FEAR OF ADDICTION

Out-of-control pain

My 60-year-old patient has breast cancer that's metastasized to her pelvis and spine. When she receives adequate opioid analgesia, she's nearly pain-free and comfortable. Unfortunately, for a good part of the day she refuses pain medication, insisting that she doesn't want to become an addict. During this time, her pain is often intense.

Her oncologist has repeatedly explained how opioids work and assured her that using them to manage pain won't make her an addict, but she won't accept this. When I try to reinforce his explanation, she accuses me of taking his side against her. I've learned that her son has a history of drug abuse and addiction, which I'm sure influences her attitude.

I want to respect her views, but it doesn't seem ethical to stand by while she suffers, especially when her pain can be effectively treated with medication. Does she really have the right to refuse this standard medical treatment? -A.F., MO.

A competent adult always has the right to refuse treatment, including pain medication. But I'm guessing that's not really the issue here. I suspect that your patient's refusal of medication is her way of keeping control when everything else seems out of control.

If possible, talk with her frankly about this concern. Teach her about her patient rights (review the information she received on admission). Let her know clearly that you and her care team will do only what she wants and that she's in charge of every treatment decision.

Ask her oncologist about ordering patient-controlled analgesia (PCA). By giving her more control over her pain management, PCA may make her more receptive to treatment.

REMOVING LIFE SUPPORT

Respect for the dead

I was disturbed by a comment you made in a recent column regarding a patient on life support who'd been declared brain dead. ("Brain death: Religion vs. Resources,"Ethical Problems, April) You advised nurses to avoid such words as "patient," "care," and "treatment" while talking to family members. This seems disrespectful. I've never referred to anyone as anything other than a "patient." Please explain your reasoning. -K.L., CALIF.

To acknowledge the reality of death doesn't indicate disrespect for someone who's died. Brain death is determined according to established and specific medical-legal criteria. When a physician determines that a patient is brain dead based on these criteria, that person is legally dead, even though still on "life support." In this case, however, the equipment isn't supporting life, it's simply perfusing the body's organs.

As I discussed in my previous column, denial is a powerful coping mechanism for family members struggling to come to terms with a shocking event. Because of denial, they may resist removing life support after their loved one's death. Once a patient is dead, however, the only justification for continuing to provide this resource is to maintain organs for transplant.

After a person dies, we refer to the remains as a "body." As a nurse, you can help the family accept the reality of death by using this word instead of "patient." For example, you might say in a gentle and respectful tone, "The body of your loved one will now be taken to the funeral home." Healthcare professionals should never imply that they're continuing to provide treatment or care after a patient has died.