn't get a chauffeur?

And I guess the doctors are as afraid of offending Admin as you all are. Evil incarnate. Just evil incarnate.

You could always tell the doctors that you will give them the Demerol for them to administer to their patient because you cannot do so in good conscience.

I am glad the Ethics Committee will be getting involved.

Why does someone need the procedures you mentioned every 2 weeks? Is that anywhere near normal?

Maybe you can report his doctors to their licensing Board.

[Closed Account 12345]

12 minutes ago, Kooky Korky said:

She will be canned about 2 minutes after doing the things you say, even though you are right to give the counsel you gave.

Right is right, regardless of the outcomes or consequences. Ethical nurses choose to do the right thing even when it's hard.

I don't agree with you that someone automatically gets fired for speaking up and doing the right thing. I've spoken up throughout my career when something seems unethical or like a poor practice, and I've never been canned.

Unfortunately, your creative solution is a violation of HIPAA. There are very limited situations where nurses can report patient information to police, and a mentally competent patient choosing to leave AMA and acting like a VIP is not among them.

[amoLucia]

57 minutes ago, Kooky Korky said:

.... Why does someone need the procedures you mentioned every 2 weeks? Is that anywhere near normal?

Maybe you can report his doctors to their licensing Board.

Just thinking - who's paying for those procedures? Insurance? Are they clinically indicated? Could this be a case of FRAUD?

I've a cousin who performed investigative forensic insurance fraudulent billing cases. He prob would have loved this one!

Being investigated for billing fraud would carry more impact than being reported to a Board of Med for the doc. He'd somehow justify the need and the BOM would just nod.

[caliotter3]

This sounds too good to be true. I only wish I could get pain medication when I needed it, much less when I wanted it.

5 hours ago, FacultyRN said:

Right is right, regardless of the outcomes or consequences. Ethical nurses choose to do the right thing even when it's hard.

I don't agree with you that someone automatically gets fired for speaking up and doing the right thing. I've spoken up throughout my career when something seems unethical or like a poor practice, and I've never been canned.

Unfortunately, your creative solution is a violation of HIPAA. There are very limited situations where nurses can report patient information to police, and a mentally competent patient choosing to leave AMA and acting like a VIP is not among them.

I have always been canned when I spoke up.

[amoLucia]

cali - sad commentary!

[JKL33]

On 8/6/2020 at 11:19 PM, amoLucia said:

Just thinking - who's paying for those procedures? Insurance? Are they clinically indicated? Could this be a case of FRAUD?

That was my first thought.

**

I would follow @FacultyRN's general procedure. I'm sure the physician who has been going along with this would be irate upon hearing that I don't plan to administer the med; at that point I would remind them that they are free to give the medication themselves. I have been in that general situation before where there's a mini stand-off like this. I haven't been so much as reported to management; I assume because the person in question has no leg to stand on as far as pointing to what wrong I might have done and they don't really want to have to answer for the shenanigans they were doing. They hope to bully or bamboozle nurses and when challenged it ends pretty quickly. You have to be a combination of pleasant + I'm-dead-serious-here. Also, don't entertain arguments about the details. The point is "I cannot [legally/ethically] and so I will not."

As far as the leaving and driving (assuming the doc or someone else gave the med, and assuming I hadn't been replaced on the case). I'd probably defer his d/c until his ride was present. I assume at some point there would be another stand-off wherein he would simply walk off while being instructed about the things we're talking about. After that there's nothing left to do but immediately notify supervisor and write the note about what he did (including "the patient was reminded of the post-procedure ride policy and rationale, during which he stated "[xyz]" and abruptly ambulated from the department)." Include the name of the admin immediately notified.

I do know I would not go along with this; the details of each step depend on what kind of pushback I get, but I've held my ground plenty of times when something is thoroughly wrong and ridiculous and putting people in danger or at real conceivable risk. Never fired or even so much as written up.