While this is a very difficult situation, and our profession calls for us to be sensitive to other countries' social and religious beliefs, my primary role is to serve my patient in her best interests. I was not very familiar with Haiti culture, when I researched it, I cannot find strong information to verify the males will make decisions for any family females even if it is against their wishes. I would have to go through all the proper legal channels to assure we managed this in the best possible legal manner. That being said, I must fight to advocate for Marie in this case. Marie has terminal cancer, she has verbalized the desire for pain medication, and she is a patient in my hospital in The United States of America. I will fight to make certain she is medicated and the palliative measures she has requested are honored. The continued administration of pain medication would likely fail to respect the religious beliefs expressed by Jean, but Jean is not my patient, and he does not have a legal POA or healthcare surrogate designation concerning Marie. Until I hear Marie verbalize she does not want the pain medication that is ordered, as long as I have an order I will administer it. If the physician discontinued it because of Jean's request, I would contact our ethics committee to review the case, and continue to advocate for my patient until it was resolved.
I agree Shelley the patient and her pain is the most important thing in this situation. I know we won't ignore the patient's family but the patient should come first before all of that.
I absolutely agree with your stance. One thing to realize is that this will probably make the job of the RN more difficult due to a hostile situation it will create.
It probably will, Jessica. I would handle it as tactfully as possible, but I have no qualms about being a string patient advocate, as I'm sure none of us in this class would. Tact works sometimes, but usually will only go so far if someone is unreasonable and irate.
I mean that is what we have been constantly taught, is that we have to believe the patients pain. Where as we think that this medication might be too much we still can't refuse unless the patient is hemodynamically unstable and then at that point we would be able to refuse giving the pain medication.
I think that it would be a hard situation to be in here and I agree with Shelley I would handle this as tactfully as possible as I could. I would try and educate as to the best of my abilities and then also make sure that I was advocating for my patient.
I know that this has nothing to do with religion but I actually had a patient like this where the family was the ones who were trying to control the medications I gave him. He was a younger man about 21 and he had a long history of drug abuse and had came in for a collapsed lung and long story short they had to do some pretty extensive surgeries for his case. He was in a great deal of pain and of course we all know that recovery addicts are hard to treat due to tolerance but the family kept telling me to stop giving him any type of medication that he could potentially become addicted to again. He was in so much pain and at this point I was my patient advocate and stood up to the family and said you know we will cross that bridge when we get there but right now we need to control his pain. It is just a hard thing to judge especially then family is involved. But we do have to respect everyone, however, out patients are our number one priority.
This is a very fine line you have to walk in this situation. On one hand it is very important to respect the culture and religious practices for all patients. In these situations there isn't always one right answer. I would go back to my early days as a nurse when they teach you to prioritize and I believe the priority here is your patient and to help treat her pain. I would continue to have her treated for pain and have the Dr. also explain to the family member that is a side effect of the pain medication and it is not a result of spirits in her body. Since it is the patients wishes to use pain medication I feel that I couldn't discontinue the medication without consulting her first once she is in a coherent frame of mind.
I agree with you completely, Alex. I would imagine that he would actually respect your words much more than he would mine due to gender. You would possibly meet much less resistance from her brother than we female nurses. He would likely respect your opinion and you'd get less hassle than we would.
Agree. That's where educating becomes important. It may very well allow the family to be more open minded hearing this from someone else such as the doctor.
If Marie is competent as the study states then I would initiate a conversation between the patient and her brother when Marie is capable and the pain medication has worn off enough for her to not be mumbling and delirious. I feel like this would provide me with more information on where the patient stands. If the brother tells her that the pain medicine and the side effects are against their religion or culture and the patient agrees, I would take that into consideration. I would also speak to the patient alone after the conversation to see if this in fact was her true feelings and beliefs and see how she wishes to proceed and ultimately advocate for what she decides and tells me she wants. Maybe she does value her family’s believes on this issue and needed reminded, she may have overlooked this aspect of herself given her painful circumstances and the altering psychological effects of the pain medicine. Or, maybe she doesn’t either way, I feel like a conversation with her family when she’s not under the influence followed by a one on one conversation between her and I would clear up this predicament.
Good plan! Pain can definitely cloud someones judgement and perhaps Marie wasn't thinking clearly. By stopping the medication to clarify with her I am sure that will appease the brother for the time being since you are not giving her the pain medication. Once she is lucid you can clarify and advocate for her whichever way she chooses.
Good insight, Erin. If she's alert and in enough pain, she might be bold enough with her brother. My concern is would she feel obligated to back down, then suffer because she chose for him.
this is a very sticky situation. I feel as though with good education about the medication and the patients rights to make her own decisions the RN needs to stand up for her patients wishes. Nobody deserves to die in pain. This will make the nurses job more difficult, however with the support of her team (doctors and charge nurse) she needs to make the patient comfortably. Another option may be to change medications with the consent of the physician to lessen the side effects of the medication.
As the nurse responsible for Marie's care, I feel it's my responsibility to her, the patient to help with her pain control. Possibly an adjustment in medication to find a balance between reasonable pain control and alertness could be discussed with the doctor. I also would try to explain to her brother that the effects from the pain medication is what causes her delirium. Hopefully he could understand this, if not, it would still be my responsibility to treat her first. Giving respectful consideration to his beliefs could come in for form of understanding and emotional support.
Good point, Gloria. I do think that at some point, if she has terminal cancer, the lines between sedation and altered mental status due to the disease process will become blurred, also I know the pain medication necessary as her disease progresses will make it impossible to avoid this. At some point, the brother will just need to come to terms with the fact that it's unavoidable. If she were in Haiti, without medication, she would reach the point of altered mental status and experience the same. Unfortunately, it would be after she had endured much pain.
If Marie were my patient, I would continue with what the patient had expressed as her wishes and give her pain medication. I do understand that the scenario states that it is a competent request, so I am assuming that the patient can speak English and an interpreter is not needed. I would have explained all side effects to be sure Marie understood what she was taking before giving her the prescribed medication. If she appeared to be overly sedated or having adverse side effects from the pain medication I would be sure to evaluate her. If Marie’s brother Jean came in and caused a ruckus I would calmly explain to him that this was her request and that I am an advocate for her and her needs. I would listen to his complaints and try my best to understand his viewpoint. I would acknowledge respect their religious beliefs, but if Marie had not expressed these beliefs and wishes, I cannot take his word that that is what she would want. If he continued not to listen, I would advise him security would be notified and he would be escorted out.
Yes, you used those words- if he's acting crazy escort him out! LOL.... When I was thoroughly thinking about this situation, I was fairly certain the brother would look down on us as females who were also beneath him, and not respect us as trained, educated professionals who dealt with difficult situations daily and actually had good. I imagined he would demand to the physician, anticipating a male, and was curious how he would be if the physician was also female.
Yes that is a point I didn't even think of if that family member is out of control he can be even a bigger detriment to your patient and since your patient is the priority he may need to be removed.
I know our hospital culture is family centered care, but when it comes down to it, Marie is the one you must advocate for. As Jocelyn put it, calmly explaining to her brother, with all respect, is all you can do for him. When it comes to Marie, we as nurses know exactly what we need to do for her.
We are our patient's voice when they can no longer speak. We must abide by the patient's request and put the brother's request to the side. We will respect him, but caring for the patient is our number one priority.
I am not, or is my patient, in Haiti. If she has terminal cancer and wants to die pain free that is her right. I am an advocate to my patient. The family has to come to terms with the decision that the patients make. I would not honor his request over my patients request. I would try to accommodate by lowering the pain medication dose as long as the patient was comfortable. I believe that her request should be honored over her cultural context. It is her decision to make. If her brother was laying their with terminal cancer and the pain that is associated with it, would he want to endure the pain. Jean's religious views can not be forced on his sister. If it is a male dominated society in Haiti, he must realize that is not practiced in the United States. I would continue to administer pain medication if she requested it.
As a hospice nurse, I'm presented with this situation often. Not necessarily the religious aspect, however, there are times when family members are trying to call the shots. As the nurse caring for Marie, it is my responsibility to treat the patient first and then try to respect her culture. The patient has a terminal cancer diagnosis. Lung cancer can be very painful with each breath. The patient requested the pain medication and the nurse administered it. The brother shows up and demands the medication to be stopped because his religion believes the medication brought in evil spirits. How do we know if the patient was practicing this religion and this was her beliefs as well? She did ask for the medication. I believe the nurse did the right thing and should continue to access and manage the patient's pain. Unless her brother is the patient' healthcare surrogate, then he just needs to sit back and enjoy what time he has left with his sister. If he is the healthcare surrogate, we will grant whatever his decision is if the patient is unable to speak for herself, however, we will continue to manage the patient's pain regardless of his requests to stop the medication. Our first and foremost duty is to care for the patient.
When caring for those of other cultures, it is always important to be sensitive. However, you also must consider the patient. Marie is an alert and oriented adult who is competent to make medical decisions for her self. If she is uncomfortable and is requesting something for pain, it would be my job as a nurse to provide that to her and keep her comfortable. Yes you should be sensitive to families requests, this may be where extra education is needed. I'm sure they would not want to be hurting is they were in Marie's position. Culture is very important. I do believe that self determination takes priority here. If Marie decided on her own it was against her culture that would be one thing, but as long as she is requesting your help, you have the duty to help and care for her.
While this is a very difficult situation, and our profession calls for us to be sensitive to other countries' social and religious beliefs, my primary role is to serve my patient in her best interests. I was not very familiar with Haiti culture, when I researched it, I cannot find strong information to verify the males will make decisions for any family females even if it is against their wishes.
ReplyDeleteI would have to go through all the proper legal channels to assure we managed this in the best possible legal manner. That being said, I must fight to advocate for Marie in this case. Marie has terminal cancer, she has verbalized the desire for pain medication, and she is a patient in my hospital in The United States of America. I will fight to make certain she is medicated and the palliative measures she has requested are honored. The continued administration of pain medication would likely fail to respect the religious beliefs expressed by Jean, but Jean is not my patient, and he does not have a legal POA or healthcare surrogate designation concerning Marie. Until I hear Marie verbalize she does not want the pain medication that is ordered, as long as I have an order I will administer it. If the physician discontinued it because of Jean's request, I would contact our ethics committee to review the case, and continue to advocate for my patient until it was resolved.
I agree Shelley the patient and her pain is the most important thing in this situation. I know we won't ignore the patient's family but the patient should come first before all of that.
DeleteI absolutely agree with your stance. One thing to realize is that this will probably make the job of the RN more difficult due to a hostile situation it will create.
DeleteIt probably will, Jessica. I would handle it as tactfully as possible, but I have no qualms about being a string patient advocate, as I'm sure none of us in this class would. Tact works sometimes, but usually will only go so far if someone is unreasonable and irate.
DeleteI mean that is what we have been constantly taught, is that we have to believe the patients pain. Where as we think that this medication might be too much we still can't refuse unless the patient is hemodynamically unstable and then at that point we would be able to refuse giving the pain medication.
DeleteI think that it would be a hard situation to be in here and I agree with Shelley I would handle this as tactfully as possible as I could. I would try and educate as to the best of my abilities and then also make sure that I was advocating for my patient.
I know that this has nothing to do with religion but I actually had a patient like this where the family was the ones who were trying to control the medications I gave him. He was a younger man about 21 and he had a long history of drug abuse and had came in for a collapsed lung and long story short they had to do some pretty extensive surgeries for his case. He was in a great deal of pain and of course we all know that recovery addicts are hard to treat due to tolerance but the family kept telling me to stop giving him any type of medication that he could potentially become addicted to again. He was in so much pain and at this point I was my patient advocate and stood up to the family and said you know we will cross that bridge when we get there but right now we need to control his pain. It is just a hard thing to judge especially then family is involved. But we do have to respect everyone, however, out patients are our number one priority.
This is a very fine line you have to walk in this situation. On one hand it is very important to respect the culture and religious practices for all patients. In these situations there isn't always one right answer. I would go back to my early days as a nurse when they teach you to prioritize and I believe the priority here is your patient and to help treat her pain. I would continue to have her treated for pain and have the Dr. also explain to the family member that is a side effect of the pain medication and it is not a result of spirits in her body. Since it is the patients wishes to use pain medication I feel that I couldn't discontinue the medication without consulting her first once she is in a coherent frame of mind.
ReplyDeleteI agree with you completely, Alex. I would imagine that he would actually respect your words much more than he would mine due to gender. You would possibly meet much less resistance from her brother than we female nurses. He would likely respect your opinion and you'd get less hassle than we would.
DeleteAgree. That's where educating becomes important. It may very well allow the family to be more open minded hearing this from someone else such as the doctor.
DeleteIf Marie is competent as the study states then I would initiate a conversation between the patient and her brother when Marie is capable and the pain medication has worn off enough for her to not be mumbling and delirious. I feel like this would provide me with more information on where the patient stands. If the brother tells her that the pain medicine and the side effects are against their religion or culture and the patient agrees, I would take that into consideration. I would also speak to the patient alone after the conversation to see if this in fact was her true feelings and beliefs and see how she wishes to proceed and ultimately advocate for what she decides and tells me she wants. Maybe she does value her family’s believes on this issue and needed reminded, she may have overlooked this aspect of herself given her painful circumstances and the altering psychological effects of the pain medicine. Or, maybe she doesn’t either way, I feel like a conversation with her family when she’s not under the influence followed by a one on one conversation between her and I would clear up this predicament.
ReplyDeleteGood plan! Pain can definitely cloud someones judgement and perhaps Marie wasn't thinking clearly. By stopping the medication to clarify with her I am sure that will appease the brother for the time being since you are not giving her the pain medication. Once she is lucid you can clarify and advocate for her whichever way she chooses.
DeleteThat's is a good idea. Would help to get everyone on the same page.
DeleteGood insight, Erin. If she's alert and in enough pain, she might be bold enough with her brother. My concern is would she feel obligated to back down, then suffer because she chose for him.
Deletethis is a very sticky situation. I feel as though with good education about the medication and the patients rights to make her own decisions the RN needs to stand up for her patients wishes. Nobody deserves to die in pain. This will make the nurses job more difficult, however with the support of her team (doctors and charge nurse) she needs to make the patient comfortably. Another option may be to change medications with the consent of the physician to lessen the side effects of the medication.
ReplyDeleteI agree, it's all about the patient's wishes. Nursing school 101 - be a patient advocate.
DeleteYes maybe lowering the dose or medication change should be considered to lessen the effects but allow the patient to still remain comfortable!
DeleteVery well said!
DeleteAs the nurse responsible for Marie's care, I feel it's my responsibility to her, the patient to help with her pain control. Possibly an adjustment in medication to find a balance between reasonable pain control and alertness could be discussed with the doctor. I also would try to explain to her brother that the effects from the pain medication is what causes her delirium. Hopefully he could understand this, if not, it would still be my responsibility to treat her first. Giving respectful consideration to his beliefs could come in for form of understanding and emotional support.
ReplyDeleteI was also thinking she may need her dose altered. You hate for her to have pain, yet you don't want to over sedate her and potentially cause harm.
DeleteGood point, Gloria. I do think that at some point, if she has terminal cancer, the lines between sedation and altered mental status due to the disease process will become blurred, also I know the pain medication necessary as her disease progresses will make it impossible to avoid this. At some point, the brother will just need to come to terms with the fact that it's unavoidable. If she were in Haiti, without medication, she would reach the point of altered mental status and experience the same. Unfortunately, it would be after she had endured much pain.
DeleteI didn't consider altering her dose. She does seem to be possibly over medicated according to her brother.
DeleteIf Marie were my patient, I would continue with what the patient had expressed as her wishes and give her pain medication. I do understand that the scenario states that it is a competent request, so I am assuming that the patient can speak English and an interpreter is not needed. I would have explained all side effects to be sure Marie understood what she was taking before giving her the prescribed medication. If she appeared to be overly sedated or having adverse side effects from the pain medication I would be sure to evaluate her. If Marie’s brother Jean came in and caused a ruckus I would calmly explain to him that this was her request and that I am an advocate for her and her needs. I would listen to his complaints and try my best to understand his viewpoint. I would acknowledge respect their religious beliefs, but if Marie had not expressed these beliefs and wishes, I cannot take his word that that is what she would want. If he continued not to listen, I would advise him security would be notified and he would be escorted out.
ReplyDeleteYes, you used those words- if he's acting crazy escort him out! LOL.... When I was thoroughly thinking about this situation, I was fairly certain the brother would look down on us as females who were also beneath him, and not respect us as trained, educated professionals who dealt with difficult situations daily and actually had good. I imagined he would demand to the physician, anticipating a male, and was curious how he would be if the physician was also female.
DeleteYes that is a point I didn't even think of if that family member is out of control he can be even a bigger detriment to your patient and since your patient is the priority he may need to be removed.
DeleteI know our hospital culture is family centered care, but when it comes down to it, Marie is the one you must advocate for. As Jocelyn put it, calmly explaining to her brother, with all respect, is all you can do for him. When it comes to Marie, we as nurses know exactly what we need to do for her.
DeleteWe are our patient's voice when they can no longer speak. We must abide by the patient's request and put the brother's request to the side. We will respect him, but caring for the patient is our number one priority.
DeleteI am not, or is my patient, in Haiti. If she has terminal cancer and wants to die pain free that is her right. I am an advocate to my patient. The family has to come to terms with the decision that the patients make. I would not honor his request over my patients request. I would try to accommodate by lowering the pain medication dose as long as the patient was comfortable.
ReplyDeleteI believe that her request should be honored over her cultural context. It is her decision to make. If her brother was laying their with terminal cancer and the pain that is associated with it, would he want to endure the pain. Jean's religious views can not be forced on his sister. If it is a male dominated society in Haiti, he must realize that is not practiced in the United States. I would continue to administer pain medication if she requested it.
Amen Chris...my sentiments exactly!
DeleteAs a hospice nurse, I'm presented with this situation often. Not necessarily the religious aspect, however, there are times when family members are trying to call the shots. As the nurse caring for Marie, it is my responsibility to treat the patient first and then try to respect her culture. The patient has a terminal cancer diagnosis. Lung cancer can be very painful with each breath. The patient requested the pain medication and the nurse administered it. The brother shows up and demands the medication to be stopped because his religion believes the medication brought in evil spirits. How do we know if the patient was practicing this religion and this was her beliefs as well? She did ask for the medication. I believe the nurse did the right thing and should continue to access and manage the patient's pain. Unless her brother is the patient' healthcare surrogate, then he just needs to sit back and enjoy what time he has left with his sister. If he is the healthcare surrogate, we will grant whatever his decision is if the patient is unable to speak for herself, however, we will continue to manage the patient's pain regardless of his requests to stop the medication. Our first and foremost duty is to care for the patient.
ReplyDeleteTracy, I love getting your hospice approach to it, and hearing your experience. This truly is your specialty.
DeleteWhen caring for those of other cultures, it is always important to be sensitive. However, you also must consider the patient. Marie is an alert and oriented adult who is competent to make medical decisions for her self. If she is uncomfortable and is requesting something for pain, it would be my job as a nurse to provide that to her and keep her comfortable. Yes you should be sensitive to families requests, this may be where extra education is needed. I'm sure they would not want to be hurting is they were in Marie's position. Culture is very important. I do believe that self determination takes priority here. If Marie decided on her own it was against her culture that would be one thing, but as long as she is requesting your help, you have the duty to help and care for her.
ReplyDelete