No, you can't do that!

LoveMyRNlife · Oct 29, 2018

Ethic committee is 1) cannot be gathered emergently, and 2) useless as it is. Ethics committee holds only "recommendation" power, an expert's opinion which can be followed or ignored according to any involved party's wishes.
APS, on the other hand, can wield real power. There have to be right circumstances for them - for example, APS cannot do anything for real about family who keeps 98 years old deeply demented LOL on torturous treatments and full code because "they still have hope" IF that "hope" is the only one thing in question. But in like 9 cases out of 10 I'd seen, there was something beyond hope - for example, an SSI check coming monthly, or inheritance battle, or manipulative religious nursing home administration who pocketed fees while convincing family that to let poor old dear go would be a mortal sin for which they all will be damned forever. In these cases, with a good presentation from SW and involved provider, APS can find something fishy in most cases. And "something fishy" from APS = very real trouble. So even a nudge toward that side frequently moves things back to reality.

Thank-you, that was helpful! I have not had to make that call yet, but that info was good to know for the future.

LoveMyRNlife · Oct 29, 2018

I wouldn't say full-on ethics committee as much as basic care conference. In using that tool, it is routinely possible to facilitate more reasonable conversations because they are removed from the environment that has become chaotic, for number one. That is a huge benefit. Just this woman's screeching in the presence of the patient is making things worse for the patient, which reinforces her own rationales for the demands she is making ("Look at him, look how agitated he is! I want something done!")
If she can't/won't participate in a care conference, it should take place without her. She should know that her presence is desired and it is hoped that she will attend, but it will be held regardless if she chooses to attend. As far as what is happening at the bedside, in real time I would probably involve security. People don't have the "right" to severely disrupt and obstruct patient care by virtue of the fact that they are presently a decision-maker. She needs to understand clearly what needs to happen or the alternatives (and when I say what needs to happen, I don't mean not listening to her ideas about what the patient needs, I mean that she needs to know she is obstructing patient care and is not demonstrating decision-making capability and in that sort of a situation, here are the measures that we will take...)
Additionally if something is not going to happen she needs to be calmly and clearly informed of that. "We will not order additional haldol for reasons we have already discussed. It is not an option." Sometimes these difficulties go on and on because one clear message is not delivered early in the game. She isn't listening to the whys and wherefores. She needs to hear, NO, we must come up with a different plan, that one is off the table.

I agree, thank-you for your response. Unfortunately a care conference was not called for in this situation.

viprn21, BSN, RN · Oct 30, 2018

I've totally discharged people AMA for refusing everything. Usually in those cases they are legit refusing EVERYTHING.

kbrn2002, ADN, RN · Oct 30, 2018

You just described perfectly the spouse or child of about a half dozen of our residents. I work in a SNF that is probably similar to the place you would be discharging this patient to and believe me a lot of the time the resident isn't the behavior problem, it's the POA. Disturbing and very frustrating! I've found that with time and patience the POA usually comes around, but time isn't an option in the acute care setting and it doesn't always work anyway.

We've dealt with some doozies, have even occasionally discharged a resident to home with one of those family members. When that happens we hope for the best but expect that the resident will end up back in the hospital and subsequently back with us or another SNF as the care they are receiving at home really isn't appropriate. Yes, we have refused to re-admit these residents sometimes. It must be a not so fun process for the hospital trying to find someplace, anyplace that will take that patient when the family has burned through just about every SNF and received a well deserved poor reputation in the area with multiple short term admissions.

elkpark · Oct 30, 2018

Give them some AMA paperwork and tell them if they're going to refuse all appropriate interventions for their condition, they may as well go home.
That's my fever dream response, because I know no place would actually let you do that. Too bad though.

It's not a fever dream; I've worked in at least one hospital where the position of the legal/risk management department and general administration were that we were running a hospital, not a Holiday Inn; you were welcome to decline treatment, but you couldn't just stay in the hospital and decline all treatment. If you didn't want any of the treatment we were offering, you were welcome to leave. And they would administratively discharge people and send them home.

elkpark · Oct 30, 2018

If the family member is POA and refusing appropriate care for the patient, is it worthwhile/doable to get Adult Protective Services involved?

Yes, it is, and I've seen that happen. The family members' actions may constitute medical neglect.

mi_dreamin, BSN · Oct 31, 2018

This makes me think about my little palliative lady today. She had said on admission that she wanted to be able to go home. Today she was completely out of it and daughter from out of town came and wanted her to stay in the hospital. She was yelling "Mom, do you want to go home or do you want to stay here?"

Even to the point that EMS was outside the room to transport her for the 10-minute drive and the daughter was going to refuse to allow her to be transported because someone had promised her that she could ride in the back of the squad with her mom; riding in the front (where mom could still hear her) would be "abandoning her" and she had promised not to leave her alone :rolleyes:

She oscillated between "I think she was being unrealistic when she said she wanted to go home" and "only 1 of four kids wants her brought home."

ETA: I really was much more sympathetic than I sound, the cold hard facts make me sound heartless:nailbiting:

LoveMyRNlife · Oct 31, 2018

You just described perfectly the spouse or child of about a half dozen of our residents. I work in a SNF that is probably similar to the place you would be discharging this patient to and believe me a lot of the time the resident isn't the behavior problem, it's the POA. Disturbing and very frustrating! I've found that with time and patience the POA usually comes around, but time isn't an option in the acute care setting and it doesn't always work anyway.
We've dealt with some doozies, have even occasionally discharged a resident to home with one of those family members. When that happens we hope for the best but expect that the resident will end up back in the hospital and subsequently back with us or another SNF as the care they are receiving at home really isn't appropriate. Yes, we have refused to re-admit these residents sometimes. It must be a not so fun process for the hospital trying to find someplace, anyplace that will take that patient when the family has burned through just about every SNF and received a well deserved poor reputation in the area with multiple short term admissions.

We had another patient that was banned from every ECF in the area due to the patient's behavior and their family member.

In my original post it was indeed the family member that was causing all of the problems. The patient was not bad at all. Unfortunately the family member was there every waking second.

LoveMyRNlife · Oct 31, 2018

It's not a fever dream; I've worked in at least one hospital where the position of the legal/risk management department and general administration were that we were running a hospital, not a Holiday Inn; you were welcome to decline treatment, but you couldn't just stay in the hospital and decline all treatment. If you didn't want any of the treatment we were offering, you were welcome to leave. And they would administratively discharge people and send them home.

I am still amazed at the people that come to the hospital and refuse all treatments, complain about everything and everyone, and then refuse to leave. I'm not sure why they think it is acceptable behavior. I guess the pop, turkey sandwiches, and service are better than home. Ugh

LoveMyRNlife · Oct 31, 2018

This makes me think about my little palliative lady today. She had said on admission that she wanted to be able to go home. Today she was completely out of it and daughter from out of town came and wanted her to stay in the hospital. She was yelling "Mom, do you want to go home or do you want to stay here?"
Even to the point that EMS was outside the room to transport her for the 10-minute drive and the daughter was going to refuse to allow her to be transported because someone had promised her that she could ride in the back of the squad with her mom; riding in the front (where mom could still hear her) would be "abandoning her" and she had promised not to leave her alone
She oscillated between "I think she was being unrealistic when she said she wanted to go home" and "only 1 of four kids wants her brought home."
ETA: I really was much more sympathetic than I sound, the cold hard facts make me sound heartless:nailbiting:

Not heartless just honest. The tough conversations go better when people listen to actually understand the staff rather than simply respond. I have actually ridden in the back of an ambulance with a family member so my guess is the EMS heard the "discussion" and opted for the family to be up front. In the situation I posted about the EMS people refused to let the family member ride with them at all based on the family members behavior.

NurseSpeedy, ADN, LPN, RN · Oct 31, 2018

I've totally discharged people AMA for refusing everything. Usually in those cases they are legit refusing EVERYTHING.

This just reminded me of a diabetic patient that I had in the hospital that called me on the phone to report she was having chest pain. So, a rapid response was called and the woman refused EVERYTHING. No to the VS, no to the bloodwork, no to the EKG, no to the nitro, etc....lady, you came in here for a necrotic toe, but would rather be toe tagged than cooperate with us when you may be having an MI. Eventually after trying to reason with the patient the MDs gave up and allowed her to kick us out of her room. Her words, "I'd be fine if all of you would just get the hell out of my room". Guess she didn't know that chest pain is one of the few things that will get you to see a doctor-FAST.

She left AMA but it was a few days later.

KatieMI, BSN, MSN, RN · Nov 1, 2018

This just reminded me of a diabetic patient that I had in the hospital that called me on the phone to report she was having chest pain. So, a rapid response was called and the woman refused EVERYTHING. No to the VS, no to the bloodwork, no to the EKG, no to the nitro, etc....lady, you came in here for a necrotic toe, but would rather be toe tagged than cooperate with us when you may be having an MI. Eventually after trying to reason with the patient the MDs gave up and allowed her to kick us out of her room. Her words, "I'd be fine if all of you would just get the hell out of my room". Guess she didn't know that chest pain is one of the few things that will get you to see a doctor-FAST.
She left AMA but it was a few days later.

"You either have the worst headache in your life - in which case you would agree to a firing squad, not only for that needle in your back for a few seconds, - or you do not have the worst headache in your life, in which case I have no reason to bother".

Neurology pearl of wisdom :)