Refusing a PRN opioid after hours
It is 22:40 on a surgical ward. You are the only RN on shift with one EN and one AIN caring for 24 patients. Mr Kaur, 68 years old, day 2 after an open bowel resection, has an IV opioid ordered 1–2 mg every 4 hours PRN for severe pain. At 22:35 his pain score is 8/10, BP 108/64, HR 92, RR 18, SpO2 96% on room air, sedation score 1 (awake and alert), and he last received 1 mg at 21:00. He tells you he is frightened of 'getting hooked' and asks you to skip the opioid and just give paracetamol, which is due at 23:00. The EN is in another room with a patient who has pulled out a drain, and the AIN is on a break.
1. Analyse the competing priorities and decide what you will do in the next 15 minutes. Justify each action against the RN Standards for Practice and the principles of person-centred care.
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The competing priorities are uncontrolled severe pain (8/10), the patient's autonomy and fear of dependence, workforce constraints, and my duty to assess before delegating or delaying. I would not simply accept the request to skip analgesia, nor override his wishes.
Reasoning steps:
- Recognise the risk. A pain score of 8/10 two days post-laparotomy is not adequately controlled. Untreated pain impairs deep breathing and mobilisation, increasing atelectasis and VTE risk. His observations are stable but I must repeat them after any intervention.
- Explore the fear. 'Getting hooked' is a common but clinically unfounded concern in acute postoperative use. I would explain, briefly and without jargon, that short-term PRN opioid for acute surgical pain carries very low risk of dependence, and that the order is for his comfort and recovery.
- Offer a genuine choice. I would present options: the ordered opioid now, or paracetamol brought forward only if the prescriber authorises it. I cannot change the route or timing myself.
- Escalate. I would page the surgical registrar to discuss multimodal analgesia - regular paracetamol, an NSAID if not contraindicated, and possibly a reduced opioid dose - so the patient's preference is respected while pain is treated.
- Manage the ward. I would ask the AIN to return from break early to observe the drain patient while the EN completes the urgent task, documenting the delegation and its scope.
- Document the conversation, his refusal or consent, the escalation, and the response.
2. Mr Kaur continues to refuse the opioid. What are your professional and legal obligations, and how would you document this?
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A competent adult may refuse any treatment, including analgesia. My obligation is to ensure the refusal is informed: he understands the likely consequences (ongoing pain, reduced mobility, respiratory complications), the alternatives, and that he can change his mind at any time.
Obligations:
- Respect autonomy while continuing to assess and offer alternatives.
- Do not coerce or imply he is a difficult patient.
- Escalate the uncontrolled pain to the treating team so a multimodal plan is made.
- Continue monitoring - pain, sedation, respiratory rate, and mobility - and reassess regularly.
- Recognise deterioration: if he develops shallow breathing, tachycardia, fever, or a silent abdomen, that changes the picture and requires urgent review.
Documentation should record, factually and contemporaneously: the time; his pain score and observations; the exact information given about risks and benefits; his stated reason; that he was offered the opioid and declined; the alternatives discussed; the prescriber contacted and the advice received; that he was told he may request analgesia at any time; and the reassessment plan. I would avoid judgemental language such as 'non-compliant'. A refusal is a clinical event requiring a plan, not a note in the margin.