The Family

[NurseKrissy]

I work in the icu where family members are given certain visiting hours but almost always fail to acknowledge them. My patient had spiked a fever while recieving ffp prior to a scheduled open lung biopsy for the next day. His wife, sister and mother were all in the already small room swooning over him rubbing his legs, up in his face. They were driving me crazy too, coming out the nurses station to tell me/ask me something every two minutes. I was getting so far behind, I had barely payed much attention to my other patient. I called the doc to notify him of the spiked temp and he instructed me to continue the infusion (given he had spiked temps all day and he was admitted for neutropenic sepsis secondary to leukemia) but I was just doing the cya thing in case of a possible rxn. I just could not concentrate with this family up in my face and up in my patient's face. I was fed up, walked in the room looked at my patient and asked him if he would like to sleep, he looked up at me like a sick child would look at his mother and shook his head yes, I felt so bad for him. How could he realize the situation was not conducive to his healing, his pulse was up in the 130's partially d/t his fever, but also his anxiety from these three women hovering. I looked at the wife and said- maybe it's time for you to leave. She looked at me like- how could you say that! But i guess something clicked in her head and she immediately complied with my request. So they gathered up thier things and the sister asked me 3 times if I would come get them if anything happened, as if i'm retarded or something. UGGGH! I just thought to myself if this guy codes you will not be the first thing on my mind! Shortly after they left his temp came down from a whopping 39.5 back down to 37 within two hours.....hmmmm... I wonder why. He actually got to get some sleep.

I just think it is fascinating how a reasonably stable situation can worsen tenfold when you are struggling with the family. Maybe I was harsh in asking them to leave but it was certainly in the best interest of my patient.

I understand looking at it from their perspective how the majority of their actions were emotional, however I can't get over how angry it made me.

Thanks for listening to me vent!!!

[Pamelita]

Don't you just love when 20 family members come in the room and don't want to move??? ha,ha we don't have visitor hours at all!! there is family members that come every day and stay from 8am until 6pm they do 12 hours shifts and then another comes in and since we are long term vent-facility we see them for months even years!!

What upsets me the most is when there are obese family members and you ask them to move so you can get through your patient and they look at you like saying can you just get by me????? like there is enough space??? they kill me!!

I always try to be nice when I ask them to leave the room, some people don't like it some people don't have a problem, but YOU are the nurse and you have the power to do it. I never forget that.

family can be the heaviest thing in an assigment..

[shoelace]

Wow, this was quite inflammatory. I agree with the consensus that NurseKrissy was just venting. I'm sure she took her anger out on the board instead of the family. Everyone knows that families show their concern in different ways, and even if they are showing it not to comfort the patient, but themselves, they are human and that's how it goes.

On the topic of visiting hours, my manager always says that the patient does not belong to us. They are on loan to us so that we can help heal them and we have no right to separate them from their families, unless THEY want it, which clearly your patient did. Our visiting hours are open, there is no limit except at the discretion of the nurse. There's no 10 minute every hour rule or anything. Of course we have had problems with some visitors, but we handle it case by case. Would asking the 3 visitors to stay in the room, but try not to bother the patient have been effective? I know that sometimes they simply don't listen, or would agree to comply only to restart 5 minutes later.

When I'm exceptionally busy, sometimes I tell a family that is demanding a lot of my time that I'm very interested in answering their questions, and that right now my main focus is on their loved one because they are requiring a lot of attention. I then assure them that when I get a few minutes, I will address their concerns.

Then I carry on with whatever I need to do with my patient and when I find a few minutes, I go straight to them and give them an overview of why I've been so busy with that patient and what I'm doing about it.

The key is telling them that you're interested/eager in helping them understand what is going on. Sometimes all it takes is 5 minutes of undivided attention to help calm them. Sometimes it takes more.

I agree with NightMoonRN in that in asking family to leave, they will sometimes respond to the old "go get rest so that you can effectively be here for the patient," and it is the truth... They do need to take care of themselves and just want to know that their loved one is being cared for.

Unfortunately, you had about 3,000 things to get done, and had another patient besides. We're only human. You did the right thing, both in asking the family to let the patient rest, and in taking your frustrations out in an arena that should be comforting and supportive.

[essarge]

I have been on both sides of the fence, plus I am a student nurse and working in the ER. I find when families are there, yes it is distracting, and yes, sometimes they are "in the way" but that's ok. I found that while I am working on the patient, explaining what I am doing while I am doing it, seems to help.

I've also found that if a patient's family is "hovering" I call the social worker who is on call or pastoral services (I do not ask the family if they want to talk to them) to come in and talk to the family to let them talk about some of their fears or concerns. Sometimes just having someone "different" to talk to helps and the people that I call never mind spending some time with the family, especially pastoral care.

I hope that your days are going better and you have found some way to resolve this problem. Oh, and by the way, I totally support you and understand the frustrations that you mentioned.

[BBFRN, BSN, PhD]

Originally posted by KRVRN

Our unit (NICU) is open 22 hours a day. Usually not a problem. A problem we do run into is that we occasionally have parent(s) that stay late into the night and snooze at the baby's bedside. We have trouble drawing the line. If they were awake and sitting there, there isn't a problem. But if they fall asleep then they truthfully shouldn't be there.

I don't know about this one. When my daughter was 6 months old and in the hospital, I stayed in her room with her 24/7. I stayed out of the way, but there was no way I was leaving. Of course I fell asleep, but, being a mother, I woke up every time she so much as made a peep. I changed all of her diapers, and fed her all of her meals. Who wants their baby to wake up in the middle of the night in a strange place with no one there?

[OHmom2boys]

Originally posted by KRVRN

Our unit (NICU) is open 22 hours a day. Usually not a problem. A problem we do run into is that we occasionally have parent(s) that stay late into the night and snooze at the baby's bedside. We have trouble drawing the line. If they were awake and sitting there, there isn't a problem. But if they fall asleep then they truthfully shouldn't be there.

When my son was in PICU after a brain injury I was asked to leave the room once. Very sternly, but politely asked to leave. My son was on a vent and was starting to wake from his coma and was fighting. The nurse (who was one of my favorites by the way for this VERY reason) told me to leave because my presence was upsetting him more. He knew I was there and wanted me to do something for him. Yes, it hurt to know my presence was what was NOT what my son needed, but I also understood that my leaving the room was the very best thing for him at that moment. Especially since she explained WHY I should leave.

As far as sleeping: I agree completely with KRVRN. Parents should not be sleeping in the NICU or the PICU. They would not let me stay in the room and sleep. As one of his nurses explained to me, if he would have coded they need to be able to get to him fast and they wouldn't be able to do that if I was sleeping in a chair by his bed. Completely understood that also...because of the nurse's explaination.

I think if you explain to the patient's family why they should leave, and how it would benefit their family member, you won't have a problem. I just hope my presence was never disgusting or angering to the awesome nurses who took care of my son, because I did ask a million and one questions the whole time he was there. :) But, I also stayed out of their way when they were caring for my child.

[LadyDee]

Well said Tolina, I couldn't agree with you more

[kidsccrn]

I have been on both sides of the bed let me tell you it's not easy! First my daughter was born in full arrest and then spent 8 weeks in the NICU. She has had many admissions and I am always there! Second my father-in-law was diagnosed with AML on a routine pre-op lab for a valve replacement (he was not at all sick the murmur was found at a routine physical) he died within 2 weeks of induction of chemo! Was I at the bedside, you bet, did I break the visiting policy, you bet because I was the only one he felt secure with. Everytime I left he would go into resp distress, I'd come back and he would settle down. The one night I left because he was intubated he arrested and died. I still feel the guilt that I left. As far as being a pain in the nurses eyes I probably was,however the care was less then even adequate. He was scared and there were several mistakes made like the wrong amphotericin was hung (it had another patient's name on it when I questioned it she said we do that all the time if his didn't come up we use another pt's) 5 mins later she came back to say it was the wrong dose!!!!!!!! Most of the time I spent holding his hand and letting him sleep. I was always out of the way of monitors, pumps etc. I very seldom asked for anything except ice chips.

I have been an PICU nurse for 21 years are there difficult families YES but 99% of the time it is fear. They are afraid to be left alone with the pt. for fear they are going to die. Kindness and information works wonders.

For the other 1% nothing you do is right or ever will be, they are usually the people who sit in front of the pump and when it alarms just sit ther and are annoyed when you ask them to move.

As for family prescence in a code I am very torn, if there is someone assigned to just be with the family fine but if the family is there with no staff to explain what is being done and support them I DO NOT AGREE WITH THEM BEING THERE. During a code it is stressful enough for the staff if you have a hysterical family there it makes it worse. I personally do not think I would want to be present I do not think I want to see my love one being pumped on, stuck, chest opened etc.

Sorry for the long post but families are a part of our job, not just caring for the pt.

[rncountry]

It is not a crime to ask a family member to leave the bedside. I have done it rarely in my career, but when I have done this it is because of what the patient needs. There are times that no matter how much you have explained to the family what is happening, how many questions you have answered or how much time you have spent with them, the family is not absorbing what is being said to them. And frankly there are many, many times that the family have not managed to realize that ultimately it is the patient who has to have their needs meant, not them.

When I worked in the neuro ICU years ago I had an 18 year old kid who had been in a bar on a false ID, who managed to pick a fight with the wrong set of people. He ended up with a severe head trauma. Family flew in from Chicago, mom and dad divorced. They would go to the nurse with, "tell my ex-husband this", "tell my ex-wife that" these two parents could not even manage to be decent when their son was hovering near death. The ultimate problem they simply could not manage to put aside their own needs to take a look at their son's needs. The mother would come into the room and rub his legs, and his arms. Crying or talking to him constantly. I would watch his ICP's hit 100 or more. For those of you who don't understand this, any intercanial pressure above 50 is causing damage to the brain. I repeatedly explained to her that she needed to be quiet, that she needed to please not rub his body at all. Educated her that she could sit quietly at the bedside and hold his hand as long as she wasn't rubbing his hand or making any type of repetative movement. But she just couldn't manage to do this. After a number of hours of dealing with this, I asked her to leave, and explained that her repeated disregard for the instructions I had given her was causing harm to her son. She refused. I called security and had her removed. Did this mean I could not understand that this woman was had fear? Or that I didn't understand that she simply needed to have a physical connection to her child? Or course not, I understood that well, I have children myself. But when it comes down to allowing a family member to do something that is obviously contraindicated for the PATIENT'S health regardless of the reasons or what the family member is feeling I fully believe it is up to the nurse who is EDUCATED to know what the patient needs and who has the ultimate responsiblity to protect that patient, to request that family members need to remove themselves away from the patient.

Talino, I am sorry about your own mom. Having lost my dad 2 and a half years ago after some terrible care and some things that should have been done that weren't, I think I understand your upset. Saying that however, what I see here is what in school we learned was transference. You feel that the family members were looked at as only a pain, perhaps the way you felt when no one was there for you when your mom was in ICU. Perhaps because of your experience in the ICU you are able to empathisize with family members in a way that other nurses do not. I know that because of the way things happened with my own dad I get angry pretty quickly when I see nurses who are not through with their own assessments on patients, it also led me to become vocal about what nurses need in order to do our job's appropriately. It may be that you have yet to run into a situation where you had to make a choice between the patient and the family needs, I don't know. I do however, know that this bb exists in part to allow a place for nurses to come in and vent, to ask advice, to ask for support etc... and while one can most certainly disagree with one another, it need not be done rudely. All of us learned how important family and the family dynamics for a patient is, and there are times I'm betting that each of us have dealt with families that we just don't understand where they are coming from. As long as what they are doing does not interfere with the ultimate responsiblity of taking care of the patient then there never needs to be a problem. But when that line is crossed, it is the nurses duty to step in and ensure that the patient is the center of care, not the family. Disagreeing with this is certainly your right, but again I say it need not be done rudely. And when a nurse is neglecting another patient in favor of spending time with a family that is not even the family of the neglected patient, than priorities need to be set. I agree with another poster, there are times when pastoral care should be brought in or social services to deal with these situations. As nurses we can't do it all, should not be expected to do it all. And no matter what our ultimate responsibilty is to the person who is ill and in our care. The ultimate responsibility is not to the family.

[baseline]

rncountry.......I , as usual, am in your debt for your eloquence. I've been looking at this thread for awhile now, wondering how to respond, and you just said it all for me. Thanks!

[igloorn93]

I too was an ICU nurse for mamy years before I switched to my first love (Psychiatry). I know of the difficult balance of what is best for the patient as well as what is best for the family. I have also been the family member of a loved one dying in ICU. It's a hard place to be both from a family members and a nurses perspective. I think you handled it approp. by asking the patient what he wanted and then gently suggesting to his family that perhaps it was time for them to leave. They obviously understood that you weren't kicking them out to be mean, but that you had the best interests of their loved one in mind. As for them asking you to let them know of any change, that is a very reasonable request and shouldn't have annoyed you. Yes, as his primary nurse your first responsibility is to him and trying to stablize him should something happen. In the ICU I worked in, we (the nurses) as a team all had a certain role to play during a code, and each knew our responsibilty. We always had a person delegated to go and inform the family that a change had taken place, and that the patients nurse (with whom they had formed a bond) would be out to talk with them just as soon as the crisis was over, and that we would let them back in to see their loved one just as soon as was feasable. This system worked really well for us, and generally we didn't have too many family problems. Most family memembers were very understanding and realized that we were only doing what was best for their loved one. Perhaps your unit could implement something like this.

[sphinx, BSN, RN]

I don't know. When I worked in the hospital I had times when the family may have gotten "in the way", but having been on the other side (ex husband with multiple serious health problems), I tried to be as accomodating as is possible, within the realm of pt safety as well as their wishes. I haven't worked in the hospital in a while though.

What I do remember is fresh in my head, from a couple months ago, as a patient. I wasn't in an ICU, so it's a little different than this scenario, but I was sharing a room with a patient who had a very overbearing family. The rooms aren't very large, and despite the fact that the woman was sleeping, several family members felt it necessary to be right there, no matter what. Not only was it disturbing to have the tv blasting (they were watching, not the patient), the constant chatter (the patient was so out of it she didn't notice, but I did), but the worst of it is, there was no room for all these people, so they were sitting on the floor, even directly blocking the door to the bathroom. Everytime I had to pee, I felt like I was imposing on them, asking them to move, as they would reluctantly scoot out of the way, then promptly sit back down, leaving me in the same pickle when I had to come out. (All this in my lovely designer gown with my rear end showing). I felt too yucky to protest, my husband had to go be with the kids (we had no babysitter), and I never saw a nurse to complain to......I wish I had a nurse who wouldv'e advocated for me and asked for some of them to leave. Yes, they have the right to be there, but considering she was sleeping, I don't see shy 1 or 2 couldn't sit with her, while the 3-4 others were in the lounge, and took turns watching over her. Instead, the whole clan took over the room, and I had no privacy, and no one to advocate for me either. When I finally saw a nurse, I signed out, called my husband, and had him take me home, where I could sleep, and pee without 6 people seeing my butt and having to impose on someone who is enjoying a nice sit-down a dirty hospital floor!!

OK, I just had to get that out. I know it's not really the same as the rest of the topic. Sorry all!!!!

[EmeraldNYL, BSN, RN]

Excellent post, RNcountry. I couldn't agree with you more.