Telling it how it is.

[twistedpupchaser]

I have a question for everyone here and fully expect vigorous debate as well as some cranky remarks but here goes;

To start with I am a caring nurse and I don't want anyone construing my post to mean that I am not compassionate or lack empathy for my Pt's. I have found that I have recently started telling some of my Pt's the truth in a blunt manner laced with humour at times, with surprisingly good results.

Examples of this are: telling a Pt that if he didn't start with the exercises physio were giving him he might as well turn into compost, (this Pt instead of being home with his family was still in too much pain to move, this to the point we considered pressure area care until he was found sitting up to watch the football around a conveniently drawn curtain). He started doing his exercises with no further prompting.

Asking another Pt if he wanted me to pre-book his room becasue he would be back within the month. He was heard bragging about what he was going to do as soon as he left "this ......... prison" - no my ward is not that bad.

I have come out with these and a few other remarks. These Pt's are those that I have cared for and gotten to know and have felt comfortable to tell them. I was overheard by another nurse who said that we can't be blunt because it comes across as judgmental, I feel that whatever works (within reason) should be used in our Pt education, isn't this part of our advocacy role?

What does everyone here think?

[beachbum3]

Reminds me of a pt I had last week...just a mean and nasty guy... nothing was good enough, everything was a bother, but yet he wouldn't allow us to do anything to try to alleviate what ever his issue was .. ie.. complained his bed was wet, but refused to allow us to change it. He would be moaning and groaning in his room, and tell his room mate how much pain he was in, but when I'd go in and ask him if he was having pain he would just get annoyed and tell me to take my pain pills and stuff it. (even though I hadn't even gotten the pain meds out of the pixis. I was just going to offer) He wouldn't let me take his blood pressure, pulse ox, do an assessment... nothing. He barely took his meds. I'd go in to give him meds, and he'd get all annoyed and huffy. At one point at about 2 am, after he'd been throwing me out of the room all night, he called his daughter in law to tell her how they needed to come and see how he was being treated, and that he was laying in a wet bed, SOB and having pain. (He hadn't even attempted to tell anyone, just threw us all out of the room, and calls his family) The DIL calls the nurses station, but knows how he is and was very apologetic. So I reported this to the dayshift nurse. When I came back that night she reported that she went in there and he tried the same crap with her and she said "Then why are you even here?!" he replied "I don't even know, I don't want to be here in the first place!!" so she said "Then get your shoes on and sign out and go!"

I had him 3 more nights after that and he was like a different person!

[NurseyBaby'05, BSN, RN]

There's a difference between being straightforward and using "just being honest" as an excuse to be a jerk. The former needs to be done. There's no reason for the latter. You have to assess the needs of each patient. For some, the old adage about catching more flies with honey than vinegar holds true. It goes back to the Nursing 101 lesson about individualizing care.

With my Onc patients, I find I'm able to be straightforward with them when a lot of people won't. We see a lot of the same faces over and over. They trust us. I find I'm often one of the first to have a frank discussion about code status with them when others "don't want them to give up hope." I tell them that it's not like on TV where DNR is syonoymous with Do Not Treat. They can still be treated, but if they go in their sleep that that is not a bad way to go. I ask them if they want to be brought back to suffer for a few more days, weeks, months only to do it all over again. Most of them say "I've never thought of that." Is it technically blunt and something that needs to be left up to the docs, probably. But it often facilitates the discussion with the doc that needs to be had.

[lovingtheunloved, ASN, RN]

Looking at your specialty, I feel I have to accept that your are reporting your experience accurately, but my own in acute care neuro/neurosurg has been nearly the opposite. I can explain to an AOX3 pt that bumping their fresh crani may have dire consequences, but I've occassionally seen well-meaning people turn a confused/agitated patient into a confused/combative one in the name of honesty. I suspect this might be a difference between chronic and acute confusion, say a recent CVA vs late Alzheimer's.

WAY different. The Alzheimer's patient needs simple, direct communication. This man needed to hear what would happen if he chose to walk alone. I also know my residents very well, so I know how to approach each one. That same statement would not have gone over well with another man I care for. You have to individualize communication to what each patient needs.

[nursemike, ASN, RN]

WAY different. The Alzheimer's patient needs simple, direct communication. This man needed to hear what would happen if he chose to walk alone. I also know my residents very well, so I know how to approach each one. That same statement would not have gone over well with another man I care for. You have to individualize communication to what each patient needs.

I've only had a couple of pts with known Alzheimer's. One was fairly early and "pleasantly confused." Would have been funny, except knowing what lay ahead for him. The other was late and tending to get mean. Neither was admitted for Alzheimer's, of course, since there's no making it better in a week or two. I don't readily recall what their admitting diagnoses were, but keeping them safe in bed wasn't much of a problem. The latter, though, was tough to get to take her meds. But it seems like I spent as much time caring for her family--really nice people under a ton of stress--as her.

Another nurse and I were once discussing that a CVA would be our least preferred COD, but now that I think about it, maybe not.

[nursemike, ASN, RN]

There's a difference between being straightforward and using "just being honest" as an excuse to be a jerk. The former needs to be done. There's no reason for the latter. You have to assess the needs of each patient. For some, the old adage about catching more flies with honey than vinegar holds true. It goes back to the Nursing 101 lesson about individualizing care.

With my Onc patients, I find I'm able to be straightforward with them when a lot of people won't. We see a lot of the same faces over and over. They trust us. I find I'm often one of the first to have a frank discussion about code status with them when others "don't want them to give up hope." I tell them that it's not like on TV where DNR is syonoymous with Do Not Treat. They can still be treated, but if they go in their sleep that that is not a bad way to go. I ask them if they want to be brought back to suffer for a few more days, weeks, months only to do it all over again. Most of them say "I've never thought of that." Is it technically blunt and something that needs to be left up to the docs, probably. But it often facilitates the discussion with the doc that needs to be had.

I imagine we all agree that individualizing is crucial. A lot of time a little tact goes a long way, but sometimes you do have to be a little blunt. I do believe one must always be honest, though. I've had female patients who were pleasant, attractive, and a little overweight, comment on their weight problems, and it's hard not to give a gentlemanly answer. As a nurse, and a fat one, at that, I feel it's okay to assure them that they don't look bad, and I'm in no position to preach, but you can't let the teaching moment pass without offering suggestions to help and reinforce their desire to be healthier.

Another time I've found honesty takes some effort is when a patient asks whether they are going to die. This hasn't happened often, but when it has, it seems necessary to be truthful, without overstepping my scope.

An incident like this is fairly fresh in my mind, when a patient was having some fairly serious hypertension that wasn't responding to the meds we were giving. "We're working very hard to prevent that," was the gist of my reply, along with what we were doing and that I thought we had a very good chance of succeeding. In cases were the risk of death is less imminent, like a patient with a glioblastoma, I usually tell them their doctors are more qualified to make a prognosis and given them a chance to discuss their feelings about it. But, "You're going to be fine," is not an option.