Coping with emotionally difficult patients

[calivianya, BSN, RN]

Hi guys!

I'm sure this has been done to death, but what is your personal strategy for coping with tough emotional situations?

I have had a ton this past month, and they are starting to wear me down. People in their 30s and 40s that are vent dependent, kidney failure, liver shutting down... pretty much living in ICU on pressors. You know the kind - they transfer out to stepdown for usually no more than two days and come back, too sick to go to LTACH, too sick to live anywhere but ICU.

Two of these patients have had mental breakdowns on me this week - frantically gesturing that they want out, that they're done, clawing at their neck, the siderails, and whatever else, and sobbing. One in her thirties with two kids, while bright orange from her liver failure, trached, and running CRRT. She is only five years older than I am. All I can do is push a ton of Versed, Ativan, whatever to momentarily diffuse the situation and keep the patient from ripping everything out. I'm not tying down an alert and oriented patient if I can help it. That would make me really feel like a terrible human being.

One of them has been in ICU since December and the other since the beginning of January.

I have sat there and held their hands - even popped out my phone on Pandora and sang along to one of them, but there is just no helping these people. They are way too distraught.

How do you guys handle these patients? Psych consults? Palliative has come for both of them but neither of the families want to withdraw care. Drug them up all the time? There has got to be a better solution. There is only so much TV I can watch in a day; I can't even imagine the emotional torment that having nothing to do but watch TV and/or get on a tablet day in and day out does to a person's mental health. Both, of course, are so debilitated they can barely move their arms or legs at this point, and have pressure ulcers. Can you imagine being 30 years old with young kids and having a pressure ulcer? How about being previously young and healthy and knowing you're probably never going to get out of the hospital now?

I am just at my wits' end. Both are very sweet patients and usually a pleasure to take care of when they're not in the middle of a total emotional breakdown.

[CrunchRN, ADN, RN]

I have no answers, but just want to thank you for being such a caring nurse.

[Magsulfate, BSN, RN]

It's a sad situation. Case management should be involved and the md needs to be aware of these situations. Definitely chart chart chart all the details of the patients behavior. Try to be objective. And just remember, sometimes there's just nothing you can do but continue to be the caring nurse that you are!

[calivianya, BSN, RN]

It's just one of the many perks (insert sarcasm here) of working night shift that the middle of the night is when the patients tend to have their emotional breakdowns. They have sunlight and visiting friends/family in the day time, so their spirits are much better. Just thought I'd make it clear that neither seem like they are ready to die yet. They are just miserable in the middle of the night.

Case management is involved with both of them already, and the physicians are definitely aware of the behaviors.

[Sassy-Kat]

maybe, with the patients that have kids, when they are there visiting during the day, have some cards or pictures available for them to color or write notes to mom...that way when she breaks down at night, you can say- look jimmy drew you a new picture today....or, sarah actually spelled mommy right this time-...something new to focus on in the middle of the night can sometimes bring them down out of their tree. Kind of like in OB, having a focal object that you can show them, get them to calm down, breathe through it..ive been a patient too (alot) and just having one of the kids stuffed animals with me to cling to helped.

[TheMoonisMyLantern, ADN, LPN, RN]

All I can do is push a ton of Versed, Ativan, whatever to momentarily diffuse the situation and keep the patient from ripping everything out. I'm not tying down an alert and oriented patient if I can help it. That would make me really feel like a terrible human being.

.

Please, DO NOT feel bad for medicating your patients. Often times due to a patient's overwhelming mountain of medical problems we underestimate (for the lack of a better word) the effect it has on a patient's psyche. It's not uncommon to see extreme anxiety or agitation as a result of a prolonged, complicated, and life altering/ending illness and while listening and providing emotional support are pivotal things to provide to a patient so is medication that can ease those intense feelings.

Simply put sometimes pushing the Ativan/Versed/Whatever is the best thing we can do for our patients that are in horrific situations.

[VANurse2010]

Hmm... why was CRRT offered to the liver patient? Giving CRRT to a hepatorenal failure patient is unethical unless that person is eligible for the transplant list. I wonder if that's the case.

[KatieMI, BSN, MSN, RN]

Please, do not be afraid to just medicate them... they deserve these moments, even if there is nothing else to be done. Be honest with family (after you got your bosses' support). Time of "she's doin' fine, she had her BM today" is over.

Try to make nights dark. Melatonin deficiency and sleep deprivation are not good for psycho. These blazing tv screens have to go off for a while!

Some of them just want certain things. Children, maybe even a pet visit, music, blanket from home. Some are just great. We recently have an unfortunately one sitting in ICU/LTACH for a whole year completing online prereqs and going to Masters' in ancient history. That guy learned three living and three dead languages in a process, he was amazing and got alive and walking out of there. But too many just want a few minutes of peace, even brought by Versed shot.

[calivianya, BSN, RN]

Hmm... why was CRRT offered to the liver patient? Giving CRRT to a hepatorenal failure patient is unethical unless that person is eligible for the transplant list. I wonder if that's the case.

I seriously doubt she's eligible - we can't get her off the vent either, so that's at least three body systems that are shot.

I tend to see this job err on the side of absolutely ridiculous extravagances when a patient is a full code. Sometimes it really bothers me. I had a patient once whose only palpable pulse was a 1+ carotid "live" for four days because family wasn't ready to withdraw yet. Never mind the patient would have to have both arms and legs chopped off at the seams, would need new everything in the abdominal cavity because all of it was dead, and would need a new brain as the EEG was totally flat on no sedation. But the family wasn't ready to let her go, and of course, that trumps the patient having a 0% chance of survival.

[Hollybobs]

I seriously doubt she's eligible - we can't get her off the vent either, so that's at least three body systems that are shot.

I tend to see this job err on the side of absolutely ridiculous extravagances when a patient is a full code. Sometimes it really bothers me. I had a patient once whose only palpable pulse was a 1+ carotid "live" for four days because family wasn't ready to withdraw yet. Never mind the patient would have to have both arms and legs chopped off at the seams, would need new everything in the abdominal cavity because all of it was dead, and would need a new brain as the EEG was totally flat on no sedation. But the family wasn't ready to let her go, and of course, that trumps the patient having a 0% chance of survival.

I've liked your post as I agree with it wholeheartedly, there's something that really wears you down about aggressively and actively treating patients for whom there is no chance of improvement. Doctors and families make the decisions but nurses see the real life consequences. It is very hard to do.

In answer to your original post, that just sounds like really challenging nursing. You are witnessing another human's pain first-hand and close up for hours each day and don't have any real solution for them as there is none. As a patient in the situation I'd want the drugs please and some kind words. As a nurse I'd come on shift, try everything I could (like the good suggestions above and all the stuff you are already trying) and then I'd go home again and try to forget about my job. I'm sorry I don't have anything practical to suggest.

[jadelpn, LPN, EMT-B]

Thank you for all you do. It is a tough gig.

It should be part of the "advanced directive" portion of every admission that part where we need to ask if a patient has one, give one if they do not, etc. back when they are in a place to be able to fill one out--what exactly it means. There are people who are "do everything" kind of people, which is simple to say when one really has no idea what that entails. And unfortunately, when that time comes, they are not in a place sometimes to make decisions.

Further, the families who are "well, I know she wanted xyz but now we want pdq". It is hard to choose proxy who will actually DO what one wants when the time comes.

Curious to ask--if they are with it for any portion of the day, visiting with family and the like, and have an understanding, can they choose on their own (with accommodations) to stop the treatments? Which would probably take a mountain of legal-ease to make stick...

Rock and hard place. Liberal Ativan all around. Breaks my heart. Sometimes all you can do is sing.....

[KatieMI, BSN, MSN, RN]

If patient is still A, Ox3, he may be declared "competent" even when unable to speak. Depending on the state, one or two physicians might need to evaluate, but if patient is "competent", he can be asked directly of his wishes and opinion of the family doesn't matter. If he wants to be "comfort", so be it.

If patient is comatose or otherwise incompetent, the family needs to be told the truth. All these "she's doing good, she just had her today's BM" should be stopped, by every single person they encounter. It is much easier just to state facts ("her heart is beating but we need to give her strong meds to keep her heart and blood pressure running, and she needs to be sedated so she could be on the vent and do not feel much pain") but without any references to being good, bad, better or worse. In a few days, if nothing changes, things usually dawn on them. Care conference with clergy, CM and physician(s) usually helps a lot.

If patient is legally dead (aka diagnosed brain death), the case belongs to ethical committee which, at least where I work, gathers within hours and makes decision to stop the show for the reason of "medical futility". Family is called, and told that they have 2 hours to say their prayers, after what vent will be turned off because the patient is dead and nothing else can be done.

It may seem to be rough and "taking hope away" but sometimes people need to get out of their Neverland. The key is stopping them thinking that "everything is going just fine, it'll be okay". They need sometimes to be given a bit of benefits of doubt and a little time to get together, but they should be not given obviously false hopes. If they cannot stomach reality, at least they need to be given facts they are able to comprehend. Choosing a "speaker" (the one who seems to be more rational and able to be spoken with) helps sometimes.

Of course, all that comes to direct contradiction with "customer service policies", but once in a while we need to start thinking about that poor suffering human body, still feeling and breathing.