Approriate PCA use

[Alphabet soup nurse]

I would like some advice on a situation I encountered:

I happened to be in charge on a med-surg floor and another nurse had called me to help her with family being upset about MD. Background: Pt had advanced dementia--could not eat due to swallowing difficulties, was alert but little verbal responses and disoriented--- newly developed generalized edema and respiratory congestion. Pt was not comfort care but had poor prognosis. Family did NOT want comfort care measures. The MD and clinical coordinator were called and met with the family. The family kicked out the MD and just talked with the clinical coordinator who suggested a PCA pump, suction at the bedside and O2 sat monitoring. The nurse caring for the pt provided ordered Roxanol for pain, set up suction at the bedside and O2 sat monitoring, but felt PCA was inappropriate as pt was mostly in and out of sleep, and could not use PCA button due to confusion/disorientation.

Family became IRRATE that the promised PCA was not set up even though pt was asleep at this point and stated MD "was an idiot and will only have a job at McDonald's when I am done with him" The Clinical coordinator was called and upset with nursing staff and MD that the PCA was not set up stating "this is going to hurt our patient satisfaction and our numbers and we have to think about our surveys" and demanded that nursing staff and her family PUSH THE PCA! Stating the family "will see that we are trying instead of nursing giving meds because the family will not know what we are giving when we come give pain meds and forget that we gave them"

I questioned the decision/appropriateness of PCA and stated nurses/family could not press PCA for the pt and told the nurse to document what the coordinator had said and to call the MD to the floor to discuss with the nurse and coordinator. At the point my shift was over and I had already stayed an extra 20 minutes to make sure that all was going to happen. Well, the next day the pt was on a PCA. I told the manager I thought it was very inappropriate and the pt could not elaborate pain/was confused/disoriented/and lethargic and could not press the button herself and coordinator told staff to do it and let family.

What do other nurses think? I am out of line to question this?

[Been there,done that, ASN, RN]

Agree that the family/staff should not be administered pain medication with the PCA.

Surely this is against hospital policy.

However your clinical coordinator and the physician have chosen to go against policy in this case.

You did question it, the powers that be are now in charge of it, let it go.

[Galendria]

Is your clinical coordinator a RN or advance practice nurse? I'm a bit confused because in your story she seems to be suggesting a plan of care/new orders to the family which isn't really in a nurse's scope of practice, especially since she wasn't collaborating with the physician when she did so. We have a clinical coordinator on the med-surg unit I work on as well (and I feel that that role has been a great addition to our unit). However, our coordinator rounds *with* physicians, works to increase communication between patients/families and the physician, coordinates care with consulting services, PT/OT/social work/case management, and makes follow-up phone calls when patients are discharged. Our coordinator definitely never acts divisively like the story you told in your post.

I'm also a bit confused as to the goals of care. You mentioned that the family didn't want "comfort measures" but in an elderly patient with respiratory congestion (I would be concerned about declining respiratory function), increasing narcotics seems like it would be harmful to the patient *unless* a comfort care only approach was taken. Even then, I've never seen a PCA pump used in a confused patient. What I have done is give Q 1 hour Morphine to a DNR-comfort care patient, along with an agent to dry secretions and anti-anxiety medications.

Contrary to the beliefs of some managers, families generally *do* notice when staff RNs genuinely care about their patient, perform basic comfort measures such as oral care/turning/etc., advocate for them, and work together with the physician and other disciplines. Trying to boost nurse scores on surveys by bad mouthing the physician is never a good idea and erodes any teamwork which may be occurring on the unit. Surveys are a tool, but stories like this one which portray patient satisfaction as a goal above all others make me worried for the future of nursing.

[OyWithThePoodles, RN]

It is against our hospital policy for anyone other than the patient to push the PCA. Family is made well aware of this. If the patient is not with it enough to push the button and it is in fact being pushed-you can see how many times it has been used-I would bring this to the attention of someone soon.

Also, educating the family on over-sedation (hence, why we don't let family push it). If the family is truly concerned with their family member being in pain, maybe suggest to the doc a basal rate on the PCA pump, something small that will keep the patient comfortable without taking the chance of over-sedating.

But it sounds to me like the family is wanting comfort measures...without wanting comfort measures. Maybe they need more education on their family members disease process?

[Neural]

One of the most important safety features of patient controlled analgesia is that when the patient is too sedated to push the button, they don't get any more drugs.

When "PCA by Proxy" is taking place, the proxy (family or staff) cannot properly judge the level of sedation, thus running the risk of over-sedating the patient, which can lead to respiratory depression and arrest.

Drop that little nugget on the family! But given the fact that they think they're going to get a doctor's license pulled over their discontent, I'm guessing they'll disregard it and continue to think they know better than trained medical staff.

[mmc51264, BSN, MSN, RN]

We have set up morphine drips using a PCA machine but never allow a family member to have the button. It someone has dementia, they get prn roxinol or morphine administered by nurse.

[Wile E Coyote, ASN, RN]

I concur with previous posters, a demand dose from the PCA must be admin by patient only.

Hopefully, someone especially skilled (or just lucky this time) can bring this family back down from the clouds.

Why PRN pain meds are superior in this pt's instance, and very clear communication with family on it's admin frequency, times, etc. (Use that white board in the room) can address this. Since family is presumably hoping for recovery, emphasize the staff's wishes to avoid harmful effects of narcs. (constipation, resp depression leading to aspiration, anoxia, pneumonia, you know the drill)

[ProgressiveActivist, BSN, RN]

This is bad medicine. Notify Risk Management via a report detailing the deviation from policy.

When the woman is found apneic, at least they cant say they were never told.

*these people may have their own agenda for wanting the pca. Monitor the doses and vtbi and keep the door open. If they're nodding out you will know why.

[caliotter3]

When I was still a nursing student and with my daughter in the ICU, her assigned nurse told me that I could press the PCA button for her. She explained the signs of pain and why it was better for her to be able to rest with pain relief. No problem whatsoever. I do not know whether or not the nurse was going against hospital policy. If that issue had become a topic of conversation, I doubt she would have allowed it.

[Anna Flaxis, BSN, RN]

When the primary RN asked for your assistance, did you go in and speak with the family personally?

When the primary RN decided not to set up the PCA, did she discuss this decision with the family?

The reason I ask is that in my experience working with demanding family members who are angry and attempting to direct care, blaming doctors or nursing staff for things that are not their fault, and these sorts of things, is that this is usually due to the family trying to cope with a difficult situation. What they need is an "ally"- someone who is on their side. The trick is to be their ally while simultaneously supporting your staff and not undermining them.

It sounds like this clinical coordinator person got the being the ally part, but missed the boat on the not undermining staff part. That is really unfortunate.

As a charge nurse, you are the first person your staff will come to when they find themselves in a difficult situation where they need some support. This is an opportunity to model for your staff problem solving actions and behaviors.

What i might have done, before calling the clinical coordinator in, was to enter the room and pull up a seat, sitting down with the family at their level, face to face, and introduce yourself as the Charge Nurse. Identify the "spokesperson" by whoever is doing the most talking and the most "directing". Say things to this person, such as "we are all on your side here", and mean it. Be sincere. Use open, confident, and calm nonverbal communication. Say things like "I understand this is a really hard situation, and I want to do everything I can to help, but I need you to help me. What can I do?". Offer suggestions for interventions that your nursing staff can actually do. Avoid using language that will trigger them, such as "comfort measures"- offer comfort measures but don't call it that.

If they ask for something that is not appropriate, such as a PCA for a person that doesn't meet criteria, say something complimentary, like "normally, that would be a really good idea, and that's really resourceful for you to think of that, but in this situation...." and then explain why it's inappropriate here, emphasizing staff concern for keeping her comfortable while balancing her safety. Be sure to offer more than one alternative, such as "we can set up an IV that will give her a small amount all the time so she can rest comfortably and not have to worry about pushing a button, or we can make sure the nurse comes in every hour to check on her pain level and give medications if she seems uncomfortable, and of course, you can always press the nurse call button if she seems uncomfortable and the nurse hasn't been in yet".

I've always found that explaining my assessment findings to the "spokesperson" in a way that sounds collaborative, like I'm including them in the decision, such as "I can see what you mean- her brow is furrowed, but I'm concerned that her respiratory effort is impaired, and she's not responding to my touch. I want to keep her comfortable, but I don't want to overdose her. Maybe we could try repositioning and a warm blanket. Would you like to help?" to be a good approach.

Ask questions about the loved one. Does she like music? Can you provide a music player with a selection of genres to see if that helps soothe her (if not, can the family bring something in?). Does she like a certain kind of food, and can the family bring that in for her?

Ask them what questions they have, and answer them honestly, and if you don't know the answer, be honest about that, too.

Reiterate the plan, stating something like "Okay, so it sounds like we're all agreeing to ____________".

Before you leave the room, say something positive about the primary RN, like how smart s/he is or how caring s/he is.

If all of this fails, then call in your resources, such as social work or the clinical coordinator, or spiritual care, or ask if they have a pastor or clergy person they'd like you to contact. But, if you use the right language and behave with the right demeanor, you may be able to smooth things over with these folks and make all of that unnecessary. As a Charge, it's part of your role to problem solve and smooth things over for patients and families, while also supporting your staff. It's not always an easy thing, and it can challenge even the best of us. But it does get easier with practice, and you will learn things that help and things that don't help.

And of course, be sure to document these interactions- the concerns verbalized by the family, the interventions offered, and a summary of the plan that the family agreed to.

You might know all of this already, and if so, pardon me. But, maybe it can be helpful to someone else reading this.

[lavenderskies, BSN]

When the primary RN asked for your assistance, did you go in and speak with the family personally?

When the primary RN decided not to set up the PCA, did she discuss this decision with the family?

The reason I ask is that in my experience working with demanding family members who are angry and attempting to direct care, blaming doctors or nursing staff for things that are not their fault, and these sorts of things, is that this is usually due to the family trying to cope with a difficult situation. What they need is an "ally"- someone who is on their side. The trick is to be their ally while simultaneously supporting your staff and not undermining them.

It sounds like this clinical coordinator person, unfortunately, got the being the ally part, but missed the boat on the not undermining staff part. That is really unfortunate.

As a charge nurse, you are the first person your staff will come to when they find themselves in a difficult situation where they need some support. This is an opportunity to model for your staff problem solving actions and behaviors.

What i might have done, before calling the clinical coordinator in, was to enter the room and pull up a seat, sitting down with the family at their level, face to face, and introduce yourself as the Charge Nurse. Identify the "spokesperson" by whoever is doing the most talking and the most "directing". Say things to this person, such as "we are all on your side here", and mean it. Be sincere. Say things like "I understand this is a really hard situation, and I want to do everything I can to help, but I need you to help me. What can I do?". Offer suggestions for interventions that your nursing staff can actually do. Avoid using language that will trigger them, such as "comfort measures"- offer comfort measures but don't call it that.

If they ask for something that is not appropriate, such as a PCA for a person that doesn't meet criteria, say something complimentary, like "normally, that would be a really good idea, and that's really resourceful for you to think of that, but in this situation...." and then explain why it's inappropriate here, emphasizing staff concern for keeping her comfortable while balancing her safety. Be sure to offer more than one alternative, such as "we can set up an IV that will give her a small amount all the time so she can rest comfortably and not have to worry about pushing a button, or we can make sure the nurse comes in every hour to check on her pain level and give medications if she seems uncomfortable, and of course, you can always press the nurse call button if she seems uncomfortable and the nurse hasn't been in yet".

I've always found that explaining my assessment findings to the "spokesperson" in a way that sounds collaborative, like I'm including them in the decision, such as "I can see what you mean- her brow is furrowed, but I'm concerned that her respiratory effort is impaired, and she's not responding to my touch. I want to keep her comfortable, but I don't want to overdose her. Maybe we could try repositioning and a warm blanket. Would you like to help?" to be a good approach.

Ask questions about the loved one. Does she like music? Can you provide a music player with a selection of genres to see if that helps soothe her (if not, can the family bring something in?). Does she like a certain kind of food, and can the family bring that in for her?

Ask them what questions they have, and answer them honestly, and if you don't know the answer, be honest about that, too.

Before you leave the room, say something positive about the primary RN, like how smart she is or how caring she is.

If all of this fails, then call in your resources, such as social work or the clinical coordinator, or spiritual care, or ask if they have a pastor or clergy person they'd like you to contact. But, if you use the right language and behave with the right demeanor, you may be able to smooth things over with these folks and make all of that unnecessary. As a Charge, it's part of your role to problem solve and smooth things over for patients and families, while also supporting your staff. It's not always an easy thing, and it can challenge even the best of us. But it does get easier with practice, and you will learn things that help and things that don't help.

And of course, be sure to document these interactions- the concerns verbalized by the family, the interventions offered, and a summary of the plan that the family agreed to.

You might know all of this already, and if so, pardon me. But, maybe it can be helpful to someone else reading this.

I want you to be my family members nurse!

[Anna Flaxis, BSN, RN]

I want you to be my family members nurse!

...aw, shucks.

Don't tell anybody, okay? Reputation and all that...