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  1. Salladay, Susan A. RN, PhD

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Put a lid on the labels

Some nurses in the unit where I work frequently label patients; for example, as complaining, or demanding. I'm uncomfortable with this type of labeling, which seems disrespectful to patients. What do you think?-O.M., ILL.


Labeling patients should make everyone uncomfortable because it clearly violates patient rights. The rights of any hospitalized patient stem from ethical principles, the most basic being the right to be treated with respect for his human dignity.


When patients are admitted to a facility for care, they should receive a statement of the hospital's Patient Bill of Rights and Responsibilities. In most facilities, this is modeled on recommendations issued by a federal advisory commission in 1998. One of these patient rights is the right to considerate and respectful care from all healthcare providers. According to healthcare rights expert George Pozgar, a surveyor with The Joint Commission, "an organization's description of patient rights[horizontal ellipsis]should be viewed as a document with legal significance[horizontal ellipsis]. The rights of patients must be respected at all times."1


Labeling patients is dishonest and deceptive. It shows disrespect by stereotyping them instead of trying to understand their complex behaviors and concerns.

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How can you start to turn this situation around? Have an honest talk with your manager. Come prepared with evidence (such as your hospital's policy on patient rights) to show why you're uncomfortable with the situation. Sounds like a staff-development session is in order to raise staff awareness about this important issue.



Exploring other options

I'm an advance practice nurse (APN) with expertise in pain management. Recently, I was asked to see a 90-year-old woman with severe chronic osteoarthritis pain refractory to nonopioid analgesics. After a thorough history and physical exam, I prescribed a trial of oral morphine. During a follow-up phone call, she revealed that she hadn't filled the prescription because she'd heard that "most older people who receive it eventually die." How should I handle this?-H.S., FLA.


Start by scheduling a follow-up appointment. Then listen closely to her concerns and questions. Maybe she has a different interpretation of what happened during her first appointment.


Depending on what you learn, you have several options. Role clarification may be the most helpful. Explain the work of an APN: "I've had specialized education and training to help people manage all kinds of pain. Sometimes this pain is caused by a life-threatening illness like cancer. But more often my patients' pain is caused by injuries or other conditions, such as osteoarthritis, that aren't life-threatening." Explore nonpharmacologic therapies with her and provide patient teaching, including printed materials she can take home with her, about pain and its management.


By being open and empathetic, you can show her that she has real options for managing pain and that you'll work with her to find the best approach.



Not-so-sweet solution

As a nurse in a busy pediatrics practice, I'm rarely surprised by parents' questions. But recently the mother of a 7-year-old patient asked my opinion about giving placebos and I wasn't sure what to say. She said she gives her daughter a fruity chewable candy whenever she complains about a sore throat or an earache that suddenly appears when she doesn't want to go to school or do chores. "I don't want to give her medicine for something that she's just making up," she explained. "Giving her a little candy seems safer than giving her a real drug for no reason." What's your view?-C.M., CALIF.


Giving placebos, whether to children or adults, is always controversial. Some healthcare providers support placebo use because they believe that placebos stimulate the mind-body response, triggering real physiologic changes that aid healing. But many medical and nursing professional organizations take a dim view of placebo use except in certain narrow circumstances, such as controlled research involving adult subjects who provide informed consent for its use. Without informed consent, placebo use always involves deceiving the patient, risking the essential trust that patients place in their care providers.


Parents might argue that placebo use with children represents a "beneficent deception" -somewhat like telling children about Santa Claus or the Tooth Fairy. But I believe that using a placebo this way can become an easy way out for a busy parent who doesn't want to spend time comforting her child and truly considering why she doesn't want to go to school or do chores. I also fear the repercussions of teaching a child that taking a candylike "pill" can make things "all better."


Finally, the mother's safety argument is misguided. Telling a child that candy is medicine (or vice versa) is just plain dangerous from a medication safety viewpoint. Many children are poisoned every year when they mistake a drug for candy.


I hope you'll talk with both your patient and her mother to explore all these issues.



Behind the times

I work in a long-term-care facility caring for patients with dementia. Mostly I love my job, but one aspect troubles me: having to sedate or "chemically restrain" one of my patients. The philosophy here seems to be that it's ethically acceptable to do this when a resident is verbally abusive, disruptive, and upsetting other residents. How do you feel about this?-H.M., MICH.


The standard for restraint use has changed dramatically from years gone by, when the attitude you describe was commonplace. Legally and ethically, a restraint of any kind-physical or chemical-should be considered only as the last resort to protect a patient or other resident from imminent harm. Restraints aren't acceptable simply to quiet an agitated patient, for example. If necessary for safety, the restraint should be used for the shortest possible time and the patient should be closely monitored and reassessed for as long as the restraint is in use.


Review your facility's policy and procedure on restraint use. It should list a series of interventions that must be tried (and their results clearly documented) in a stepwise fashion from least to most restrictive before any form of restraint can be used. It should also provide clear guidelines for patient care and reassessment while the patient is being restrained. For example, under guidelines from The Joint Commission, a licensed practitioner must perform a face-to-face assessment of the patient within a certain time frame (which varies according to circumstances and patient characteristics). For more information, read "Restraint and Seclusion" at http://www.jointcommission.org/AccreditationPrograms/BehavioralHealthCare/Standa.


Your question indicates that either your facility's policies or procedures are behind the times, or the staff isn't following them. Either way, speak up. Start with your manager and go up the chain of command if necessary to make sure the facility develops and enforces policies that meet current practice standards.



Family support or emotional coercion?

My patient, a 40-year-old police detective, was diagnosed with angiosarcoma, an uncommon malignancy. He's been receiving radiation and chemotherapy but hasn't responded well. His oncologist has talked with him and his family about more "aggressive" chemotherapy. For some reason, his wife and sons understood this to mean that the oncologist wants to try an experimental treatment that may "cure" him, and they want him to try it.


I think the family is being emotionally coercive. For example, the sons tell their dad how much they always admired him because he was a fighter who taught them to "never give up." They believe that this kind of talk keeps his spirits up and prevents him from losing hope. But I know that there's nothing new or experimental about the proposed chemotherapy and that it's unlikely to help this patient. As his advocate, should I straighten out the misunderstanding or keep quiet?-C.L., ONTARIO


When nurses are caught in this kind of bind, the best response is always to ask rather than tell. That way, you can better assess your patient's needs and wishes. When you're alone with your patient, ask if he'd like to talk about the proposed treatment. Broad questions such as, "What are you hoping for?" or "What's really on your mind these days?" encourage him to open up about his real concerns. Listen to his family members' concerns in the same way.


Document these discussions (using verbatim comments if possible) and contact the oncologist if you believe the patient or family members need more education about the proposed treatment and prognosis. He's responsible for clarifying any misunderstandings about therapy options and explaining the risks and benefits of medical treatments.


1. Pozgar GD, Santucci N. Legal and Ethical Issues for Health Professionals. Sudbury, MA: Jones and Bartlett; 2005:340-341. [Context Link]