Patients families dictating care and treatment

[MomRN0913]

I am a new manager in an LTACH facility. We have critical care/acute care patients here for about 3 weeks. It's a for profit facility where it is very kiss-butt customer service oriented, but I believe it is beginning to compromise patient care. There is one patient who's daughter is an LPN in a nursing home. She is nasty and mean and thinks she can actually make orders. Well, the Dr. got sick of her, every time she "orders" something he writes it. I have dealt with this woman on numerous occasions. Many disagreements, but our CEO want sus to kiss these peoples butts. This time, I got angry. She went out of our facility for a same day wound debridement. Then she gets back and the daughter insists on her getting a PICC line and start her on an anticoagulant. Tuseday was the debridement, wednesday the anticoagulant was begun, thursday was the picc(where she started with me because i wouldn't let the wound vac leave the hospital, we are not supposed to, I eventually gave in only beacuse there was a code and the procedure was being held up over this) then friday I walk in to work and she bleeding big time from her sacral wound!!!! I am assisting the house md in stiching it (yes, I am nurse manager who gets active, bot just sits on my lazy butt despite all the work I have to do) I tell him she is on arixtra. he is shocked ot hear this. I was ****** it was started. but the Dr ordered it because the daughter said to, fresh post a major debridement! And she was oozing at the PICC site too:)

The another family member keeps complaining about the care of his father. His father is vented, nothing really upstairs. The patient spikes a fever, and is compensating against it and he is freaking out that the nruse didn't stay at his beside while the fever was breaking. *****? The nurse did everything right. Checked the temp, say the spike, gave tylenol and drew BC as ordered, called the ID and even called the house DR bc the patient was in mild resp distress while the RT was at the bedside. he is timing everything... the nurse waited by the phone whens he paged the house dr so she can explain the situtation. The RT was there. Well, the son flipped about everything. Well, in my eyes, everything that was done was done correctly. The nurse is a seasoned nurse who knows what she is doing. The son doesn't understand the process of a fever breaking. The sweat is normal. She HR being high at the beginning of the fever is normal, the way to take it down is to take the fever down. All this was explained. And then he is convinced his father is being fed too much. He thinks his stomach is too disteneded. Feeding only at 30cc/hr. Belly soft, positive BS, having BM's, no residual. feel we should stop the feeding. WHy? So his wounds don't heal? me and the director fo quality insurance handled him. She wasnted ot apologize for everything. I did not. I felt everything done was appropriate. If we apologize to make him happy,t hen it makes it look like we are doing something wrong. I explained the natural process to him, everything in laymans turns and said sorry if you don't feel like this situation waS handled correctly, but it was.

Sorry for the long vent. I believe in family members being involved in the care, but not dictating it. We are the medical professionals. The dr's have to stop encouraging this. And customer service is customer service, but not when it compromises care. Anyone agree?

[Horseshoe, BSN, RN]

Sounds like the son is asking for what amounts to 1:1 care.

God bless you guys. I don't have the patience for that kind of "customer service."

[SoCalRN1970]

NO matter what you do . Families often try to run the show. I have just accepted it. What is needed is a doctor with a pair who is willing to speak to the daughter and explain that although her input is needed, he write the orders. Period. I have NEVER met a SNF LVN who was capable of safely writing orders or think out of the box. I have seen SNF LVN's hold life saving antibiotics because the doctor didn't specifically write clearly enough a dose. I have seen them hold... meds for clarification and never call anyone. One of my hospice patients who had pneumonia, was probably going to pass anyway. Them holding a med, and calling the MD went on for 3 days! I had another SNF LVN who got orders for a Duragesic patch at 3:00 on afternoon. It was delivered at 8pm. It was held until the next morning to start at 9am....becuase that is how that SNF worked. Meds ordered scheduled times... started the next day at 9am. The patient had cancer. Do you think the family was happy? no. The family knew all about it just becaues they sat bedside 24/7. I had a one and one with the DON. Professionally I explained, I'd like the rataionale explained why? a new pain medication was held from a General Inpatient Hospice Patient.. the family is aware and they are ready to take thier complaints to where it matters...

These are mistakes made by LVN"s in a snf world. Not all are as simple minded as this. But I have a hard time taking the dtr who is on your first patient seriously. 1 year of nursing school has given her huge huge case of delusional grandeur.

[SoCalRN1970]

BTW, even though the patient was bleeding from wounds and the doctor wrote orders because an LVN SNF nurse insisted upon it. Who do you think is going to be looked at for responsibility? The daughter? Heck no. The MD... who is practicing medicine unsafely because he is listening to a delusional nurse.

[imintrouble, BSN, RN]

Anything to make the customer happy. The problem is, keeping the customer happy is killing the pt.

[IowaKaren]

Yes, we run across this type of dynamics also with family members and the same kind of situations happen in non-profit facilities also (full pay gets there way, almost a motto). Well, that's generalizations but sometimes it seems true. Teach, teach, teach, and document, document, document if you can find any spare time while spoon feeding some of these types of families. They generally get better and go home, or do not thrive and have to find a new permanent home, or the do not thrive and stay with you until they expire which typically doesn't last years and years but anything can and will happen in between. You need a strong management to help with the fall out also. Not for the faint of heart, that's for sure.

[Horseshoe, BSN, RN]

BTW, even though the patient was bleeding from wounds and the doctor wrote orders because an LVN SNF nurse insisted upon it. Who do you think is going to be looked at for responsibility? The daughter? Heck no. The MD... who is practicing medicine unsafely because he is listening to a delusional nurse.

Well, if he is held responsible for practicing unsafe medicine, that's a good thing; why he is writing bad orders is basically irrelevant.

[umcRN, BSN, RN]

we see this in the peds world too. "Family centered care" becomes "Family directed care". Had a father once who wanted daily CBC's on his 3lb son...do you think that kid had enough blood for that? Well docs ordered it anyways and dad kept on top of them so HE could decide when the baby need a transfusion or not. Other parents going to the charge nurse in the middle of the shift demanding their child be a 1:1 (ICU environment) and the charge nurse giving in when it wasn't really warranted. Not holding feeds because a parent didn't want us too, one mother went so far as to claim the nurse put the bloody stool in the baby's diaper because she didnt want the baby to have feeds stopped. On and on and the docs get so tired of it they give in to these parents

[Sparrowhawk]

NO matter what you do . Families often try to run the show. I have just accepted it. What is needed is a doctor with a pair who is willing to speak to the daughter and explain that although her input is needed, he write the orders. Period. I have NEVER met a SNF LVN who was capable of safely writing orders or think out of the box. I have seen SNF LVN's hold life saving antibiotics because the doctor didn't specifically write clearly enough a dose. I have seen them hold... meds for clarification and never call anyone. One of my hospice patients who had pneumonia, was probably going to pass anyway. Them holding a med, and calling the MD went on for 3 days! I had another SNF LVN who got orders for a Duragesic patch at 3:00 on afternoon. It was delivered at 8pm. It was held until the next morning to start at 9am....becuase that is how that SNF worked. Meds ordered scheduled times... started the next day at 9am. The patient had cancer. Do you think the family was happy? no. The family knew all about it just becaues they sat bedside 24/7. I had a one and one with the DON. Professionally I explained, I'd like the rataionale explained why? a new pain medication was held from a General Inpatient Hospice Patient.. the family is aware and they are ready to take thier complaints to where it matters...

These are mistakes made by LVN"s in a snf world. Not all are as simple minded as this. But I have a hard time taking the dtr who is on your first patient seriously. 1 year of nursing school has given her huge huge case of delusional grandeur.

Wait...What!? Wow. Ok then.

[JacknSweetpea]

NO matter what you do . Families often try to run the show. I have just accepted it. What is needed is a doctor with a pair who is willing to speak to the daughter and explain that although her input is needed, he write the orders. Period. I have NEVER met a SNF LVN who was capable of safely writing orders or think out of the box. I have seen SNF LVN's hold life saving antibiotics because the doctor didn't specifically write clearly enough a dose. I have seen them hold... meds for clarification and never call anyone. One of my hospice patients who had pneumonia, was probably going to pass anyway. Them holding a med, and calling the MD went on for 3 days! I had another SNF LVN who got orders for a Duragesic patch at 3:00 on afternoon. It was delivered at 8pm. It was held until the next morning to start at 9am....becuase that is how that SNF worked. Meds ordered scheduled times... started the next day at 9am. The patient had cancer. Do you think the family was happy? no. The family knew all about it just becaues they sat bedside 24/7. I had a one and one with the DON. Professionally I explained, I'd like the rataionale explained why? a new pain medication was held from a General Inpatient Hospice Patient.. the family is aware and they are ready to take thier complaints to where it matters...

These are mistakes made by LVN"s in a snf world. Not all are as simple minded as this. But I have a hard time taking the dtr who is on your first patient seriously. 1 year of nursing school has given her huge huge case of delusional grandeur.

While your post does have some merit, especially when it comes to certain policies in a SNF, but you are very insulting to us LPN/LVN's who go to work everyday and take excellent care of patients. Believe it or not....there's a few of us who "can think out of the box". Also, no LPN or RN should be writing any orders of any kind without consulting with a MD/NP/PA, or whatever. Do not judge all LPNs by the ones you've met. Besides, I caught an RN a few yrs. trying to start an IV with a luer-lock syringe needle. Does this mean all RNs are idiots? No, I don't think so. Keep your prejudices to yourself.

[RxOnly]

While your post does have some merit, especially when it comes to certain policies in a SNF, but you are very insulting to us LPN/LVN's who go to work everyday and take excellent care of patients. Believe it or not....there's a few of us who "can think out of the box". Also, no LPN or RN should be writing any orders of any kind without consulting with a MD/NP/PA, or whatever. Do not judge all LPNs by the ones you've met. Besides, I caught an RN a few yrs. trying to start an IV with a luer-lock syringe needle. Does this mean all RNs are idiots? No, I don't think so. Keep your prejudices to yourself.

Thank you for sticking up for the LPN crew here!!

[caliotter3]

Wait...What!? Wow. Ok then.

I wonder where the RN supervisors are when these footloose and fancy-free LVNs are doing all these things you talk about.