Pt sat on the edge of the bed with a menu on his lap in "roll-a-joint" position.". He quickly removed "something" from the menu and placed it into his cigarette packet, which he then tucked away under the pillow on his bed. He then placed the menu on his table and sat back in the bed.
What I did not see:
Marijuana. Rolling papers.
What I know about the Pt:
Active AIDS. Cancer. Goes outside to smoke in his WC a lot. Enjoys IV morphine, Ambien, Ativan, and Norcos a little too much. He's a clock-watcher. Once smoked a cigarette in the BR of his hospital room while under the care of another nurse.
What I said:
Hey, it's a shame your doc cannot write you a prescription for "that," as I pointed to his packet of cigarettes. I give "it" here in the hospital in a capsule-form called "dronabinol." We discussed legalization of marijuana. I stated that he must not smoke in his room due the risk of fire, the fact that smoking is obviously not allowed within the grounds of the hospital.
What I did not say:
Hey, I see that you are rolling a joint with marijuana there.
What he did not say:
Yes, I was rolling a joint with marijuana.
My reaction and action taken upon the above discovery:
Nothing further than the above description of my implied knowledge of what he was up to and a genuine discussion of my true feelings towards legalization.
I'm just curious as to whether anyone else has experienced such an occurrence, anyone else's feelings towards this incident, and anyone's opinions on whether I acted well having been faced with this "ethical dilemma."
Maybe I'm misunderstanding you, but seem to be suggesting that there might be some risk, such as to your license, by not reporting to police that a patient has admitted to you they use an illegal drug. If you were to discover through your nurse-patient relationship that a patient has or does use illegal drugs, and you called that cops, that's where you could potentially risking your license.
Honestly, I don't know the risks associated with the board of nursing, my license, and this particular issue. My first worry would be the facility's reaction. All I understand of the board of nursing is that are very strict and usually come down on nurses pretty hard.
I would imagine not mentioning at least to the doctor that this patient smokes weed would be something they may take issue with. I don't know.
I did ask the guy if his doc was aware, and he said she was aware.
I have taken care of a pt before who did the same, and according to the patient, his doc knew too. Personally, I have never felt it something I needed to report whether the pt is telling the truth or not.
OP, I think you've unintentionally hit a nerve which has gotten a stronger response than you intended, which unfortunately for you has made you a punching bag for what is a pet peeve of many nurses.
There is a significant bias against patients who aren't really doing anything more than experiencing the intended effects of the medications we are giving them. There are nurses who view some patients as "getting high" off the medications we give them. "Getting high" would seem to refer to the euphoric effect many medications can produce. Everyone, not just the ones we view as druggies, experiences these effects, and that's actually OK. Aside from the fact that the general purpose of most medications is to make people feel better in general, these effects actually account for a significant portion of it's intended purpose. With pain medications for instance (opiates), we know that the direct pain blocking mechanism only accounts for a small portion of it's pain control effects, the euphoric effects count for the rest. We know this because we can compare two drugs with equal mu receptor blocking capabilities and they won't have anywhere near the same effect on pain. The addition of the effects the produce euphoria account for a significant portion of the perceived pain control as well. So it can be frustrating to hear nurses suggest they would withhold medications if they think the patient is 'enjoying them a little too much'. I think you've pretty well argued that you wouldn't do that, but just the use of the phrase sort of opened up a can of worms for you.
Honestly, I don't know the risks associated with the board of nursing, my license, and this particular issue. My first worry would be the facility's reaction. All I understand of the board of nursing is that are very strict and usually come down on nurses pretty hard.
I would imagine not mentioning at least to the doctor that this patient smokes weed would be something they may take issue with. I don't know.
I did ask the guy if his doc was aware, and he said she was aware.
I have taken care of a pt before who did the same, and according to the patient, his doc knew too. Personally, I have never felt it something I needed to report whether the pt is telling the truth or not.
You can get a new job, you can't get a new license.
Specializes in LTC,Hospice/palliative care,acute care.
I have had patients go out to the parking lot of the hospital and boot heroin through their hep lock.I have had patients have sex with their SO's in the hospital bed, I have had end stage cirrhosis patients bring booze in to the hospital and hide it under the bed, .I have had to give milk and molasses enemas to a patient who turned out to have a serious bowel fetish (and masturbated! !! during the enema) I have walked into rooms and discovered NPO patients eating fried chicken. My feelings over the years have ranged from shock and surprise when I was young and naïve to anger when I was more judgemental (and menopausal) to "crap, another incident report" now that I am old and tired.
"Feelings" and personalizing our patient's behavior leads to burn out.You did exactly the right thing-you addressed the safety issue of smoking in the room. And moved on...This is long term care,correct? It's his home, he has rights there that he may not have in acute care.
Practice your Poker Face....you patient should never feel judged in any way for his lifestyle choices....It's our job to educate,not to shame.
I think the reason why others might take exception to your description is that you mentioned the pt's "fondness" for pain medications and the pt's tendency to "watch the clock." It does come off a little bit judgmental.
I have, in my very limited experience, met pt's who have gone through exceptionally painful operations for exceptionally painful conditions that were unfortunately prescribed their pain meds PRN. The pt mentioned having struggles with some RNs questioning their need (which, seriously for this pt, were very, very legitimate) for the pain meds, especially prior to wound dressing changes (!). I can see a pt watching the clock in order to advocate for him or herself when it is time for more medication in order to promote pain management, especially if they know they may have to convince the nurse assigned to them that they really do need the meds. I have also heard nurses griping about the drug seekers and that it's a problem as they have to do their follow-up evaluation following the administration for medication for pain that doesn't exist in the first place -- major time waster, I get it.
But, for a Ca pt with AIDS, whatever, let him watch the clock and let him enjoy something that provides him with likely one of the few moments in his life that are pleasurable. Seriously, he doesn't have the opportunity to enjoy many other pleasures in life so, as long as he's being safe about fire precautions (if he smokes outside it is very unlikely a cop is going to bug him about it -- I had a pt roll his own cigarettes and would smoke them outside the hospital with no issues) so let him outside, enjoy the fresh air and let him have his "evening constitutional" as it were (along with his pain meds, too). :)
Now, if this were a pt with a known drug habit who had a sprained ankle, that's an entirely other thing if they're enjoying their Norco a little too much.
I have had patients go out to the parking lot of the hospital and boot heroin through their hep lock.I have had patients have sex with their SO's in the hospital bed, I have had end stage cirrhosis patients bring booze in to the hospital and hide it under the bed, .I have had to give milk and molasses enemas to a patient who turned out to have a serious bowel fetish (and masturbated! !! during the enema) I have walked into rooms and discovered NPO patients eating fried chicken. My feelings over the years have ranged from shock and surprise when I was young and naïve to anger when I was more judgemental (and menopausal) to "crap, another incident report" now that I am old and tired.
"Feelings" and personalizing our patient's behavior leads to burn out.You did exactly the right thing-you addressed the safety issue of smoking in the room. And moved on...This is long term care,correct? It's his home, he has rights there that he may not have in acute care.
Practice your Poker Face....you patient should never feel judged in any way for his lifestyle choices....It's our job to educate,not to shame.
Ohh man, all this ---and your STILL a nurse?! Wow, the bowel fetish. I don't think I could have carried that order out while a patient masturbated. THAT'S where I would draw the line because that infringes on MY rights a bit too much.
OP, it seems like you might as well stop following this thread. Online forums can be great, but they can also be a huge pain in the rear, especially when people don't take the time to read your responses throughout the thread and feel like unloading all of their years of annoyances on you. Been there, done that. When threads get derailed like this one, I personally choose to peace out instead of spend time/energy with the frustration and defending. I recommend it! ??✌️
OP, I think you've unintentionally hit a nerve which has gotten a stronger response than you intended, which unfortunately for you has made you a punching bag for what is a pet peeve of many nurses.
There is a significant bias against patients who aren't really doing anything more than experiencing the intended effects of the medications we are giving them. There are nurses who view some patients as "getting high" off the medications we give them. "Getting high" would seem to refer to the euphoric effect many medications can produce. Everyone, not just the ones we view as druggies, experiences these effects, and that's actually OK. Aside from the fact that the general purpose of most medications is to make people feel better in general, these effects actually account for a significant portion of it's intended purpose. With pain medications for instance (opiates), we know that the direct pain blocking mechanism only accounts for a small portion of it's pain control effects, the euphoric effects count for the rest. We know this because we can compare two drugs with equal mu receptor blocking capabilities and they won't have anywhere near the same effect on pain. The addition of the effects the produce euphoria account for a significant portion of the perceived pain control as well. So it can be frustrating to hear nurses suggest they would withhold medications if they think the patient is 'enjoying them a little too much'. I think you've pretty well argued that you wouldn't do that, but just the use of the phrase sort of opened up a can of worms for you.
I feel this is exactly the case here. I was a little upset at first, but I'm over it now. I try to see everything for all points of view. I just figured most people would too.
But yes, I have always wondered what was the problem with nurses who "held off" on giving pain meds to certain pts. I think the majority of them, the ones I have questioned about it anyway, have experienced a pt coding d/t the over administration of pain meds. We have had many patients complain as they are not receiving prn pain meds on time, manipulate nurses into calling docs at midnight to request extra shots of dilaudid, etc. after having been told by the doc himself that day that no, they are not getting any more than what is currently ordered for the above reasons. It is a big issue, as many of these patients are so anxious and really do need certain meds to make it. But yeah, lots of them end up overdosed and being rushed to the ICU. Don't judge a nurse who gives pain meds to patient as described above who is trying to keep them happy, as we all know, no matter well you know a patient, how good every thing looks, they may very well code due to overdose, even if all you are trying to do is keep them comfortable, shut them up, get the, off your back....whatever your motivation is and then judge someone for being cautious.
Of course, there is a huge difference between the cautious nurse and then nurse who just lazy and power-tripping. However, each case is different, and quite honestly, if you don't know the patient, the situation, the patient's history, you really have no idea until you do.
I have given report plenty of times and mentioned that yeah, this guy likes his dilaudid. The nurse getting report will know what I mean. It's part of my report. When I am telling the on-coming nurse this I'm also saying, and his last dose was given at 6am, so he'll be calling at 9am, or whatever time, because he will, and this is something she should know about the patient. I don't say, yeah the guy is a ******* dickhead drug addict...make sure you don't give him any pain meds. I will receive report sometimes and such a patient is calling during report, for pain meds. After report, this is the first thing I will take care of. I do that, then I can get on with my job until the next prn pain med time comes up, which I discuss with the patient when I meet them. I'll ensure they know that I am aware of when the next does is due and that I will be there on time. I'll tell them that if I am not, they should call, and they do. They will call usually 15 minutes before the actual time. they'll do this , as they are used to waiting for so long to get a response. Once you've established that trust, or repoire with them, that you will be there on time, all is cool from then on out. An guess what? The patient who was ready to leave, who would complain to the CEO daily, suddenly iss requesting you as their nurse every time you work.
I don't get it -holding pain meds. These people will be fast asleep and will wake up on the ******* hour that the next dose is due. I understand why, and I don't judge them for it, especially when they are obviously in pain, whatever, etc. However, I am going to describe them as a patient who likes their pain meds. A patient who likes their pain meds, whatever a little too much is gonna get described as exactly that too. Because patinets who enjoy their pain meds a a little too much really do exist just like patients who enjoy being bathed by a young chick a little too much really do exist.
None of us are perfect. We all learn something new about people, our job, whatever every time we work a shift. I'm sorry some of you guys have had bad experiences with ****** nurses holding pain meds or whatever lead you to jump all over me for making that comment. We all have experienced this, and worse!
I guess, at the end of the day, you guys are here to defend this guy this patient, his rights, his comfort, his "life.", which I do commend you for. We need this, as this is the only reason we are here and do what we do. When I say "we" I'm referring to nurses who actually care and aren't what we all know exist in our world. These people need us, especially people who have know one else.
Don't get me started on how I feel a lot patient in LTAC are treated like the humans in the Matrix when the machines are using them as batteries. I am a huge right to die advocate. When I have a patient who either the patient themself or the family has made the decision to switch of to TLC, comfort measures only, whatever it is called in your state, and they die, it really is the best feeling in the world, and the reaction of the family after such a patient has passed is always contentment, melancholy of course, but still.
I had a patient recently, a young guy...40 something who had just made this decision as I was coming on. He requested me as his nurse that night. He was a pharmacist and was already on a morphine drip. During my assessment (he was on a vent, so it took effort to communicate...I always make I do this) he wanted to know what does of morphine he was receiving. I guess the nurse who had hooked it up had not discussed it with him? Either way, at first he was like, wait that's too much. He discussed this **** with his wife for a bit, and then decided it was cool. I had told him outright what he was receiving and said, look dude, we both understand what this means, and I will do anything you want. He decided it was cool and it was one of the most moving experiences of entire career. This guy's acceptance of his own death. Seriously, moving ****. He was born with some serious heart crap, beat that, ended up with pulmonary fibrosis. I deal mostly with transplant patients whose transplants have ****** up, so I can only imagine the decisions this guy was dealing with.
OP, it seems like you might as well stop following this thread. Online forums can be great, but they can also be a huge pain in the rear, especially when people don't take the time to read your responses throughout the thread and feel like unloading all of their years of annoyances on you. Been there, done that. When threads get derailed like this one, I personally choose to peace out instead of spend time/energy with the frustration and defending. I recommend it! ✌️
:)
I'm almost there. I just like to try and educate where I can. I just have a hard time believing that people can miss a point so far. Actually, I can't.
If you see someone in "rolling a joint position", assume it is legal tobacco and they are hiding it because the rule they are breaking is "possible intention to smoke inside". You can "know" whatever you want, but if you don't physically see it--you aren't there to enforce the law. You provide medical care, treatments, and education. Possibly about the rules of your facility which include "no smoking".
If your clinical judgement is that a patient is endangering him or herself (or anyone else), and you sincerely suspect illegal drug use that endangers anyone at all--you need to present this to your manager or security and follow whatever your facilitiy's protocol might be.
My point is--consider the effect and scenario. Sounds like you have a reasonable handle on that.
If you accidentally stumble on actual evidence--generally this should be reported. Again, consider the effects and the scenario. But you do need to protect yourself even as you provide caring and sympathy for your patients.
I think the problem many of us have with the "enjoys his meds too much" is we're wondering what the appropriate amount he should enjoy them would be? At what point is he appropriately enjoying his meds and at what point is it "too much"?
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Anonymous666
138 Posts
I would imagine not mentioning at least to the doctor that this patient smokes weed would be something they may take issue with. I don't know.
I did ask the guy if his doc was aware, and he said she was aware.
I have taken care of a pt before who did the same, and according to the patient, his doc knew too. Personally, I have never felt it something I needed to report whether the pt is telling the truth or not.