Hostile families

KC,RN · May 16, 2016

The families might seem hostile, but from my recent personal experience as the family member of my loved one who was an inpatient, I'm not so sure 'Hostile' is the right word. Frustrated, aggravated, tired, so tired of all the stuff we had to go through, terrified, but not hostile - at least for me. I can't speak for everyone.
My LO has been on opiates for several years for chronic pain. When he went in for a totally unrelated illness recently, they judged him to be zonked. Blood gases confirmed a way high CO2 and he was very hard to wake. He was not able to give history because he was so out of it. I see him like this almost every day, I know it's not good, but it is not unusual for him. The staff, however, were legitimately alarmed. What did they do? Stopped his scheduled opiates that he's been on for years and gave him only enough to control his pain from the current illness.
I understood, but asked what they would be doing to prevent withdrawal. No real answer except "We'll watch him". That would be great if he had a personal nurse who would actually have seen him when he started, a few hours later, to thrash about with involuntary "restless leg" movements and lots of other "just can't get comfortable" thrashing. If his nurse had heard him hallucinating and seen him sweating and heard the teeth chattering as he portrayed Frank Sinatra in "The Man With the Golden Arm" I think it was (showing withdrawal from heroin), he might have realized my LO was in opiate withdrawal.
His nurse feared zonking him with his usual dose of opiates and feared giving IV push morphine, so got an order for, not quick onset morphine, but MS Contin. It was an hour and a half between asking for pain med and the time I called the Manager. I saw our assigned nurse busy with other patients, so called Manager, not to c/o but to let Mgr. know nurse was swamped and my LO needed help right away. I hope no trouble comes for the staff RN.
I just could not endure my LO thrashing and hallucinating any more. I was not hostile, I just couldn't take it any more. And LO's nurse was not goofing off, he was busy with other patients, legitimately busy. Didn't make it any easier. IT took 2 more hours for the MS Contin to begin to give any real relief.
As a nurse, I know how the hospital works - I know the doc has to be paged, there's time between page and response, it takes time to get the med once it's ordered, especially if it isn't floor stock and has to come from Pharmacy, there are other patients.
Somehow knowing doesn't help take away the pain I endured watching my LO suffer. Obama and other VIP's would not have to endure waiting, however minimally, why should my LO? Of course, wounded enlisted men, in the ocean after planes and ships were destroyed, were not supposed to be rescued before even non-wounded officers. RHIP. Doesn't make it right or easy to endure.
So imagine how it is for those who only see you doing "nothing" and do not understand the way things work.
Just do your best, do some educating, then try to forget about it.

I don't know if I expressed this clearly, but I truely do not think this son had any intention of causing trouble in the hospital. I think he felt helpless seeing his mother in that much pain and he was not able to do anything about it. I also think that when he saw me standing in the hallway talk to the other nurse in front of my computer he probably thought I was just hanging out ignoring his mothers pain. I think his gut instinct was to put on his tough guy act to get things done. I never doubted that his mom was in real pain. I was doing what I could in that particular moment to ease the pain, I had given the pain meds I had available and was calling for more. In hind site, I could have made a phone call sooner, next time I will.

I feel for this family, it is not easy to see a loved one suffer. I have to ask and I don't mean for this to sound disrespectful, but how should the nurse "act" in front of the family when they are trying to get what they need done? Obviously sympathetic , but do they need to stop and explain every move they are making?

NursesRmofun, ASN, RN · May 16, 2016

Adding: I am sure you advocated for the patient. To an extent, it comes with the territory. Still have an incident like this come up occasionally. No perfect solutions and there are different reasons for why it happens. You communicated with the doctor, which is the right thing to do. Occasionally, the patient is habituated to higher doses (at home). And then there is that movie- "Terms of Endearment", where the mother goes to the desk and screams. I am sure some think it is "the" way to do it.

tyvin, BSN, RN · May 16, 2016

I call stat! There's no excuse. Doctors are very receptive if you sound like you know what you're talking about. I don't interject family wants this or whatever, it's the patient that needs it. In my experience, most docs don't care what the family thinks about pain control. Make it about the patient's pain; not a complaining family member...don't wait, as we all know the pain will only climb.

Ruby Vee, BSN · May 17, 2016

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?

People learn how to behave in the hospital environment from TV shows like "ER" and "General Hospital." Those are dramas, so the characters behave in a dramatic fashion. And intimidation often works. Do your best to stay calm and professional. Educate the patient and the family about the correlation between having no pain and not breathing.

And understand that not every family member has their heart in the right place. I've seen family members throw a fit to get their family member more drugs so that THEY can get their hands on the drugs.

Conqueror+, BSN, RN · May 17, 2016

Even though I knew what the title meant my second thought when I saw it was family members that were straight out of a horror movie.

attachment.php?attachmentid=22140&stc=1

TheCommuter, BSN, RN · May 17, 2016

Hostile family members displace their anger onto nursing staff because we are perceived as a less threatening target than the 'real' source of their hostility.

This fact still doesn't make the situation right. Nurses aren't verbal punching bags.

dudette10, MSN, RN · May 17, 2016

A big issue that was only tangentially mentioned was that the providers FAILED. Yes, they FAILED to anticipate the patient's needs based on the diagnosis and the level of relief received from ER pain management.

You did the best you could under the circumstances, and it happens every day that nurses have to endure understandable pt/family anger directed to nurses because of provider FAILURE to order acute pain management appropriately or discuss the medical plan of care.

IceDancer · May 19, 2016

I am not seeing how long you have been in nursing. As others have mentioned, you did not get good orders to begin with to control pancreatitis, especially given what the patient was showing you with her response to the ER/first floor arrival meds. That said, I have two points of advice regarding orders. Firstly, as you get to knew your docs, meds, and disease processes more precisely, you will find that it may behoove you to ask for ranges in prns....for example, Dilaudid 1-2mg IV q2 hours or something of that sort. It allows you room to play a bit and find what really works for your patient. Also, the pain may change as time goes on and the nurse on the next shift will be grateful for the extra wiggle room. Second, just because a doc gives a order for say, piddly morphine when you first talk to them, does not mean you can't have input. Saying, "Hey, she had a bit of a response to the toradal but that morphine she had did not do squat" will usually get them to rethink the order. Otherwise they get called again if it doesn't work....they are fairly inclined to listen if it helps avoid repeated calls.... especially if you have a good case, and even more so if they know and trust you.

**canoehead, BSN, RN** · May 22, 2016

I think its inappropriate for the ER to send someone up without controlling their pain. I work in the ER, it's just not done to let someone suffer through their visit at 10/10. Of course, once they got up to you, they were primed for the same lack of pain control on the floor. That's not your fault.

If I have someone at 10/10, writhing and moaning, I ask for those 2mg morphine doses Q10min until the pain is under control, THEN start the maintenance doses po or sq. At 10mg, if it didn't work, I'd call for a different drug, and the same Q10 min dosing. You'd need a sat monitor, and frequent reassessments. This aggressive approach really works to solve the pain problem without overdosing, and show family that you mean business, their pain isn't being ignored. Even if the doctor doesn't give you the exact order you want, they are aware that more calls are likely coming, and hopefully will stay near a phone. Watch when you change drugs, because the 10 of morphine may have done nothing, but 1mg Dilaudid on top of that (the effective drug) may result in more sedation than it otherwise would. That's the time to make sure you watch the sat alarms, and go back to reassess in a timely manner.