Vent: Dysfunctional Family Dynamics

[abundantjoy07]

Why do some families feel the need to document every single interaction or occurence with their loved one? I don't understand why some families keep spiral notebooks and write down every vital sign reading, every medicine, every time the patient coughed or sneezed, and everytime anyone came in the room.

Last night I was talking to a family member and he had his sister on the line. Everything I said to the patient was relayed word for word to the sister. The family member in the room described me, what I was wearing and spelled my name for the sister on the phone line. He kept asking, "Are you a nurse? What kind of nurse are you? Do you give her medicines?"

When it came time to give medications...oh that was hell on earth. I'd tell the patient, I'm giving you Colace. Then I hear it from the family, "Colace! How many milligrams? 100 milligrams is too much! When is she going to have a bowel movement? Does she really need it? What are the side effects? Who ordered it? Will it give her gas? Will you give her pain medicine if she has gas pain? She wants Vicodin for gas pain. Call the doctor to get an order for Vicodin!" Then I had to hold on as the family discussed the medicine on the phone, which by now they were having a three way conversation. Every medication had this same response. The patient who was alert and oriented just wanted her meds but the family would refuse medicines for her. "No, she's not taking that! Give her a half of that. Call the doctor and see if she can take more of this. Etc, etc, etc."

The patient started yelling. She said she wanted the medicines like her doctor prescribed and not to listen to the family. But the family was so adamant and mean. I was caught in between a rock and a hard place. I felt threatened by the family as they treated the patient like she was completely ignorant and incapable of making her own decisions. It was like the patient was a 85 year old child. Even though she was pretty oriented and knew which end was up.

The patient then started complaining of dyspnea after arguing with the domineering family. Checked her sats, she was 90% on 2L. Then it started again. "90%! Call the doctor! Why is she 90%? Etc. Etc." So I call the RT for neb treatment for the patient. They started arguing over that! So I bump her up to 3L, recheck her sats and she's 100%. Family starts in again..."100%? Can't she go higher than that? 100% is not good enough! Give her Narco! She needs Narco!" I explain Norco is not for giving to patients who are satting fine. It's for pain control. Their response? "We don't care if Narco is for pain! We want Norco! Narco is for her breathing" I ask the patient are you in pain? She says no. Family doesn't care. They want it and they want it now. 1 minute is too long to wait.

At one point I had to step out of the room. I felt like I was unable to exercise my nursing judgement and provide adequate care. I wasn't able to interact with the patient as I wanted to because everything was blocked by the family. If I asked her if she was cold then the daughter who was on the phone with the brother and another sister would say, "No, she's not cold! Don't touch the air conditioner. You can bring her blankets but only one blanket and don't cover her feet!" Even small things like do you want a snack was dictated by people who really had no say so about what the patient wanted to eat or drink.

Everything I asked was answered by someone on the phone and not the patient. I felt like a servant and not a professional caregiver who obtained a college education and actually had some knowledge and could give input. When they decided on the breathing treatment for the patient I paged for the therapist but she was not quick enough to get to the floor. Mind you, we have one RT for our building who happened to be with other patients in ICU. I mean think about priorities... patient on a vent whos fighting the vent? Patient who's satting 80% on a NRM? Or the patient satting 100%? Hummm? It's like it didn't even matter that the RT was on the way it wasn't quick enough and it was like they were the only people in the hospital and others didn't matter even if the others were dead or dying!

What is behind this behavior? How can I deal with family members like this? I thought maybe it was me. I'm young and they think I don't know anything and can't take care of their loved one because it looks like I was born yesterday. I offered to have another nurse take care of the patient. That didn't pan out and they swear it wasn't me and told me not to be offended. But I was incredibly offended I have never felt so stressed or belittled.

[ktwlpn, LPN]

No I disagree, never kick a family like this out, ever. Somewhere along the line, they have lost TOTAL trust of nursing an medical care and the link is broken. "

In my experience this is not often the case.I see people with a little bit of knowledge trying to take control because they think they know it all. People with Google degrees. Folks that believe that running a cash register in a pharmacy gives them "a background in healthcare" You can clearly see the families dysfuction in the way they relate to each other and the patient. They have NO idea what a nurse really does-they are the people for whom limits must be set by all staff involved. I think that is what the OP is dealing with here.

People who have really lost their trust in medicine are easy to spot-just start asking questions. You may hear some tragic story about how "Poppa went to the er with a sprain and died a week later" They blame everyone involved from unit clerks thru the nursing staff...You can gain their trust by proving yourself trustworthy.

[Kim O'Therapy, BSN, RN]

Usually, I let the family know that my priority is getting necessary medications to their family member; however, I will be happy to come back post-med pass and explain things further. AND I DO IT. Once, to make things quicker, I just printed out the drug information and gave it to the family. Usually, they are grateful. That being said, I have also had several family members behave in the manner described by the OP because they have been absent from the patient's life or have not helped pawpaw out all of these years and now they have a "chance" to show how MUCH they care by nit-picking at the nurse and acting as some sort of "guardian". However, I also note that said "guardians" leave skid marks at the door when it is time to help feed/clean/change/provide financial assistance to pawpaw. Gets me every time! ;0)

[SchnauzersRock]

This reminds me of a new admit I had when I worked in long-term care. He had just gotten to the floor (during the heaviest med pass, no less). While the STNA's were getting him settled in, I was finishing up with my meds. While I was finishing up, the "family spokesperson" came up to me, handed me a packet of information from the other facility, wanted me to read it right then and there, and started telling me about dad's likes and dislikes, how bad the other facility and nurses were, what they all expected to be done, blah, blah, blah. I stood there politely, took it all in, and when it was my turn to speak, I informed the "family spokesperson" that when I was the nurse assigned to that particular unit, they could all rest assured that the patient would get what he NEEDS, with the emphasis on the word "needs". The patient was there for PT/OT and various other problems, and, as part of the health care team, it was my responsibility to see that he got what he was there for.

Amazingly, I never did have any problems with the patient or his family. I think it is in the way one carries oneself, and the setting of the ground rules right off the bat without being mean-spirited or confrontational. You CAN get the message across with the choice or words you use. I think alot of the time, people want to see what we as nurses are made of, and they try these tactics to see how far they can push us. When they see that they don't have a push-over for a nurse, they will soon back off, or just get pi$$ed. In any case, just remember you are there for the patient.

[tri-rn]

This takes a team meeting with a plan of care with the family so they know that they are negatively affecting the patient care. Then in the meeting, a plan and an agreement is reached.. where all meds are reviewed in that meeting ONCE and the explanation given, with printed out handouts for them to read. This meeting is done with a nurse, a manager and the primary doc.

Upon this agreement, any changes will be discussed with ONE, one primary family rep, but the doc has the ultimate say, the nurse will not be questioned about meds and dosages again because they are printed out, the reasons well known in advance.

If the pt were disoriented, sedated, or otherwise unable to make thier own decisions, I would wholeheartedly agree with this approach (other than the fact that meds may change multiple times in a week) . But with an A&O pt there is no need for this and in fact would violate HIPAA, because the family has no right to recieve information or to make decisions for a patient capable of doing so for herself.

I also think that allowing a patient's family to contradict an A&O patient's decisions is completely disrespectful to that patient. She has the right to make her own decisions; as her advocate I have to respect that right and uphold it.

That being said, nobody wants to make a patient's family uncomfortable with the care thier loved one is recieving. I know I try my darndest to answer family members' questions because being scared to death about a loved one's illness is a crappy place to be. And I DO agree with Zookeeper3 that trust is often an issue, and that sending the family takes away almost any chance of building it.

It sounds like this family needed to be politely reminded that the patient can and should make her own decisions. An easy "well, it's up to her whether she wants to take this Colace, folks" might have done the trick. Or maybe even asking whichever relative is most closely related to speak to you for a second, then ask them "Is there a reason the patient can't decide for herself that I'm not aware of?" THEN when the family member says no, remind the family member that the pt can and should make decisions for herself without familial interference.

If none of that works, they need to be respectfully asked to step out.

As always, let the charge nurse know there's a problem early on, and DOCUMENT

[mesa1979, BSN, RN]

If that patient is competent, I could care less what the family says......

[mamamerlee, LPN]

Hi! My name is Mama Nurse, and I'll be your nurse this shift. To he family - "Is anyone here POA for healthcare? No? Is there a designated spokesperson? No? Then who wants to be that person? Having just one person ask the questions and get all the info will make everything go more smoothly. Thanks"

I have tried varients of this with fair success. Best wishes!

[RhiaRN75, RN]

I have seen families behave unreasonably for several reasons. Mistrust is certainly one of them but it's not the most frequent one I have encountered. It's really important to find out why they behave this way because the best way to deal with one will make another worse.

Besides mistrust..... Some families feel guilty because they haven't been attentive. They're not around much when Momma is home but stick to the bedside when she's in the hospital. Others live far away and now that they are all present while Momma is a pt they are determined to 'get a handle on her care and fix everything'. Some are frustrated that Momma won't 'listen' at home so they take charge when they can. Some families don't agree- some want Momma in a nursing home, others don't... that type of thing. A few I really think are just looking for a lottery ticket should Momma die. The possibilities are near endless.

The big one though, and I don't think it's been mentioned yet, is abuse. I'm always suspicious when the family micromanages everything, with a heavy emphasis on arguing with the reasonable care (colace), and requesting 'shut up' care, like sleeping pills and pain meds that are really not indicated. Norco is a fairly strong medicine for some elderly pts.... do they want want Momma drugged into complacency? It's easier to hide some types of abuse, like mismanaging Momma's money or helping yourself to a few of her norco, if she's doped up. It's hard for a caregiver who isn't familiar with the pt to know if she's confused or under the influence. These families use 'Momma's best interest' as a pretty effective shield to cover the fact that they are using Momma.

I'm not saying that abuse is necessarily what's going on with your pt but it does happen.

So. Document like crazy. Absolutely get the CN, NM, MD, case management, ethics, risk management AND social services involved. You can set limits and kick that family out all day long, but if you don't have support then it won't work and may come back to bite you. I have also found that one simple statement, calmly but directly, can make a world of difference. "Mrs. Doe certainly has the right to refuse xyz. I have to document that refusal, and the reason why, in her chart so that it can be considered in re-evaluating her plan of care so that she can receive the treatment she needs in an appropriate manner." It doesn't matter how you word it, so long as you are polite, make it clear that you document as well, and make it clear that the responsibility of said refusal is in their hands.

If a family is distressing a pt to the point of physical harm, then damn the torpedos and kick them out. Politely, of course. Even better to have backup (wittness)- NM at your side, for example.

The patient started yelling. She said she wanted the medicines like her doctor prescribed and not to listen to the family

That is enough, for me, to round them all up and send them packing. "I'm sorry, but your loved-one is too ill to to endure this stress. She may have one person stay but she's not healthy enough for more then one visitor at this time. I promise I will relay all your requests and concerns to her doctor and document them in her chart so it will be addressed." They will react in one of two ways- comply and settle down, or raise all manner of hell. Either one can work to your advantge if you play your cards right. If they get totally unreasonable, have a hissy fit and show their coccyx, it certainly backs up your point. Just make sure you are polite, don't lose your cool, and have wittness/backup. CYA!

And don't be offended. Once you take it personally, the family has the upper hand. Bring everything back to what's best for your pt. "Oh I'm not offended, I want Mrs. Doe to have the best care possible." Everything needs to be phrased as cause/effect, and explained in 'best for my pt' terms. Never bring it back to you- it shifts the blame onto you. "I kicked the family out so I could get to her side to take care of her" shifts the debate to whether or not you did the right thing. "Pt arguing w/ family, states "I want to do what the doctor said, don't listen to them", noticeably upset, o2 sats now xyz, family asked to leave at this time so pt can rest." demonstrates the cause and effect.

[brillohead, ADN, RN]

The big one though, and I don't think it's been mentioned yet, is abuse.

I tried to post this last night and it wouldn't go through for some reason (does that happen to anyone else? seems to be a random thing for me, and I can't find any rhyme or reason for why it happens?)

Like you, I was thinking elder abuse:

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The patient who was alert and oriented just wanted her meds but the family would refuse medicines for her.

The first thing that popped in my mind was that it's time to call Adult Protective Services. These people are at a minimum mentally abusing their mother, and I think a judge would also accuse them of medical negligence/abuse as well.

I'd work my way up the chain of command at your facility until an appropriate resolution was found. At a minimum, a social worker needs to get involved to ascertain if the woman needs legal protection (having a medical POA named, legal guardian, or restraining order against the kids, etc.).

When my FIL was going into a LTC facility, we needed to have someone named his legal guardian. I had thought we could name both my husband and me (my husband travels out of state a lot for business, and wouldn't always be accessible if a decision needed to be made; his siblings live 3-18 hours away by car), but the courts told us only ONE person could be Dad's guardian. In the end, we decided it would be me even though I was just the "kid-in-law", since I was available 24/7/365 but my husband and his siblings were not.

At first I thought it was a stupid rule that there could only be one guardian -- why not let us BOTH do it? Then I realized that if you have multiple people involved, you could end up with exactly the type of situation that you had, where everyone needs to be consulted and have a say in the decision that is made. (What happens if they don't all agree? Would their mother get a full dose, half a dose, or nothing at all?)

Think of it this way -- if I (a 40yo woman) was your alert and oriented patient and my neighbor came in and started telling you what you could and could not do for my care/treatments, would you listen to me, or to my neighbor? Would you allow my neighbor to bully you, or would you tell him that it's MY choice to make decisions about MY care? If he insisted on preventing you from giving me my prescribed meds, would you hesitate to call security and/or the police to have him physically removed in order to give me the care that I needed?

It's not any different, IMO, just because the bossy non-patient(s) is or isn't a blood relative, unless they have a POA or guardianship papers. I guess it all comes down to YOUR PATIENT in the end. What would you want the nurse to do if it was YOUR mother in that bed not getting the care she needed?