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??

[R!XTER]

When they present to the ER its Strictly ER staff, unless they get admitted and their onc team would get involved. With the case I mentioned, the MD just focused on the issue of the moment - the pain, and the multiple serious issues we found on labs - neutropenia, anemia, thrombocytopenia... She was quite sick, and was admitted to MICU. The other patient was also end stage and in her 40's, coming for pain control and it was a different MD on the case. He actually asked her what she knew about her diagnosis, if she was aware it was terminal, if there was family in the picture, etc. I was actually very impressed with his interest in finding out the social aspects as well. I guess a lot depends on the doc.

[rnlately]

My dad was diagnosed with PC in September 2009. He didn't pass until September 2012. Also received chemotherapy and when one treatment would fail; he would switch to another one even tried radiation therapy. He wasn't in denial, he just had a lot of faith and hope. He was well aware as well as the family that the outlook was bleak but in cases like this hope is all you have.

[BiohazardBetty]

Imagine how many times people who are experiencing the emotional crisis of being given a diagnosis with an extremely poor prognosis need the information repeated.

Amen. It's way too easy to forget this sometimes.

[gcupid]

And pass the buck to someone else? Niiice...

It is the "EASIEST" thing to do. When a situation is complex, subjective, and has ethical politics involved, I'd gladly pass it on. Everyone has their limit. I know situations like these would have me to the breaking point. I'd gladly trade a coworker who hates dealing with Trachs&suctioning and/or time-consuming quadriplegics bc it makes him/her sick in the stomach. Nursing is stressful enough. Reassign me to something I can handle. My nerves is shot all ready from the previous two 12 hr shifts I worked. Lets just be happy that I didn't call in and showed up today.