I heard a story the other day about a lady who accidentally overdosed on her pain medication and died. It’s a story we have all heard before. The media always reports on those deaths. It scares doctors into being hesitant to prescribe adequate pain medication and it scares the public to be prescribed those medicines. But where do our responsibilities as clinicians lie and the patient’s responsibilities begin?
Our responsibility to our patient’s is thorough education and follow-up, and in many ways we fall short. How many times have you left your doctors office or hospital with a prescription for a new medication with nothing in writing explaining that medication? Hopefully the doctor or nurse gave you a few words of wisdom about that medicine, but how complete was that information or will you remember it correctly. Then, after receiving this new prescription, your doctor tells you to "follow up with me in 3 months and call me if you have any problems". It then becomes the patient’s responsibility to "follow Doctor’s orders". Is that enough? Does the patient know what kind of "problems" they may have with that medicine and really when they need to call?
We now have printouts from our pharmacies that give us information on our medication, but how many times have you completely read yours, and if you are one of those type-A professionals who read every word of that printout, how do you know your patient is reading theirs?
This is even more important when it comes to pain medication. Because of the possible adverse outcomes and fears of the professionals and patients, good education and verification of understanding is essential. The more adverse outcomes we hear and read about the more it negatively affects our willingness and ability to manage pain correctly and completely. Once we have educated our patients and have documented, not only their education, but also their understanding of that education, then can we can turn responsibility over to them.
We can do some simple things to help our patient’s and ourselves:
1. Go over new pain medications with the patient in person. Just a simple printout is not enough. They ought to be able to ask questions and clarify with a health care professional their concerns. Make sure they understand about the dosing and the side effects. Don’t give them an option on listening to this teaching. Do not ask, "do you have any questions" before you have gone over the material. Even if they are a doctor, nurse, or other health care professional they need to hear this teaching as it applies to them.
2. When possible, give them simple instructions IN WRITING. They can refer to this if they forget or get confused. This can easily be done with the technology we have today. We as nurses can develop teaching tools that can be printed off with a click of a mouse that give our patients great information and support. These instructions should include the name of the medication, how to take it correctly, potential side effects and when to call the doctor for problems. Spell out these "problems" for the patients as our definitions of "problems" and theirs can differ greatly. We can also include in the patients chart a signed copy of those instructions stating they received and understand them. This protects us, showing we provided teaching – something that is frequently neglected even when we do.
3. Encourage the patient to call if needed. Many people are hesitant to "bother" the doctor and try to fix the situation themselves. Tell the patient that you want them to call and that that call is not a bother. Let them know verbally, and in writing, that they own a part of the responsibility for their care and if there are problems they should not try to fix it themselves but instead need to call immediately. If they do not feel like they can (and should) call they may try to adjust the dose or add other medications with it (over the counter or other people’s prescriptions). This can be a devastating decision.
4. Follow-up for drug efficacy. This is probably the area that needs the most improvement in pain management. The patient should be followed-up quickly (within a day or two) to determine if a pain medication is working. Patients who are left with uncontrolled pain, who have a full prescription of pain medication and who try to adjust doses themselves can quickly be in trouble. If efficacy is followed-up on then dose adjustments can be made safely. Follow-up should occur after each change or increase. Too many times we leave the patient too long in pain and, because of their need to be out of pain, poor decisions are made and result in tragedy. Furthermore our patients deserve good pain control. If a pain medication is not working, or only partially working should we be asking them to wait a month to have it adjusted? Physiological changes that happen in the presence of pain would have a long time to have negative effects. We owe our patients better pain control than that.
The challenge is how do we follow-up on every patient we send out of our clinics and out of our hospitals with pain medication. What mechanisms can we put in place, that are cost effective, that can support follow-up for all our patients? And whose responsibility is it, the discharging facility or the caregiver the patient is discharged to. There is a lot of work still to do in this area. I challenge all my Nursing colleagues to make whatever improvements they can make in their own practice to improve education and follow-up and to work in their professional groups to improve standards of practice. Together we can make a real difference!
Arnold graduated from University of Oklahoma in 1987 with her BSN. She is currently employed at Good Shepherd Hospice finding her niche in hospice and pain management. She is a Board Certified Pain Management Nurse.