The right to an opinion

Here.I.Stand, BSN, RN · Jul 4, 2016

For me, the issue is if the family's wishes are not in line with *comfort care*. In cases like these --

Some families don't want pain medication, because they want their loved one to be alert. Some families want to keep feeding their loved one, even though they are not alert enough to protect their airways. Some families want their loved one up in the chair all day, despite excruciating pain.

I absolutely retain my right to an opinion, because my preeminent duty is to that patient. A family member can refuse to have his own pain treated all he wants -- that dying person's pain is that dying person's pain. Pt's right to have that treated trumps the family's desire to have them alert, or desire to see them in a chair.

The example of feeding them, again, depends on the pt. When working SNF some years ago, we had a 90 yr old gentleman who was completely oriented, and decided not to be NPO anymore. He was aware he would aspirate and die, and in fact he did. He decided that he would rather enjoy food and live a little less, than survive on tube feeds.

We all said, good for him. Banana or apple pie, Mr D?

That's very different than someone who is clearly struggling to eat a meal. If food does not provide comfort, our job is to make families understand that -- and to perform comfort care. Not to drown the pt because it makes them feel better to see food in their loved one's mouth.

NurseGirl525, ASN, RN · Jul 4, 2016

Everybody is entitled to their own opinion, you are right. But when it interferes with the comfort of that dying patient, that's when I'm going to intervene. Just because someone in dying, their health care proxy does not immediately defer to all of the family members. That patient still gets to make their decisions. Unless they have designated a single, health care proxy to make all of their decisions, I could care less what that family thinks. If that person is in pain, I'm treating it. If they don't want to eat, they don't.

I get the feeling that some people just defer to the family no matter what. No, they don't get to make the decisions. Unless they are designated as such. And at that point and time, I am educating that person about end of life care. Educating on what is important and how morphine is not "killing" their loved one. That is so ridiculous. I know in my final hours, I want to be as comfortable as possible.

Everyone can have their own opinion. That's what makes this country great. But my job is to be the advocate for my patient. 100%, hands down.

Libby1987 · Jul 4, 2016

We provide a professional service and are obligated to provide appropriate opinions based on EBP.

For example, I will advocate for a patient when they are exhibiting non verbal symptoms of discomfort and I would state my opinion that their pain is not adequately controlled, and intervention will be taken. That may be limited to reporting my concerned opinion to the MD or it might include some strong persuasion. That's where the part art of nursing comes in.

But simply rattling off recommendations and suggestions do not meet the patients' needs nor my obligations.

macawake, MSN · Jul 4, 2016

Every family that I have worked with as we support their loved one is different. All are dealing with something new- losing their loved one- and most are experiencing very acute grief. Most families are excellent, and are in agreement with our general philosophy of care, to promote comfort at end of life. But some aren't. And that is really the crux of this post.
Some families don't want pain medication, because they want their loved one to be alert. Some families want to keep feeding their loved one, even though they are not alert enough to protect their airways. Some families want their loved one up in the chair all day, despite excruciating pain.

I agree wholeheartedly with Here.I.Stand.

If I see a person being physically assaulted in the street I won't ignore it and simply keep on walking, even if the assailant happens to be a family member of the victim. It makes no sense that I wouldn't offer my patients the same protection as I would a random stranger in the street. Unless I know for a fact that my patient's wish is completely in line with what the relatives desire and that the patient has made that decision fully informed about the various treatment options available, I will advocate for treatment that provides comfort, both physical and emotional.

I'm sure that some of you might think it's harsh to compare the situation with how families wants the patient to be treated with an assault. To me however the similarities are there, even if the motivation behind the act might be quite different. It's my firm belief that we only have the right to choose "excruciating pain" for ourselves, we don't have a right to insist that someone else suffer through it.

In my line of work, I don't claim the right to have any opinion outside of my professional assessment of a situation.
How about you?

It is my professional assessment that no one should have to spend the end of their life in excruciating pain or choking on food unless they themselves (not a family member) explicitly tell the healthcare professionals handling their care, that's what they wish for themselves.

Patient autonomy matters. Making sure that the patient's wish is respected is in my opinion my responsibility. I don't work end-of-life care but I think this is a duty a nurse has to her/his patients, regardless of the field/area we work in.

Educating on what is important and how morphine is not "killing" their loved one. That is so ridiculous. I know in my final hours, I want to be as comfortable as possible.

I agree with you NurseGirl525. I honestly think that's what most people would want.

Dogen · Jul 4, 2016

If the family is putting food in the mouth of a patient who can't protect their airway and can't consent... That would potentially be contributing to the death of the patient.

Horseshoe, BSN, RN · Jul 4, 2016

I have been working as an RN for 6 months now. Enough time to rub the innocence and naivety off of anyone I think. My position is in a long term care, and seems to be equal helpings of caring for the geriatric population and providing support for families with loved ones in our home.
In the last half a year, I have walked with 25 people as they complete life's final transition- dying. I have talked to dozens of families about what to expect at end of life, what's normal, and what are uncomfortable symptoms that we can control with medication and other interventions.
Every family that I have worked with as we support their loved one is different. All are dealing with something new- losing their loved one- and most are experiencing very acute grief. Most families are excellent, and are in agreement with our general philosophy of care, to promote comfort at end of life. But some aren't. And that is really the crux of this post.
Some families don't want pain medication, because they want their loved one to be alert. Some families want to keep feeding their loved one, even though they are not alert enough to protect their airways. Some families want their loved one up in the chair all day, despite excruciating pain.
It is about these families that I hear my coworkers say "I would never treat my father/mother/friend that way" or "they are just totally out of touch".
And it is about these families that perhaps I still wear my rose-coloured-new-nurse-glasses. Because I truly don't see myself as having a right to have an opinion, outside of my professional explanations and recommendations for care. I don't see that I have the right to harshly compare what my decisions for my loved ones would be against the decisions made by others. And to be honest, I don't see how my personal opinions are relevant at all to the care that I provide.
Truthfully, I see my role as both complex and simple: to provide concise and easy to understand information, to provide support, to present options, and to execute the decisions that families make based on the options that are presented. In my line of work, I don't claim the right to have any opinion outside of my professional assessment of a situation.
How about you?

Lots of talk about what families want. What about what the PATIENT wants?!

NOADLS · Jul 4, 2016

Everyone has a right to their own opinion. A caveat to that is that everyone is also entitled to being wrong.

As a professional, there is a point where you need to be able to point out that someone's opinion is wrong. That is simply part of your job. It is different than if you are out on the streets and see an overweight dude with a lot of facial hair flaunting a skimpy dress claiming to be a woman. In that situation, you don't have any obligation to explain to the person that he is wrong. But if you see a family member mistreating one of your patients, you are obliged to say something.

Cab411 · Jul 5, 2016

What I have recently come to realize is that we are all entitled to have an opinion, but that opinion isn't right or wrong when it comes to a patient ls plan of care.

Everyone has a right to make choices about their Healthcare and the choice and decisions they make are not right or wrong they are just choices the person feels is the best durning that time. One person might have a different direction with their health care verses another but one isn't better worse or right or wrong.

We do not know all the ins and outs in people's lives.

We aren't there to judge people's choices about their lives or healthcare, we are there to educated and inform patients of all possible outcomes so they can make the best decision that fits their needs.

Anonymous865 · Jul 5, 2016

Everybody is entitled to their own opinion, you are right. But when it interferes with the comfort of that dying patient, that's when I'm going to intervene. Just because someone in dying, their health care proxy does not immediately defer to all of the family members. That patient still gets to make their decisions. Unless they have designated a single, health care proxy to make all of their decisions, I could care less what that family thinks. If that person is in pain, I'm treating it. If they don't want to eat, they don't.
I get the feeling that some people just defer to the family no matter what. No, they don't get to make the decisions. Unless they are designated as such. And at that point and time, I am educating that person about end of life care. Educating on what is important and how morphine is not "killing" their loved one. That is so ridiculous. I know in my final hours, I want to be as comfortable as possible.
Everyone can have their own opinion. That's what makes this country great. But my job is to be the advocate for my patient. 100%, hands down.

Every state has a law that defines who can make medical decisions for a person.

In my state the law says that the patient makes the decision.

If the patient is not able to make medical decisions, then the healthcare POA makes the decisions.

If the patient has not appointed a healthcare POA, then the law specifies that the decision maker is in this order

1. spouse

2. adult children

3. parents

4. adult siblings

5. any other family member

6. friend

The law explicitly states that the decision maker may NOT be the treating providers.

So yes, by law it does automatically default to the family if the patient hasn't specified otherwise.

Your job is to advocate for what the patient wants.

If the patient is not able to voice their choice, then it is the responsibility of the patient's decision maker to decide based on their knowledge of the patient's expressed wishes and values. It is not up to you to decide based on what you would want if you were dying.

BellionRN · Jul 5, 2016

I don't see advocating for your patient as being an opinion.

mrsboots87 · Jul 5, 2016

I do t take the "I want them to be alert" crap from families. First, the only family, friend,or loved one that has any day over the care of an actively dying patient who can no longer consent for them self is the MPOA. If anyone beside the MPOA is requesting to not give MSIR or Ativan to a dying patient, I don't care. I politely tell them they have no authority to decide that for the patient and explain the benefit of medicating. I then chart detailed about it to protect myself. If the MPOA is requesting no meds, I have only come across 1 who won that battle.

I I am never rude or condescending to a family. I give all the support I can while their loved one is dying. But I do make it plain as day that even though the patient may not look it to a lay person, that moaning or fidgeting is a sign of pain and/or anxiety and they need medication. I make them make it personal. I have them imagine it were them in that bed in excruciating pain because they can't have meds. I make them imagine they had lost ALL their choices because their family wants them "alert". While I do this as nicely as possible, I definitely make it known I don't agree with not medication and find it selfish. My priority is my patient first and family second. And if I have to upset a family member for a day to get my patient comfortable I will.