How would you of handled this? Family scenario...

[SoCalRN1970]

I was in a situation that was not atypical of what we see and deal with on a day to day basis. This patient per se' is a man end stage dementia bed bound, contracted, multiple superficial decubitus. He is in pain with movement or care rendered. His symtoms warrant continuous care as the daughters who are the pcg's are not able to provide the 24 hour care nor the routine medications for pain.

Scenario.

Daughter to Hospice RN.... My dad is too groggy to take the morphine. That dose you gave him knocked him out for hours so we decided not to give it anymore. We want to use the vicodin only. The vicodin is ordered q6 hours prn and we have been giving it routinely.. but my dad is pain still but this is the only thing we want to use.

Hospice RN. I do understand what you are saying. Let me recap to make sure I understand completely. You do not wish to use the morphine for pain at all. You wish to use the vicodin only, and give it routinely. You also feel your dad is in pain, yet you don't wish to use anything but the vicodin is that what I am understanding? ( prolonged approval of whatever family wants provided by me... the hospice RN )

This caused the family member to call the office and complain.. Please let me know just what I should of done differently. My supervisor and I are at a loss. She seems to think she would of said very similarly what was shared with family. Yet... I was called

Dominant? All because I wished to clarify what the family wishes were....

Sometimes there is no winning no matter what we do,but I just keep playing this scenario in my head and I can't think I did anything against better judgement.

[morte, LPN, LVN]

1) Tone of voice.

2) You pointed out to her that she was leaving her father in pain, and she wasn't happy with that.

There isn't much to be done here, I don't think. For whatever reason the caregiver isn't seeing the same scenario that you are....good luck

[Whispera, MSN, RN]

Since he was being given the Vicodin routinely and was still in pain it wasn't enough.

How about saying something like this: "You want to stop using morphine and use just vicodin for your dad's pain. Would you like me to contact the doctor and see if we can give a bigger dose of vicodin, or give it more often? Would you like me to ask the doctor about other alternatives?"

Is there any chance your tone of voice or body language indicated disapproval?

[SoCalRN1970]

The disapproval factor may of been there for me. The family was not going to budge on the medication. Denial on many levels is s agood thing for a short period of time, however, incidents like this.. the patient's pain can't properly be addressed, yet the family complains he is in pain.

I am working with this family member diligently. I am trying to win over her trust. But she is a hard nut to crack. Meanwhile I will document and offer other medications to treat the patient, if declined then will docuement and try to do my best.

[Whispera, MSN, RN]

It sounds like the family member does want the pain to be controlled but it's the morphine that's the issue. She could have the old addiction or hastening death beliefs. Can you talk to her about her reasons other than the sleepiness? I would think enough vicodin to make your patient painfree would also make him sleepy.

Try not to think of the family as an opponent or as nuts to crack. You're a team and want what's best for you primary client--all of you are "in it" for him. Always ask what they would like to see happen, since they are your clients too as well as your team-mates in the care of the patient.

[nhelkhound]

The daughter doesn't want to use the morphine because of increased somnolence? How about adding a little Ritalin or Provigil?

[tewdles, RN]

The DPOA/M gets to decide what the plan of care will include. Make sure that MSW and pastoral care are as involved as possible with this daughter. As a team, discover what other options may be available and appropriate for the patient's pain control and present them to the daughter.

The only thing we can do is to educate family and the carry out the best plan they will allow.

We all have to reflect upon our personal/professional communication styles when we rub up against someone who is offended by an interaction with us...it is part of the job...especially in hospice.

[heron, ASN, RN]

How is a guy with end-stage dementia swallowing the vicodin, anyhow? Are they giving it rectally? Perhaps if you offered oxycodone - without the tylenol - they might be able to feel more comfortable with medicating. Not ideal, but at least it's available as a high-concentration liquid.

[SoCalRN1970]

He can take vicoden... he is end stage FAST Fc according to our regs he is appropriate. He eats a soft diet. His vicodin is broken into pieces or crushed according to his family. I have offered elixier.. its a no.

Here we are at almost two weeks later. Dtr still as of yesterday is HAPPY with the vicoden only. All I can do is ask every visit and attempt down the road educate, document. and assess.

Sometimes family members have SO MANY issues. I really can only attack and work on the one at hand.

[heron, ASN, RN]

Well, maybe changing to plain oxycodone instead of vicodin would help ... dosing could be a little closer together or dose raised without running into tylenol toxicity. Does the dtr have an idea of what med she wants to use?

[leslie :-D]

i agree about increasing/doubling vicodin dosage and frequency...

since the dtr seems to be focused on vicodin only.

you might want to directly ask her, what can 'we' do to minimize his pain...since he obviously is still experiencing it.

more often than not, families don't know what they want, when it comes to managing the dying of a loved one.

leslie