Don't you just LOVE when a pt's family knows more about how a patient feels than the patient?!? For a week now I have been caring for a completely alert and oriented person who just happens to be a little elderly and has a POA for healthcare. And since he is a little "elderly", his family seems to think that he has no business making decisions for himself! When I go to assess him, I ask him, "Are you having any pain?" (Mind you, I'm looking directly into the eyes of the pt) And from somewhere behind me in the crowd of family a voice appears "Yes, he is. Tell her, Dad, it's about time for your pain pill. It probably wouldn't hurt for you to go ahead and take your nerve pill, too." AAAAAHHHHHH!!!!! Does anyone have an oozie they're not using??? :angryfire The patient conveyed his wish to me and another nurse a few days ago that he wishes to be a DNR. However when this was brought to the attention of the family and the POA all he** broke loose and they were having NONE of that. The poor man just looks at you with pleading eyes everytime you walk in the room as if to say "Yes, I love my family, but they will not obey my wishes no matter what - I am simply no longer a human being to these people, and how I want to play out my final years on this earth will never matter to them!" i have told the family repeatedly that the pt is alert/oriented and can make decisions for himself as long as he is competent and that all questions directed to the pt are for the pt to answer and not anyone else!!! WOW! I am on a roll here!! This has been so hard for me to overcome this week - it's just so sad that I have literally cried all week about it? He is so powerless right now, and simply just looks defeated. Anybody have a similar experience? Sometimes need a shoulder....
It's practically impossible to get the pt alone. The only time he has ever been by himself during my shift was when the family went downstairs to get something to eat. But since then they have brought their food into the room. I'll just clarify a little to say that the pt does have some medical issues that does require him cae. He had a stroke several years ago that has left him with a feeding tube - however, speech therapy worked extensively with him after his stroke and he was able to eat a thickened diet. His stroke left him no other residual effects except a slight bit weak on one side (he walks with a slight limp), but no speech or mental inconsistencies that I can see. And about documentation - I have written practically a novel regarding his care and every interaction I have had with the family, and from what I've seen so have the nurses from the other shifts. The Docs have been pretty good about their documentation from what I've seen, but it just seems like in this day and age, a pt, or family member can railroad you no matter what you do. Everyone is so "sue happy" that you feel like you have to walk on eggshells to avoid a lawsuit. Whatever happens, I don't think it's going to be a happy ending for this guy. There was one nurse who was pretty stern with the family (good for her - she is an awesome nurse), but the family got mad and will not allow her to care for him. If I ever in a million years felt like I had EVER stepped on someone's toes regarding their wishes regarding their own life, well then just shoot me. What right do I have to dictate someone else's wishes??
I had something so similar to that when I was working ER. We had an elderly gentleman come in who was at the end of his battle with lymphoma. He was very ill and was having some respiratory issues and it was pretty apparent this was "the end". He conveyed to the ER doc and I that he knew what was happening (he was completely with it) and that he did NOT wish to prolong the inevitable. He was very comfortable and wanted NO life sustaining measures. We talked to him several times about this over the span of a coupld of hours.
He became very ill very quickly and within about 3 hours was unresponsive. We had called the floor and the residents were coming down to take over care. Just about that time his son came in and said that he wanted "everything done". I informed him that that was not what his father wanted. We had an extensive discussion with his dad and he was ready for this. The son said "we're going to fight this to the end" to which I replied "this is the end".
When the med residents got there they decided they were going to intubate this guy. :angryfire The ER doc and I told them of his wishes and that this was not what he wanted. He said basically "too bad". Then he came out and told me to get an intubation set up and I refused. There was no way I was going to be a part of this. It was barbaric, disgusting, and SOOOO against this patient's dying wishes. I hate the fact that everyone's so afraid fo lawsuits that we'll do exactly what we know that the patient didn't want. He asked for it again and I refused again. He called my NM who told me what the resident wanted and I refused again. I told her that I was advocating for my patinet and I would in no way help with this. If he wanted it done he could do it himself.
He did. I went up to see the gentleman the next night. He was actually off the vent and I apologized for everything that happened to him. He was very understanding and told me it wasn't my fault. He died the next day.
I know that I could have lost my job probably for insubordination or something but I truly felt as if I was doing the right thing and I just could not stomach these people doing this to this little old man who was just ready to stop fighting.
*sigh* I'm not sure what my point was.... I guess this just brought up that same old story again.
I work in an ICU and we see a lot of this. I've seen several families insist on keeping miserable vegetables alive. It's disgusting, morbid, barbaric, grotesque, inhumane....shall I go on? I feel like I'm sinning by participating in their torture whenever I care for them.
This man needs to tell a Dr. his wishes and get the DNR ordered ASAP! Hell, conspire with a Dr. and get this all done the moment the family steps out. That's something I'd do. At my facility the Dr. just has to explain what DNR means and be satisfied that the pt. understands it and agrees to it. Then he/she just puts in the order. Doesn't take long. Just gently tell this patient that he gets to make his own decisions while he is of sound mind, not anyone else....then go fetch the doc. No one has to tell the family about it.
When you enter the room, acknowledge the family, then go directly to the patient making eye contact and using touch. When the family speaks up, pause to listen, but stay focused on your patient. Continue speaking to the patient, &, if pertinent, validate with the pateint what the family member has stated.
This is one case that requires multidisciplinary staff meeting with the patient's physician, social worker & nurses, along with other health care providers who care for this patient. Nurses do not have to stand alone. The entire health care team can identify the patient's wishes and discuss ways to keep the care patient centered and still respect the family.
It is just maddening to me to see that some families feel thay can rule a competent individual by committee. If the patient's wishes are not being respected, then how about the legal and ethical supports in your institution? Where's the risk manager? The Ethics Committee? The family has POA if the man becomes incompetent is that right? If he is not incompetent, then maybe to protect themselves legally, the facility may want to ascertain what the man's wishes are and recognize them. It is also possible that this man does not want to control his healthcare. He may not want resuscitation, etc., but may fear even more being abandoned by this family. He may not want to take responsibility for making the "wrong" decision. In other words, the family are allowed to be jerks, so they are running the length of the leash. Isn't it great when patients and/or families are so aware of their rights, but so ignorant of their responsibilities?:angryfire
Kudos, Mom23RN!! I wish I could tell the family to take a flyng leap. I guess I feel like that would only escalate the prob. I've tried to look from all perspectives. I know that by taking all the steps and getting everyone involved, we could get the pt what he wants. At the same time, we would risk a nasty lawsuit, but more, we could alienate his entire family from his, and he would REALLY be alone. And he has told me that he loves his family. They just need to ask him what he wants instead of telling him what he wants when they are actually only thinking of themselves. I guess while this has struck a particular cord with me (probably because he is totally lucid), I have seen this situation over and over with totally mentally and physically incompacitated patients. When they are suffering and family refuses to make them No Codes. If there is ever one thing you learn in this profession is that there are some things worse than death.
Specializes in Med/Surg, ER, L&D, ICU, OR, Educator.
This is one case that requires multidisciplinary staff meeting with the patient's physician, social worker & nurses, along with other health care providers who care for this patient. Nurses do not have to stand alone. The entire health care team can identify the patient's wishes and discuss ways to keep the care patient centered and still respect the family.
I feel your pain. Had a situation like this a couple of weeks ago. The pt just happened to be a nurse in her other life before illness took it away. She was totally in her right mind, answered appropriately, followed commands, etc and reached a point where she knew she was not going to be able to recover from this last bout and wanted to be made a DNR. Family would have nothing of it. The last morning that I took care of she told me she only wanted comfort care and I told the family, the patient is who I take my orders from when it comes to their care and that's exactly what I did. However, b/c she was not a DNR, she was moved to ICU where of course she was hooked up to every peice of equipment imaginable (against her wishes). We talked to her family many times that day about agreeing to her wishes and they would have no part of it and one of the family members is an RN. The last day that she was on the unit, her family FINALLY agreed to DNR. They took her home last Thursday night on hospice and she passed peacefully in her bed the following night. She most likely would have passed the last day that she was on the floor with me, she was headed home and then tortured, IMO, in ICU. I prayed so hard for her the night they took her to the unit to be able to pass quickly b/c she was in immense pain. I don't know if that makes me a bad nurse or not for praying for her passing but it seemed the right thing to do. I just felt like such a failure by not being able to help her on her journey that I was like the OP crying and just feeling rotten until I heard that the family had agreed to the DNR. Her funeral is today.
that's funny. Some people just can't read. We have "advanced directives" etc etc. It doesn't mean that whenever this person gets sick that the POA makes the decisions. Should the patient be "unable" to make decisions for themselves or are rendered incapacitated, then the POA can make the decision on their behalf.
Many times on our unit, the POA tries to interfere and request info about the patient's status. But if we are talking to the patient and the patient isn't confused, then we tell the POA to go and ask the patient. It's part of our mission statement to treat ppl with dignity and respect.
Sometimes when it's necessary to communicate with the POA, I only communicate with the POA. The other night, I was talking to the daughter of a patient (who was the POA) and her husband tried to butt in. Just because he was the "man of the house" didn't mean he has the authority to speak to me and make demands. That'll be enough of that!!! I have no patients who try and quote the law and no nothing about what they are saying. Just because they are shaking advanced directives in front of my face, doesn't give them the right to make decisions if the patient is able to make it themselves. I consider that patient advocacy. POA's just don't know anybetter.
My father has advanced directives. Should he become incapacitated, I've been appointed the health POA and my sister is the financial POA. But for now, he's still a practising physician and would have a big bird if I tried to make decisions for him!!!
i had something so similar to that when i was working er. we had an elderly gentleman come in who was at the end of his battle with lymphoma. he was very ill and was having some respiratory issues and it was pretty apparent this was "the end". he conveyed to the er doc and i that he knew what was happening (he was completely with it) and that he did not wish to prolong the inevitable. he was very comfortable and wanted no life sustaining measures. we talked to him several times about this over the span of a coupld of hours.
he became very ill very quickly and within about 3 hours was unresponsive. we had called the floor and the residents were coming down to take over care. just about that time his son came in and said that he wanted "everything done". i informed him that that was not what his father wanted. we had an extensive discussion with his dad and he was ready for this. the son said "we're going to fight this to the end" to which i replied "this is the end".
when the med residents got there they decided they were going to intubate this guy. :angryfire the er doc and i told them of his wishes and that this was not what he wanted. he said basically "too bad". then he came out and told me to get an intubation set up and i refused. there was no way i was going to be a part of this. it was barbaric, disgusting, and soooo against this patient's dying wishes. i hate the fact that everyone's so afraid fo lawsuits that we'll do exactly what we know that the patient didn't want. he asked for it again and i refused again. he called my nm who told me what the resident wanted and i refused again. i told her that i was advocating for my patinet and i would in no way help with this. if he wanted it done he could do it himself.
he did. i went up to see the gentleman the next night. he was actually off the vent and i apologized for everything that happened to him. he was very understanding and told me it wasn't my fault. he died the next day.
i know that i could have lost my job probably for insubordination or something but i truly felt as if i was doing the right thing and i just could not stomach these people doing this to this little old man who was just ready to stop fighting.
*sigh* i'm not sure what my point was.... i guess this just brought up that same old story again.
good for you for standing your ground and advocating for your patient!!! you are strong and very brave. if i could i'd give you a standing ovation!!! you did a good thing.
Poor man. My heart goes out to him. He probably wants the DNR so his family wouldn't have to see him suffer, but they seem so selfish and self centered that they are not thinking about how he feels and what he wants. I mean it is his life. And just because he is an older gentleman doesn't mean that his mind has gone the way of the tale tale signs of his biological age. I think one day he is gonna snap, or at least I would, and the truth will be told. Sometimes I really do wish we could say to people who seem to want to control everything "could you please shut up" or my fav. statement is "get out right now! I had enough of you and your smart mouth", but alas we have to remain professional. Maybe asking them to leave the room while you perform your treatments for him would work out. At least that way he may feel a little more relaxed, and the subjective info that you need from him will be given by him and not the others.
He asked for it again and I refused again. He called my NM who told me what the resident wanted and I refused again. I told her that I was advocating for my patinet and I would in no way help with this. If he wanted it done he could do it himself.
Cute_CNA, CNA
475 Posts
Is there any way that you can get the pt.'s wishes in writing? Perhaps he could get a lawyer?
I think some actions need to be taken w/o the family present.