Dad says I have to learn to tune this stuff out

[AlisonBSN]

I'm new to nursing and new to the politics in the hospital. Since I've been on orientation I've witnessed a few situations that left me wondering. Like about ethics...

For instance, we had a patient that was end-stage Multiple Sclerosis. She was very contracted and had a very difficult time speaking, but if you took the time to figure out what she was saying, you'd see that she makes perfect sense when she talks. She never had episodes of confusion, and even made jokes every now and then. So she was completely there, mentally.

She's had a Hospice consult but the family refused Hospice...so she stayed in the hospital for way longer than was medically necessary because she had nowhere to go. No nursing home would take her either. But I don't understand how the family can refuse. What does "the family" have to do with the decision...

When anybody would ask why this lady was here for so long, the social workers and nurses who had been working with her forever would say that it's because the daughter lives in her mother's house, and if the lady goes to Hospice, then the daughter won't have anywhere to go, or will stop getting goverment money...something like that. But the daughter is grown with a 10 year old kid herself. (I don't completely understand because I don't understand Medicaid or Medicare, and what happens to that when people go into nursing homes or Hospice.)

So...my questions are:

1) Why is her daughter being a loser ANY of our concern...especially when our obligation is to our patient who would have a much better death in Hospice than on our crappy MedSurg floor...and especially when there's plenty of other government programs who give free housing to broke chicks with kids.

2) Why are we accepting the family's refusal when the patient is competent? Why isn't the final decision made by the patient? ...perhaps in a private conversation between the social worker and the patient without the loud-mouthed daughter talking over her mother...

:monkeydance: And the lady told me she would rather go somewhere like Hospice, but they ended up discharging her home. It just makes me sad and frustrated because I keep seeing the rules broken. Like we tell one family that we can't give out info over the phone, and then we give info over the phone to another family. I just want to know what I can and can't do.

[AlisonBSN]

Please excuse my oddly placed dancing monkey.

[SuesquatchRN, BSN, RN]

The hospital can't legally release a patient unable to take care of basic ADL's to her home unless there is someone there who will accept responsibility for her. Clearly, the daughter won't. Or wouldn't. And hospice home care isn't 24 hours a day.

Some patients don't want their families to have information. Others do. It's easier to just say, "Sorry, can't give that out over the phone" than explain that Grampa thinks you're just waiting for him to kick and he'll be durned if anyone tells you anything.

You don't have close to the whole story on any of this. Listen to your dad, do your job, and let the social workers do theirs.

[Myxel67]

If a pt is mentally competent, the pt should be the decision maker. But you'll see this concept bent, often depending on who is talking the loudest. You will also see family members who don't want Mom told of the true nature of her illness. "She just couldn't deal with it." And often physicians go along with their requests.

I believe if a person is in a long term care facility that is not paid for by some kind of insurance, they may qualify for Medicaid which will pay for the care. To qualify for Medicaid, person usually has to spend down assets first and use those assets for care before Medicaid starts (the house) The person's estate would reimburse the state for cost of care as long as there were assets. Social Security benetits also would go to state to help pay for longterm care. There are provisions in the law to prevent impoverishment of a living spouse (but not able-bodied daughter). These are often reasons family would vote against longterm care.

Your case sounds like a good one for an ethics consult. Perhaps no one has taken the time to try to communicate with this pt/former pt.

About your comment re giving info to family. Perhaps hospital personnel is certain of identity and has discussed pts care with this person in the presence of the pt, or knows the person to be health care surrogate or proxy. But sometimes people are just people and tend to give more information to people they like or who treat them nicely.:balloons: :monkeydance:

[AlisonBSN]

The hospital can't legally release a patient unable to take care of basic ADL's to her home unless there is someone there who will accept responsibility for her. Clearly, the daughter won't. Or wouldn't. And hospice home care isn't 24 hours a day.

Some patients don't want their families to have information. Others do. It's easier to just say, "Sorry, can't give that out over the phone" than explain that Grampa thinks you're just waiting for him to kick and he'll be durned if anyone tells you anything.

You don't have close to the whole story on any of this. Listen to your dad, do your job, and let the social workers do theirs.

No I have pretty close to the whole story. I think you missed the part where they did send her home to her family yesterday just because the daughter would rather have her home than at Hospice House. The daughter accepted responsibility for her mother's ADLs...so she'll continue to put Iodosorb on her sacral wound and Dakin's on her feet. At least the daughter will be taken care of.

So I'm just supposed to "do my job" and not feel a little bit let down when the system fails when it didn't have to this time? I guess I'm just an idealist. Which brings me to my second point...I'll get my little year of MedSurg and move on, and if this kind of crap goes on constantly in every job I take, then I'll be out of nursing... I'm too young for this.

[barbyann]

Alison, keep advocating for your patient. If she tells you she wants to go to a hospice facility, and it is an appropriate request, then you have the obligation to make this request known.

When I have found myself in this situation (more than a few times) I made sure every shift I worked with the patient that I documented their request and send copies to SW, CM and MD. I'm not saying this system works great, but at least I can leave my shift knowing that I did my job and advocated for the pt. I have gone as far as helped a pt. find a family law attorney in the yellow pages, dialed and translated for the pt through slurred speech. Guess what! That guy won his court case and the family was removed from his house!

The more you handle these situations the better you get at it. You win some you lose some, that is the reality.

[AlisonBSN]

barbyann - I wish I would have thought of that earlier. Thanks for telling me what I can do about it, even if I can't win them all.

[txspadequeenRN, BSN, RN]

does someone have the durable poa?

[SuesquatchRN, BSN, RN]

No I have pretty close to the whole story. I think you missed the part where they did send her home to her family yesterday just because the daughter would rather have her home than at Hospice House. The daughter accepted responsibility for her mother's ADLs...so she'll continue to put Iodosorb on her sacral wound and Dakin's on her feet. At least the daughter will be taken care of.

So I'm just supposed to "do my job" and not feel a little bit let down when the system fails when it didn't have to this time? I guess I'm just an idealist. Which brings me to my second point...I'll get my little year of MedSurg and move on, and if this kind of crap goes on constantly in every job I take, then I'll be out of nursing... I'm too young for this.

No, I got it. MY point was that until the daughter - or someone - agreed to perform the ADL's her mom couldn't go anywhere. Why are you shaking your finger at me?

You are supposed to do your job and use that idealism to trust that the social workers aren't uncaring idiots, AND to fight for your patients. But you do not have the whole story, you do not have the entire family history, you have never been part of that mother/daughter dynamic and can't judge it, and you are not omniscient.

I got myself into a lot of trouble on my first nursing job with thinking that I knew more than I did, about a lot of things. Don't do the same.

[SuesquatchRN, BSN, RN]

Oh, and if every idealistic nurse leaves nursing we're all screwed. Including you, down the line. Don't bail because reality isn't pretty. Hang around with your mouth shut for awhile and then, when you have all the pieces of the puzzle you need, and none of us can in our first year of nursing, including me, fight.

[GingerSue]

you do not have the whole story, you do not have the entire family history, you have never been part of that mother/daughter dynamic and can't judge it, and you are not omniscient.

I got myself into a lot of trouble on my first nursing job with thinking that I knew more than I did, about a lot of things. Don't do the same.

I have to agree with Suesquatch - you don't know the family history and you don't know the reason why the daughter is in the house with the mother.

Do you know whether any money was exchanged between the daughter and the mother re: living in the house?

Are you concerned about the child having a home?

[llg, PhD, RN]

Please excuse my oddly placed dancing monkey.

I've been active on the Internet since the www was in its infancy in the early 1990's. The post quoted above is DEFINITELY one of my favorites of all time.

:chuckle

About your serious question, Alison ... there are ways to address these issues and with a little time and experience, you will learn the political skills necessary to help patients with these sorts of problems. Those interpersonal and political skills do not magically appear just because you have RN after your name. You have to work on those skills in the same way you work on developing other nursing skills.

Also, understand that no one has the ability to provide "perfect" care to everybody. We do the best we can from day to day and help those we can help in whatever way we can help them. As your skills improve, your ability to help more people will increase.

As for the situation in your post ... I would start by identifying those people who could be the patient's advocate and resources for you. You might start by having a heart-to-heart with the Social Worker. You also might want to talk with a hospital chaplain. Don't forget the senior nurses on your unit, the unit educator, manager, etc. as well as the key physician. Explain your concerns with them and ask them for advice on how to handle the situation.

Keep seeking help until you find someone who responds in a way that satisfies your concerns -- but approach each person tactfully so as not to appear compative and beligerant. Present yourself as a new nurse trying to find a way to help your patient and understand why certain decisions have been made and try to avoid sounding too much like you are criticizing the decisions that have been made by your colleagues.

As you work on each problem case, you'll be able to help some of those people -- and you'll be developing political skills along the way. Running away from those difficult situations will help nobody.