Families and Healthcare: What Do You Think?

[DREAMSDOCOMETRUE0610]

Picture yourself in this situation and tell me what you think or what you would do differently:

I am in orientation in an ICU with one patient assigned to my care. Since I am still orienting, I have a preceptor for the duration of my day, I am still not really familiar with this environment, and I am only able to perform basic care tasks on my shift. This particular patient who I am assigned had a major MI a few days ago and is currently on ventilation, has a balloon pump in his groin, has continuous vital signs, and is hooked up to multiple IV drips including a sedative, insulin, heparin, and a vasoconstrictor. The family, who are not very educated and not as capable as most to do and to have access to research, visit frequently. I inform them that they can ask questions if they have any and they almost immediately begin asking me questions such as "What are these numbers on this machine (talking about the ventilator) and why are those numbers different from these numbers (talking about the vital signs being consistently read in comparison to the numbers on the ventilator)?" I explain to them how the ventilator works, why the numbers are different on the two machines, and why the patient needs these machines during his stay in the ICU in as elementary terms as possible. The family also begins to ask about how his vital signs have been doing, if these numbers are good, and if any significant changes have happened over the patient's stay. I explain to them exactly what each vital sign was, how they are read, what the normal ranges for each are, how some of the medications are helping these vital signs stay WNL, and why we need to reinterpret them so frequently. As I was explaining this, my preceptor interjects by saying that she needed to show me something in another area, pulled me to the side, and proceeded to reprimand me for giving the family too much information. She told me that with all of this information the family might make judgments about our care or begin to think that we were attempting to make the patient DNR (which I really didn't understand). She proceeded to tell me to keep it simple and to not disclose so much information about this patient's care.

These are the people who care about this patient most. These are the people who will be caring for this patient for the rest of his life. These are the people who are taking the time out of their days to visit their family member and make sure he is being adequately cared for and comfortable. With all of this being said, not only was I completed offended by this statement by my preceptor and very taken aback by such a bold statement but I was also very curious as to what others would think about this situation. So, my questions for you all are:

Did I go too far?

Did I give too much information to the family?

Does the family deserve to know this information?

Isn't it our jobs as nurses to be patient advocates and give the family as much information and teaching as possible to help them understand that we are doing all we can to help their loved one? And if so, why was my preceptor so adamant about me giving the family too much information?

Is my preceptor feeling guilty about something and therefore not comfortable with disclosing information about this patient's care?

Is this teaching and education within our scope of practice?

Was I wrong to inform the family of and keep the family informed of the patient's situation?

What do you think?

[KJStarling]

...families, for the most part, don't need to know all the "numbers" and the normal ranges. what they're most interested in (or should be, anyway) is how well mom is doing. i would have told them that "we're monitoring her vital signs and her breathing, and today she's doing just a little bit better. we're having to use less of the blood pressure medication to keep her blood pressure where we want it, and she's doing more of the work of breathing on her own. our plan for today is to get rid of some of the extra fluid she has that's making her so puffy -- we'll give her a medication to make make her pass more of the fluid out in urine. and we plan to improve her breathing muscles by letteing her do more of the work for a few hours, and then we'll let her rest for awhile. those numbers let me monitor how much of the work she's doing, and i'll be able to tell when she starts to tire out so we can let her rest." or whatever your plan for the day might be.

i'd rather have a family looking at the big picture -- is mom getting better or not? and is her breathing improving or not? -- than focusing on numbers that they don't understand and pestering whoever is taking care of mom to explain each change in the numbers.

besides, looking at the numbers can make you crazy. i make sure i don't look when the patient is my family member! or at least not to stare at them, transfixed, when i should be looking into mom's eyes and reassuring her that i love her.

i agree, the monitors, numbers, machines tend to freak people out, and encouraging them to really visit and support the patient is great advice!

[Horseshoe, BSN, RN]

Many people really appreciate when nurses take the time to explain to them what's going on, and don't assume they "don't need to know". You should never change!!! When my son was in the hospital and nearly lost his fingers due to a vascular injury, there were nurses that came into the room and acted like he was a checklist, couldn't take the time of day to say anything but "We're working on it", "Don't worry", etc. and I continued to sob and worry.

Then there was a nurse who TOOK THE TIME to explain to me that what I was most concerned about - my sons losing fingers, was not as imminent as I had thought because a small amount of blood was still getting to the fingers through other smaller veins.

So please, whatever all the other nurses say about giving general answers and trying to do everything as quickly as possible - don't listen. You will be the kind of nurse families remember and talk about for years as having been the phenomenal nurse that took such good care of their loved one and provided them whatever peace of mind that you could afford to give them.

There is a whole lot of ground between not providing important information (intentionally leaving family in the dark) and overwhelming them with information beyond their ability to understand in context. I think many are saying she needs to find a happy medium. The OP came here asking for opinions, therefore I completely disagree with you that she should not listen to anyone who doesn't validate her actions 100%. We should always be open to the possibility that there could be another way to do things or handle situations.

[highlandlass1592, BSN, RN]

Don't know if you've come back to read these answers or not. But something struck me in your post, you spoke of being on orientation in the ICU. I don't know your background but I'm wondering if you are a younger nurse. That is going to affect your own response to the question you posed.

Critical care is a speciality in nursing. It takes a lot of skill, interest, compassion and honestly strength of spirit to excel in that arena. As a new nurse in the ICU, I used to feel it was my "responsibility" (as you appear to feel) to explain everything in minute detail to families, I couldn't understand why other more experienced nurses didn't do the same, just chalked it up to "they don't truly care, I do" thinking.

I'm a few years out now...as I'm starting to join the ranks of the "Older nurses", gosh feeling older more some days than others! But what I realize now is back then, I was young, scared and trying to reassure myself by over-explaining to families what was taking place. Yes, families have a right to know what's going on with their loved ones. But what experience has taught me is that, just like with my patients, I have to custom that teaching to the patient and the environment. You also have to assess where your families are at in the process: have they just been told there is truly nothing more that can be done? is this the first day in the unit, scared to death of all that noised and equipment? what is their relationship to the patient...has it been tense leading to them feeling a level of shame or guilt that now they may lose their loved one, they have even harsher grief to deal with? All these things take into account how you should deal with the family.

Explaining generally "Mom's blood pressure is really low right now so we are giving her medicine to try to maintain it" is a wonderful way to explain what we're doing. Do we need to tell the family mom is on norepi and vaso and we're struggling to keep her cardiac output up? No, all that is going to do is cause higher anxiety in a stressful situation and honestly, unless they understand the pathophys and the diagnosis, is explaining the pressor requirement going to truly educate them?

I'm not saying, by any means to not educate family members. But I always try to encourage the relationship aspect as well. Assure them I've been doing this for a while now and am going to do my best to give their loved one the best care possible. And I encourage them to talk about their loved one, reflect on times past, to realize in this situation they should be the daughter, sister, whatever....it's normal to feel anxious and concerned. And I always encourage family members to go home, take a shower, eat a meal and sleep. (I work night shift so frequently family members are there all day, waiting and worrying.) I assure them if things are stable it's safe to go and if anything happens, either I or my charge nurse will call them right away. Sometimes, you need to give families permission to leave, they are afraid to go but they do have to take care of themselves (and I remind them that's what their loved one would have wanted). When families see my confidence, realize I know what I'm doing, they usually sigh then go for some much needed rest.

I'll be honest. I do the best I can to help care for my families as well. Making them leave to eat, take a nap..just to even take a walk to get away from the bedside for a short while. My job is to manage all that equipment they see and I know how to do it well. I keep them updated as to the overall plan and how we are faring in achieving that plan. I also remind them there will be good and bad days as we go down this journey..do not let a small setback send you into a tailspin that your loved one won't get better.

In my practice, I've found this is truly the kinds of information family members want to hear. They don't truly care about all the knobs on the vent...they focus on that as a way to cope with the unimaginable pain they are now going through. And with time, you will find you may change how you handle these family situations as well. Watch the senior nurses on your unit, see how they interact and deal with these issues. You can learn a lot..you don't need to copy them but I bet you will find things you will want to encompass in your own practice.

[Horseshoe, BSN, RN]

Well said, Highlandlass1592. :)