11/19: Handle the Harvest Moon with Care

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Specializes in Pediatrics, Emergency, Trauma.

Hi everyone!

This has been a VERY strange week, as far as flow and the amount of trauma, resuscitation and social issues entering my ED this week.

I have officially decided to blame the Harvest Moon that decided to shine over my area.

I juggled flu-like symptoms with working and having educational days and a conference this week, capped by another funeral for this year for me; the previous was this summer where my ex-coworker was missing and found dead.

Both were from a job where we interacted as a small family-we all who have attended these funerals have treated our mini reunions as a chance to see each other more besides on social media and in tragic circumstances.

Without further delay, what I have learned this week:

1. I learned that alternating my hand through pronation can have someone off balance and in my control when it gets busy, emotions are high and my patients and their family members who lives are already out of control want to unleash such aggravation;

2. That lymphomas can literally "drown" a patient by leaking into the pleural space, thus getting into the lungs.

3. That such lymph drainage can be cleared by a substance similar to crazy glue-who knew?

4. That my pressure point of the fingernails beats my sternal rub any day of the week.

5. That abdominal pressure can be largely ignored; can be a cause for shock, and fluid resuscitation must be with care.

6. That the only thing I miss from a former employer is resources and the cafeteria food; otherwise, I am very content where I am; although it was nice to see the recruiter that recruited me and if I need that critical care experience to become an ACNP, I could at least consider that per diem route-I have some thinking to do...

That's it for this week...it's a tad late due to working overtime, flu-like symptoms and paraflu; and trying to recuperate.

What have YOU learned this week?

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It's on the other side of the patient-caregiver relationship, but I learned that a provider billed my insurance no fewer than 5 billing codes, some of them timed codes, for 5 minutes of face-to-face care and 5 minutes unatttended on a machine. There's more to the story about violating written agreements on out-of-pocket expenses. I'm no expert, but I'm pretty sure that's insurance fraud. The practitioner is arrogant (or ignorant) enough to repeatedly admit to and defend his practices in writing.

I'm reporting him to the relevant regulatory agencies.

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This week I have been looking more into end-of-life (EOL) problems in advanced heart failure / end stage heart failure and the dilemma we are facing as those patients approach a stage where all common sense nurses wonder if "living in the hospital" or "advanced therapies like heart assist device/ home inotropic medications for a bed bound patient or patient with a low functional status is "the right thing to do."

Nurses have voiced that they feel ambivalent about spending costly resources on patients who in turn will only live somewhat longer with a questionable quality of life. This is especially true when those patients also have other co-morbs that could be life-limiting like cancer, Parkinson's , dementia, and so on and forth or are already at a very low functional level.

Here some literature for the actual topic heart failure and position statements from the ANA regarding EOL care:

Dilemmas in end-stage heart failure

http://aquila.usm.edu/cgi/viewcontent.cgi?article=1045&context=ojhe

Ethics: Deactivating a Cardiac Pacemaker: Is it Ethical?

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements/EndofLife-PositionStatement.pdf

The problem seems that with the "new" standard of shared-decision making there can be a common misunderstanding what that actually means. Shared-decision making is a sign of high quality care but it does not mean that the patient/family will choose "whatever they want".

The idea is to have the patient/family participate in decision-making because not everybody would want every option.

It turns out that a lot of patients and families view this "new" model as a burden and do not want to make a decision or feel guilty no matter what decision they make. There is probably some research on it but this has been my and my coworkers experience for a while now. There is a subset of patients/HCP who are will informed about their illness, who are proactive and seek information, who want to be in control, and who engage in a meaningful dialogue around shared-decision making. It depends on your patient population how prevalent this group is but it has been my experience that this group is larger in the more affluent and financially well off areas. Where I work, this group is the minority.

It seems that most patients and HCPs in my area feel burdened by this process, they do not wish to discuss any choices if they boarder on EOL issues, and they do not wish to make a decision because they feel that they do not have the knowledge to make "the best choice" or do not want "to feel guilty if I am signing his death papers" by declining some invasive measures. Mistrust into the healthcare system also plays a role - there are people who feel that providers will suggest the most cost effective solution and not the one that they think is best.

The whole crux is that the providers who should discuss choices (yeah we know that this is not really happening that much....) also have to make a clear recommendation! It is not ok to just dish out the medical diagnosis and prognosis and after that tell the patient of family "we can try this medication for heart failure, we can also try home tele health to optimize management of heart failure, we can send you to a larger hospital to evaluate you for advanced therapies, or you can sign up for hospice --- which one do you want?"

There is a certain formula to have those discussions, one suggestion is here :

The SHARE Approach | Agency for Healthcare Research & Quality

What I do not like is that they put all the choices before the goals and preferences. Because once the provider dishes out the "options" they start to get into a panic mode and try to figure out what they want and what is best. By exploring the goals and values first you actually get to talk about the items that should be the foundation of shared-decision making. Which is why I like this format from the Ariadne lab better :

https://www.ariadnelabs.org/wp-content/uploads/sites/2/2015/08/Serious-Illness-Conversation-Guide-5.22.15.pdf

The other model often does not lead to a meaningful dialogue and decision-making because the focus gets shifted towards the "options" and not the "values" and can derail any meaningful process. If a person says "I would not want to be on machines" the "option" of a heart assist device may not be what the patient would want even though it might extent the life span. Or if the patient says "my family is most important to me and I want to spend as much time as I can with them" the "option" of sending a very sick patient with a poor prognosis to a large center where they may or may not be able to leave home ever again seems questionable.

When providers put the options first, people get caught into circles easily, which can create a significant amount of stress.

I am not a provider, I am not a nurse practitioner. Naturally my question is - how does the primary nurse/bedside nurse fits into this model of shared-decision making?

First of all - families and patients often approach the bedside nurse for an opinion after a "discussion" with the provider because they are confused and do not understand, because they are unsure what to do "what would you do if this was your father?" or because they want to learn about more information. Sometimes they just want to vent about the stress and how "unfair" everything is ...

An article for nurses is here

http://journals.lww.com/nursing/Fulltext/2013/08000/How_nurses_can_encourage_shared_decision_making.19.aspx

the article suggest that nurses get familiarity with the process and also use shared-decision making tools.

However, I find that for the day-to-day work in a busy hospital or nursing home the nurses usually do not have the time to sit down and elaborate on different tools and walk the patient through it. But there are things that nurses can do to set the patient up for success.

When a "family meeting" is planned /schedule in a facility, it can be helpful to hand some blank papers and pen and say "the doctor has scheduled a family meeting to talk about what is going on. I want to give you some papers so you can take notes. Generally speaking, it is good to think a bit about what is important to you in your life and write it down perhaps in single words because this usually determines who people make decision about their healthcare and options." You can give an example so they understand.

After the meeting, when you touch base with the patient / family (if you do not attend) and ask "how did the meeting go?" you should also pay attention to the details. If you feel that they did not understand "what is going on" please ask "do you feel you have a good understanding of what is going on?" but also "can you tell me in your own words what your understanding is - if this is ok with you?" and if you feel that there is a discrepancy between what the provider tells you "they understand" and what they verbalize "I have no clue what it means" inform the provider. There are times when I have to page whoever had the discussion and tell them that there is no understanding.

If they are torn between decisions, you can offer to connect them with more resources. If it is an EOL decision and they want to explore for example hospice care to focus on maximizing comfort with advanced heart failure at home as opposed to "last ditch" treatments that would result in sacrificing comfort - the case manager can request a hospice liaison visit or provide more information.

When families/ patients ask the nurse about "what should we do" one of the best answers is probably to say "it depends on what is important to you in your life right now and how much you are willing to go through or sacrifice in order to get "more time".

That simple sentence reframes the decision-making process totally without putting the nurse into an uncomfortable spot. Often , just the reflection on "what are willing to go through" changes everything as a lot of people do not really want to go through a bunch of stuff with a serious illness or only through certain things and finding the care plan or goal based on that makes sense to most people.

I find that as our healthcare system and the way we deliver care is changing, the role of the nurse also needs to adapt.

Some nurses advocate for a new role as a "decision-making coach" but I think that this should not be a separate role and mostly be integrated into primary nursing. Granted, I work as a specialist care nurse in palliative care but the majority of our population who has palliative care needs or needs to make a decision is not served by the specialist team and general primary nurses in all settings will face the dilemmas more and more. So why not give bedside nurses the tools and communication skills to be successful?

Our scope is not to diagnose or prognosticate and so on - but we are involved in all aspects of healthcare around it.

Besides my thoughts on heart failure and shared-decision making and related research I also learned that

- low carb diet is hard during the holiday season - temptation is everywhere

- black friday shopping in stores can be a scary idea

- shoulder strains and injuries have an impact on a lot of activities and PT can actually help a lot

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I have learned so much in the last few weeks that I don't even know where to start. So instead of the clinical side I'll focus on the emotions related to transitioning from student to new nurse.

Conflicting input from preceptors causes extreme frustration for me.

I had been told that I need to shorten my report by skipping benign assessment info. This resulted in being told that I need to provide more info in report at the end of my next shift.

When my preceptor constantly jumps in on report and conversations, it undermines any sense of competency I have. End result is optical leakage on my way out the door.

I'm seriously wondering if I made a mistake taking this job. Between scheduling, rotating preceptors and nearly constant illnesses at home I feel totally burnt out and overwhelmed.

Im due to come off orientation in the next week or two and I don't feel confident in my abilities.

Clinically I have learned that femoral access closure devices sometimes fail. The resulting bleed can be large, rapid and terrifying.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.

I am tired of being pregnant. I was so sick Thanksgiving that I didn't go to my SILs. Not to mention my son is going through his terrible twos. I'm going crazy because I can't do much & my son is so fussy.

Also this weekend & next my MIL won't be taking my son (she normally takes him every weekend). I'm not mad, it's just tough because he won't listen half of the time & I'm already really exhausted. It's not bad when my husband is off, but he works until Monday.

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I have learned so much in the last few weeks that I don't even know where to start. So instead of the clinical side I'll focus on the emotions related to transitioning from student to new nurse.

Conflicting input from preceptors causes extreme frustration for me.

I had been told that I need to shorten my report by skipping benign assessment info. This resulted in being told that I need to provide more info in report at the end of my next shift.

When my preceptor constantly jumps in on report and conversations, it undermines any sense of competency I have. End result is optical leakage on my way out the door.

I'm seriously wondering if I made a mistake taking this job. Between scheduling, rotating preceptors and nearly constant illnesses at home I feel totally burnt out and overwhelmed.

Im due to come off orientation in the next week or two and I don't feel confident in my abilities.

Clinically I have learned that femoral access closure devices sometimes fail. The resulting bleed can be large, rapid and terrifying.

Alas, optical leakage is a common side effect of early nursing. With the right treatment and environment, you will make it through to the other side.

I don't know if you're in a job that is truly a bad fit, but I felt very insecure for the better part of two years (being thrown in the deep end of LTC/SAR then first year med-surg). You get your footing, learn what YOU think is the right thing to do (darn preceptors yanking you in both directions :(), and forge ahead.

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Specializes in M/S, LTC, Corrections, PDN & drug rehab.

Is it March yet?

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