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LOVEGREEN 2,026 Views

Joined Aug 4, '12 - from 'Central NY US'. LOVEGREEN is a RN. She has '4' year(s) of experience. Posts: 12 (50% Liked) Likes: 42

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  • Oct 16

    Hi - I wanted to increase some awareness about the most underused question to patients/families based on my recent experiences including a family pushing for a patient with endstage dementia to get a g-tube placement "because we can't let him starve to death" while at the same time saying "obviously we do not want the nurses to draw blood, take vitalsigns, or get an xray - we want him to be as comfortable as possible". Nothing matched the overall goals for the patient as identified by the family ("comfort") and got worse by the family's poor understanding of trade-off when it comes to therapies/interventions and the inability to understand that a certain treatment will not change the overall outcome or trajectory of illness (because the patient will continue to aspirate secretions and get pneumonia while the dementia functional decline increases further - but now we are prolonging the end of life with artificial nutrition and hydration and the patient will need restraints because of agitation).

    Unfortunately, despite the fact that there were other admission to the hospital, nobody had a conversation with the family to explain the illness, how it progresses, what is to be expected, and the choices for treatment plans/care plan once the illness is at a certain stage. Now in crisis mode the family is overwhelmed and they do want the patient to be comfortable but they also feel that they "need to give him a chance" (???) because the primary care physician who is biased about treatment choices told the family "he will starve to death" and "there is a feeding tube" while not talking as much about other options or implications.

    As nurses, you know that a lot of times out discussions and interactions are short and focus on the task on hand. Typical questions or discussions center around symptoms and scales "how would you rate your pain?" or "have you fallen the last 6 months?" and such.

    I want to encourage everybody to also consider some other important questions that will actually point to if the care plan / care we provide is congruent with the patient/family wishes. It becomes more important to also consider this piece as we have much more treatment choices and options but they all come with a trade-off and do not necessarily meet what a patient considers a goal or is important to them. Also, patients and families still often do not understand that they have choices when they face a serious illness or an advancing illness and getting closer to the point where the physician estimates a life expectancy of 6 months or less. Often times we can see "the writing on the wall" in the progression of a chronic or serious illness and know that things are changing in the trajectory of the illness.

    It is not the scope of a nurse to diagnose or to give a prognosis and the physician/ APN/PA conveys the diagnosis and prognosis. But as nurses we have another powerful tool which is based on a functional assessment. With a few questions you can usually get a good idea about "how patients are overall doing" because you also know their diagnosis from the MD.
    The Palliative Performance Scale (PPS) is a validated tool which evaluates 5 items:
    Ambulation level, activity level /evidence of disease, self care, po intake, conscious level

    When you assess those 5 domains and also ask "how was that before this episode of illness" or "how was that 6 months ago?" you can draw some conclusions about the functional decline, which usually points to overall disease and symptom burden especially in conjunction with diagnosed conditions.

    What is important is the difference in score or activities. Somebody can have a low functional status with a PPS 30% and stay in that state for some while especially when there is some artificial hydration or artificial nutrition is going on. But when a patient tells you that 6 months ago they were independent, able to walk, eat and drink, awake and now they are in the hospital and can't get out of bed, unable to eat or drink much, need help with all ADLs you know that there is something bigger going on.

    I find it important to ask patients who have a significant functional decline or who come in already very declined to also ask with the initial assessment or at any point later if time was too short
    "Can you tell me what is important to you?" and "do you have specific goals?"
    If the patient can't tell because of confusion/ inability to converse I ask the family. The goal is to initiate a discussion earlier in the disease process when people are less stressed out and able to think about it.

    It is important because as nurses we want to know our patients better and also understand if the care plan is matching their overall goals/ priorities/wishes. Nurses are in this unique position to identify when the care is not congruent because we see the patient throughout the shift / day and do not look at the diagnosis only. We can see the patient in a more holistic way.

    Have you ever wanted to pull your hair out because the specialist says to the patient/family "everything looks great - your heart is excellent" and the patient also has multiple other significant problems besides CHF like COPD, cancer, forgetfulness, diabetes, and can hardly get out of bed or take care of themselves ? Because as nurses we know that the spcialist is just addressing this one piece but the bigger picture conveys a different message.

    By asking about what is important to them and explore important goals, you can get an idea of congruence and you might be able to intervene and advocate for your patient in a different way.

    If a patient is chronically ill and let's say 85 y old and tells me that he only cares about "not feeling short of breath" and the overall ability to sit in the recliner and watch football and values some form of getting out of bed highly the care plan and treatment approach can be very different from somebody who is chronically ill and also 85 y and who says that the goal is to get to the granddaughter's wedding in 2 months and to go through aggressive treatment because that patient is willing to sacrifice / trade-off for example comfort if it means he can in the end go to the wedding.

    Nursing implications are to advocate and educate patients and families about the fact that they have choices and that they can talk to the physician about treatment that matches their overall goals and preferences best. Provider bias in some cases leads to families not knowing that they do not have to put in a feeding tube in end-stage dementia for example or that they can talk to the oncologist about stopping a palliative chemo that is making the patient so sick that the patient feels they are gaining some time (because it is not curative - will only extend time) but now they can not use the time for anything because they are constantly weak, nauseated, tired, and so on.
    Nurses often know instinctively that when a patient comes in more often or appears very sick that there should be a serious illness conversation preferably with a team/family meeting to make sure that there is a discussion about "where to go from there". In an ideal world, the primary care provider would have this discussion within their trusting relationship and before a crisis but we know that only a very small amount of patients have those discussions and often enough the hospital is the place where this happens.

    Nurses can help a lot by identifying when a patient needs to have a more comprehensive discussion about their goals, wishes, preferences if the illness gets worse. The goal is to make a "plan B" and discuss if the treatment/care plan is congruent with wishes.
    At times I mention to the provider what I learn from my questions to give them a different perspective and it can really shift the way providers talk to their patients about treatment options.
    When I tell the hospitalist that the patient feels strongly about spending quality time without pain/suffering and does not care about the amount of "time" that can get added - meaning quality of life becomes more important than just purely "longer life" it changes the approach and the way providers talk to patients. What I found is that they will also tell patients in this scenario the options but most often also add if that therapy or treatment will change the overall outcome or if it will most likely add mostly discomfort or negative things while not providing some benefit that is important to the patient. That influences what patients and families decide.
    If a provider explains that "yes, we can try the new immune-therapy for cancer that you have seen on TV but it will also take x weeks to work and will most likely have this and this side effects that could interfere with your goal to spend quality time with your family at home" instead of "let's try this immune-therapy" obviously the patients and families will start to think more about the trade-off.
    Nurses are the biggest advocates and patients appreciate when nurses advocate for them / give them the tools they need without pushing their own agenda.

  • Oct 14

    Quote from 1Sharon1
    Should I just quit nursing?
    If you just inherited a small fortune, then quit. If you have another degree in something highly marketable, look for something in that field. If you need the income and have no other marketable skills, sleep on it ...then wake up and go to work.

  • Oct 14

    If she stays then he knows exactly where to find her.

  • Sep 30

    Quote from smartnurse1982
    Let's say by 2030 80% of nurses have Bsn Degrees.
    What happens to the Lpn's and ADN Rn's that do not have one?
    Some ADN's will notice no difference - especially if they live in an area without a lot of BSN's. Some will simply stay in the current jobs and be fine as long as they never want to leave that job.
    Most will have problems getting a new job -- moving to another place or wanting to transfer to another department, etc. because they will have to compete against BSN's. So, many will be stuck having to stay where they are, or accepting jobs that are not very popular -- the jobs that most BSN's don't want.

    I've had friends in that situation already. Their jobs were secure and the ADN was acceptable to the employer -- but they wanted to leave and couldn't get another good job because they lacked the BSN. They were stuck.

  • Sep 17

    I don't think it's all that complicated; if people are always leaving because it's a ****** place to work, then make it a less ****** place to work.

  • Sep 8

    Don't know about the rest of you but I too am ...gasp... IN IT FOR THE MONEY! I expect to be PAID for what I do! But that's just me. The rest of you can volunteer if you want.

  • Sep 8

    Quote from Jenny.jsk
    There are a lot of people who choose nursing as a career for the money knowing too well that they don`t belong.
    I am one of the so-called dregs who entered nursing for the steady paycheck.

    Just imagine that your manager approached you one morning and announced, "I regret to inform you that we can no longer pay you for your services. However, I am sure you would not mind one bit. After all, your compassion will pay the bills and your devotion will keep food on the table."

    Would you continue to work your butt off without the promise of money in return? For me, the answer is "Heck no." I am shamelessly in it for the money.

  • Aug 28

    I've worked nights for 12 years with many different people and I believe there are just some people that can't do nights. There are people like me who can switch back and forth between days and nights relatively easy. Then there are other people that struggle on nights no matter how much rest they get. Some people never adjust.

  • Aug 21

    I had a similar situation with a doc, he asked me for tool, and I didn't know WTH it was. I asked for clarification, but I've been around enough to not wither and tear up with a snarky remark back. I just asked "well is it sterile? Is it bigger than a bread box? I have to look for it, and you need to give me some clues."

  • Aug 16

    "Could of". I just want to punch the person in the face.

  • Aug 16

    Quote from NurseGirl525
    In my state, we are not allowed to mention it. At all. We do not talk about it even if they bring it up. They are promptly referred to our state's organ team.
    I've worked in multiple states and this has always been the policy- for hospital staff not to discuss donation with the family at all, under any circumstances- if they initiate the conversation, we still can't, they're referred to the organ donation organization.

    I don't think it's accurate to assume that families changing their minds after talking to someone trained in donation issues must necessarily have been coerced. In those cases I've seen where the family changed their minds, it was because they initially had misconceptions about donation (that it would change the care their loved one would receive, that it would prevent an open-casket funeral, etc) and decided in favor once those concerns were allayed, and having considered the positive aspects (so many people are looking for some glimmer of positivity in a terrible situation).

    It's not wrong to consider the ethics of these things but I don't know how this could be done in a way that entirely allays the concern of coercion or potentially upsetting a family by raising the issue at all, other than simply never addressing the issue with anyone who didn't positively affirm their wish to donate in life. And that itself has major ethical issues- it denies the family the opportunity to make the donation (something many people value in retrospect) unless they happen to think of and raise the issue on their own under extreme stress within the narrow window (unlikely), and it would almost certainly massively reduce the number of donations (already inadequate to the demand) leaving many more people to die and suffer needlessly.

    Those seem like harsh costs for the possible benefit of avoiding a possibly uncomfortable conversation, even for the grieving.

  • Aug 3

    Quote from ToriAneal
    Wow. Calling you stupid? That was really out of order. The nurse at my facility told a few of my co-workers that they were beneath her and all they do for a living is wipe ass. I was like wow
    I've wiped a lot of butts in my time. I don't mind, it has paid for a house and cars.

  • Jul 29

    The test will most likely be positive if you have taken opioids within the last 90 days. If you have a prescription for narcotics within that time frame, you will be covered.

    I would be more concerned about the "reports" of erratic behavior. Were you written up for that.. and do YOU feel you have a problem?

  • Jul 27

    Sounds serious. You should put her picture up with a warning at the local Greyhound bus station, too. And anyone who walks by without looking at it should get a hard slap to the face.

  • Jul 27

    I think you're overstating the likelihood of a $15 federal minimum wage, but you're fears are based on some very bad math, which seems to be common to most anti-minimum wage increase hysteria.

    First, cost of living and inflation would not increase by the same amount the federal minimum wage increases, which is where I assume you got your "cost of living budget increase by 1/3 or more" figure from. Even at businesses most heavily affected by an increase in the MW (fast food and other predominately near MW paying restaurants), an increase to $15 would raise prices only 4.3%, which is a far cry from the 33% or more that you quoted. And that 4.3% increase assumes a sudden increase to $15, when actually a phased increase to $12 is more likely. And for you to experience all of that 4.3% increase your entire budget would have to be spent at MW paying businesses.

    Keep in mind that we're not talking about an unprecedented minimum wage value, the relative buying power of the MW has been steadily declining, the proposals that are out there only catch us back up to where we once were, and when the MW was at those levels the economy thrived. We can also look at smaller minimum wage increase experiments, Washington state has had a minimum wage tied to inflation and despite having the highest minimum wage in the nation they also have one of the most vigorous economies including in terms of job growth in the country.

    The biggest problem with allowing the MW to continue to fall is that it moves more towards a federally subsidized business economy, not all that much different from communism. Currently, the majority of those on public assistance programs work. We've been allowing businesses to transition from having to cover their costs to simply paying employees a token amount and then having the government pay for the rest of their basic expenses (ie communism).

    I'm a small business owner, and as a result I fully support returning the MW to it's historical peak, here's why: With a MW far lower than a livable wage, as a responsible owner of a successful business I get punished and end up having to support less responsible and poorly run businesses. While I may pay my employees a livable wage, the restaurant next door is free to underpay their employees and make up for it with public assistance programs that I then also have to pay into. So my "reward" for running a good business is that I also get the bill to make up for the failings of other businesses.

    In general, I don't agree that businesses should be immune to the competitive market forces that keep an economy healthy by replacing an adequate minimum wage.