Vent: Dysfunctional Family Dynamics

[abundantjoy07, RN]

Why do some families feel the need to document every single interaction or occurence with their loved one? I don't understand why some families keep spiral notebooks and write down every vital sign reading, every medicine, every time the patient coughed or sneezed, and everytime anyone came in the room.

Last night I was talking to a family member and he had his sister on the line. Everything I said to the patient was relayed word for word to the sister. The family member in the room described me, what I was wearing and spelled my name for the sister on the phone line. He kept asking, "Are you a nurse? What kind of nurse are you? Do you give her medicines?"

When it came time to give medications...oh that was hell on earth. I'd tell the patient, I'm giving you Colace. Then I hear it from the family, "Colace! How many milligrams? 100 milligrams is too much! When is she going to have a bowel movement? Does she really need it? What are the side effects? Who ordered it? Will it give her gas? Will you give her pain medicine if she has gas pain? She wants Vicodin for gas pain. Call the doctor to get an order for Vicodin!" Then I had to hold on as the family discussed the medicine on the phone, which by now they were having a three way conversation. Every medication had this same response. The patient who was alert and oriented just wanted her meds but the family would refuse medicines for her. "No, she's not taking that! Give her a half of that. Call the doctor and see if she can take more of this. Etc, etc, etc."

The patient started yelling. She said she wanted the medicines like her doctor prescribed and not to listen to the family. But the family was so adamant and mean. I was caught in between a rock and a hard place. I felt threatened by the family as they treated the patient like she was completely ignorant and incapable of making her own decisions. It was like the patient was a 85 year old child. Even though she was pretty oriented and knew which end was up.

The patient then started complaining of dyspnea after arguing with the domineering family. Checked her sats, she was 90% on 2L. Then it started again. "90%! Call the doctor! Why is she 90%? Etc. Etc." So I call the RT for neb treatment for the patient. They started arguing over that! So I bump her up to 3L, recheck her sats and she's 100%. Family starts in again..."100%? Can't she go higher than that? 100% is not good enough! Give her Narco! She needs Narco!" I explain Norco is not for giving to patients who are satting fine. It's for pain control. Their response? "We don't care if Narco is for pain! We want Norco! Narco is for her breathing" I ask the patient are you in pain? She says no. Family doesn't care. They want it and they want it now. 1 minute is too long to wait.

At one point I had to step out of the room. I felt like I was unable to exercise my nursing judgement and provide adequate care. I wasn't able to interact with the patient as I wanted to because everything was blocked by the family. If I asked her if she was cold then the daughter who was on the phone with the brother and another sister would say, "No, she's not cold! Don't touch the air conditioner. You can bring her blankets but only one blanket and don't cover her feet!" Even small things like do you want a snack was dictated by people who really had no say so about what the patient wanted to eat or drink.

Everything I asked was answered by someone on the phone and not the patient. I felt like a servant and not a professional caregiver who obtained a college education and actually had some knowledge and could give input. When they decided on the breathing treatment for the patient I paged for the therapist but she was not quick enough to get to the floor. Mind you, we have one RT for our building who happened to be with other patients in ICU. I mean think about priorities... patient on a vent whos fighting the vent? Patient who's satting 80% on a NRM? Or the patient satting 100%? Hummm? It's like it didn't even matter that the RT was on the way it wasn't quick enough and it was like they were the only people in the hospital and others didn't matter even if the others were dead or dying!

What is behind this behavior? How can I deal with family members like this? I thought maybe it was me. I'm young and they think I don't know anything and can't take care of their loved one because it looks like I was born yesterday. I offered to have another nurse take care of the patient. That didn't pan out and they swear it wasn't me and told me not to be offended. But I was incredibly offended I have never felt so stressed or belittled.

[Magsulfate, BSN, RN]

THis has happened a few times to me. Your situation sounds very extreme and I am so sorry you have to deal with this because it can be very stressful. Just know that most domineering families will not act this bad, but you DEFINITELY need to use this as a learning experience.

FIrst and foremost you are there for the patient and if she is aaox3 and able to make her own decisions, then the patient has the right to make the decisions. IF she is getting distressed over the family's behaviour, GET THE FAMILY OUT OF THE ROOM. I know this may prove to be difficult, but figure out a good way to do this before it escelates. For example, you may want to say, could you please step out, we need to clean her bottom at this time and we need privacy for just a few minutes. You could even plan to somehow get them out of the room when you are giving medications. The patient is very well able to take them and be educated on her own medicaitons without the family in the room. Sure it might be considered decietful by some, but it is not illegal and my be the best thing you can do until the situation gets better. Just get them out. If you can't, then call the charge nurse or nurse manager immediately. The patient is competent, if you have to, you can get security to remove the family. That would be my last resort, but keep that in mind.

There are ways to deal with it at the moment it happens, once you do that, get on the phone calling the doctor, nurse manager, hospital ethics committeee, case management or anyone that works in the hospital who is in charge to deal with familes and patient care crisis. This seems to be turning into a crisis. When it is affecting the patient emotionally and physically there must be action taken .

There can be effective family involvement and there can be toxic family involvement. There should really be a meeting set up with the family and the healthcare team to address their behaviours. Sometimes they act like this because they are undereducated about the patient's care plan and sometimes it is because the family is just disfunctional. Either way, they must be told that this is not acceptable.

It sounds like that you would not be able to aleviate any of their behaviour by yourself but maybe someone of authority can get stern with them. Educate and tell them they MUST understand that they cannot act this way.

Nothing is wrong with them writing everything down. Sometimes families do this for different reasons, just try to ignore it. Also, with this kind of family, you have to be very careful what you say to them and DOCUMENT ALL INTERACTIONS on the patient care chart. Get an extra piece of paper and add it to the nursing notes if you have to. I have had to add TWO PAGES one time because I was documenting each and everything that the family said to me and to the patient that was witnessed by me. The behaviour must be documented along with the response that the patient is having to the behaviour of the family. Also anything that you do or say to try to help the patient. Pretty much, just document everything. In QUOTES.

[Magsulfate, BSN, RN]

I wanted to add one more thing. You are doing a good job and please remember to stay calm so that you can be more effective when you handle this. It was the right thing to do when you stepped out, and do it again if you have to, but just don't ignore this. it could get worse for the patient, and you are there to be her advocate. She needs an advocate very badly right now, it seems.

[PostOpPrincess, BSN, RN]

Patient is oriented.

Family is causing her to be distressed.

Kick them OUT.

Nicely, of course.

[PostOpPrincess, BSN, RN]

P.S. This won't be your only time dealing with control freaks. Give them what you can give them, but set limits.

Let them know the patient has the option NOT them...let them do what they want. They need it. Also, the other type of dysfunctional family is the type that wants to be your friend. Don't do that. You will be manipulated.

Good luck, and BTW, if you are easily offended, then learn not to be. You're making THEIR issues YOURS.

Let it go.

[Reigen]

I feel your stress and pain on this situation. This must have been a very difficult time for you.

When family or others interfer with patient care , you as the patient's advocate must inform your charge nurse, supervisior and the physician what has been happening. If the visitor/family member become distruptive, you can ask them to leave, and if they do not call security and have them escorted out of the facility.

We must follow physician's orders, or if we think that the orders are not the best, then we must speak to the physician and clarify the order. That is our duty and responsibility.

We will always have that type of situation happen, it is best to inform those in a postion that has authority to assist, when our explainations do not have the best outcome.

[mickey_RN]

I dont have a comment for the OP because Im still a student. I must admit these kind of stories send a shiver down my spine, but this site is wonderful, all of you guys provide a sounding board, and advice, and I am sure I will need some in the future, Thank you for helping all nurses, new and veteran. :)

[Zookeeper3]

No I disagree, never kick a family like this out, ever. Somewhere along the line, they have lost TOTAL trust of nursing an medical care and the link is broken. You can't ever fix this in one shift. This takes a team meeting with a plan of care with the family so they know that they are negatively affecting the patient care. Then in the meeting, a plan and an agreement is reached.. where all meds are reviewed in that meeting ONCE and the explanation given, with printed out handouts for them to read. This meeting is done with a nurse, a manager and the primary doc.

Upon this agreement, any changes will be discussed with ONE, one primary family rep, but the doc has the ultimate say, the nurse will not be questioned about meds and dosages again because they are printed out, the reasons well known in advance.

please trust me... if you tell family to leave, that lacks trust.. they will show their ass, refuse to leave as they have a right to and be more suspicious. Meet once a week and the goal is spoken... "our goal is that you gain trust in our nursing care of your loved one".... period....

This is hard work, requires the same caregivers... not the frequent "one hit wonders and high five it's not my turn".. to regain trust you must keep the caregivers the same as much as possible.

In return, management will support your holding your boundaries... I've been in here for 30 minutes and need to care for my other patients, last request now and I'll be back in an hour. If you can't make it, a back up buddy shows up and checks on the patient and family.

TRUST has been broken, it's NOT YOUR FAULT, but you are left with repairing it now and it can be done. Call a meeting ASAP, and do not hesitate to listen to a litany of complaints, then state... we have to start over... "what do you need from us".... as well as... "you are interfering with the care of other patients and we will not have that.

I've actually said..."do you realize that the nursing staff does not want to care for your loved one because of your behavior ... we need to fix this now"

[kellyc034]

Hmmmm.........

Are these people POA? No- pt is alert, oriented, and ******.

1. Tell the charge RN

2. Ask them to leave or allow the pt to make her own decisions.

3. Get the nursing supervisor involved.

4. Have security escort their butts right out of that room.

Document everything thoroughly and repeatedly.

This happens ALOT at my workplace. Family isn't doing it to be mean, it's just their loved one is in the bed and ordering you around is the only way they feel they have any control over the situation.

That being said, they are still hindering the pt's care and that is priority #1.

Kelly:twocents:

[Ruby Vee, BSN]

about the time i ascertained that the patient wanted the meds just as the doctor ordered and wasn't on board with all of the micro-managing, i would have asked the family to step out. then, with them gone given the patient her meds, taken vital signs or anything else i needed to do. family wouldn't be allowed back until i was finished.

the next time i entered the room, if the family was still out of control, out they go until i'm finished with what i need to do. after a few episodes of this, they'll either get the message or "fire" you as a nurse. (firing is nearly always a good thing! a family who wants to dictate which nurses "get" to take care of mom is a family i'm happier not dealing with!) believe it or not, there are nurses who feed into this type of behavior and get a charge out of it. let them take care of this patient after the family has "fired" you.

a little micromanaging on the part of the family, suck it up and deal. but this family sounds as if they're totally out of control and in dire need of some consistent limit-setting.

[Rabid Response]

Oh lord. I feel your pain. I have had families like this, too. One patient I saw during rapid response rounding had eight children, one of whom was always at the bedside. Every decision, even at 3am, had to be run by at least 3 other siblings via cell phone. And the family member at bedside was always frantic to the point where the patient would start to bellow. At one point the patient was yelling, "I can't breathe, I can't breathe!" over and over for half an hour (seemed to me she had plenty of breath to spare), and the son was literally running around the room with hands flapping. Her sats were 97% on NC, but I put her on an NRB at the son's insistence and called the senior ICU resident to the bedside. He ordered an ABG, but I could not draw it until the patient's entire family had been called and informed/asked. Mom would not even hold still for regular labs, started screaming before I'd even stuck her, and the son yelling, "STOP STOP You're hurting her too much!!!!" Finally, the resident had had enough. He popped back into the room to ask me if I had sent the labs yet, and I told him what was going on. He was a huge guy, probably 6'7" and 300 lb. He stepped in front of the son (who was again on the phone) and said, "Enough!!! Either you want us to treat your mother or not. We cannot stand here all night while you second guess every decision I make. Get out of the room and let the nurse draw labs or I'm cancelling all the orders and leaving her the way she is." My god, he was my hero that night. The son stepped out, the patient stopped screaming, labs were drawn (abg's WNL of course), and all was well until the next night at the same time when it started all over again.

Amazingly, I was this family's favorite nurse after this.

[phoenixrn]

No I disagree, never kick a family like this out, ever. Somewhere along the line, they have lost TOTAL trust of nursing an medical care and the link is broken. You can't ever fix this in one shift. This takes a team meeting with a plan of care with the family so they know that they are negatively affecting the patient care. Then in the meeting, a plan and an agreement is reached.. where all meds are reviewed in that meeting ONCE and the explanation given, with printed out handouts for them to read. This meeting is done with a nurse, a manager and the primary doc.

Upon this agreement, any changes will be discussed with ONE, one primary family rep, but the doc has the ultimate say, the nurse will not be questioned about meds and dosages again because they are printed out, the reasons well known in advance.

please trust me... if you tell family to leave, that lacks trust.. they will show their ass, refuse to leave as they have a right to and be more suspicious. Meet once a week and the goal is spoken... "our goal is that you gain trust in our nursing care of your loved one".... period....

This is hard work, requires the same caregivers... not the frequent "one hit wonders and high five it's not my turn".. to regain trust you must keep the caregivers the same as much as possible.

In return, management will support your holding your boundaries... I've been in here for 30 minutes and need to care for my other patients, last request now and I'll be back in an hour. If you can't make it, a back up buddy shows up and checks on the patient and family.

TRUST has been broken, it's NOT YOUR FAULT, but you are left with repairing it now and it can be done. Call a meeting ASAP, and do not hesitate to listen to a litany of complaints, then state... we have to start over... "what do you need from us".... as well as... "you are interfering with the care of other patients and we will not have that.

I've actually said..."do you realize that the nursing staff does not want to care for your loved one because of your behavior ... we need to fix this now"

Wow.... I'm printing this out. What a proactive and positive approach. Thank you!