When family refuses IV pain meds for cancer pt...?

[BiohazardBetty]

What do you do when a pt's spouse refuses to allow you to administer IV pain medications as ordered? Pt has end stage cancer w/ brain mets. DNR. Confused most of the time. Has not been deemed incompetent, has no power of attorney. Says "no" when you ask her if she's in pain, all the while she's yelling out that she's in pain. Spouse tries to console her if he's in the room, but is often gone... But has an unpredictable schedule.

Spouse said he doesn't want pt "knocked out" & she "isn't herself" after she's had IV pain meds. (Like rolling around in pain IS her??) He will allow PO Percocet 10, but pt has swallowing difficulties r/t confusion. Spouse has been educated many times by many different nurses regarding pain associated w/ pt's type of cancer.

Talked to the doctor during rounds, but he offered no guidance and the spouse wasn't present. Went to the charge nurse who said to talk to the nurse manager who said to address it with the social worker who said to contact the oncologist (again) who said that if the pt can't swallow then "she'll just have to hurt." Seriously??!!??

What would you do?? It feels ABUSIVE to allow her to be in such awful pain for so long, but the spouse will cause a HUGE scene if he thought the pt had received IV pain meds. What are my options to protect my pt & keep her at least reasonably comfortable??

[twinmommy+2, ADN, BSN, MSN]

Question...

The patient denies being in pain even though she is showing signs of being in pain. The husband does not want her medicated. Could this be an issue of culture instead of allowing a patient to suffer?

[NicuGal, MSN, RN]

Is she saying she isn't in pain when the husband is there? Do you have a CNS to get involved also? If he is NOT her POA then she should be medicated when necessary! You need to be the squeaky wheel if no one else will! Are there any children that visit? If so I would involve them and call a family meeting. If her doc isn't doing anything then go up that chain too.

[jadelpn, LPN, EMT-B]

His survey is the least of my concerns...

What do you feel he could he sue for?

People are strage.....and can sue for anything. I would NOT take this on myself.

And I am curious as to why all of the concern about the husband when he is not your patient? He has no power as of yet (or if at all per a POA or HCP deems someone else) and I just don't understand that part of the equation at all.

[BiohazardBetty]

morte was being facetious.....hospitals press ganey surveys are the facilities bible these days.....sad.

He could sue for anything that will cost the hospital time and money....not that he would win. Forcing a patient to take a med she doesn't want...(her saying no no no no all the time) is assault. Now we all know she is confused and is in pain but that doesn't mean he can't sue later just to cause a stink.

People are crazy....and do weird things.

For example.....I had a patient that survived a horrible fire and lengthy hospital stay and sued for a breakdown over the right ear for O2 tubing.....it wasn't bad never needed plastic surgery like their burns...but it did get red and blister. He got a settlement from the facility. It never went to court.

That's good info... I was worried that I had already done something that may invite a law suit! The spouse is kinda crazy... SUPER attentive when staff are present- rubbing her feet & talking sweet, singing to her- but when we aren't in the room he sits in the corner & ignores her. We have observation type windows where we can see into the room without disturbing the pt, so I've noticed this frequently. Now that I think about it, I've actually never seen him showing her any attention when we weren't in the room... But then again, my 4 seconds 4 times an hour is hardly a good judge of what they do the rest of the time.

I don't feel like its a cultural/religious thing- they're southern baptist just like most of the staff. Even used to go to church with one of our CNAs. It feels more like a control issue to me, sadly.

[rumwynnieRN]

That's good info... I was worried that I had already done something that may invite a law suit! The spouse is kinda crazy... SUPER attentive when staff are present- rubbing her feet & talking sweet, singing to her- but when we aren't in the room he sits in the corner & ignores her. We have observation type windows where we can see into the room without disturbing the pt, so I've noticed this frequently. Now that I think about it, I've actually never seen him showing her any attention when we weren't in the room... But then again, my 4 seconds 4 times an hour is hardly a good judge of what they do the rest of the time.

I don't feel like its a cultural/religious thing- they're southern baptist just like most of the staff. Even used to go to church with one of our CNAs. It feels more like a control issue to me, sadly.

...that sounds a lot like a crappy home dynamic, if this is a mirror of their home life.

People are strange.

[dishes, BSN, RN]

Cancer pain managment has come full circle, I remember a time when some nurses would refuse to give end stage CA patients PRN morphine, telling the family members your just trying to knock them right out.

Maybe the husband is frightened about his wife dying, maybe his wife expressed a strong fear of being too confused by the side effects of the medication to talk before she goes into a coma and dies, maybe the way he sees it, he is just trying to keep a promise he made to his dying wife.

[BiohazardBetty]

Cancer pain managment has come full circle, I remember a time when some nurses would refuse to give end stage CA patients PRN morphine, telling the family members your just trying to knock them right out.

Maybe the husband is frightened about his wife dying, maybe his wife expressed a strong fear of being too confused by the side effects of the medication to talk before she goes into a coma and dies, maybe the way he sees it, he is just trying to keep a promise he made to his dying wife.

That would be a nice thing to do, if that were the case... Neither the patient or the spouse has mentioned anything like that & today I specifically said "I feel like I'm not doing a very good job managing her pain since she's been yelling out for the past 2 hours. What do you think?" & he said "She's fine. I'll let you know when she's hurting." She's already so confused from the brain mets that medication probably wouldn't change much.

[dishes, BSN, RN]

Just because the spouse and patient never mentioned a promise they made to each other, doesn't mean it doesn't exist. His manner is bossy and intimidating and preventing the pain medication is an ethical dilemma, but it doesn't necessarily mean he doesn't want what's best for his wife, from his perspective.

[Penelope_Pitstop, BSN, RN]

I cannot wrap my head around not medicating a patient because spouse might show up and be upset.

Exactly. If he's not around and she's clearly in pain from my nursing judgement...(all sorts of pain scales exist - and a lot of neuro-impaired patients will say "no" and mean "yes") well, he has left her in my care and she is getting her pain medication!

[chrisrn24]

I think you have to balance family wishes with patient needs. Sometimes patients' relatives will say "could you hold off on giving her pain medication? It makes her loopy/agitated whatever." But if the person is clearly in pain I will still give it.

[jadelpn, LPN, EMT-B]

That would be a nice thing to do, if that were the case... Neither the patient or the spouse has mentioned anything like that & today I specifically said "I feel like I'm not doing a very good job managing her pain since she's been yelling out for the past 2 hours. What do you think?" & he said "She's fine. I'll let you know when she's hurting." She's already so confused from the brain mets that medication probably wouldn't change much.

With all due respect, the husband is not your patient. He has absolutely no say in whether his wife needs pain medication or not. You need to treat the patient, and not the husband. I am not sure why you are debating this. I can not stress enough that as a patient advocate, you really do need to try and meet the patients' needs. And if you have no one else on board with you regarding this, it is not a good thing to say the least. To be quite blunt, this patient is not suffering because of any other reason but her own declining of pain med, or the inability and/or unwillingness of staff to appropriately medicate the patient based on the order, and if the order is not working, then you need to obtain alternate orders.

[ComeTogether, LPN]

Not a nurse so shouldn't be piping in but I can't help it.

Can you re-word it when he isn't around? Like say "would you like me to give you something to make you more comfortable"? So that she says yes?