Page 25 - Demo

20 Your Loved One%u2019s SymptomsPAIN ASSESSMENT AND MANAGEMENTPATIENT AND CAREGIVER RIGHTS AND RESPONSIBILITIESI understand that I am a patient under the care of Samaritan and a member of the hospice care team. I understand that Samaritan has a commitment to giving patients quality care, including treatment of their physical pain and emotional suffering.As a patient of Samaritan, I understand that the goals of pain management treatment are to reach a level of pain control that is agreeable to me and the other members of my hospice care team, to relieve my pain and control my side effects that may result from the use of pain medication, to keep me from experiencing withdrawal symptoms, and to care for my emotional and spiritual suffering that are a part of my pain experience.As a patient of Samaritan, I understand that I have a right to be treated with respect and dignity, and to have my reports of pain accepted and respected as the best sign of how much pain I have. I also have a right to have my pain treated by the members of my hospice care team in a way that is medically and ethically appropriate. I agree to treat all members of my hospice care team with respect and dignity.I WILL:%u2022 Use the pain rating scale provided by Samaritan to report my level of pain to the members of my hospice care team.%u2022 Use the pain medication log provided by Samaritan to keep a record of the pain medications that I am taking and the effect they have on my pain.%u2022 Receive my pain medications, including narcotics, from one single provider: Samaritan.%u2022 Not seek any medication from any other health care provider or from an emergency room.%u2022 Not sell, trade, or give my pain medications to others.%u2022 Not take part in any illegal activities to obtain or distribute pain medications.%u2022 Be responsible for keeping my pain medication out of the reach of children, pets and others.%u2022 Be responsible for not misplacing or losing my pain medications.%u2022 Be aware of the side effects of the medication I%u2019m taking and let hospice team be aware so they can manage them for me.I DO:%u2022 Understand that taking my pain medications when using alcohol or other drugs could be extremely dangerous to my health and could result in my untimely death.%u2022 Understand that my doctor and Samaritan may supply me with %u201cbreakthrough doses%u201d of pain medication for me to take if my pain increases. I will inform my nurse as soon as possible if I need to take more medication than the prescribed amount, and I will agree to reevaluation of my pain treatment program at that time.%u2022 Agree to have my pain treated by all members of the hospice care team, including the doctor, the primary nurse, the social worker, the spiritual support counselor, and anyone else that my team feels could help control my pain and suffering.%u2022 Understand that I should report any side effects that I may experience. Possible side effects can include constipation, nausea, vomiting, drowsiness, dry mouth, and unsteady gait, etc.I understand that if I have difficulty meeting the above responsibilities, or if other problems occur, the other members of my hospice care team will review my plan of care, and I may have my plan of care altered or be discharged from the hospice program.