Does her family know how sick she is? - page 3

by SuesquatchRN | 3,726 Views | 34 Comments

Asked the doctor this morning. I told him that they come in a lot and he mentioned comfort care, which can mean many things, but it always means end-of-life. They had come in to see their mom and I opened the discussion. ... Read More


  1. 4
    I have to agree that I don't understand what some of the fuss is about here. In my years working in geriatrics, I was the one who ALWAYS (and I mean always) initiated the end-of-life care talk with the family. Then, I let the doctor know what the family and resident wishes were.
    The one thing to remember is that the doctors not only make rounds on all the residents in a facility, but they also have their own private practices to manage as well, so they depend on us to manage these types of issues. That's why I love LTC and gerontology....once you gain the trust and respect of the doctors, you're a bit more independent to handle these issues and then get orders.

    To the OP, I think the gist of your post got lost in translation, but I feel that you did the right thing. It is a good feeling to help families and residents through difficult times. I'll never forget one family that I worked with. After their father died, they said, "We didn't know anything about death or the process. You made it a very spiritual experience for us. Thank you."

    It's a great feeling! :redpinkhe
  2. 2
    In LTC when you see a patient going in and out of the hospital every week you have to look at the quality of life. The hospital doesn't want her, we can't fix her, family doesn't know what their options are. In the OP's case, the MD suggested comfort cares and the nurse brought it up and explained to the family. I work in LTC too, and oftentimes after speaking to the MD and reading off the list of interventions we have attempted for a declining patient, the MD will say, well maybe its time to discuss comfort cares with the pt and family. Nursing & maybe social work then goes in to ask how aggressive they wish to be treated and go from there. It's true, not many people want to talk about this. Good job AlmostABubbieRN for helping the family to make an informed decision.

    Quote from AlmostABubbieRN
    Asked the doctor this morning. I told him that they come in a lot and he mentioned comfort care, which can mean many things, but it always means end-of-life.

    They had come in to see their mom and I opened the discussion. "Why didn't the doctor tell us this?""Have you talked to him?" "Yes, this morning." "I guess because no one likes to talk about it so it falls to the nurses."

    Anyway, I explained that there are various ways to handle their mom, including extensive measures and also including not even using antibiotics. I told them that she would recover from this bout of pneumonia but that her heart is failing and she will get penumonia again and soon. And that this will continue. I also assured them that should they decide to continue hospitalizing her that we would support that as well. And to take their time in figuring it out.

    I got thanked for my honesty. They're going to call a family meeting and hash it out.

    I love my job when I feel competent. But it's a bittersweet love.
  3. 8
    Quote from elizabeth321
    It is not about YOU feeling good about what you did....if I start picking it apart one comment by one comment I can find many things wrong...I see your responses as presumptuous...."I guess nobody likes to talk about IT so it falls on the nurses"....that is burdening the family with info they do not need....that is a conversation to have with the team...also by the doctor saying "comfort care" you are clarifying this to mean end of life but then you tell the family the different courses of care they might take including extensive care (whatever that means)....how do you know that is one of the options???? Then you tell them she will recover from this bout of pneumonia but will get it again soon.......how do you know that....do you have a crystal ball.......I am not sure what the point of your post is....just remember when you take actions to make yourself feel good often times you are not actually being a patient advocate or caring for the caregiver you are doing it for yourself....IMHO
    Ok....gonna have to chime in on this one.

    1. I don't think the OP actually SAID to the family "I guess nobody like to talk about IT so it falls on the nurses" THAT would have been wrong. I think OP was just stating that is how many nurses feel when they work with critically, chronically ill patients. Some MDs will talk about death in plain English, but many will not.

    2. We can ALWAYS treat aggressively until a person's appendages start to turn black and fall off in the ICU bed (seen it, by the way). Or we can stop all of those aggressive measures and make sure the person is comfortable. The only thing I don't agree with is the part about stopping antibiotics. In hospice we usually do treat pneumonias, etc. with antibiotics because that provides comfort to the patients.

    3. As to recurrent pneumonia. Ummm.....do you know the pathophysiology of CHF? It doesn't require a 'crystal ball' to know that the patient most certainly WILL get recurring pneumonias, fluid overloads, etc. We don't know when, but it does happen.

    Talking about death and dying IS being an advocate for the patient. They need to know what they're up against and what their alternatives are. And people do not live forever. Just because we can prolong 'life' (if you can call it that when you're hooked up to a ventilator and 20 different meds to stabilize your vital signs) doesn't mean we should, unless a patient has specifically said "I want it ALL" after knowing the consequences. That is a different story.

    Be curious to know what area you've worked in, Liz.

    And to OP: Her family knows....denial ain't a river in Egypt.....sigh. People hear what they want to hear, and only hear it when they're ready. You did the right thing.
    Last edit by tencat on Jun 22, '10
    tewdles, Hospice Nurse LPN, Moogie, and 5 others like this.
  4. 1
    Just throwing my support behind the OP. Everyone else who supported you said everything I could have said.
    SuesquatchRN likes this.
  5. 2
    Yep...not too much to add on this one. I did have the same type of experiece this week tho.
    We LTC nurses are real actual nurses. We develop the relationships with our residents over time and get to know the family and resident and their wishes. We are the ones taking care of them...the docs see them once a month? The don't come in and won't be the ones talking to the familes.
    I think the PP that disagreed (elizabeth?) has never worked LTC before.
    tewdles and SuesquatchRN like this.
  6. 4
    Where do you start with this one? Most docs see the resident for maybe 10 minutes every other month. We, on the other hand, see the resident and their families every day. Who do you think the family is going to go to for straight talk? US..the nurses who have been caring for their family member for weeks or months or years. Many a time a family member has asked me "What would YOU do." We can't decide for the families, but we can be there to tell them the truth as uncomfortable as it may be. We can remind them that when they agreed to be the HCP, they agreed to speak for what the resident would want. We can remind them that sometimes doing nothing but comfort care is the best thing to do....that WE know their family member...we know what they like, what makes them afraid, what makes them laugh and at the end of their time it would be nicer for them to be with people who know them and care for and about them than to send them to the hospital with a bunch of strangers.
    We should advocate for our residents and support their families whether we agree with their decisions or not. We can tell them what we've seen in our careers, what we think might happen. Like it or not, most of the time it IS the nurse who has this discussion with the family NOT the doc.
  7. 4
    Quote from CapeCodMermaid
    Where do you start with this one? Most docs see the resident for maybe 10 minutes every other month. We, on the other hand, see the resident and their families every day. Who do you think the family is going to go to for straight talk? US..the nurses who have been caring for their family member for weeks or months or years. Many a time a family member has asked me "What would YOU do." We can't decide for the families, but we can be there to tell them the truth as uncomfortable as it may be. We can remind them that when they agreed to be the HCP, they agreed to speak for what the resident would want. We can remind them that sometimes doing nothing but comfort care is the best thing to do....that WE know their family member...we know what they like, what makes them afraid, what makes them laugh and at the end of their time it would be nicer for them to be with people who know them and care for and about them than to send them to the hospital with a bunch of strangers.
    We should advocate for our residents and support their families whether we agree with their decisions or not. We can tell them what we've seen in our careers, what we think might happen. Like it or not, most of the time it IS the nurse who has this discussion with the family NOT the doc.
    I mentioned the "do not hospitalize" yesterday for that very reason - let her die at home, with the people who care about and know her. I also stressed that whatever their decision, which they should not rush, we will continue to care for her with tenderness and dignity.

    People just want a straight answer. SOmetimes they refuse to hear it but it's a process. I had a care planning meeting today with a daughter who has a plethora of problems and called State on us (and is my documentation good!) to no avail. She came in with guns blazing and by the end of the meeting I had explained dementia and its prograssion, disinhibition, the inability to make memories - and was thanked, again, for explaining things that they did not understand and that no one had taken the time to help them with. I was told afterwards that everyone from work was impressed with how I handled it. They were expecting a blood bath and were astonished at how I defused the situation. So was I.

    I love my job. And I feel clinically competent again. I've had a good week so far.
    tewdles, Moogie, Nascar nurse, and 1 other like this.
  8. 4
    Quote from elizabeth321
    It is not about YOU feeling good about what you did....if I start picking it apart one comment by one comment I can find many things wrong...I see your responses as presumptuous...."I guess nobody likes to talk about IT so it falls on the nurses"....that is burdening the family with info they do not need....that is a conversation to have with the team...also by the doctor saying "comfort care" you are clarifying this to mean end of life but then you tell the family the different courses of care they might take including extensive care (whatever that means)....how do you know that is one of the options???? Then you tell them she will recover from this bout of pneumonia but will get it again soon.......how do you know that....do you have a crystal ball.......I am not sure what the point of your post is....just remember when you take actions to make yourself feel good often times you are not actually being a patient advocate or caring for the caregiver you are doing it for yourself....IMHO

    You are WAY off base here-remember this is the LTC forum. As others have said we at the bedside have a rapport with the residents and their famiilies and this discussion is almost always initiated by us.We are the resident's advocate and every time one experiences a change in condition we review the advance directives and discuss plan of care with the family and the physician.Only occassionally have I had a family member call the physician directly themselves-I know most of them well,have gained their trust over the years and they have confidence in me.
    At my facility we have comfort care and end of life care.Comfort care means we are not d/cing meds,tx,labs etc.Only when the resident enters into the active phase of dying do we start to do that.Comfort care means just that-we have the rescue meds at hand and use them if needed-no hospitilization. Some families do want extensive care-hospitilization with IV fluids,etc. I always lay everything out on the table-comfort or hospice care does NOT mean we don't treat their loved one. We can send a resident to the ED for a faster eval then we can perform in the LTC.Sometimes the family opts for that but then refuses admission for their loved one and they come back to the LTC to die. I ALWAYS explain to the family in layman's terms exactly what they can expect to see as things progress.
    When you have worked in LTC for a few years and seen the progression of these diseases (CHF,end stage Alzheimer's,etc) you pretty much DO have a crystal ball.... Whoses duty is it to advocate for these residents? You say it's up to the "team" Crisis situations NEVER occur on team meeting days,in my experince and who do you think is at these team meetings? Here's a little secret-It aint the doc....
    Nascar nurse, Moogie, CapeCodMermaid, and 1 other like this.
  9. 1
    Hard to touch this post as every situation is so different and must be analyzed individually. Of course there are legal issues, and none of us play G-d or can foresee the future. I am sure the OP read the situation and responded appropriately as an experienced nurse who has the best interest of her patient at heart. I thank her for sharing and opening a very sensitive subject.

    I see too many children of end stage patients who are kept in the dark ( due to the patients request that we not discuss his or her condition with their children) , and inevitably are in shock at the funerals. They often have a hard time dealing with the death, and have residual issues.

    I believe in a multidisciplinary approach to this kind of situation and would get the SW (if available) on board. If appropriate, I would also invite the families religious or spiritual adviser to provide whatever assistance necessary. I would chart my conversations and care plan the problem.

    Bottom line, - I, too, would have approached the topic with the family gently and with assistance of my team. I admit that this is not always available.
    SuesquatchRN likes this.
  10. 0
    Quote from michelle126
    We LTC nurses are real actual nurses.
    We are all real actual nurses. Having a relationship with your patients is a part of your specialty but doesn't make you anymore a nurse than any other nurse in another specialty. I may have a shorter contact/relationship with my patients but I can still have a big impact on their lives. I know you didn't mean it the way it sounded, or I hope not, but I felt the need to clarify.


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