"Don't tell her why she's here"

[anashenwrath, ASN, RN]

I'm a student in my last semester, where we just do 12-hour shifts twice a week for a month. I chose to work on the hospice floor, since my goal is to become a hospice nurse. So far it's been an amazing experience!

Sunday night, just as I was wrapping up my shift, we got a new admission. The patient was an older woman who came in with her family. She did not speak English, but the family did.

While the nurse was out of the room at one point, the family told me that the patient did not realize where she was or why. Even though she was perfectly cognizant, she couldn't read the sign outside the unit that said "Hospice." And her children had told her she was moved bcs she was nasty to the nurses on the other floor and they had requested she be moved. So, basically, the family didn't want anyone to speak to the patient and reveal that she was in Hospice and dying.

I told them I would inform the nurse of their request, and that it was highly unlikely anyone would come into her room and casually mention death or Hospice. But it got me thinking: is this an ethical issue? It certainly sounds like Veracity to me. If this patient asks where she is or why she is here, what would I say?

I played it out in my mind, and decided that if I was put to it, I would say that this was a floor that specializes in pain management, and that she is here so that we can make sure she does not have any pain (the Hospice unit is also the Chronic Pain/Palliative Care unit). But I'm curious what nurses in the field do in situations like this. I'm sure there are similar instances that are probably much more dramatic than the one I experienced: how do you handle an issue like this?

[SoldierNurse22, BSN, RN]

If she is A&Ox3 and still in charge of her own care, yes, she has a right to know. Check up on her history, look for legal documents, talk with the team and think about getting a translator. This could be an ethics committee issue if the matter is further complicated.

[tewdles, RN]

Yes, you are correct that this is an ethical issue. The oriented and alert patient does have a right to that information. I suspect that she signed a consent at SOC which indicated her RIGHT to that knowledge. If she did not sign her own consent, then that is a different problem...given that she is alert and oriented.

Our hospice team would begin a social work intervention with the family to assist them in developing more realistic, helpful, and appropriate goals for their loved one. The interdisciplinary team should discuss this within their meetings to address this problem, setting appropriate goals and interventions.

Their bereavement status will likely hinge on how they move through this issue. Getting families to the other side of death with few regrets is important.

[anashenwrath, ASN, RN]

Thank you both. I'm realizing this was a much more serious issue than I first thought. I go back on Saturday, and if the patient is still there I'm definitely going to look for more information and discuss with the nurses.

I'm realizing this was a great opportunity to do further assessment. I had assumed (bad, anashenwrath, bad!) that the family was trying to spare their mother. But there could be a variety of reasons they don't want to tell her, some reasons may even be not-so-honorable. But most importantly, it comes down to whether or not SHE would want to know.

Now, maybe she specifically said to her family that she never wants to be told if she's dying, but it was my job as the nurse to find that out. I should have first assessed the family and investigated why they don't want their mother knowing, then I could have provided teaching where necessary and clarified my obligations.

Ugh, I feel kind of gross about myself. Lessons definitely learned.

[tewdles, RN]

Don't beat yourself up!

[MomRN0913]

We do not sign on patients without them knowing they are on hospice if they are awake, alert and oriented. I had a patient on homcare who we were trying to transition into hospice. His daughter (who is a social worker) did not want us to tell him he was on hospice. He wouold get upset if we were to talk in the other room and he would say "Speak in front of me, it's my body you are talking about"

I discussed it with the team and ethically we could not sign him on without telling his to some extent.

So, a another hospice (won't say the name, it's kind of popular in my state) took the case because they will take anyone because all they see is $$.

I found one of the hardest challenges in hospice is ethical issues. They are not so black and white.

Good luck to you!

[Ginapixi, BSN, RN]

we live in such a fake world!

most patients know very well that they are dying! some may deny that fact, but they know once hospice is involved.

Some families try to spare the patient, some patients try to spare the family, but the longer one works in Hospice the more one realizes no one is spared that way; so yes SW to the rescue!

it sounds to me like the woman neither reads nor speaks English, so you also have cultural believes to consider....

[heron, ASN, RN]

Hmm ... I'm struck by the story the family told the pt. re the reason for transfer. Did they really tell her it was her fault she was transferred, because she was "nasty"?

I agree that sussing this out is way above your pay grade ... SS and the interdisciplinary team need to sort it out. The lady may truly be a nasty person and the family felt they could not deal with the way she would be likely to react to a terminal prognosis. Remember, our "unit of care" is the patient and their family of choice. With dysfunctional family dynamics, the balancing act is a tricky one.

I think your decision to look for more info and discuss w/ nurses is a wise one.