End of Life and Difficult Discussions Part I

Palliative care, end of life discussions, invasive care talks - all of these are current topics for advanced practice nurses (APNs). This is the first in a series of articles about how we, as APNs can deal with these hard topics. I would also like to solicit your opinions on this subject. We all have different practice situations, but in the end, we all have the same goal - to provide excellent care to our patients Nurses Announcements Archive Article

End of Life and Difficult Discussions Part I

As APNs, most of us have had to deliver bad news to families and sometimes patients. Whether it's the fact that 95 year old Grandma isn't going to recover from her latest bout of CHF or that your infant actually died three or fours hours ago and we are running this code for you now. Or, that intubation of the chronic COPD patient isn't going to help them survive. All these discussions and more take a certain finesse and knowledge.

I thought I would start a series of articles that deal with end of life issues. This is necessary as we push the life expectancy of even very seriously ill patients further and further. Recently, there have been articles about a 13 year old who was pronounced brain dead after an operation and the family that refused to allow the ventilator to be stopped. This was also a very popular and controversial thread here at AN. Then, there was the mother who was kept on a ventilator until her unborn child reached the age of viability at which time the child was delivered and the mother's ventilator turned off.

I'm an APN in a large nephrology practice and it's my job to round on chronic hemodialysis patients in three geographically distant chronic units in the Midwest. I've been in this position almost 8 years now. I have also worked in a community ED as an APN. In both roles, end of life care knowledge has been necessary.

About 10 years ago I became interested in end of life care. I did my masters thesis on family presence in the ED during codes. I always tried to be a family and patient advocate. However, as the years have passed, I find myself more often than not, on the patient's side of the fence, against their family and sometimes even against a physician. And this is what I've learned:

The patient should always be our focus.

Develop a trusting relationship before any end of life or difficult decision discussion if possible. Patients don't automatically trust us just because we were a white lab coat with a name tag with lots of initials behind it. Trust comes from being a good listener. We all have time constraints but making good eye contact, sitting at the patients level, matching the language of the patient are all good basics of communication.

Sometimes there is not any time to establish a relationship with the patient and/or family.

I am often reminded of a single mother who awoke to find that her six week old infant wasn't breathing. She frantically called 911 and performed CPR. As the child was still warm, EMS ran the code since the scene was only a few blocks from the hospital. As soon as the child arrived in the trauma bay, there was a realization that this wasn't going to have a good outcome. I went and got the mother and escorted her into the trauma bay and she held onto the child's foot while CPR continued. I absently stroked the child's other foot and said that the child (I called her by name) was obviously well taken care of and that there was just nothing that could be done and we needed to stop CPR. I told the mom that she should say goodbye and then we stopped CPR and the child was pronounced. I got a rocking chair and wrapped the child in a warm blanket and let the mom sit and rock her child for the last time. About two months later I was told I had a call at the main desk. I answered it and it was the mother. She thanked me for caring enough to get a rocking chair for her and wrapping her child in a warm blanket so that her last memory was that of peace. Its all about connecting with the patient and/or family.

Well, this is the first in a series of hard discussions that APNs often have with their patients and families.

How do you handle the difficult questions? Do you find that having an established relationship with the patient and/or family helps? What do you do to establish a relationship in an acute situation?

Trauma Columnist

14-yr RN experience, ER, ICU, pre-hospital RN, 12+ years experience Nephrology APRN. allnurses Assistant Community Manager. Please let me know how I can help make our site enjoyable.

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amygarside

1,026 Posts

Thanks for sharing your thoughts. I gladly appreciate it.

It is tough to be the one who has "the" conversation with families. I feel it helps if you have an established relationship with the family, but in acute care often this is not likely. Taking the time to make the moment as calm and positive as possible is important. I think providing the chair with the warm blanket was an amazing idea. I also tell Nurses that if it is a child to do handprints/footprints, saving a small piece of hair from the back of the head, etc can make a huge difference. It's important to ask the family first and to make sure you wash the ink off. Giving the family time to spend with the deceased is just as important.

WordWrangler

38 Posts

Leads back to "treat others how you'd want to be treated." If it was YOUR sister/mother/daughter in that situation, what would you do for her?

Trauma Columnist

traumaRUs, MSN, APRN

88 Articles; 21,249 Posts

Specializes in Nephrology, Cardiology, ER, ICU.

Thanks for all the comments. Being a pt advocate is so important for all nurses.