Ethical issue?

Ruby Vee, BSN · Oct 14, 2017

elkpark said:
This is just one of the many reasons why it is considered unacceptable and inappropriate to use family members as interpreters in healthcare settings. Hospitals are required to have interpreter services, whether live interpreters or interpreter services like the telephonic service you mention, available for clients who need them. How long ago did this happen at your hospital?

I disagree -- partially. While I agree that it is unacceptable to use family members as interpreters when imparting medical information -- diagnosis, proposed treatment, treatment alternatives, patient teaching or that it is time to start getting one's affairs in order -- the family can be helpful in less nuanced situations. "She has to go to the bathroom," "can she have a glass of water?", or "I'll tell her you'll be back to get her up to the chair in half an hour" are relatively common ideas to require translation. I can't think that it's the best use of an official translator's time to show up to facilitate communications so easily interpreted by a bilingual family member.

NutmeggeRN, BSN · Oct 16, 2017

If the patient is competent and they are NOT the DMPOA, then they cannot tell you what to do or not. I would have called ethics, or the social worker to help.

azhiker96, BSN, RN · Oct 17, 2017

The Chaplain or social worker could have been a good resource for you.

One time I was recovering a roughly 40 year old man after an emergent surgery. When I went to get his family (brother and sister) they said they didn't know what to say if he asked about his mother. He had been her primary caregiver and was at her bedside across town when he suddenly needed surgery. While he was in surgery she passed away.

His siblings thought they would keep that information from him and deflect any questions that came up about mom. I suggested they consider how he would feel later when he finally did find out she had died and they had lied about it. That could be a trust breaker. I assured them he was strong and stable and offered to break the news to him for them, they accepted. I also offered to call the Chaplain but they declined.

I led them into the PACU and presented them to him saying his vitals are stable, he is doing well, and that we are just waiting for a room to be assigned. Then I turned to him and said I wanted to offer my condolences as I had just found out his mother had passed away. I offered to call a Chaplain, which was declined, and then I closed the curtains to give them privacy.

I checked back in about 10 minutes when a room was assigned and found the three calmly discussing whether an Uncle had been called and some preliminary funeral ideas. Rather than keeping secrets the three were able to support each other in their grief and strengthen their sibling bonds.

elkpark · Oct 17, 2017

Ruby Vee said:
I disagree -- partially. While I agree that it is unacceptable to use family members as interpreters when imparting medical information -- diagnosis, proposed treatment, treatment alternatives, patient teaching or that it is time to start getting one's affairs in order -- the family can be helpful in less nuanced situations. "She has to go to the bathroom," "can she have a glass of water?", or "I'll tell her you'll be back to get her up to the chair in half an hour" are relatively common ideas to require translation. I can't think that it's the best use of an official translator's time to show up to facilitate communications so easily interpreted by a bilingual family member.

For everyday chitchat, sure. For anything that actually matters, no.

NightNerd, MSN, RN · Oct 17, 2017

Almost without exception, I feel like transparency and honesty are the best policy in situations like this. I haven't encountered this matter before, but for smaller things that families have asked me not to share, I generally say that I will do my best to respect their wishes, but I will not lie if asked something point blank by the patient. It's also important to remind them of all the reasons to tell the patient the entire truth, as many posters have already mentioned. As an added encouragement, it may also be helpful to start mobilizing resources for when the family does come clean, and to strongly suggest that they commit to a specific point in time when they will break the news. I'm sure their intentions are good, and I can't imagine the pressure they're under while grieving one loss and caring for the survivor - however, the patient is ultimately responsible for their reaction, not the family or the nurse or doctor. People need to be given the opportunity to freely hear and respond, even to bad news. If they didn't have coping skills before, they are certainly not going to develop them within a few days of a traumatic incident.

HermioneG, BSN, RN · Oct 17, 2017

This reminds me of some cases I read in school on paternalism, and it's really upsetting to think about.

In my personal opinion, just because she's elderly doesn't mean she should be treated like a child. The woman has probably seen more things in her lifetime than we could ever even think of and deserves the respect of making her own decisions if she's competent to do so.

She may have very well shared most of her life with her husband who probably was not only her lover but her best friend and possibly even next of kin too. I would think that if anything she deserves to know the most, and to keep her in the dark when she's asking mightve put her in even more distress in the long run. I get the family was trying to protect her but if she's A&O x4 and asking she has a right to information about her spouse.

I would definitely get my charge nurse involved as well as social work and ethics and anyone else that I could on the patient care team. In the end, it's such a hard situation. This is just my opinion and I've had an interesting time reading the other perspectives.

KelRN215, BSN, RN · Oct 18, 2017

The patient has rights to this information. The family does not have a right to demand that staff withhold it from her. Ethics or Social Work should have been called to speak with the family. Lying to a patient is always unethical. As someone else pointed out, your patient was probably her husband's next-of-kin so obviously she should have been informed.

This reminds me, kind of, of a situation I encountered recently with one of my patients. He is a 22 year old with a history of lymphoma who was admitted for something (I forget what, exactly) and one of the possible diagnoses was relapsed lymphoma. Because this is a pediatric hospital, staff sometimes lose sight of the bigger picture when they are caring for an adult and default to speaking to the parent. Anyway, for DAYS, it was documented in his notes that the possibility of relapse was discussed with his mother but not discussed with him, per his mother's request. He is a competent adult who is his own legal guardian. (In pediatrics, we deal with many adults who are not competent/not their own legal guardians.) Therefore, his mother's request is irrelevant. The Social Worker finally stepped in and told the team that the patient was an adult who had a right to know this information and that legally it could not be withheld. Actually, sharing the information with his mother over him was illegal.

dec2007 · Oct 18, 2017

As someone who has experienced this from the patient's viewpoint, I can tell you that having my family withhold information made me feel lied to and betrayed. The health care worker who told me the truth gave me a great gift....the gift of honesty.

DeeAngel · Oct 19, 2017

Call pastoral services and hospital social workers as consults to cover your butt. If anything goes wrong no one will hesitate to pitch you right under the bus.

Julius Seizure · Oct 20, 2017

I've seen a few comments saying that this should be handled by the MD rather than the nurse. Can anyone give me a reason as to why they think this would be outside of the nurses role? I can't think of any other solid reasons.

jdub6 · Oct 20, 2017

I understand your distress...I once had a pt transferred to med-surg from CICU for comfort measures. As i read the notes prior to his arrival i noted the cardiologist saying that the change to comfort measures was made at family request after family was informed there was nothing further that could be done for the pt. Thr family requested the pt not know any of this so no one told him.

He arrived 60 years old fully alert and oriented thinking he was full code and recieving cardiac drips etc. When he asked why he wasnt on a drip anymore the daughter (who had been allowed to sign his DNR) was glaring and gesturing to be as well.

I sidestepped his question long enough to tell her ib private that i would NOT lie to him, that i would keep the news on hold until morning if possible since it was 2am but that he needed to be told what his condition was and he needed to be in control of his care. Come 6am I called the hospitalist who agreed and called the cards to come speak with his patient...that was the end of the charades. The patient took the news fine and agreed to remain CMO.

It is illegal to sidestep the legal next of kin or proxy and illegal to defer to family of a competant patient about their own care. In this case the spouse is the next of kin and has a right to know the husband is deceased. It isn't necessarily out of our scope to tell in the situation you presented (it would be more appropriate for a doc to tell family in the waiting room if the husband was the patient and died...but this is different). It certainly is more difficult though when the doc bows out...i probably would have gotten others like SW and the doc back in to discuss formally what to do.

Kooky Korky, BSN, RN · Oct 22, 2017

nursesmatter said:
Hello. I have a question to ask because I have been reading about ethical issues and moral distress. I recently experienced an event on my unit which caused multiple staff including myself to feel frustrated and somewhat angry. I cared for one member of an elderly couple that were involved in an accident. Unfortunately, the woman's husband passed during the accident. She survived and I cared for her for 2 days immediately after the event. Her adult children were present at her bedside throughout her hospitalization for her emotional well-being. Upon arrival to my unit, one of her family members pulled me aside and told me (not asked) not to disclose her husband's death because they wanted her to get well first, then eventually tell her. Family members also told each staff that provided her care the same thing. During the 2 days I cared for her, multiple times she asked me about the condition of her husband. Whenever she asked me this, I looked at her family members and they would glare at me. So I ended-up distracting her or would tell her to focus on her healing first. Not telling her what happened to her husband ate me inside. If that were my significant other, I would want to know right away. Finally, the family told her about her husband's death on her 5th day of hospitalization.
I'm not sure but I feel as though this type of situation may be more common than I think. But my question is: Do you think this is an ethical issue that could have initiated an ethics consult??? Thanks for your input!

You should have just told her to "ask your children because they are right here with you".

He's going to be dead forever. What's the rush in breaking the news to her?

But if I were denied a straight answer and told to focus on my own healing, I'd know something was wrong and would want to refuse further care until someone told me the truth. It wouldn't have to come necessarily from the nurse. How about from my dang kids? I know you and they all meant well but it's just not realistic to avoid the truth.

How did she take it when she was finally told? How is she now? Who informed her?

I'm not sure what the legalities are. Where is the doctor? Your manager? Social Worker? Chaplain? Risk Manager?