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THE CHALLENGE
There is a neighborhood coffee shop my husband and I like to walk to on Saturday mornings. We usually take our German shepherd, Callie, and tie her outside while we order our coffee. A couple of weeks ago while I was tying her up a little boy, maybe 4 years old, came out with his mom, took one look at Callie and said, “Mom, it’s a wolf.” She reassured him it wasn’t. I asked if he wanted to come over and pet her, adding, “She looks like a wolf but she’s a dog.” He looked at Callie, then, taking his mom’s hand said, “Ears like a wolf, tail like a wolf, hair like a wolf,” as he backed away. No amount of talk would convince him that Callie was not a wolf.
Oddly, that encounter came to mind when I met a patient recently. One of the nurses on the cardiothoracic unit asked if I could help her with a patient with pain issues. He didn’t have cancer but had a history of chronic pain and just had a thoracotomy, itself a painful surgery. He was driving everyone crazy with his constant requests for pain medications.
She asked for my help not because she couldn’t handle him; rather she was looking for a different perspective. Asking for my input was a mixed blessing for me—on one hand it could be construed as the staff reaching out for my expertise, but more likely it was a dump!
The atmosphere at the nurse’s station was tense. I asked his nurse what she thought the problem was. “He’s just a big faker.” I asked what she meant. “When I check on him he’ll be sound asleep and fifteen minutes later he is on the call light saying his pain is 10/10.” She shook her head and added, “You know, walks like a duck, talks like a duck.” Her tone was clear: she did not believe him. I looked through his med list. He was on a long acting and had q 2 BTP medication. On average he was getting his BTP every 4 to 5 hours, not because he wasn’t asking for it but because the groupthink was that he didn’t really need it. I asked his nurse what she thought we should do and her answer confirmed my suspicion. It was one I know I’ve used before. “I don’t believe he has that much pain.” Interestingly, one of the reasons she wanted my input was to validate his malingering and get him to stop complaining. The goal of care had shifted from pain management to complaint management. I said, “Let’s see if we can come up with another solution.” We went through his med list. I showed her the available frequency of his BTP. “What if we started by giving him what he is asking for?”
We went into his room together and before I finished introducing myself he interrupted with a tirade about his pain and about needing more medication. I let him talk for a few minutes than took a chance and cut in, “I can’t fix what has already happened. We came in here together to see if we can come up with a plan to get you more comfortable.” I believe he might have liked more time to review all of the problems he had had, to complain a bit more, but he nodded his agreement. I explained the nuts and bolts of the plan. He would get his scheduled long acting medications just as he had. The difference would be that his BTP meds would be offered every 2 hours. He had the option of refusing those. The patient interrupted several times, his skepticism forbidding any silence. “How do I know she will bring me the medication?” I told him we would create a contract for the day that we all agreed on. I asked him, “Do you want your nurse to wake you up if it is time for the medication?” “Yes.” That part was difficult for his nurse. She bit her lip and gave a weak smile but nodded to the patient that yes, she would offer him the medication even if he was sleeping. I explained that this was a trial. We would try it for the rest of the day and re-evaluate at 4 pm. He agreed. His nurse agreed, though with some reluctance. I think she and the others caring for him believed he was the one who needed a plan, not them. The caveat was that if the plan failed we would come up with a new one.
At 4 pm I returned. He was still annoying …but his pain was less and his nurse confirmed he was complaining less. He was not oversedated as she feared he would become. The patient even delayed one dose by an hour. He had gotten what he wanted; more than medication, he had been heard. Maybe skepticism about his pain remained, but he felt listened to. An article I read recently said that patients who feel they are treated with compassion have less pain.1 Changing the parameters of his care allowed everyone to adjust their thinking, kind of like rebooting the system.
DISCUSSION
So how is this related to the story about the little boy and my dog Callie? The patient looked like a malingerer. Just as I couldn’t convince the little boy that Callie wasn’t a wolf it was difficult to convince the nurse that this patient wasn’t “a faker.” By listening to him complain (at least for a little while) and by formulating a plan we all agreed on, we managed to decrease his pain and his complaints. We gave him what he asked for. Once that happened his anxiety was reduced. He still wasn’t a happy camper, but he stopped making everyone miserable.
Some of our patients are like the little boy. They need someone to take their hand and convince them that the reality they have created in their mind might be something else. Sometimes though, it is we nurses who need reminding. We don’t believe what we see because we are already convinced it is something else. The patient’s complaining behavior made him into something else, something like a dog who looked a lot like a wolf. ONA
Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.
REFERENCE
1. Ware LJ, Bruckenthal P, Davis GC, O’Connor-Von SK. Factors that influence patient advocacy by pain management nurses: results of the American society for pain management nursing survey. Pain Management Nursing. 2011;12(1):25-32.
