Ever experience a patient's family member grieving in an odd way?

[shhhh]

My patient came in with a devastating injury and he has a very poor prognosis. The trauma docs I work with made this prognosis very clear to his family, and all of them seem to grasp the situation well except for his wife. After the trauma attending spoke with the family, he brought the wife and her friend back. He and I were at the bedside trying our hardest to be supportive, but we grew more and more uncomfortable watching the wife with the patient. While this was going on, her friend was looking at ME with this mortified expression on her face.

While acting pretty histrionically, she began kissing his hands, then she kissed his face and neck repeatedly. Then a couple minutes later, she pulled the blanket off of him and unsnapped his gown and started stroking and kissing his bare chest. The doc kept looking at me with this "What the heck do we do?" look on his face, and I'm sure I was giving him the same expression. At first, I thought that if she wasn't really doing any harm to him, then she should be able to do what she needs to do to help her grieve, because her husband will most certainly die from this. Then a couple minutes later, I thought that how she was exposing his chest and touching him like that in front of her friend wasn't giving him much dignity (the trauma surgeon and I were talking after and we both thought that a lot of what we saw bordered on sexual...bleuughh), so I decided enough was enough. Before I got my courage to say something about her behavior, I had to leave the room to take a phone call. Then the doc left the room to return a page. When I came back, she was basically straddling him in the bed. I said, "I need to collect labs. Do you want to go get coffee downstairs while I get them?" They left, but came back a couple hours later. I made it clear that she can't expose him (he had a low temp, so I put on a Bair Hugger) and that touching him so much interferred with the EKG. She didn't really listen to me and I returned to the room to find her laying next to him in the bed with her legs draped over his, stroking his chest. I told her she couldn't be in the bed with him and she got out, reluctantly, but as soon as I left and then came back, she crawled back in the bed with him. I needed to retape his ET tube with RT, so I asked her to leave again. I ended up putting the bed high in the air and put all the bed rails up so she couldn't climb up into the bed when she returned. She never did return to the room by the time my shift was over, but I reported all this to the on-coming nurse, who's a very seasoned nurse and she was a little shocked by what I told her I witnessed.

Part of feels like I'm being way too judgemental about this, but I've been a nurse for almost 8 years and have dealt with a lot of end of life cases, and this was by far the most bizarre reaction I've ever seen. Would you agree that this reaction is pretty off the wall, or do you think I'm being a bit too prudish? Do any of YOU have a comparable story (or more odd story) to share?

[Little Miss Coffee]

I don't have a comparable story...yet. But as they say about opinions...everyone has one...

I remember commenting in another post similar to this a week or so ago, but will write again because it's such an interesting issue unique to the health care system.

First of all, I strongly agree with many posts here. As long as the behavior doesn't threaten either spouse's physical or mental safety and well-being, it should be allowed to happen, whatever it may be.

But that doesn't mean it doesn't SEEM odd to you and all bystanders. It's fully understandable, too, of course. She probably felt like any moment could be their last moment together...

The part that would make me feel awkward would be the un-private nature of the more sexual behaviors. I know you had to provide care for a while, so you did have to have access to him for that time at least.

If it were me? I would never have jacked up the bed and put the rails up. I'd have taken her aside and said I needed to provide care for a little while but she could come back when I was done. I would have prepared her for the fact that she will have to let us take care of her husband but not prevented her from having access to him when it was safe to do so. Even the sex stuff - if she wanted to engage in that behind a curtain, that would be completely fine.

Remember, "appropriateness" as it relates to the behavior of dying patients (and to some extent grieving families) isn't what I'd call a "top priority." What's most important is gleaning everything they can from their last breaths.

You have the luxury of time to ruminate on these issues and compartmentalize your private life from your public life - this couple does not.

With that said, you are worried about what's right here, so I'm not accusing you of being intentionally cruel. <:>

[DLS_PMHNP, MSN, RN, NP]

I totally disagree with most of what has been posted above. .I am not talking about holding a hand or kissing a hand or arm....I am talking about blantant sexual behaviour. Yes, caressing your husbands chest.......is way out of line for a critical care patient. This patient is intubated and likely sedated....with NO say in how his wife is exposing his body. I think it is very strange and very appropriate to let her know what the appropriate conduct is.....this can be done is a very careful and considerate way.

I'm curious, please tell me about YOUR definition of appropriate conduct? How about the pt's wife's definition? How about management's definition of appropriate conduct? How about the patient's? How does the facility define appropriate conduct? How would you explain appropriate conduct to the pt's wife?

This couple has been married for a long time.. you make it sound as if this pt's wife is all but raping him. Her husband is critically ill. that fact should speak for itself. Sex is probably the last thing on her mind. I applaud your desire to advocate for your pts. But sometimes it's important to think outside the box.

I would be completely livid if someone "instructed" me on how to "appropriately conduct myself" with my critically ill/dying husband. And I hope and pray that day never comes.

Best,

Diane

[mcleanl]

I'm curious, please tell me about YOUR definition of appropriate conduct? How about the pt's wife's definition? How about management's definition of appropriate conduct? How about the patient's? How does the facility define appropriate conduct? How would you explain appropriate conduct to the pt's wife?

This couple has been married for a long time.. you make it sound as if this pt's wife is all but raping him. Her husband is critically ill. that fact should speak for itself. Sex is probably the last thing on her mind. I applaud your desire to advocate for your pts. But sometimes it's important to think outside the box.

I would be completely livid if someone "instructed" me on how to "appropriately conduct myself" with my critically ill/dying husband. And I hope and pray that day never comes.

Best,

Diane

Diane,

Let's clarify a few things. First this is not a hospice situation. This patient is in a critical care......despite a poor prognosis there is no mention that the patient is comfort measures.

What may or may not be appropriate in hospice is one thing......this is not appropriate in an intensive care unit. I have listed multiple reasons for this. First and foremost patient safety.....again these are not hospice patients. This man is intubated....a form of life support. I have mentioned the multitude of possible lines and other supportive devices. The man had on Beaur Huggar to maintain his body temp. Second.....as I mentioned this patient is intubated and most likely sedated or obtunded.....he cannot consent to someone exposing his chest and I can't close the curtains on a critically ill patient. Third, there is a definent "ick" factor .....like it or not.....these patients have oral secretions that can ooze, stool incontinence, weeping skin.....I cod go on forever. The ICU is not like in the movies.....there are a tremendous amOunt of germs to get or give to the patients.

Again....if this patient was comfort measures and we pull off all the monitors and various other equipment then I am fine but the ICU is no place for this behavior.

I am sending this via iPhone.....pleAse disregard the typo's!

Often times even with a poor prognosis we attempt to save lives in the ICU.....it is the nature of what we do.

[Seas]

Isn't raising the bed and leaving it like that a safety issue anyway? And doing it so the wife can't reach the dying loved one? Goodness... Maybe you need to learn how to support families of dying patients. If I was the family, you'd get in trouble.

[flashpoint]

The straddling part seems a little odd to me, but as long as she wasn't interfering with tubes or lines, I would have left her alone. The chest stroking and caressing seems pretty normal to me…and might have brought a lot of comfort to both of them.

We recently had a man who got hit by a car and sustained multiple life threatening injuries. When his wife got to the hospital, she kissed him on the cheek, despite his face still being covered with blood and vomit. She picked glass out of his long hair. She touched his bloody beard and picked grass and weeds out of it. She kissed his blood-covered hands as she lay her head on his chest. When she whispered, "Squeeze my hand…just one last time," he did. The other nurse told her not to get her hopes up…the hand squeeze was just reflex, it didn't mean anything. The doctor told her that although we all knew his situation was very grim and that she should not get her hopes up, that he didn't believe it was reflex…that he saved every bit of what he had left just for her. I think that was much more comforting than what the other nurse said. We got the patient into the helicopter, he was transferred to the trauma center, and he died in surgery.

I cannot imagine denying the patient and his wife those last few moments together.

[Hospice Nurse LPN, BSN, RN]

Many times when my husband was hospitalized for chemo, blood transfussions, etc, I'd climb in bed with him and cuddle for a while several times a day. No one ever said anything about it, except once. It was something we both wanted and needed. With every transfussion, we knew his time on earth was was a little closer to the end.

There is a reason you knock on a pts door before entering. Whenever someone came into his room I'd get up and sit in a chair. A couple of the nurses would laugh and say "BUSTED!" The one nurse who made a comment was young and real snotty. She came in one morning, without knocking, and muttered that this wasn't a hotel. She put the s/r up and I put them back down. I bit my tongue and when I had cooled down some, I went to find the nurse manager to make a complaint. My husband was assigned another nurse.

Human touch is so important to pts and I'm sure this poor woman wasn't thinking about sex. I know I never was. I just wanted to love on my honey while I still had the time.

[traumaRUs, MSN, APRN]

I think this thread points to the many ways of grieving and how we as nurses support our patients and their families.

[DLS_PMHNP, MSN, RN, NP]

Diane,

Let's clarify a few things. First this is not a hospice situation. This patient is in a critical care......despite a poor prognosis there is no mention that the patient is comfort measures.

What may or may not be appropriate in hospice is one thing......this is not appropriate in an intensive care unit. I have listed multiple reasons for this. First and foremost patient safety.....again these are not hospice patients. This man is intubated....a form of life support. I have mentioned the multitude of possible lines and other supportive devices. The man had on Beaur Huggar to maintain his body temp. Second.....as I mentioned this patient is intubated and most likely sedated or obtunded.....he cannot consent to someone exposing his chest and I can't close the curtains on a critically ill patient. Third, there is a definent "ick" factor .....like it or not.....these patients have oral secretions that can ooze, stool incontinence, weeping skin.....I cod go on forever. The ICU is not like in the movies.....there are a tremendous amOunt of germs to get or give to the patients.

Again....if this patient was comfort measures and we pull off all the monitors and various other equipment then I am fine but the ICU is no place for this behavior.

I am sending this via iPhone.....pleAse disregard the typo's!

Often times even with a poor prognosis we attempt to save lives in the ICU.....it is the nature of what we do.

I DO recognize the difference between the ICU and hospice. Haven't seen too many "ICU movies" but I do realize they are laden with germs, just the same as every floor in the hospital.

Thanks for the reply back.. but I'll have to agree to disagree with you on this one.

All the best!

Diane, RN

[shhhh]

Thank you all for replying! I know there was a lot of questions (particularly WHY I did some certain things), so I'd like to reply back.

It seems that those of you who didn't find her behavior out of sorts are those who said you were hospice nurses. I think a lot of how I reacted to this situation is only because I'm a trauma nurse and not a hospice nurse. It's most common for family of my trauma population to step aside and let me do everything I need to do to keep their loved one alive, and I've apparently become used to THAT behavior and not what I witnessed.

This was a self-inflicted gunshot wound to his temple. When I left, he only withdrew from painful stimuli in his lower extremities. The wife wants everything done for him. So, this patient was a full code and intubated, monitored, and was on a massive transfusion protocol for a dropping crit as a result of an unlocated vessel being severed. As someone did suspect, he was your typical ICU patient in that he was complete oozy mess, despite my best efforts. Neurosurgery was on the way to see if he needed a bone flap or a bolt. So, I was pretty busy with him. I stand by my belief that what she was doing was inappropriate behavior in an ICU, particularly while heroic effects are attempting to be made, so that's why I stopped her and suggested she take breaks. Whenever she would touch him, his BP would raise up to 220/110 and his HR would rise to 120, then it would drop when I'd ask her to give him space. He had no bolt at the time, but I was just assuming his ICP's were through the roof during these events. Physiologically, he looked uncomfortable when she touched him, and that made me very uncomfortable because I was concerned he'd herniate. So, yes, I felt that her contact was compromising his safety. Also, knowing that he was trying to divorce her before all this happened made me uncertain that he would have consented to what she was doing to him if he could have spoken for himself. Despite the marital problems, they're still legally married, so legally she's the decision maker and wanted everything done to keep him alive and I was trying my hardest to do that. I was present in the room at all times and he was certainly not a fall risk, so I don't feel that raising the bed was an issue of safety. I did feel that the constant stimuli she was providing WAS an issue of safety, so that's why I did everything I did and don't regret it.

I appreciate all of you hospice nurses who told me that what I witnessed was actually not "odd" like I had previously said. I'll be able to go on to the next situation with more of an open mind. Being in trauma, I'm just used to being given a wide berth by families so I can do what I need to do, so what I saw this time was just "odd" to me. In my original post, I should have explained what was going on physiologically and how I felt what was going on might have been affecting his outcome, but I felt it wasn't pertinent as I was hoping to recieve feedback on what's considered appropriate grieving rather than a critique of my nursing care.

Again, I appreciate you all who shared your own stories on what you experienced. :)

[~Mi Vida Loca~RN, ASN, RN]

If my loved one is dying I am not likely to be grossed out by their "ick" factors. Much like I can pick a pimple on my husband but would be grossed out if it was anyone else.

If someone tried to keep me from laying next to my loved one while dying and it wasn't causing any harm to them, only making the Nurse uncomfortable, I would be livid. I have no doubt that I would be one of those crazy people holding and rocking my child for hrs if I lost them, even if they were already gone. In fact security would probably have to pry them from my hands.

Lastly I don't see the situation as sexual at all. Often times when I am upset or hurt and needing comfort I lay on my side on my husbands chest maybe rubbing it while he holds me with my leg across him too. Nothing sexual about it at all but I feel comforted by it. When my brother died a few months ago this was how I slept and the only way I could sleep I was in so much grief and shock. It sounds to me like this woman needed the comfort. I think that they should have been given privacy. It sounds like the nurse was able to leave to make a phone call and doc left so the patient wasn't having to be "watched" 24 hrs. But it's not about the nurses comfort level, or the friend of the wife. It's about the fact that this womans husband was about to die and it was completely unexpected so she had no time to prepare and she needed comfort and there is nothing to say he didn't need her comfort as well in his dying days or moments. I don't see his chest being exposed in his room as not having dignity. People keep saying this was done publicly as if the patients bed was in the middle of the cafeteria. I mean patients are made to walk around the halls in a gown with their rear hanging out. :|

ETA: The updated post with a lot more details and info came after I wrote my post.

[DLS_PMHNP, MSN, RN, NP]

Again, I appreciate you all who shared your own stories on what you experienced. :)

OP,

Thank YOU for starting this thread... great topic.

All the best to you!!

Diane

[Hospice Nurse LPN, BSN, RN]

Thank you all for replying! I know there was a lot of questions (particularly WHY I did some certain things), so I'd like to reply back.

Again, I appreciate you all who shared your own stories on what you experienced. :)

Thanks for starting this thread. It's interesting to see how different nurses react to such situations.