Let's dialyze the actively dying pt....

[nrcnurse]

I work for a Hospice Continuous Care team. We spend our shifts (8-16 hrs) with one pt, and see the entire specturm of humanity: behavior, living conditions, beliefs, drama, etc. Today was a first for me. The pt (primary dx liver CA, c mets to bone and brain) is experiencing reduced urinary output, a common sign of decline. The family wants to know, "where is the fluid going? His intake far exceeds output." We (nurses over several shifts) have explained respirations, cellular functions, perspiration, and the usual and customary "shutting down" of the kidneys. Their first response is, "There's something wrong with the urinary catheter." (New cath, no distention, no bladder CA involvement, no blood in urine.) We explain s/s of retention, etc. The family has asked these questions every shift for the past three days.

Today, during what has become a usual and customary dialogue, the PCG says, "What about dialysis, you know, like for people with diabetes whose kidneys don't function properly? I have a friend whose husband had a portable dialysis machine, and they even traveled!" The patient's BP is 80/48, he's eaten up c CA, and she's talking about dialysis and travelling. It was all I could do to keep a straight face.

I just had to share. This was too strange to keep to myself.

[santhony44, MSN, RN, NP]

Sounds like they're focusing on something they (mistakenly) think can be fixed to avoid thinking about what can't be fixed.

[deeDawntee, RN]

Oh man, talk about denial at its worst!! Makes you wonder doesn't it? It is really amazing what the human mind does to protect us, isn't it? The patient is receiving hospice care, so I would have to assume that the family knows he is not long for this earth? Do they think a miracle is coming? Sounds very challenging. In the meantime, the patient can't be getting the acceptance he needs from his family.

[leslie :-D]

Oh man, talk about denial at its worst!! Makes you wonder doesn't it? It is really amazing what the human mind does to protect us, isn't it? The patient is receiving hospice care, so I would have to assume that the family knows he is not long for this earth? Do they think a miracle is coming? Sounds very challenging. In the meantime, the patient can't be getting the acceptance he needs from his family.

sigh...

families like this, make it extremely difficult for the pt.

if i know my pt accepts their dx, but the family continues to deny, i have no problems in setting the family straight.

yes, they will get extremely upset w/me.

but this anger quickly turns to grief, which is the same as acceptance.

and the work can continue.

leslie

[deeDawntee, RN]

The five stages of grieving are denial, anger, bargaining, depression, acceptance. So getting that family out of the denial stage into anger is certainly a step towards acceptance. Depending on how the family handles their anger, it may or may not be helpful to the patient.

Of course, the grieving process is not a smooth transition from one stage to another, people move back and forth through this process in a way that is unique to them.

To the OP, where is the patient in his own grieving process? Or is he just too ill for you to know for sure??

[Sabby_NC]

They are grasping at straws to keep their loved one with them.

Maybe a family meeting with the Social Worker and Pre Bereavement is in order?

It is hard when things get 'down to the wire' for some family members.

Obviously dialysis is futile. Have you discussed benefit versus burden with them?

I wish you well in your role with this family. I also wish peace and comfort to the pt and his family.

[SuesquatchRN, BSN, RN]

I find families more difficult than patients.

I had a lovely wife this week. Husband came in with a GI bleed. Parkinsons, dementia. Cx that's metastasized to the sacrum. She's taking him home with morphine and help from hospice.

I wish her peace, and him a quick, painless passing.

[leslie :-D]

The five stages of grieving are denial, anger, bargaining, depression, acceptance. So getting that family out of the denial stage into anger is certainly a step towards acceptance. Depending on how the family handles their anger, it may or may not be helpful to the patient.

dee, the 5 stages of grieving, generally pertain to the pt's process.

of course the family is going to grieve, but my focus is first/foremost, on the pt.

always.

afterall, it's their life and their death.

i exercise extreme sensitivity when i remind families, that we need to focus on the needs of their loved one.

usually, this puts everything into perspective for them.

and i make myself totally available to their needs, once i'm done caring for the pt.

leslie

[deeDawntee, RN]

dee, the 5 stages of grieving, generally pertain to the pt's process.

of course the family is going to grieve, but my focus is first/foremost, on the pt.

always.

afterall, it's their life and their death.

i exercise extreme sensitivity when i remind families, that we need to focus on the needs of their loved one.

usually, this puts everything into perspective for them.

and i make myself totally available to their needs, once i'm done caring for the pt.

leslie

OK, I see what you're saying. That makes total sense.

[ktwlpn, LPN]

and sometimes familes/s.o's need a :trout: I worked on a unit over the weekend and dealt with a few cases of family denial.My co-workers have their work cut out for them.I'm a float and thrilled to be. I had a gal with an explicit advance directive have a massive cva a week ago and come back to the ltc with a feeding tube.The family claimed she told them she wants to live and agreed to the tube-then expressed surprise when I told them she told the staff during her am care that she "wants this to end" The family could not believe that we could understand her speech..hmm-but she was clear in the hospital when she over rode her advance directive? I think the family over rode the directive-not the resident.And-"when can mom get her hair done?" Hello? Mom came back with a pressure ulcer and you want her to get a perm? Another gal with a fracured hip=we saw family coming out of the woodwork-people we have never seen at the ltc.But now they hover-where were they when the poor soul was admitted and tearful and depressed because she was taken from her home? They were fighting over her furniture.Most of them could not find her room and did not recognize her.She's been with us over a year...sad....Then we have a younger gal with a neuro muscular disease in it's final stages .The family are coming in more frequently now that she is end stage.They stand around her bed and CRY...she is a alert and oriented...After they left Sunday she was so upset she was choking and frothing at the mouth.What are people thinking? Clearly most of them are thinking only of themselves-and it's our job to focus their concerns towards our patient-their wishes and thei comfort....

[SuesquatchRN, BSN, RN]

and sometimes familes/s.o's need a :trout: I worked on a unit over the weekend and dealt with a few cases of family denial.My co-workers have their work cut out for them.I'm a float and thrilled to be. I had a gal with an explicit advance directive have a massive cva a week ago and come back to the ltc with a feeding tube.The family claimed she told them she wants to live and agreed to the tube-then expressed surprise when I told them she told the staff during her am care that she "wants this to end" The family could not believe that we could understand her speech..hmm-but she was clear in the hospital when she over rode her advance directive? I think the family over rode the directive-not the resident.And-"when can mom get her hair done?" Hello? Mom came back with a pressure ulcer and you want her to get a perm? Another gal with a fracured hip=we saw family coming out of the woodwork-people we have never seen at the ltc.But now they hover-where were they when the poor soul was admitted and tearful and depressed because she was taken from her home? They were fighting over her furniture.Most of them could not find her room and did not recognize her.She's been with us over a year...sad....Then we have a younger gal with a neuro muscular disease in it's final stages .The family are coming in more frequently now that she is end stage.They stand around her bed and CRY...she is a alert and oriented...After they left Sunday she was so upset she was choking and frothing at the mouth.What are people thinking? Clearly most of them are thinking only of themselves-and it's our job to focus their concerns towards our patient-their wishes and thei comfort....

Families continue to astonish me.

[nrcnurse]

Families continue to astonish me.

That, right there, wraps it all up in a neat little package~