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??

[MunoRN, RN]

Many states have laws that specifically state even a POA cannot refuse pain meds for a patient on comfort care, the advantage to this is pretty much bullet-proof lawsuit protection. But even when a patient is not officially on comfort care, a terminally ill patient with an incurable condition has been considered in court to reflect the spirit of which the comfort care laws were intended, providing similar protection. There are well established pain assessment tools for patients who are unable to take part in the traditional verbal scales, you've got an order to treat pain and the husband doesn't have the legal or ethical right to refuse that. Proceed until apprehended.

[dishes, BSN, RN]

helloberry Is it possible for your unit to include the MD, SW, manager and nursing staff in a team meeting to discuss the situation? The team needs to be in agreement and not send you around in circles to talk to each of them separately.

[OCNRN63, RN]

devil's advocate....he will out live her, and he will be filling out the press ganey form. also, the dead don't sue, but the living do.

Let him try to sue me for doing my job. I wouldn't care one fig what he'd say on a Press-Ganey.

[morte, LPN, LVN]

Let him try to sue me for doing my job. I wouldn't care one fig what he'd say on a Press-Ganey.

but the hospital may....we have all read the stories here at AN about persons that should have been DNR, in fact had made that decision for themselves, but when they failed sufficiently that they could no longer voice their opinion the family said that they were now to be a full code, "do everything". And docs have acquiesced because they were afraid of being sued, hence the saying the dead can't sue, but the living can.

[Altra, BSN, RN]

So OP ... how are you planning to change your approach to care of this patient?

[nurseprnRN, BSN, RN]

The doctor IS involved, he just won't address the problem. She would be a great candidate for a continuous PCA, but I also think the PRN dilaudid that she has ordered would keep her comfortable if I was allowed to give it to her. She isn't a hospice pt or even a palliative care pt at this point... The family just recently agreed among themselves on a DNR status.

I'd need the doctor to order a palliative care consult, & even then it's just a nurse who counsels the family on end of life issues. I'd also have to have a doctors order to consult the ethics committee :/

If she has a prn Dilaudid prescription, then you are within your rights and obligations as a registered nurse to give it as you assess appropriate. You are a patient advocate by licensure. Whether anyone believes it or not, if the husband does not have legal guardianship (not just medical POA) he cannot legally stop you from giving appropriate care as prescribed already by the physician. Also, it is legal and appropriate under the terms of your RN license to consult an ethics committee in a situation like this. You are her advocate. She cannot speak for herself. That is why RNs are who we are.

Beyond that, all you can say to the husband is how terribly upsetting it must be to have this terminal diagnosis for his wife and see her in such a distressing condition. Sometime when he comes in and she's peaceful, you can tell him that, and then mention that she is peaceful and resting comfortably because she has pain medication prescribed via a safe route, subq or IM or IV, whatever it is, so she won't choke.

[BiohazardBetty]

So OP ... how are you planning to change your approach to care of this patient?

Starting yesterday afternoon, when I honestly felt she was suffering I asked her if she was comfortable. She said no & I said okay I'm going to help you get comfortable... & pushed dilaudid as ordered. She was a totally different person. Even smiled a time or 2! Spouse said oh she's doing so much better... Said, "Keep up the good work & you'll get to go home!" I never said a word about the med to him. Just did what I knew was the right thing & charted accordingly. One of the hardest choices I've had to make so far in my short nursing career, but I'm proud that I finally chose to care for her like she deserved. Thanks to all of y'all for your advice & support!!!!!!!

[blondebabe0625]

Starting yesterday afternoon, when I honestly felt she was suffering I asked her if she was comfortable. She said no & I said okay I'm going to help you get comfortable... & pushed dilaudid as ordered. She was a totally different person. Even smiled a time or 2! Spouse said oh she's doing so much better... Said, "Keep up the good work & you'll get to go home!" I never said a word about the med to him. Just did what I knew was the right thing & charted accordingly. One of the hardest choices I've had to make so far in my short nursing career, but I'm proud that I finally chose to care for her like she deserved. Thanks to all of y'all for your advice & support!!!!!!!

Great news!!!! :-) you're a great nurse! I'm glad everything's working out now.

[nurseprnRN, BSN, RN]

Now make sure everyone else knows to do that, and in a few days you can let her spouse know why she's better. Pain relief is, well, a relief.

[november17, ASN, RN]

This is just wrong, wrong, wrong.

[november17, ASN, RN]

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.

She probably wasn't in horrible pain when/if they made such a promise either.

[november17, ASN, RN]

Starting yesterday afternoon, when I honestly felt she was suffering I asked her if she was comfortable. She said no & I said okay I'm going to help you get comfortable... & pushed dilaudid as ordered. She was a totally different person. Even smiled a time or 2! Spouse said oh she's doing so much better... Said, "Keep up the good work & you'll get to go home!" I never said a word about the med to him. Just did what I knew was the right thing & charted accordingly. One of the hardest choices I've had to make so far in my short nursing career, but I'm proud that I finally chose to care for her like she deserved. Thanks to all of y'all for your advice & support!!!!!!!

I know they really stress treating the family as well as the patient as holistic care but I'm glad you did what you did. If he finds out and makes a fuss, stand your ground.