Inpatient Patrick Payne has a broken hip and a medical history of fibromyalgia. Different methods of pain relief have been tried, none with much success. He only seeks help when the pain is "really bad," and often abandons follow-up care until the next episode.
Mr. Payne requests pain medication earlier each day. His nurse, Fran Firth, asks the resident about an increased dosage. "Let's try something else first," he replies, and orders a saline injection when Mr. Payne again requests early meds. When Fran enters the room with the saline he asks, "Is that my pain medicine?" What should Fran do?
A placebo is a treatment without specific effect or an inert agent. Placebos are commonly used in research to compare outcomes between subjects receiving a specific therapy against those receiving placebos. Subjects are informed they will receive one or the other, though they do not know which until the study ends.
Clinical use of placebos is generally considered wrong because patients are lead to believe they have received effective treatment. The harm caused by this deception outweighs positive aspects of placebo use (Mr. Payne feeling cared for the way he wants, or experiencing the placebo effect—pain reduction after the saline injection).
Deception should not compromise the collaborative relationship between a patient and the medical team. If Mr. Payne discovers he received saline, he has good reason to wonder whether other betrayals have occurred. This could compromise his trust, not only in Fran, but in all health care professionals.
Placebos are most likely used with difficult patients, or when therapies prove ineffective—giving placebos may mask the team's underlying frustration or resentment toward a patient. Once placebos are initiated, creative problem solving may wane, and different pain management approaches may go untried. If Mr. Payne becomes known as a malingerer or potential addict, future complaints may be taken less seriously and important problems could go undiagnosed.
Most concerns about placebo use focus on negative results for patients, but deceiving patients also harms clinicians. In this case, the resident's order put Fran in the uncomfortable position of either telling the truth or following orders. This compromises Fran's ability to give Mr. Payne the best care she can, either because she is embarrassed about lying, or because she does not take him seriously. Over time, she may find other reasons to ignore patient concerns. The incident may also cause resentment toward the doctor, impairing their working relationship.
Some hospitals specifically forbid clinical use of placebos. Fran should ask about this, and should also speak to her supervisor about how to handle similar incidents in the future. An in-service on this issue may be warranted to insure uniform practice.
