Comfort care

DixieRedHead, ASN, RN · Dec 2, 2011

First of all is there an RP? Is there a living will? Without the express wishes in place in that living will, the minute that resident gets to the place they are not longer alert and oriented, the family can change it if they so desire.

This might be a long complicated process for them, but in the mean time you and your facility are the ones stuck in the middle.

You need to get your social worker together with the entire family and have a long discussion.

Altra, BSN, RN · Dec 2, 2011

Assuming that the orders for comfort care only have resulted from the patient's expressed wishes, please use that as a point of reference in any discussions you have with the family. I don't mean bulldozing them, as in, "well, this what Mom wants, so what you think doesn't matter" but more like highlighting the care being provided, and using a gentle reminder that this is in line with the patient's expressed wishes as a recurring punctuation mark. It's just another flavor of providing patients/families choice where possible, but not where none exist.

You can also gently turn the conversation so that they are more aware that their disagreement with the plan of care results from their own impending grief. "Are you saying that you're concerned that she'll experience pain?" or "What did you go over re: test results in your last conversation with the MD?"

If staff avoid engaging these families, their sense of discomfort with the palliative treatment plan only increases.

systoly · Dec 2, 2011

I'm not clear on the scenario. Does the family lack support from nursing staff and needs help understanding the patient's wishes or is the family non supportive of the patient's wishes?

Kiwidanni · Dec 3, 2011

How about "I am your Dad's nurse, and his wishes were bla bla bla, which I am legally and morally bound to abide by. I'm sorry that you are in this situation and understand you are grieving but I must do what your dad wanted".

xtxrn, ASN, RN · Dec 3, 2011

How about "I am your Dad's nurse, and his wishes were bla bla bla, which I am legally and morally bound to abide by. I'm sorry that you are in this situation and understand you are grieving but I must do what your dad wanted".

Would be nice, but in the US, if the patient can't communicate, the families CAN change what care/interventions are done- including reversing a DNR, ventilator, etc...it stinks. :down:

student forever · Dec 3, 2011

Can it be reversed even if in writing?

CapeCodMermaid, RN · Dec 3, 2011

It depends on what state you're in. Some states allow living wills as legally binding documents. Some do not. Health care proxies are supposed to do what they know the patient wants, but that doesn't always happen. It makes it hard for those of us who are trying to do the best we can for the patient.

xtxrn, ASN, RN · Dec 3, 2011

Can it be reversed even if in writing?

Short answer: Yes. The dead don't sue. (and there are state differences- even if something is notarized/witnessed and in writing).

Longer answer: Family drama gets lit like a bonfire when someone is dying. Doctors don't want mad families either. Someone can have in an advanced directive, with copies sent out like junk mail, and it can still be over-ridden by family members/POAH. The big mouth usually wins.

leslie :-D · Dec 3, 2011

I have had a few patients on comfort care with unsupported families about that pts wishes, which makes it difficult for me to provide appropriate care to that patient. I am never sure how to address the family, and what to say. Any adive or personal experiences that would help? Thank you

we need more info.

"unsupported" in what way?

do families want ongoing treatment?

do they want to limit/withhold pain meds?

i'm not understanding exactly what you need help with.

often, a terminal dx is a shock to the family, and they haven't absorbed the enormity of pt's prognosis.

educating over and over, is sometimes warranted.

we repeat ourselves a million times in hospice.:)

but until i know what you're struggling with, i don't feel i can really help you.

leslie

cohrn · Dec 3, 2011

Is this patient on hospice? If not, bring 'em in. Hospice can help support families with their issues, staff support for problems they are having and most of all the patient with their own desire for a good death in their own way.