How do you tell a family member their loved one will die?

[CaliRN2019, BSN]

I had an 82 year old male with Covid who was clearly dying on my tele floor. He was on Vapotherm at 40L 100% Fi02 plus a non rebreather flush for 2 weeks. He was a DNR/DNI, yet not comfort care or hospice. You know, that icky and painful in between suffering. His family took many days to finally agree on comfort care. My last day with him he was becoming increasingly lethargic and his sats were 75-80% all day. His son was allowed to visit that day (which helped him decide it was OK to initiate comfort care orders). By the son's body language and general "feel" I got from him, I don't believe he realized the gravity of the situation and that it was probably going to be the last day he saw his dad alive.

I felt the need to educate him, warn him, or let him know that now would be a good time to say your goodbyes but I didn't know how. As the bedside nurse, how do you approach the subject?

I understand the Dr. is responsible for a large part of that conversation but the particular resident was new and seemed unfamiliar with our hospitals comfort care/hospice issues. I wasn't within earshot of their conversation at the time but I suspected she didn't get her point across.

[JKL33]

Usually open the conversation by first standing by in a mode that could be called "silently engaged" for awhile (not intrusively but anywhere from 30 sec to couple of mins) - then asking if they have any questions in an engaged, meaningful way. 

[Daisy4RN]

2 hours ago, JKL33 said:

Usually open the conversation by first standing by in a mode that could be called "silently engaged" for awhile (not intrusively but anywhere from 30 sec to couple of mins) - then asking if they have any questions in an engaged, meaningful way. 

agree, and to this if they say no to questions, I would say something like ...

How does your Dad look to you today?

Gets them looking and thinking (hopefully)

[JBMmom, MSN, NP]

I also agree that having family initiate as much of the conversation as possible is usually the best way. Often they understand more than they appear to and once they have someone to talk it out with they come to the conclusion that they are saying goodbye. One of the phrases that I usually use in these situations if they say they don't want to give up hope is that hope is a wonderful and powerful thing, but sometimes we have to shift what it is that we are hoping for. When we are not looking at hope for a cure anymore, but hope for peace and the best quality of time we have left. In most cases, even when family is in complete denial, they can see what's best when given some time to talk it through. Good luck!

[TheMoonisMyLantern, ADN, LPN, RN]

Usually I do what previous posters have mentioned. Beyond that I usually start with "Your dad's condition has changed." and then go into what we're seeing clinically and what that means is happening often I explain it in very basic terms because this type of conversation can be very hard to hear and I've found the simpler you make it the easier it is for the family to really hear what you're saying. I often will also say "If you have anything you'd like to say to your dad, now is the time to do it." This conversation is tough to have with family members, especially over the phone which with the pandemic I'm sure we've all had to have that conversation over the phone as opposed to in person. The more you do it, and the more death you see, the more comfortable you'll become at breaking the news.

Also, if the family is not receptive to what you say, or if they have questions you can't answer you can try to get the doctor involved. Your mileage may vary however because some docs are terrible with death.

The most common question when having this conversation is "How much time does dad have?" Be careful with this question especially until you see the dying process a lot because ultimately we can't give a concrete answer, we can only estimate and it's important that the family realize that. If death is imminent of course it makes it any easy question but if they're still 24-48 hours or longer before death it makes it trickier to estimate. So, I find it best to just explain that and give a general range of time based off of what you're seeing with the patient.

[T-Bird78]

Families don’t/won’t acknowledge it is the end. When my uncle was in the hospital for 9 weeks he’d gone on and off dialysis, had a colostomy bag after his colon ruptured, on a vent, off a vent, back on, etc.  We were waiting on his son to drive up from Florida, since he was going to be deployed overseas for a year the following week. When my cousin arrived, they were going to d/c support and turn off his pacemaker. I left the hospital to pick up my son and my mom told me “well, we’ll see you up here tomorrow, right?”  I told her no and she asked why I wasn’t coming back up there.  I said mom, he’s not going to be here tomorrow. My entire family was stunned that he passed that night. They knew how much he’d been through and what the plan was, yet they couldn’t comprehend that he would no longer be with us.  

 

My other uncle died Sunday night after fighting COVID for 2 weeks. The doctor told my cousin, his oldest son, that he just had two days at most left; my uncle left us 6 hours later. My aunt and other cousin were called into the hospital and got to spend 20 minutes talking to him before he took his last breath. The family needs to know it’s coming. Sometimes you have to be blunt yet gentle and just tell them it’s time. 

[JBMmom, MSN, NP]

1 hour ago, T-Bird78 said:

My other uncle died Sunday night after fighting COVID for 2 weeks. The doctor told my cousin, his oldest son, that he just had two days at most left; my uncle left us 6 hours later. My aunt and other cousin were called into the hospital and got to spend 20 minutes talking to him before he took his last breath. The family needs to know it’s coming. Sometimes you have to be blunt yet gentle and just tell them it’s time. 

Sorry for the loss of your uncle. I'm glad that your aunt and cousin were able to at least be by his side at the end. I think that the hardest part about these COVID deaths has been the lonely ending. When families can't see the day to day decline, it's hard to convey to them that the patient is as sick as they really are. We have recently had many patients that remain a full code until the very end because the family wants everything done. As hard at the conversations are in person, they are 100 times harder over the phone.  In our hospital when patients remain a full code that  means no visitors are allowed. If the family decides to make a patient CMO, they are allowed two visitors. It's so sad when have to do CPR knowing the futility.

[LibraNurse27, BSN, RN]

5 hours ago, JBMmom said:

Sorry for the loss of your uncle. I'm glad that your aunt and cousin were able to at least be by his side at the end. I think that the hardest part about these COVID deaths has been the lonely ending. When families can't see the day to day decline, it's hard to convey to them that the patient is as sick as they really are. We have recently had many patients that remain a full code until the very end because the family wants everything done. As hard at the conversations are in person, they are 100 times harder over the phone.  In our hospital when patients remain a full code that  means no visitors are allowed. If the family decides to make a patient CMO, they are allowed two visitors. It's so sad when have to do CPR knowing the futility.

I agree, over the phone/video is not as impactful/informative as seeing your loved one suffering in person and realizing they will not recover and should be made comfortable. My last covid pt who passed away was able to express to us and her family that she had been struggling to breathe for days and was so uncomfortable, suffering and knew she couldn't sustain working so hard to breathe for much longer. She straight up said she was ready to see God and her husband and children who had passed and to please help her not suffer. But not all pts have the capacity to express this, and it is conveyed through them gasping for breath and moaning, which can't be conveyed on the phone. I too am searching for a way to convey this to family without sounding harsh and graphic. Appreciating the advice

[Guest856929]

I state facts, not speculation. Tell them that the patient's hemodynamic status is unstable, and if the patient continues to deteriorate, what would the family like to pursue? Inquire about their interest in palliative care as a consult. You also must consider cultural differences and appropriate timing.