We currently have a baby on the unit whose parents refuse to allow necessary medical interventions. They refuse to allow this patient to use mist with the trach collar because they think it's too loud, they leave the floor with the patient without resuscitation equipment or even informing nursing, they refuse suctioning even if the patient is bubbling over and desatting (oh, they'll cough it up and come up, this happens a lot) and they won't allow chest PT despite the patient plugging.
They accuse staff of not responding to other patient alarms and are constantly eavesdropping on other patients and are hypervigilant for mistakes in care. They also will not allow nursing to assess the patient overnight and when this person is sleeping.
The parents have been spoken to repeatedly about at least informing nursing before leaving with the patient and to bring the BVM and safety equipment but they repeatedly state they'll be back soon and that they just suctioned the patient so bringing a portable machine isn't necessary. They absolutely will not grasp the concept that anything can happen at any moment (this patient has a critical airway), and just because they just performed suctioning does not mean the patient may not need another if they're a half hour away from the unit on a walk. The patient isn't even CLEARED to leave the unit.
Security has been involved, social work has been involved, and the parents don't care. "It's my child and I'll do as I see fit." It isn't for a lack of education as many MANY nurses and even practitioners have attempted to educate this family.
Our unit rotation is coming up and I'll be taking care of this baby. I want to make them write a statement saying I'm not responsible if something happens to their child due to their refusal of interventions. I want to put it back on them that "Okay, so I can document you're willingly risking your child's life?" if they refuse to take the resuscitation equipment.
I would actually like them to request me NOT to be their child's nurse, as I will refuse to withhold the necessary care like suctioning just because the parents don't want it done, UNLESS they are willing to release me from liability. Has anyone ever had this happen? Did you have any recourse other than documenting the parents' response?
When in doubt, blame the nursing staff for having poor communication skills. Obvious you've not done peds. It's amazing how many parents care more about their own comfort than their child's safety. Refusing humidity for the trach, ugh. Not only does it keep the secretions mobile, but who wants dry air going straight into their lungs? Who cares how loud it is!!!
Management rarely is much of a help in these situations because management is most concerned with customer service. Risk management is who needs to be involved. They're the ones that want to avoid lawsuits.
While I understand what you are saying, and agree with you to some extent, sometimes you have to do MORE to get the desired outcome. So your usual communication skills don't work in a certain situation, you just have to try something else. I think many posters are missing the true point - that it's not about a potential legal battle, but about a childs life, and also the families. The family have to consent to the appropriate care so really, it is up to the nursing staff to find a way to make that care something the family agrees is in ALL their best interests. The family aren't being difficult for the sake of being difficult - they will have reasons that are genuine and real to them guiding their decision making process. So found out what is guiding their decisions and then work from there.
Routine q4h suctioning - waste of time. Discuss with them the idea of PRN suctioning and decide on a mutually agreeable set of criteria for that PRN.
Routine vitals overnight - in childs best interests or just for the sake of "paperwork"? Can it be minimised to just recording what the pulse ox readings are and a resp count? Stuff that you can do without disturbing the child or the parents overnight.
Sit down with the family and talk to them about what THEY want the daily routine to be like. They have to deal with hospital life too, so they should have a say in how their day goes.
They don't like the humidifier overnight because it's noisy? See if ear plugs are a potential solution. Give them a physiology lesson so they understand all the why's of needing humidity.
The way I see it (and I know nursing in NZ is different to in the US, but the fundamentals have to be the same), both the family and the nurse are working to the same end - the health and comfort of the patient. So you need to find a way to make that happen without alienating a family to the whole system of health care.
I agree with the through documentation using quotation marks. I would also be writing incident/event reports. Getting my department manager, CPS, and risk management involoved. This poor child. I cannot even imagine what parent in their right mind could risk harming thier baby after they have been educated. I would do anything for my child, and would never directly do something that a experienced NICU or Peds nurse told me could be harmful. I am sickened. I hope this child is ok. My thoughts and prayers are with this little precious one. Thankfully the baby has you to be his/her advocate. :heartbeat
Parents absolutely have the right to refuse a blood transfusion on behalf of their child for religious reasons. The only way for a transfusion to be legally administered in this case is to get a court order that temporarily suspends the rights of the parents.
It is battery because the parents are the legal guardians of the child. In the eyes of the law, the parent's decisions for the child are equal to that of a competent adult. The fact that they signed a full code document doesn't mean that they forfeit the right to refuse other interventions. Though the respiratory distress may lead to a code, it is not a code situation at the time.
It sounds like nothing has made an impact on these parents' decisions regarding their child's care. It looks like the only way you will be able to get them to comply with the advice of the hospital is to have the ethic's committee bring the matter to court and get a temporary guardian appointed for the patient.
This is obviously more than a miscommunication between the patients and staff. According to the OP, the parents have been educated several times and spoken to by many staff members. This is obviously blatent disregard for the child's welfare. Asking the the child sleep without being disturbed is one thing. Refusing to allow suctioning when the child is desating or taking the child off the unit without proper medical equipment is quite another.
Do you know how small an infant's airway is? About 1/2-3/4 the size of a standard straw. How long do you think it would take to close that airway off? Infants breath 30-60 times per minute because they have such small lung capacity and need the extra breaths to get adepquate oxygen to their bodies. If that oxygen is compromised, even for a few minutes, it can lead to irreversible brain damage. Whose to say that this child hasn't already suffered damamge and it won't be noticed until the child gets older?
The only thing that is obvious is that all the "true" facts are not known. To make an absolute statement that miscommunication is obviously not a factor is going out on a limb to say the least. Poor interpersonal communication skills and lack of communication between all those that are supposed to be involved in the planning process (parents are included in this, esp when dealing with children) are one of the most common causes of lawsuits and errors in healthcare facilities. When a parent becomes involved with the healthcare process of their child and may invoke their "right" to make healthcare decisions for their child it should not automatically be assumed they are trying to harm their child. If someone would go the parents in humility and try to start over with them, respecting their rights, without trying to make them feel like their input is not valid then maybe a therapeutic relationship may be possible.
I am somewhat familiar with newborn airways having had two of my five children in NICU's for breathing issues with one on a ventilator. Regardless, being a nurse and also spending ample time on the other side of the curtain I have observed a multitude of nurses interact with my family and my little ones. The vast majority of nurses are highly skilled at communicating with parents establishing a positive nurse-client relationship. However, I have seen the few that are highly sensitive and despise the idea of a parent or family member becoming involved in the decision making process. Sometimes parents want to make it clear that staff need not assume that they have the right to do anything to their child without the permission of the parents unless their is a trust established.
When in doubt, blame the nursing staff for having poor communication skills. Obvious you've not done peds. It's amazing how many parents care more about their own comfort than their child's safety. Refusing humidity for the trach, ugh. Not only does it keep the secretions mobile, but who wants dry air going straight into their lungs? Who cares how loud it is!!!
Management rarely is much of a help in these situations because management is most concerned with customer service. Risk management is who needs to be involved. They're the ones that want to avoid lawsuits.
When in doubt call the parents selfish child abusers who risk the lives of their children for a cozy pillow...oh, and unless your a peds nurse then you can't have an opinion.........Really? I am sure that style of communication works well for parents........arrogance mixed with a little degrading, how therapeutic.
While I understand what you are saying, and agree with you to some extent, sometimes you have to do MORE to get the desired outcome. So your usual communication skills don't work in a certain situation, you just have to try something else. I think many posters are missing the true point - that it's not about a potential legal battle, but about a childs life, and also the families. The family have to consent to the appropriate care so really, it is up to the nursing staff to find a way to make that care something the family agrees is in ALL their best interests. The family aren't being difficult for the sake of being difficult - they will have reasons that are genuine and real to them guiding their decision making process. So found out what is guiding their decisions and then work from there.
Routine q4h suctioning - waste of time. Discuss with them the idea of PRN suctioning and decide on a mutually agreeable set of criteria for that PRN.
Routine vitals overnight - in childs best interests or just for the sake of "paperwork"? Can it be minimised to just recording what the pulse ox readings are and a resp count? Stuff that you can do without disturbing the child or the parents overnight.
Sit down with the family and talk to them about what THEY want the daily routine to be like. They have to deal with hospital life too, so they should have a say in how their day goes.
They don't like the humidifier overnight because it's noisy? See if ear plugs are a potential solution. Give them a physiology lesson so they understand all the why's of needing humidity.
The way I see it (and I know nursing in NZ is different to in the US, but the fundamentals have to be the same), both the family and the nurse are working to the same end - the health and comfort of the patient. So you need to find a way to make that happen without alienating a family to the whole system of health care.
Well said.......spoken with some real wisdom and concern for all those involved, not just taking the easy way out. Thanks.
When in doubt call the parents selfish child abusers who risk the lives of their children for a cozy pillow...oh, and unless your a peds nurse then you can't have an opinion.........Really? I am sure that style of communication works well for parents........arrogance mixed with a little degrading, how therapeutic.
Sometimes parents suck. And when you're a peds nurse and run in to these parents enough, you stop having a rosy, "these parents just want what's best for their child" outlook. Parents can be lazy, abusive, neglectful, and selfish. They really, truly can. And no amount of therapeutic communication helps when dealing with parents who ultimately DON'T have their child's best interest in mind.
And we don't call DHS to discipline parents but to bring in an additional advocate for the child.
Sometimes parents suck. And when you're a peds nurse and run in to these parents enough, you stop having a rosy, "these parents just want what's best for their child" outlook. Parents can be lazy, abusive, neglectful, and selfish. They really, truly can. And no amount of therapeutic communication helps when dealing with parents who ultimately DON'T have their child's best interest in mind.
And we don't call DHS to discipline parents but to bring in an additional advocate for the child.
While I agree that there are SOME parents that do suck, it's not the default setting. Most want the best for their kids, even if they aren't the best at expressing it. So why jump in to assume the worst given half the story? Why not assume the best and advise accordingly?
While I agree that there are SOME parents that do suck, it's not the default setting. Most want the best for their kids, even if they aren't the best at expressing it. So why jump in to assume the worst given half the story? Why not assume the best and advise accordingly?
I was addressing RLeeRN's indignation at being (correctly) presumed not to be a peds nurse.
I do not find it challenging to imagine that the OP's account of the situation is an accurate one. And if it is, the OP needs advice from the "assume the worst" folks as much as from the "assume the best" folks. It sounds like the actions of these parents are jeopardizing the life of their child. Perhaps no one on the staff there has thought to try to work with the parents and find ways to meet their needs and the needs of their child. I don't think careful documentation and contacting DHS are wrong in that scenario either. Our reporting requirements are pretty clear that we do not investigate ourselves but rather report based on concerns. And the OP seems concerned.
Sometimes parents suck. And when you're a peds nurse and run in to these parents enough, you stop having a rosy, "these parents just want what's best for their child" outlook. Parents can be lazy, abusive, neglectful, and selfish. They really, truly can. And no amount of therapeutic communication helps when dealing with parents who ultimately DON'T have their child's best interest in mind.
And we don't call DHS to discipline parents but to bring in an additional advocate for the child.
Regardless of how many parents or family one meets it is in the best interest of the patient, family, staff, and facility to treat each and every encounter with a high level of professionalism. Of course bad parents exist and as a peds/NICU nurse you no doubt will see a higher concentration of them due to your particular community. However, instead of using this as an excuse to not have a "rosy" outlook about parents and becoming hardened to them, there is an even greater need to find ways to communicate in a way that is beneficial to all. Being genuine, warm, empathetic, and respectful go along way with patients and family. Even parents who "suck" can pick up on the value judgements nurses are making. Thanks.
I was addressing RLeeRN's indignation at being (correctly) presumed not to be a peds nurse.
I do not find it challenging to imagine that the OP's account of the situation is an accurate one. And if it is, the OP needs advice from the "assume the worst" folks as much as from the "assume the best" folks. It sounds like the actions of these parents are jeopardizing the life of their child. Perhaps no one on the staff there has thought to try to work with the parents and find ways to meet their needs and the needs of their child. I don't think careful documentation and contacting DHS are wrong in that scenario either. Our reporting requirements are pretty clear that we do not investigate ourselves but rather report based on concerns. And the OP seems concerned.
You make a good point in that nurses are mandatory reporters of abuse by law. Obviously, anyone with authority within the hospital has found that there is no "abuse" going on or that the parents are not a "threat". One could assume that the OP would have already reported the parents if there was a substantial reason and not just frustration over the parents making decisions that staff may not "agree" with. More likely a lack of an ability to speak to "difficult" parents with any success.
You make a good point in that nurses are mandatory reporters of abuse by law. Obviously, anyone with authority within the hospital has found that there is no "abuse" going on or that the parents are not a "threat". One could assume that the OP would have already reported the parents if there was a substantial reason and not just frustration over the parents making decisions that staff may not "agree" with. More likely a lack of an ability to speak to "difficult" parents with any success.
Oy! I have stayed out till now....Lee, you remember what assume means? with the "patient is always right" attitude these days, it would not be immpossible to see this not reported and still rise to the level of abuse/neglect. TPTB wanting to keep the parents happy to avoid bad press, etc. I would find it hard to believe that there isn't ONE nurse that hasn't already try all of your suggestions over this period of time.
Obvious you've not done peds. It's amazing how many parents care more about their own comfort than their child's safety. Refusing humidity for the trach, ugh. Not only does it keep the secretions mobile, but who wants dry air going straight into their lungs? Who cares how loud it is!!!
hiddencatRN, BSN, RN
3,408 Posts
Document and call DHS. I'm surprised that they are not already involved.