Dnr In Icu

[gizelda196]

Hi.

I just had another one of those knock down drag out fights with the manager.

Our unit has its issues. (see my other post) We have just lost 12 nurses with a total of over 200 hundred years of critical care experience.We have no contract .blah blah blah.

Hence we have some just here "for the paycheck"staff. WE have now travel nurses( a few are really great) We have some perdiems. We have a few reg staff.

So let me get to the point of my post. Some times in our unit we have a rare family in a very hard situation that need to make some very hard choices.Sometimes you get a pt that was someone very special and had allot of love and support and a big family. The patient I received in report was a 50ish male myeloma for 4 years in a metastasis process. He was at work Friday. This was a guy who lived every day despite chemo and Rtx.Well Friday noc he had a GI bleed. He was a walk in to E.R with family in tow. Full CODE ,ICU admit.a&ox3 pleasant. family around. All intentions of going home. Well after multiple units of blood.ffp fluids blah blah blah. Things were not getting better. The gi bleed turned to a cecal mass large and pt was not an or candidate.Over the weekend staff went into support mode .assisting the family Pt on Sunday told wife I want to be a DNR. PT was started on mso4. hospice was consulted and by Monday he was on his path. Hospice came in on tues. .Well here is were I come in. I guess over the weekend the family had to boundaries. It was hard for the RN over the weekend Because she had a heart and this really was one of those families you just will never forget.She also had the pleasure of knowing the patient.(a&o on admission)

and was a part of the families journey.Well I came into rumors that the family was doing this and the family was doing that And the nurse let them have 3 icu rooms blah blah blah.So night nurse(Traveler) says well I put a stop to that .They are all sleeping on the pt floor! So I was sick. I figured I would assist this family. I dug up some recliners.opened up the adjoining room (shared bathroomwith pt room) woke the children up and consolidated the family into one room.Hospice came in had a 3 hour meeting with that family in that room.Then all said a prayer. family priest came up and the family had last rights and a prayer about an hour later.It was a large group but they all jammed in the room and assisted one another in the process. .Well the manager was beside herself. she wanted this family out of the unit. out of the room and transferred to another floor.I refused.this family was tucked away in 2 rooms on the other side of the unit away from other patients,.They had a rough weekend and death was interment.So blow out number one. Hospice backed me during this convo.Only nurse to do so.So we came to an agreement that pt would be transferred to rehab unit in am. We were making the plans, and tcu was going to clear an area. SO if nothing had changed in condition pt would be going there wed am. We were fine with that because the hospice nurse and I knew that it was soon.So later in the shift the manager with a chip on her shoulder came on the unit. looked at the family . walked into the adjoining room and announced they had to 3 o'clock to remove there belongings blah blah. well I was angry. So I told my manager the next time you wish to address any patient of mine you need to come to me first. well she was angry so we had a blow out.I went back the unit.Told the family hang tight.SOOOOOOOOO get this. Someone from administration is the patient niece. She visits. finds out form the family that they have to clear out and she goes to my boss and says. my family is going thru a tough time they would really appreciate the use of the rooms.and my boss says ohhh sure no problem if there is any thing else I can do. WEEEEEEEEEEELLLLLLLL. I lost all respect for this manager at that moment(I had very little any hoot)The pt died at 3pm.The whole entire family was in that room with him they told him they loved him it was okay and so on they were all there It was a very touching moment for me to be apart of.

My question is What do you do in these cases. We have plenty of dnr we transfer out to the floors for dying care. but once in a while we get that family that your heart just breaks.And it was such a tough and very quick journey to go threw with the family.The bonds and trust between staff and family were in place and moving him and bending was not the right choice at this moment. How would you have done it. And what is your policy on DNRs in the unit. Let me just add. we are a tiny community hospital struggling. we had 6 patients 4 nurses and 9 empty beds. I had a slot open and one other nuse had a slot open. And we have no staff any hoot so that would have been the max load any hoot.and we never have a code bed!!!!!(another issue)

[chris_at_lucas_RN, RN]

It does sound like a very challenging situation, like you have a manager with no spine (haven't we all worked for him/her???), and like you are where you need to be.

It sounds as though you need a large comfy waiting area right next to your unit.

If the family had never moved into those other rooms on the unit (and I'm assuming that they weren't billed for the rooms, which would be something that might even make a decent manager wince), there would not have been the issue of moving them out. I'm also assuming the rooms weren't needed by actual patients, which says something too.

It also sounds like there is no policy about this.... I suspect having family members occupying a room or rooms in an ICU could present a risk of infection issue, or a liability issue--what if one of them gets (heaven forbid) a nosocomial infection?

It does sound like your hands are full. It also sounds like this was (manager issues aside) a life changing and tremendous experience.

Thanks for your post....

Chris

[suzanne4, RN]

I hope that administration has had a little talk with your manager.

Her behaviour was completely inappropriate. Perhaps she needs some stress

management training.

Does your unit have a visitor's lounge close by that has space for patient's family members to spend the night, either with couches or recliners?

If not, then perhaps that is what they need to consider........

But second question, how could that night nurse make the family sleep on the patient's floor? Talking about not being able to get near a patient in a true emergency.....that definitely isn't safe medicine.

[zambezi, BSN, RN]

If we have a DNR in the unit, we also try to transfer the patient out. Having family sleep in other ICU rooms at my hospital would be a big no no...I would try to fit them in the room--but the rooms are small, so I could only fit chairs around the bedside. If the family wanted to sleep, they could either sleep in the chairs or out in our waiting room or conference room. If there were too many family members, I would limit those staying in they room to wife/husband immediate family...the rest would have to take shifts or if something were to happen, I would call them in immediately...it would just depend on the situation. I would try to fit as many as I could in the room...its not like we would have to have room to code the patient... Family would have to stay in the room though to keep other patients privacy protected as well...I think the most i have ever fit into a room is about ten...with only 3-4 chairs...everyone else had to stand... I agree that you need a comfy waiting room next to the unit....or try to transfer patients out sooner...or fit as many as you can in the room while still being able to do what you need to do...but I don't think that family members should be sleeping in other ICU rooms...JMO!

[gizelda196]

Well,now I am being called into a meeting.( I am bringing union with me). I appreciate all the input. Thank-you. So like I said, we are a tiny community hospital, the bed was not needed,the family was tucked into one side of the unit(away from the action). This was a very difficult situation to come into after a 3 day weekend when the hospital was running on a skeleton crew and the family had free rein of the unit thru that weekend.Their was really no rules set with them from the beginning.I was just the last one in and now my manager will drag me thru the mud.I can hold my own with her and the union will just be my ears. I am sure that the weekend nurse had all good intentions,and maybe was having some issues at being able to set limits from the start, but since I walked in and this guy was "death rattling" I wasn't going to change it all right then! I am just frustrated because

instead of her looking at the whole picture. She came in (after her 3 day weekend off)and wanted everything to change RIGHT NOW! but this was a family working in the grieving process and the wheels were already set in motion by previous staff,It wasn't going to drag out,(he had no bp and poor sats,(never mind that he had made up his mind to go)I feel I made the best decision for that patient and family at that moment giving the situation I walked into. and I will stand on that.Hopefully this will get the ball moving so that we could have a plan in place for these types of situations in the future.

[suzanne4, RN]

Good luck and know that you did the right thing.

Please keep us posted on how things turn out for you............ :balloons:

[renerian, BSN, RN]

I can honestly say I have been the nurse caring for someone dying and the grieving person watching someone dying. In the ICU we were allowed limited hours to visit,we took turns. Those were the rules I was fine with it. I have tried to work in situations where people are laying all over like dead bodies and that is not good either. I think if there is room I would put family in an empty room telling them up straight it a patient comes along needing the room/of course it would all need cleaned again, they would need to leave. I have mixed feelings having been on both ends.

renerian

[gizelda196]

So I pulled the union into this "meeting". It when better than I expected. I figured I would get flack for my verbal spat with her, but I did not.After reflecting on it I realize that although suggestions and concerns were raised and we are to establish a policy I now think every thing the manager said was fluff. Oh well. atleast it gets the staff talking. So its all ok. I plan on joining the palliative care committee.I will continue this issue,and be a part of the proceess for providing quality care for future dying patients and their families.

[suzanne4, RN]

Always remember that you were right............... :balloons: :balloons:

[kc ccurn]

I think that we have a responsibility to be compassionate to our families. If we can provide a private room on another floor for the family to have a more quiet area and privacy we should do that. But if it is felt that the pt's death is soon to come, don't disturb them! What a tragedy it is to disrupt the pt and the family at such a delicate time by moving them to another room. I once admitted a pt into the ICU from the ER who had died on the gurney in the hallway on the way down. What a terrible way to tell her daughter that her mom had died.

Families deserve compassion and respect at this time, I am appalled (sp?) at the lack of compassion your manager has. :angryfire

I hope that collectively, as a unit, you can all agree to how situations like this will be handled in the future. Good luck!

[KK92RN]

I think that we have a responsibility to be compassionate to our families. If we can provide a private room on another floor for the family to have a more quiet area and privacy we should do that. But if it is felt that the pt's death is soon to come, don't disturb them! What a tragedy it is to disrupt the pt and the family at such a delicate time by moving them to another room. I once admitted a pt into the ICU from the ER who had died on the gurney in the hallway on the way down. What a terrible way to tell her daughter that her mom had died.

Families deserve compassion and respect at this time, I am appalled (sp?) at the lack of compassion your manager has. :angryfire

I hope that collectively, as a unit, you can all agree to how situations like this will be handled in the future. Good luck!

my hospital er did that to my father in law. kept him in the er all day long then at 10 pm transfers him to hospice and he passes 30 minutes later. all because they didn't have a bed. but he had the one he was in.

[critcarenurse16]

We have DNR's in our unit as well. We try to accomadate family when we can but some families are so large that we simply can't. If a pt is dying and family want to be present we ask that only two-maybe three- family members remain. All others should go to a waiting area made just for that reason. In that room we have a sofa, recliners (2), the sofa makes into a bed as well. coffee, etc. We also provide family with a beeper so they can break away from the ICU for a brief period without worry.

I commend the poster for playing the role of a true patient advocate. In my opinion you have done the right thing. Your manager should take a feather from your cap and remember the first role of a nurse is to protect and advocate for her patients-she clearly failed in this regard by not supporting you. We need strong nurses like you--keep up the good work!:)