Patient family vs. patient

[bryson.holbrook]

Often times the patient and their families have different expectations. I love taking care of my patients but don't always enjoy pandering to their loved ones.

The issue I am specifically talking about this time is a patients daughter wants our staff to write in a log every time we come in the room documenting every thing we did, medications administered, turns, JP drains checked and emptied. My patient doesn't want us to do any of these things. My concern is that because this is not a standard of practice that a nurse or CNA doesn't log things a few times and I am now having a conversation about why we didn't check on her mom for 4-6 hours.

This is just one example of when my patients and their families have different expectations and needs. It is really hard to make a balance and keep everyone happy including our nurses and CNAs. How do you find balance? What hard patient/family difference in plan of care have you struggled with?

[brownbook]

I would get the charge nurse, and nursing supervisor, and doctor, and maybe social services, involved right away. This looks like a law suit waiting to happen!

[MunoRN, RN]

The "log" the patient's family member wants seems to be just the regular charting, in which case I would direct them to whatever processes are in place for getting access to the patient's charting. I wouldn't spend extra time creating a separate log to meet this request however, since that then takes valuable patient care time away from other patients.

[Here.I.Stand, BSN, RN]

I would advise her that such a log is neither secure/HIPAA compliant nor legally binding, PLUS even if you did agree to write on it, you can't promise that anyone else will (we already chart in the legal medical record plus have other pts, and it's not a reasonable use of limited time.)

But in any case, you say that the pt doesn't want you to log those things. Therefore, it isn't up for discussion: to note his medical info and care on a log that anyone can see, would be a HIPAA violation.

However, if the pt agrees, she is more than welcome to stay at his bedside to advocate for him.

Generally speaking, with THAT family member I may go further out of my way to explain things or lay out my plan for the shift. For example, a NP advised a family about the benefits of early mobility, and they CLUNG to that. While most other families may be ok hearing: "due to some sudden episodes with his ICP overnight, we're going to hold off on getting into a chair for today," to THAT family I said,

"It's true that early mobility is our perfect-world goal; however it's not a perfect world, and we have to weigh the risks and benefits with everything.

Overnight, your dad was looking quite stable -- until they had to do a big turn to get him off soiled sheets, and his ICP went up into the 40s. That was such a short time ago; my concern is that with an EVEN GREATER movement this will happen again. It could become a true emergency... and the chair is a very restrictive place for us to administer necessary treatment -- and impossible to obtain necessary imaging like a stat head CT.

What I WILL do is raise his HOB and drop the foot of the bed, so he's more sitting up in bed. I will stay in here, watching his body for showing any signs of distress. If it happens, I can intervene IMMEDIATELY. If he tolerates it, great -- and we'll be more confident about moving him to a chair."

I'm kind of known as the difficult family whisperer and don't even resort to customer service type gluteus kissing. I am almost always able to gain trust by 1) ensuring that they feel heard, and 2) demonstrating that I too want what is best for the pt and will do everything in my power to give the best care possible.

[KatieMI, BSN, MSN, RN]

There is one wonderful phrase in nursing I learned long ago on this forum:

- I am so sorry but THEY do not let me/allow me to do (whatever it is)

In 99 cases out of 100 there comes no question of who these mysterious "they" might be and the subject gets dropped. In that one remaining case, the answer is "my administration". The following quest about looking for and meeting "them" usually dissolves the rest of the issue.

[JKL33]

The issue I am specifically talking about this time is a patients daughter wants our staff to write in a log every time we come in the room documenting every thing we did, medications administered, turns, JP drains checked and emptied. My patient doesn't want us to do any of these things.

"I'm sorry, but we don't keep separate logs. I'd be happy to give you information on how to access medical records through the appropriate department."

Document this conversation in the medical record.

No one should be entertaining this anyway, because regardless of the better rationales already given, the patient herself doesn't want it. Since when do your staff go around doing care items that the patient has asked them not to do?

Now, reason #3 not to do it: It creates exactly the type of set-up you're facing.

[Nurse SMS, MSN, RN]

If the patient is alert and oriented doing this log is a HIPAA violation, since the patient stated they do not want it done. End of story.

[OpinionatedCNA, CNA]

That's absolutely ridiculous, if the nursing staff has to log every time we go into a room there would be no time for actual patient care. Yes, as a CNA we have to log specifically how many times we help them every shift with bed mobility, incontinence, etc. and that does ABSOLUTELY NOT reflect how often we check in on patients. She wants to know every time the CNA peaks their head in the room or adjusts her mom's pillows? LOL how about no, nobody has time for that kind of micromanagement.