Just grin and bear it!

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A little background...

I admitted a patient at the end of my shift Monday. From home with hospice, admitting dx UTI/sepsis/hematuria. He's 91, baseline non-ambulatory, very minimal verbal response, at times combative.

Plan of tx was abx, okay, I can see how that goes with comfort/hospice care, I'm on board, all is well.

Then, before I left Monday I get an order to initiate CBI, oh and can we draw another CBC since his Hgb went from 10.9 to 7.9?

Also we are doing a complete retroperitoneal UTS, which is, in and of itself relatively non-invasive, but what treatments will we do if we find something?

Now to my favorite part...

I had him again today and based on report, physician's notes, consults, and orders the care team is on board with him being comfort care/non-invasive measures. All of the care team, except his wife/POA/primary caregiver.

Denial is more than just a river in Egypt y'all.

She stormed out of a meeting with the palliative team, slamming the door, after death was mentioned. She INSISTED that he be given a diet order and spent all day yesterday and today force-feeding him.

No one is allowed to mention death or speak negatively within his earshot.

Today he was even starting to mottle but, "why aren't we giving him his cardizem and the other 9 (NINE!) vitamins that she gives him every day?

Tonight his IV went bad and his abx were switched to PO so of course I crushed them and mixed them is custard (what she happened to be force-feeding him at the moment).

I said "Mr. Smith, here is a bite with your antibiotic in it, would you like to open your mouth and take it?"

He cracked his lips open enough for me to slide the spoon in.

I put the rest of the custard/antibiotic on the spoon; "Mr. Smith, here's the rest, would you like to open your mouth for the rest?"

Nothing. I touched the spoon to his lips...nothing.

His wife became agitated, started trying to convince him that he MUST take the medicine.

I explained (again) that he has the right to refuse medications and that, perhaps, he has decided he is okay with the consequences of not taking them.

Her words (verbatim) were, "he doesn't understand the consequences...I don't tell him when there is medicine...I never tell him. If he knows there is medicine in it he won't take it...come on Dad, you've got to take it. I know it doesnt taste good, but no medicine does. You've just got to grin and bear it. How do you think women have babies? They just grin and bear it."

:wideyed:

And then when he still refused to take it she burried her heas in her hands and with teary eyes said, "dinner was going so well! Oh, it was going so well!"

She's upset that when he d/c tomorrow he will be back under the care of hospice instead of home health :banghead:

Y'all, I promise I'm a good nurse, and I'm truly not heartless, but you know some days there's that one person...:notworthy:

Specializes in Psych, Corrections, Med-Surg, Ambulatory.

"How do you think women have babies?"? Yeah, how DO they have babies - when they're 90?

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Specializes in L&D, Cardiac/Renal, Palliative Care.
"How do you think women have babies?"? Yeah, how DO they have babies - when they're 90?

:roflmao: Exactly!

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Specializes in Pedi.
I'm sorry. That's so tough.

Also, his wife called him dad?

My in-laws refer to each other as "Mommy" and "Daddy." It's so weird.

Threads like this make me so happy I'm a pediatric nurse.

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Specializes in Community Health, Med/Surg, ICU Stepdown.

I totally feel you. Today I cared for a patient who has been in a SNF for years, nonverbal and immobile, totally contracted. Came in for urosepsis and hypothermia. They discussed quality of life issues with his wife and recommended making him a DNR but she wanted full code and aggressive treatment. Now in addition to his long-term PEG tube he has a Foley, a wound vac (for the stage 4 decub he got in the SNF), around the clock blood draws, IVs, antibiotics. Everything we do to him causes him pain. It's hard to turn him, hard to draw blood because he can't bend his arms, he has a rectal tube because he was having so much diarrhea... just awful. I don't think anyone would want to live like this. I understand it's very hard to let loved ones go but it's also very difficult to feel like you're torturing someone to keep them alive against their will. I think all we can do is try to provide compassionate care, continue to advocate, and show some compassion to the patient's family even when we do not agree with their choices. Good luck to you with your situation; it sounds really tough.

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I hear you, I do, and I get that piece of it. In most cases I do see it that way and understand, and I tried to flip my persepctive with this case as well. However, I truly believe her "care" is to the point of diminishing his quality of life. When I talked to the hospice nurse she said that when therapy came to the home to evaluate him the wife was pushing him out of bed, he did not want to/was not able to participate.

I know that she loves him and doesn't want him to die and I get that, but I also feel that he has the right to refuse treatments that make him uncomfortable, which is most things at this point.

I know I probably sound heartless but I truly do understand why she feels the way she does. It is just frustrating to feel like I am not giving my patient the best care for him because his wife is unreceptive to education.

I don't think you are heartless, just inexperienced in how agonizing it is to have to see the love of your life dying before your eyes.

The wife is an integral part of the whole scenario. She is your pt too. Make things as easy for her as possible.

If you feel she is improper in her care of him, involve the Risk Manager, your supervisor, Social Work, the courts.

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I totally feel you. Today I cared for a patient who has been in a SNF for years, nonverbal and immobile, totally contracted. Came in for urosepsis and hypothermia. They discussed quality of life issues with his wife and recommended making him a DNR but she wanted full code and aggressive treatment. Now in addition to his long-term PEG tube he has a Foley, a wound vac (for the stage 4 decub he got in the SNF), around the clock blood draws, IVs, antibiotics. Everything we do to him causes him pain. It's hard to turn him, hard to draw blood because he can't bend his arms, he has a rectal tube because he was having so much diarrhea... just awful. I don't think anyone would want to live like this. I understand it's very hard to let loved ones go but it's also very difficult to feel like you're torturing someone to keep them alive against their will. I think all we can do is try to provide compassionate care, continue to advocate, and show some compassion to the patient's family even when we do not agree with their choices. Good luck to you with your situation; it sounds really tough.

Torture and keeping people alive when they likely would much rather move on - welcome to Western modern "medicine".

Lawsuit should be filed against those who let him develop that bedsore and develop those severe contractures.

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My in-laws refer to each other as "Mommy" and "Daddy." It's so weird.

Threads like this make me so happy I'm a pediatric nurse.

There's plenty of suffering in Peds, too.

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Oh my goodness... : / She's in major denial. I get the "I love my husband and don't want him to die" thing. I don't want mine to die, either, but there comes a time! Poor guy.

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Gosh, I see dollar signs....maybe when he dies she loses the house or his pension or something?

I can (and have) loved someone with all my heart and soul but I know at age 13 (for my dog) or age 91 for a human they are going to die.

Bingo! Worked in a LTC wing of a local hospital. I wondered why a vegitative patient received a certain procedure. Was told, "Wife did not want him to die near Christmas." Come to find the wife never worked. Married straight out of high school and she needed his social security and pension. Whatever happened initially ate up savings. Sad... I'm not sure how much longer she was able to justify treatments considering how quickly he was deteriorating. Left before I could find out.

Brownbook, I can relate to the dogs. Sometimes I think it's better. One had cancer. Vet mentioned aggressive treatment, we asked if there was anything to just make him comfortable after seeing the x-rays. Got those meds, two days later he dug up the yard. We said if he stopped eating, drinking or going his business it was time. Stopped all three the same day and gave us a certain look. We knew.... The only dog on earth that hated car rides, enjoyed that last one.

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Specializes in Pedi.
There's plenty of suffering in Peds, too.

Of course there is, but there's no 98 year old knocking on death's door whose family refuses to let go. Or worse, the family who insists from afar that Grandma would want everything done but never visits her in the LTAC after she's trached.

I have rarely encountered families, in my 11 year pediatric career, who refuse to let go when death is inevitable. I can honestly only think of one (parents who insisted on a trach for their toddler with a diffuse intrinsic pontine glioma, 0% survival rate, ethics team sided with the parents because they said a trach wasn't going to change the outcome, she died trached and vented in the ICU after being pronounced brain dead).

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Specializes in Geriatrics, Dialysis.

It's frustrating and very sad dealing with a POA that just won't or can't accept a poor prognosis. It's also incredibly common. There will come a point in your career where you've finally dealt with this enough to come to peace with it. As much as we as health care professionals can disagree with a family's wishes or their lack of compliance with a plan of care ultimately that's not our call to make and like it or not we need to follow what the POA wants.

There are of course some limits to this. Like I can and have refused to force a resident to take their meds or eat but I also can't intervene if it's the POA force feeding the resident. The only thing you can do in that situation is educate and document, document and document some more to cover your behind and the facilities as these are also the family members likely to run to a lawyer when the inevitable happens and their loved one does die.

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Specializes in Critical Care; Cardiac; Professional Development.

Moral distress is real and it hurts. I'm sorry you are having to participate in torturing this poor man. I hope tomorrow is better.

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