The Drug Seeking Patient

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Prepared for medical ethics course as part of a master's in nursing program.

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The Drug Seeking Patient

  1. 1. The Drug Seeking Patient Shelley Ross BS, RN California State University, Dominguez Hills Division of Nursing Nursing Ethics MSN 531 Kathleen F. O’Connor, PhD, RN, CNE December 4. 2008
  2. 2. Synopsis of Ethical Situation <ul><li>Patient presents with complaints of back pain </li></ul><ul><li>FNP examines and treats the patient for pain with Vicodin </li></ul><ul><li>FNP follows up with the patient for several months </li></ul><ul><li>Patient reports Vicodin bottle fell into the toilet </li></ul><ul><li>FNP renewed prescription </li></ul><ul><li>Then patient reports: jumped over a creek, Vicodin fell into water </li></ul><ul><li>Anonymous FNP (Personal Communication November 14, 2008) </li></ul>
  3. 3. <ul><li>FNP felt the story did not match up with patient’s complaints of pain </li></ul><ul><li>FNP called area pharmacies </li></ul><ul><li>Vicodin prescribed by multiple providers and many pharmacies used </li></ul><ul><li>FNP did not renew the prescription at that point </li></ul><ul><li>FNP reported the patient to the pharmacy board </li></ul><ul><li>Patient did not return to the clinic </li></ul><ul><li>Anonymous FNP (Personal Communication November 14, 2008) </li></ul>Synopsis Continued
  4. 4. Ethical Principles emotional responsiveness Beauchamp & Childress, (2009) <ul><li>FNP first believed patient: Benevolence and Compassion (Beauchamp & Childress, 2009) </li></ul><ul><li>Beneficence provides basis for symptom management and enhanced quality of life (Latimer, 1998) </li></ul>personal relationships sympathy compassion fidelity love what is done how it’s done mutual interdependence Ethics of Care (Beauchamp & Childress, 2009)
  5. 5. Justice Perspective <ul><li>FNP later suspected patient was dishonest </li></ul><ul><li>Ethics of care alone was no longer sufficient </li></ul><ul><li>Justice considers optimal outcomes for all based on existing universal rules of moral conduct </li></ul><ul><li>Emotional ethics of care and rational justice were bridged </li></ul><ul><li>Increased knowledge to guide decision making was gained </li></ul><ul><li>(Boersma, 2006) </li></ul>
  6. 6. Decision Making <ul><li>American Counseling Association’s (ACA) 7-step model </li></ul><ul><li>Based on Kitchener’s five moral principles: </li></ul><ul><li>These moral principles are considered absolute truths </li></ul><ul><li>(Forester-Miller, & Davis, 1996) </li></ul>Autonomy Justice Beneficence Nonmale-ficience Fidelity
  7. 7. ACA 7 Steps to Decision Making (Forester-Miller, & Davis, 1996) 1. Identify 2. Apply 3. Determine 4. Generate 5. Consider 6. Evaluate 7. Implement Identify the problem Apply Code of Ethics Determine the nature and dimensions of the dilemma Generate potential courses of action Consider potential consequences of options, choose course of action Evaluate the course of action chosen Implement the selected course of action, and evaluate results
  8. 8. ACA Decision Making Process By FNP 1. Identify 2. Apply 3. Determine 4. Generate 5. Consider 6. Evaluate 7. Implement Patient’s story did not match up Considered the nursing code of ethics Dishonest patient, illegal act, drug abuse problem Decline or renew prescription? Please patient and potentially feed a drug problem or investigate first and help prevent drug dependence FNP considered consequences to options FNP investigated, reported findings to pharmacy board, patient failed to return to clinic
  9. 9. <ul><li>Do complete evaluation and assess for: </li></ul><ul><li>genetic risk factors for drug dependence </li></ul><ul><li>psychosocial stressors </li></ul><ul><li>manipulative or demanding behavior </li></ul>Alternative Approaches for the Drug Seeker while Maintaining an Ethics of Care <ul><ul><li>(Longo, Parran, Johnson, & Kinsey, 2000) </li></ul></ul>
  10. 10. <ul><li>If Patient has known history of drug abuse: </li></ul><ul><li>Do not prescribe “as needed” </li></ul><ul><li>Do prescribe for a minimum duration on a set schedule </li></ul><ul><ul><li>(Longo, et al. , 2000) </li></ul></ul><ul><li>Education </li></ul><ul><li>Pain control contract </li></ul><ul><li>Hold patient accountable </li></ul><ul><ul><li>(Gerhardt,, 2004) </li></ul></ul>Alternative Approaches for the Drug Seeker while Maintaining an Ethics of Care
  11. 11. <ul><li>Biofeedback </li></ul><ul><li>Relaxation techniques </li></ul><ul><li>Transcutaneous electric nerve stimulation </li></ul><ul><li>Physical therapy </li></ul><ul><li>Psychotherapy </li></ul><ul><li>Refer to specialists </li></ul><ul><ul><li>(Longo, et al., 2000) </li></ul></ul>Alternative Approaches for the Drug Seeker while Maintaining an Ethics of Care
  12. 12. References <ul><li>Beauchamp, T. & Childress, J. (2009). Principles of biomedical ethics . 6th ed. New York: Oxford University Press </li></ul><ul><li>Boersma, R. (2006). Integrating the ethics of care and justice or are they mutually exclusive? International Journal for Human Caring 10(2). pp 21 </li></ul><ul><li>Forester-Miller, H., & Davis, T (1996). A Practitioner's Guide to Ethical Decision Making. American Counseling Association , Retrieved November 14, 2008 from www.counseling.org/Files/FD.ashx?guid=c4dcf247-66e8-45a3-abcc-024f5d7e836f </li></ul><ul><li>Gerhardt, A. ( 2004). Identifying the drug seeker: the advanced practice nurse’s role in managing prescription drug abuse. Journal of the American academy of Nurse Practitioners. 16(6), pp 239-242 </li></ul><ul><li>Latimer, E. (1998). Ethical care at the end of life. Canadian Medical Association Journal, 158(13). pp 1741-1747 </li></ul><ul><li>Longo, L. Parran, T., Johnson, B., Kinsey, W. (2000). Addiction: part II. Identification and management of the drug-seeking patient. American Family Physician, 61(8), pp 2401-2408 </li></ul>

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