Patient's family

[Lahryn04]

I just wanted to share an incident that happened recently at work involving myself and a patients family member. I don't know how you all feel, but personally I'd almost always rather deal with a needy/grouchy/mean/annoying, etc... patient than their family. Anyway, here is a bit of background. I work on a surgical floor, mainly ortho but we do get random other surgical patients. This patient in particular was actually an abdominal sx and in his 50's. I started taking care of him from the second day he was admitted. At that time he had already had one sx and was feeling pretty awful. His color was terrible, he ran a high fever on and off, and had lost quite a bit of blood. He just felt awful and you could tell just by looking at him. He was the sweetest man and was truly scared of what was happening to him. He was my most critical patient that night (and pretty much the most critical that whole week) and plus he had no visitors. I made a point to make sure he had what he needed whether it be pain/anxiety medication, a warm blanket, or just someone to talk to. We definitely had a good rapport and I really cared for this man and his well being. I felt I went above and beyond when it came to his care. Now lets fast forward to the end of the 2nd week of taking care of him. He had had 2 more surgeries but actually was doing better than he ever had. I finally got to meet his wife for the first time. This is where the problem began. I had gotten to work at 1900, made my rounds (she wasn't in the room at this time), and then started my assessments and first med pass. I was in another room when a coworker called me to let me know that this patients wife was out in the hall demanding to see his RN and that her husbands pain meds were late. First of all that idea of PRN medications being late is just ludicrous but I know lay people have a hard time sometimes understanding that concept. As soon as I was finished in the one room I went directly to his room. That's when his wife unloaded on me, telling me I'm a crappy nurse and that he told her I did this to him last night and wouldn't let him have his meds on time, and I had better go get them right this instant and he better have them again earlier than 2 hours because I made him wait etc... Mind you this PRN media was only 15 min "late". The whole time this is going on the patient is sleeping peacefully. I went to go get his meds and broke down in the med room. I don't think I would have so upset if I didn't have such a good relationship with this person... I felt hurt, betrayed, lied to, and only about a foot tall. This really crushed me. My coworker ended up giving the pain meds and apparently said something to the wife about the way she had treated me. By then the patient had woken up and was mad at his wife for doing that to me, which made me feel much better and by the end of my shift she was apologizing profusely. I know it's a scary time for patients and families to be so ill in the hospital but I was just wondering if anything similar has happened to any of you, how it made you feel and how you handled it? Oh and I do apologize for the book I have just written!! :-)

[SaoirseRN]

I think you hit the nail on the head there with your last few comments -- it sounds to me as though she was reacting out of fear/concern for her husband, and possibly a little guilt, too, if she hadn't been in to see him the previous week while he was so ill.

I know she took you by surprise, and forgive me but I'm going to offer a little bit of advice, and that is to stop the tirade before it escalates. Hold up your hand, and say firmly, "Please stop, and we can calmly discuss this." or something similar. Being scared does not give her the right to unload on you, and you have the right to stop it. Often just the interruption is enough to jar them from their emotions and make them stop and listen to you.

That said, yes, I have had situations where this type of thing occurred, and I found when I did as I suggested above, it helped in most instances.

Case 1) I cared for a pyelonephritis patient (she was probably just 18, old enough not to be in peds). At the beginning of my shift, she asked for pain meds. She was due for both morphine and ketorolac, so I opted to start with the ketorolac. The mother arrived shortly thereafter, and started to yell at me about why would I not give morphine, etc, etc, that the ketorolac didn't work, etc, etc. I put up my hand and stopped her, explained my rationale (no reports stating that ketorolac didn't work, patient didn't know which meds worked best, pain only 5/10, if anti-inflammatory will work, why use narcotics -- and I could still give the morphine if needed). I said, I made a judgment call based on available information, and if she is still having pain I will be more than happy to bring her the morphine. Then said, when you speak to me like that, I find it very disrespectful, and I would appreciate if next time we could have a calm discussion.

After that, we got along just fine.

Case 2) An elderly patient with no known dementia and a suspected delirium (which we later determined was related to the odd combination of medications her regular doctor, who didn't have hospital privileges, had her on for an arthritic knee). She had been doing okay cognitively much of that day, though I had noticed some sporadic increases in confusion throughout the day. She had a large group of family in to visit for the afternoon, who had to step out while I assisted her with toileting. They went back in, were there for maybe half an hour longer, when the grandson (a tall, sturdy young adult) stormed toward me, yelling, demanding to know what I had given his grandmother to make her so confused, etc, etc.

In this case, I put up my hand and said, very firmly, "Stop!" because I could not get a word in over his yelling and accusations. He stopped. I explained that I had not given her anything, that this had been happening through the day (though they knew this in theory), and that the doctor was aware and looking into the problem.

Case 3) A demented man with limited mobility who liked to kick/punch/hit us at times and was only aggravated by his wife's presence. In this case, the wife routinely told us we were torturing him, we were mean, we were this and that and the next thing because we wouldn't A, B, C, or D. No amount of telling, asking, suggesting, or explaining would make her stop this behaviour. We eventually had to start calling security and having her escorted out whenever she started into the nurses. Even her daughter said this was how she had been her whole life.

[missnurse01, MSN, RN]

I tend to give them my assessment of the situation in the spot. 'Look I know that the Pt has been a strong independant person and also that you have cared for them for years. I know this is very difficult for you because you can not make them feel better. you need to do something to contribute or feel that something is in you control right now. This is why you are focusing in x , y and z. Lets make a plan together so you can feel that you are caring for your loved one. Here is the plan of care for whatever issue it was. I want you to see how we are following the plan and meeting the needs of your family member....'

Often as soon as I point out why they are so upset , they completely de-escalate. Then the rest of the conversation is me just reassuring them. People don't see themselves well , esp when all stressed out .

I agree with setting limits for verbal abuse. We have to do it more with pts than families but it works for both.

Good luck.

Sometimes I leave when they are freaking out just to get other nurse to witness the abuse in case they go to management and it's your word at aagainst theirs.

[jadelpn, LPN, EMT-B]

First off, your patient was asleep. I would have pointed that out to her, state that your assessment is of the patient when the patient requests pain medication. That the plan of care for her husband is that when he is feeling pain, he requests medication, and currently that medication can be given every "X" amount of hours. I also would be QUITE sure that the patient WANTS the wife to have any of his medical information. If he does not, I would have just said, currently your husband is asleep. I have been his primary care nurse for 2 weeks, and it seems as if the treatment plan currently in place has worked well for pain management. You are welcome to have your husband speak with his doctor if his treatment plan is not working for him. Period. Then if she continued, refer her to your charge nurse. Seemingly, you became a bit attatched to this patient. Be really careful with that. It is a theraputic relationship, not a personal one, therefore, the wife's comments hit closer to home than they usually would. Document accordingly, don't be afraid to involve your charge nurse, and keep professional distance. The reasons that the wife did not come until week 2 could be all sorts of family dynamics which I would stay far out of. Your responsibility is your patient, and not his wife.