I wanted to hear from my fellow critical care nurses about a common but difficult situation. I'd love to hear your advice and perspective.
My mind's been buzzing around some recent scenarios that I've been involved in at work, where I've been part of a team for various patients that have treatment/goal of care options that are ethically a bit grey. By that, I mean the patients where the families want everything done, when it's questionable what outcome the patient can realistically attain. The patients that are acute but stable; may not necessarily be on death's door, but cognitive functioning and independence are extremely limited. One, we were not sure we'd ever be able to live without ventilation support due to an insult to the brain stem. Unfortunately, the family was not hearing that, and insisted that the trach and peg were just a short-term measure before he bounces back.
I feel like, in these situations, my greatest struggle was in trying to meet the family where they are and find common ground so that they can understand that, though the conversations are hard, we aren't trying to be dismissive or tell them to let go of their loved one. Rather, we're trying to explain the treatment options and their consequences. Many families don't want to explore the consequences, which doesn't allow them to make informed decisions.
These conversations are hard and people's fear at learning that their loved one may not survive or return to a certain quality of life tends to go quickly from fear to anger, and I feel it creates distrust in the treatment team.
My personal belief is that if someone truly would want everything done no matter the potential for suffering, I can be okay with that and will suffer no psychological stress from it as long as I know that the decision was made with all of the information available. But I'm starting to find that is now more of an "ideal situation" since so many families of ICU patients are deep in their stages of grief that make it difficult to effectively connect and educate. Finding the "sweet spot" between making sure that the family understands the consequences of the different options (including the more uncomfortable options), and not just absolutely beating a dead horse and causing nothing but further distrust, can sometimes be complicated. If anything, it's like trying to hit a moving target. lol
Any stories or tips on how you go about having conversations with a patient's loved ones, when the situation is "stacked against you" and it feels like the family is resentful or dismissive of the information you present? Or even in those situations where family members do NOT get it (or maybe think that they get it, but are totally off base)? Do your doctors tend to be the one doing most of the talking or do you make a point of addressing these issues yourself?
I pester the physician to either talk to them or consult palliative care depending on the situation.
Personally, I do not feel talking to a family about something they’re refusing to believe is in my scope of practice. I am there to provide a service, no matter how much I may feel it is a disservice. (Keep in mind- I WILL consult with the proper authorities (management, physicians, etc.) if it is ethically wrong. I feel that if I initiate the DNR/why are we doing this conversation (which I think is really not a nursing action in most cases; however, there’s always extenuating circumstances and if the family presents it I will talk or refer appropriately), it does not help my relationship with them if we disagree, thus harming the patient. I will tell them what I know the physicians have told them, but I will not argue or tell them they are wrong- the majority of the time the family is not in a position where they are rational.
rn409, BSN, RN
63 Posts
I pester the physician to either talk to them or consult palliative care depending on the situation.
Personally, I do not feel talking to a family about something they’re refusing to believe is in my scope of practice. I am there to provide a service, no matter how much I may feel it is a disservice. (Keep in mind- I WILL consult with the proper authorities (management, physicians, etc.) if it is ethically wrong. I feel that if I initiate the DNR/why are we doing this conversation (which I think is really not a nursing action in most cases; however, there’s always extenuating circumstances and if the family presents it I will talk or refer appropriately), it does not help my relationship with them if we disagree, thus harming the patient. I will tell them what I know the physicians have told them, but I will not argue or tell them they are wrong- the majority of the time the family is not in a position where they are rational.