Hostile families

[KC,RN]

My last two shifts I have had issues with very hostel family members who felt that my hospital and me were not doing enough to prevent a patients pain. I had medicated both of these patients and update the MD when the pain medication was not effective. I understand that these families have their heart in the right place and are doing what they can to advocate for their family member, but how is trying to intimidate a nurse the way to get things done? I did notify the supervisor about the situation. Is there a good way to handle this or is it one of those things that comes with the job?

[Anna Flaxis, BSN, RN]

My gut instinct is to tell you that it comes with the territory.

But thinking about it more, I have to say I don't have enough information.

Are you treating acute pain or chronic pain, or acute on chronic? What was ordered? When you notified the physician, did you receive new orders? What was their response? What did the family members do that was intimidating to you? How did you respond?

And, it's "hostile". "Hostel" is a type of lodging.

[LadyFree28, BSN, LPN, RN]

"Hostile" families is pretty subjective...meaning, there are patients and families that have a difficult time with pain control.

Sometimes one has to think outside of the medication spectrum...can you institute heat/cold therapy along with medication management?

Sometimes people are in pain, and one will find themselves "chasing" the pain l, making it difficult to manage pain-when I discuss this phenomenon with my pts and their families, and institute non-pharmacological methods, it helps them understand what's going on; I also get the provider involved to see if there are other pain medications of lower schedules that can be available as well, which pain assessment is key to determining whether a non Schedule II such as naproxen or a nerve medication such as gabapentin can be used as opposed or in conjunction with Schedule IIs...there are many options that can be of benefit.

[roser13, ASN, RN]

LOL! I thought this thread was about family members' overnight accommodations.

[KC,RN]

My gut instinct is to tell you that it comes with the territory.

But thinking about it more, I have to say I don't have enough information.

Are you treating acute pain or chronic pain, or acute on chronic? What was ordered? When you notified the physician, did you receive new orders? What was their response? What did the family members do that was intimidating to you? How did you respond?

And, it's "hostile". "Hostel" is a type of lodging.

I know I was very vague in my post because I didn't want to give out to much information. The incident that happened last night was this. Pt came to the floor right at change of shift after a hellish ER experience with pancreatitis. Clearly in 10/10 pain admitting nurse gave here the 2mg of morphine that was ordered. The patients husband was upset because ER had been giving her 4mg of morphine and they were told that it would be increased. I assessed the pt pain 30 minutes after med was given per protocol and called the MD right away to let him know that pt pain was still 10/10 after morphine was given. MD give me a 1x dose of toradol, went in to room to give it and husband expressed that he was upset with the care that his wife was receiving and that they were not getting answers. Gave med called nursing sup to let her know about the husbands concerns. Called MD to let him know about the husbands concerns and asked if they he could come see the patient and her husband, MD was no longer in the hospital. MD gave me order for dilaudid X1 dose. Toradol reassessed and pain had decreased to 6/10. Dilaudid given and when reassessed pain was 2/10. I told pt husband that we would control the pain and when MD returned in the morning they could discuss the plan of care. Pt husband was satisfied and left to go home. My next plan was to see my other patients and give the morphine that was still ordered 4hours after first dose that was given on the floor as ordered. Pt called for pain med while I was at dinner brake and the nurse covering my assignment gave it a few minutes early (this was the 1st I would have done when I got back). I went back to reassess the pain 30 min after med was given, walked in the room and clearly this patients pain was still 10/10. When I went to see the patient her son and daughter were in for a visit. I told the patient and her family that I would call the MD for a different pain med. I paged the covering MD and waited for a call back. I was standing next to the phone with my computer talking to another nurse and I looked down the hall and the patients son was staring at me standing in the hallway outside the patients door with his arms crossed starring at me. I moved around to the nurse station and the patients son walked over and glared at me and stated "why are you not doing anything about this the doctor needs to see her now!" I explained that the doctor had been paged and that I will get he med changed when I get the call back the patients son said "this hospital is under staffed!" I told him this was common at most hospitals that the MD is not on the floor and they are pages as needed, I also said that I was addressing his mothers pain as best as I could. He just looked at me and said "you can not tell me that this hospital is not under staffed if there is not a doctor on this floor! They need to fix her pain now!" I asked him to give me the chance to speak with the doctor. Covering MD calls back and changed morphine to dilaudid q2 and med is given to patient asap. Pt family leaves without incident.

Looking back I should have called for the dilaudid order sooner. I was just venting in my post because I do feel bad for these families because the feel helpless and the just think that hospital have meds at hand that can just be given when ever the slightest pain is detected. I also think the families feel helpless and that if they start yelling at the nurse at least they are getting something done.

My prior shift I had a 31 y/o male that had been in for 4 days with shingles and denied pain my whole shift then I get a phone call from his dad who said that he called him and his pain was out of control. The patient had never used the call light! Pain control has just become a huge cause for concern on my unit suddenly and it's frustrating when MD don't address it when see them.

Just part of nursing life I guess?

[KC,RN]

LOL! I thought this thread was about family members' overnight accommodations.

I need to use spell check when posting in the middle of the night![emoji51]

[Guest219794]

When you think about it, it is pretty astounding that a person has to lay in severe pain despite the physical availability of pain medication. And, an admitting doc ordering 2 mg of morphine, (equivalent to 1 Vicodin) for pancreatitis with no additional or prn order is pretty numb.

From the point the pain starts, an inadequate dose is given, re-assessed 1/2 hour later, a call made, an order given, and medication administered can be a really long time.

Despite it being normal, it sucks. Especially since the issue was predictable and preventable had the doc done his/her job.

Maybe: "I think if I was in your position I would feel the exact same way. I can promise you as your mom's nurse, I will do the best I can within the system, and I will give you the number of our VP in charge of patient relations."

The anger is legit, and while it is being expressed toward you, it is not about you. Deflect it and point it where it is warranted.

[LadyFree28, BSN, LPN, RN]

When you think about it, it is pretty astounding that a person has to lay in severe pain despite the physical availability of pain medication. And, an admitting doc ordering 2 mg of morphine, (equivalent to 1 Vicodin) for pancreatitis with no additional or prn order is pretty numb.

From the point the pain starts, an inadequate dose is given, re-assessed 1/2 hour later, a call made, an order given, and medication administered can be a really long time.

Despite it being normal, it sucks. Especially since the issue was predictable and preventable had the doc done his/her job.

Maybe: "I think if I was in your position I would feel the exact same way. I can promise you as your mom's nurse, I will do the best I can within the system, and I will give you the number of our VP in charge of patient relations."

The anger is legit, and while it is being expressed toward you, it is not about you. Deflect it and point it where it is warranted.

Agree.

I have learned shining the soft skills by explaining the timeline for orders, approval from pharmacy to administration, along with emphasizing SAFETY in addition to what I bolded, all while using non-pharmacological methods, even when someone denies pain-there are people who will do that, and there is still an order for comfort regardless.

Moving forward get creative: analyze, assess and start to practice in the art of anticipation and ADVOCATE early-when you are receiving a pt with a particular diagnoses and remember those care plans that helped us shape to nursing thinking...if pain is a priority, then analyze the options for the pt; have at least a mild pain reliever on board and if OTC at least the first few days, etc, even when they deny pain; guide those suggestions from your practice and the lessons learned from these patients; it's an individual approach and you have to look deeper and be in tune to what their tone, body language and even try to probe deeper when in terms of their illness.

[Horseshoe, BSN, RN]

I need to use spell check when posting in the middle of the night![emoji51]

Spell check would not have caught this error, since "hostel" is a legitimate word.

I, too, thought you were referring to patients who lived in some kind of hostel. :)

[KC,RN]

Thanks I'll double check next time.

[KatieMI, BSN, MSN, RN]

Ok, so you got a patient with condition which is known to hurt like ****. She is already got 6 mg of morphine, with no relief. You know it.

If I were you, I would access patient much sooner than 30 min after toradol. In fact, I would be hanging in room for some 15 min and in between 2) got a set of vitals and 2) asked if she is taking anything for pain regularly, and what exactly if anything. This helps me to access effect (protocols be d***ed) and make family more content. With the 1 and 2, I would page doc and let him know that the toradol us not working, and that the patient, who is kinda expected to be in 100/10 pain, has no [scheduled/U] pain med orders. I would not get off his neck till something is ordered to cover her pain to manageable level most of the time.

While doing that dilaudid, I would teach patient that, since it takes you good 30 min to call doctor, it would be better for her not to play a hero and let you know when her pain goes up to, say, 4/10, not 10/10.

You did fine, just do not be afraid to use the knowledge of pharmacology you got in school.

[Anna Flaxis, BSN, RN]

Thank you for elaborating. This is very helpful.

Pancreatitis can be one of the more painful conditions, requiring astronomical doses of opioids just to make the discomfort tolerable. This patient may have even benefitted from a PCA (Patient Controlled Analgesia).

It sounds to me like your unit/facility could benefit from implementing an Acute Pain Protocol of some sort. This way, the doctor could just order the protocol, which gives the nurses a lot of flexibility within a set of parameters to figure out what works best for the patient. It's a win-win. The doctors will receive fewer pain related pages, the nurses will have more tools in their toolbox, and the patients' need for pain control will be addressed. Do you have a unit based practice council, or could you bring this up to your manager for consideration?

As far as dealing with the (understandably upset) family members, I have a basic spiel that works well for me. First, I offer reassurance that controlling the patient's pain is important to me, and that I will do everything I am able. I explain that I cannot give medications without a doctor's order, and that I am making it a priority to obtain that order. I explain that these are very powerful medications, and that for the patient's safety, I have to be careful not to give too much, because I don't want to kill them. I explain that often, it takes more than one dose to get an acceptable result, and that we have to work together to figure out how much of what drug is going to work without harming the patient. I let them know that some conditions are so painful that it is not possible to eliminate the pain completely- that I could give them enough Dilaudid (or Morphine or Fentanyl or whatever) to kill an elephant and they still might have some pain, and that the goal is to get the pain to a level that they can tolerate- not to eliminate it completely. I might ask "If we could cut your pain in half, would that be an acceptable result for you?", and I make a plan together with the patient and their concerned family to do that. Since I work in the ER, the doctor is right there and so I don't have to page and wait for a response, but I have worked inpatient in the past, and I would explain this to the patient and family: "I am going to page the doctor to find out what else we can try, and it's going to take a little time for him/her to return my call and give me the orders. I can't give you anything until that happens, but I can offer _____________ (warm compress, ice pack, dim the lights, whatever) while you wait".

If they *still* follow me out of the room and shoot daggers at me, well then, I tried. But usually, when I make myself their ally and ask for them to participate in the plan like we're a team, they calm right down. They're just concerned for their family member, as they should be.