Family Drama and Nursing

Farawyn · Feb 16, 2016

Hi Sorebeth89. What have you been doing, or what have you noticed the nurses doing in your experience with this as a student?

Atl-Murse · Feb 16, 2016

Sneaky way to get AN to write your assignment.

Sorebeth89 · Feb 16, 2016

I think, mostly they have just been patient and as understanding as possible. I spent 2 days with a family who was unwilling to come to terms with their loved one dying, we provided as much education and time with the family member as possible. I was able to sit with the spouse and talk with her but it was all unlike any other experience I have ever had the privilege of experiencing. I was a CNA for 10 years and I thought everyone knew and accepted that their loved ones would pass. I did not expect this clinical experience and frankly I felt a little like a fish out of water.

Farawyn · Feb 16, 2016

What were they doing that made you think they didn't accept their loved one's death?

Sounds like you are off to a good start.

Sorebeth89 · Feb 16, 2016

Stating things such as, " He has to get better so we can take him home." Wanting to do a full code when he had been on hospice for the last 5.5 months.

I want to say that the family had been amazing care takers, for the pt. to be bed bound for five and a half months and not a single bed sore or mark on his body was impressive.

calivianya, BSN, RN · Feb 16, 2016

You can't change people's minds. If they are determined that the patient is going to be a full code, there's no telling them otherwise.

If you seem unbiased and just state the facts, sometimes the family members that are really digging their heels in will listen a little better. Example: "His blood pressure is getting better!" "Actually, we just added a third blood pressure medication to keep his blood pressure up. He is doing much worse than he was yesterday."

I am not good at having this conversation, but with the people who are really deeply in denial, I feel like they just turn off and stop listening if you try to convince them their family member is dying. Now, if you approach it as, "His heart is failing, his lungs are failing, his kidneys are failing, and now we think his bowels are dying, too," that sometimes opens the door for them to ask if any of those systems can recover, what are the chances they will recover, and if the patient can live if they don't.

And for those people that go, "But his brain's okay, right?!?!" as if that's the be-all end-all of survival, you can always say, "Yes, but his brain can't survive by itself - the rest of his body has to work for him to live."

Adding in a "I'm so sorry you're going through this" and a shoulder squeeze if you think the family member will be receptive to it never hurts.

KatieMI, BSN, MSN, RN · Feb 16, 2016

In cases like described, everything starts from the truth. The truth, only the truth and nothing but the truth, by everyone.

"Is she all right?" - No, she is not.

"But in ICU everyone told us that she is!" - Well, why do you think she is still on the vent 3 months later?

This sort of people, while not being "mentally disabled", usually have analytical abilities close to 10 y/o child. They were never trained, and never acquired ability to think about things as a whole and make deductive conclusions ("if I was told about something but there is a contradictory fact in front of me right now, then my assumption must be wrong"). Many of them sort of know it and so either refuse "science level" education or just completely shut off and hear only things they want to hear. Therefore, the first action is NOT to give them that. Only facts, and simple, careful questions based on them. The "collective action" is important. Every single staff member family encounters should either re-address them to primary team, or state the same facts.

After a week or so, the family usually wants to know details. This is the time when they are ready for discussion of a kind but still mostly in argumentative mode. Yes, Mom's lungs are failing but how about her bowel movements? Yes, she is on dialysis but her labs are ok? On this stage, they greatly benefit from daily, small spoon teaching. They have no idea about authonomic body functions, about wholeness of organism, so every such question must be clearly explained. I usually draw a lot, it works better than pre-made pictures, and ask them to keep the pics so they could make connections.

After another couple of weeks, approximately half of them, with cues or not, makes the right conclusion: coding Mama will be useless and probably very painful way for her to die. It is a lot of absolutely thankless, mentally exhaustive work, but I think that nowadays a quiet, peaceful death in dignity and love is a good outcome, too.

Been there,done that, ASN, RN · Feb 16, 2016

Familiarize yourself with Kubler-Ross stages of grief. Two days after a loved one's death, whether expected or not, the family member will most likely still be in a state of shock.

You haven't lost a loved one yet, have you?

kakamegamama · Feb 16, 2016

I am a nursing student and I have seen some pretty dysfunctional families the last couple of weeks. The dysfunction seems to stem from the children or spouse not being able to accept their loved ones death. How as a nurse is the best way to approach those who cannot accept what you know is the inevitable...death?

I don't think you've seen dysfunction as much as you've seen grief. I KNEW my husband was dead the night he died, but I hung onto hope...he DID have an EKG rhythm, after all. It was only after the ER doctor told me, using the words :"He is gone." that I was able to believe, fully, that nothing was going to change that reality.

Grief messes with people, so please, keep that in mind. Dysfunctional is a term that is used, sometime, inappropriately, to describe grief coping skills/stages.

Here.I.Stand, BSN, RN · Feb 16, 2016

I was a CNA for 10 years and I thought everyone knew and accepted that their loved ones would pass. I did not expect this clinical experience and frankly I felt a little like a fish out of water.

((((Hugs)))) If only that were true. We see this all the time in critical care, and it's hard. I once had a pt who'd had a stroke and then went into status epilepticus on the floor, was intubated and brought to us. Neurologically, she was doing absolutely terribly with a GCS of 4 or 5 on NO sedation and no pain meds. I cared for her all weekend with the knowledge that there would be a care conference on Monday. Not sure why, but I honestly thought "Just a couple more days and this will be over." I came back to work a few days later...and became physically nauseated when I passed her room and saw her in there, with a new trach.

I had another pt with a very severe TBI. She was either T-boned or in a head on collision I don't remember. She was another one who had a very low GCS and on no sedation, although I did give her a fair amount of pain meds because her ICPs would increase during turns and oral care. One lady who was close to this pt kept holding onto this one fact: "When she came in, she was breathing! So I know she's strong, and I know she'll be okay. She was breathing!" It was heartbreaking. I am naturally empathetic and my voice tends to be gentle when talking about difficult things -- I just say that so you can picture my tone of voice not being cold or harsh... anyway I said something like "I know, but the thing with brain injuries is what you see initially is often not what you get. Have you had your wisdom teeth out, or known someone who has? Yes? Do you remember how the day of surgery you didn't feel well but looked fine, but then a couple days later your face was probably swollen like a chipmunk? Or sometimes when you bump into something, the bruise looks worse a day or so later? Sometimes that happens with a blow to the head as well; the brain is injured in the blow, but then a few days later it can swell. Bruising on the brain can grow also. That's why she is no longer breathing on her own, and why she doesn't respond."

My aunt who is to put it mildly, bat guano crazy, completely shellacked my grandma when she made her husband of 62 years at the time a DNR/DNI. My grandpa was 102 years old!! This aunt screamed at her "You just want him dead!!!" My mom was telling me this story over the phone, saying that my grandma had called her crying so hard she could barely breathe, and I was in tears thinking of my poor grandma. I felt like that needed a stronger approach, and I would have said this to my aunt's face had I been part of the actual conversation... but I told my mom "You tell Grandma that there is NO circumstance that CPR is appropriate for him!! Ribs get broken. Even if they did get his heart going again, his brain would be anoxic. Right now he still enjoys tossing a ball around, he enjoys milkshakes, he enjoys sitting outside, he enjoys his trips home for Sunday dinner, and he enjoys hugs from his great-grandkids. He would probably be a vegetable after surviving an arrest." (to use the common lay term. He had lived at home with his wife until he was 102, fell and got some compression fx's in his spine and never regained the strength to go home. Several bouts of pneumonia and AKIs left him weaker and confused, although still retaining some QOL.)

So yeah, just a few examples there of how unfortunately people deny the undeniable. We tell them the truth about the situation. When they ask how their loved one is doing, we should be kind but honest. Sometimes we can help them come to terms with it...sometimes we can't. In some cases, we get the ethics team involved -- for example when the family starts overriding the pt's documented medical wishes once the pt can't speak for himself anymore.

In the cases where they can't let go, we provide the best nursing care to that pt that we can. I also tell myself: "Imagine it was my child. Do I really know what I would do?" I like to think I would make the right decisions and let them go, but the reality is I haven't had to make that decision...and it helps me not to be judgmental of the family.

CBlover, BSN, RN · Feb 16, 2016

Familiarize yourself with Kubler-Ross stages of grief. Two days after a loved one's death, whether expected or not, the family member will most likely still be in a state of shock.
You haven't lost a loved one yet, have you?

This^^ Please realize that a grieving family really shouldn't be referred to as causing "drama." Death that occurs in a family among loved ones comes with sadness, anger, denial, etc. This is just part of it and really until you experience it for yourself it may be hard to grasp.