What to do when family says no to care?

CapeCodMermaid, RN · Aug 24, 2004

Where is the social service department at your facility? The Health Care Proxy can make decisions for the patient, but it's supposed to be in accordance with the wishes of the patient.

We NEVER let anyone stay in bed unless they are actively going to die. We explain it to the family and unless they convince the doc to write an order for bed rest, we get them up.

juley0129 · Aug 25, 2004

Our Social Service person is brand new and has never worked in a Nursing Home. There is not anything in her papers about emergency care for chest pain, etc. I am at a loss as what to do. Also, I feel the same way you do. Every since I came to work there, everyone in the facility has gotten out of bed. This lady is not terminal. It is very frustrating when the Doc seems to do whatever makes the family happy. State is due this week for a follow up from before I came full-time, and I don't want to be there to explain these things to them that I don't even agree with.

Where is the social service department at your facility? The Health Care Proxy can make decisions for the patient, but it's supposed to be in accordance with the wishes of the patient.
We NEVER let anyone stay in bed unless they are actively going to die. We explain it to the family and unless they convince the doc to write an order for bed rest, we get them up.

LTC_LPN · Aug 25, 2004

Our Social Service person is brand new and has never worked in a Nursing Home. There is not anything in her papers about emergency care for chest pain, etc. I am at a loss as what to do. Also, I feel the same way you do. Every since I came to work there, everyone in the facility has gotten out of bed. This lady is not terminal. It is very frustrating when the Doc seems to do whatever makes the family happy. State is due this week for a follow up from before I came full-time, and I don't want to be there to explain these things to them that I don't even agree with.

I would definitely speak with social services about this situation. Even if a doctor writes the order for "comfort care only" - like they do when someone is gravely ill or failing, I would think that chest pain would be uncomfortable and should be treated. Evidently it's causing the resident distress? Does she have nitro SL? I'd try that if ordered, but if no effect, would send to ER. You always have to cover yourself and be responsible for your actions, so be ready. Then again, you never know.....if she had chest pains and you did nothing but let her stay in bed and she died of a heart attack, the family could always come back and say "why didn't you send her to the hospital?!?!" or "You did nothing to help her!" I've seen this happen before....the family will tell you one thing, then if something happens they "had a change of heart" or would file suit due against the home. But you're right for leaving the job...if the facility has no better structure than that, I'd leave too. I think the DON turnover rate would have been a red flag. However, you can always put in an anonymous call to the ombudsman for the nursing home with your concerns for the patient....they can step in and try to help do what's right, according to the patient/resident's rights!

juley0129 · Aug 25, 2004

Thanks for your input! That is why the daughter was mad (why I called a care plan meeting). I sent her mom to the ER after three nitro's did nothing for this women's chest pain. She says mom has reflux really bad and it hurts like He--.

They sent her back from the ER and said nothing was wrong, but I am sorry, if someone is crying out with chest pain and mylanta (which we did try first) and nitro doesn't help, they are taking a trip.

I would definitely speak with social services about this situation. Even if a doctor writes the order for "comfort care only" - like they do when someone is gravely ill or failing, I would think that chest pain would be uncomfortable and should be treated. Evidently it's causing the resident distress? Does she have nitro SL? I'd try that if ordered, but if no effect, would send to ER. You always have to cover yourself and be responsible for your actions, so be ready. Then again, you never know.....if she had chest pains and you did nothing but let her stay in bed and she died of a heart attack, the family could always come back and say "why didn't you send her to the hospital?!?!" or "You did nothing to help her!" I've seen this happen before....the family will tell you one thing, then if something happens they "had a change of heart" or would file suit due against the home. But you're right for leaving the job...if the facility has no better structure than that, I'd leave too. I think the DON turnover rate would have been a red flag. However, you can always put in an anonymous call to the ombudsman for the nursing home with your concerns for the patient....they can step in and try to help do what's right, according to the patient/resident's rights!

leslie :-D · Aug 25, 2004

i am not sure about the legalities of your specific case.

but i think what the family really wants is a do not hospitalize, which means the patient could be treated at the facility to the extent possible.

i am assuming this patient is a dnr already, therefore i would think getting a dnh would suffice.

have you sought advice from the medical director?

also, if you do have ethical problems with the family decisions, make sure you write a nurse's note regarding conversations, interventions and other pertinent data that would reflect your concerns.

leslie

txspadequeenRN, BSN, RN · Aug 25, 2004

My thought is this , These are the families that you want to run over!!!!! These little people have little to do as it is what is it going to hurt to get her out of bed. I am a alzheimers nurse and have worked in LTC a while. Have you as the nurse sat down with this family one on one and explained what happens when you stay in bed to long ,bed sores muscle deteriation etc..... There is such thing as a patient refusing to stay in bed... Talk to that damn dumb doctor and get that order dc'd. Well guess what about the heart patient , I one time had a patient have chest pain just like yours sent her to the ER ,they said it was heart burn . The son came to me the next day and said " Dont send her out anymore for chest pain cause it's probably just heartburn". Guess what this fat nurse told him. "Mr. SO and SO reguardless of how you feel about your mother having chest pain, if she has it she is going by ambulance to the ER for a evaluation PERIOD!" I futher explained that the one time I didnt send her ,she would have the big one. Then who would be at fault ,that's right me!!!!! I am not qualified to say yes she is having one or no she is not. My job is to evaluate the S/S and make a educated assessment, which includes the decision ,YOUR GOING TO THE HOSPITAL. I wish that once the families came gave me admission info they would leave and come back only when we do the D/C. I feel for ya hon good luck!!!

stsdoc · Aug 25, 2004

My thought is this , These are the families that you want to run over!!!!! These little people have little to do as it is what is it going to hurt to get her out of bed. I am a alzheimers nurse and have worked in LTC a while. Have you as the nurse sat down with this family one on one and explained what happens when you stay in bed to long ,bed sores muscle deteriation etc..... There is such thing as a patient refusing to stay in bed... Talk to that damn dumb doctor and get that order dc'd. Well guess what about the heart patient , I one time had a patient have chest pain just like yours sent her to the ER ,they said it was heart burn . The son came to me the next day and said " Dont send her out anymore for chest pain cause it's probably just heartburn". Guess what this fat nurse told him. "Mr. SO and SO reguardless of how you feel about your mother having chest pain, if she has it she is going by ambulance to the ER for a evaluation PERIOD!" I futher explained that the one time I didnt send her ,she would have the big one. Then who would be at fault ,that's right me!!!!! I am not qualified to say yes she is having one or no she is not. My job is to evaluate the S/S and make a educated assessment, which includes the decision ,YOUR GOING TO THE HOSPITAL. I wish that once the families came gave me admission info they would leave and come back only when we do the D/C. I feel for ya hon good luck!!!

It doesn't sound like any of you know the rules. When a person is incapable of making decisions for themselves (ie, in Alzheimer's), their power of attorney's wishes are taken just like they were the patient's, as long as they are fully aware of the consequences, understand what they are doing, etc. Failure to follow their orders can result in malpractice which sucks for everyone. The only thing that can be done is to counsel the patients family and hope they make the right decision. You can't forcibly treat anyone. It doesn't seem right, but that's the way things are.

NYCRN16 · Aug 25, 2004

I worked for 2 years at a LTC facility before working in the ER, and I would like to offer my opinion. When I was at the LTC facility, we would send the patients out with chest pain, and more often than not it was not an acute event. I was always scared that if the family refused to allow us to send the patient out (which happened frequently) and the patient had an MI that I would get sued, but when it comes down to it, there is not really much they can do to you. If the patient tells the nurse that they are having chest pain, and the nurse contacts the MD and tells him/her about the patients complaint and condition, and they decide not to send the patient out, you are covered legally. The family cannot come after the nurse for not sending the patient out, because you did not have an order to send them. If anything, the MD would be responsible. In addition, now that I work in ER, and I see what we recieve from the nursing home, I have to say, if the person is DNR/DNI there is not much we can do for them anyway! For example, what are they going to do in the ER for a patient in respiratory distress that has an order not to intubate? You are going to give them treatments and oxygen via face mask..Things that could be done in the nursing home, in the patients own environment.

On the second issue, about the family member wanting the person to stay in bed all the time..That is one battle that I would fight. There is no good outcome for a patient that is never taken out of bed, and I would certainly call social services for this one.

txspadequeenRN, BSN, RN · Aug 25, 2004

Rules Rules Rules,

Your not telling me anything about the rules I dont know. But you tell me the rules on how I am going to explain to the BON after I have let my patient die in front of me of a MI ,why I did not react with emergency care. Is this ethical, do you know a better way to handle this type of situation? This patient Im speaking of told me they wanted to go to the ER ,yes I do work in a alheimers facility. Yes ,she had a POA and he did not want her sent out again. But my admin set his *** straight real fast. These are the kind of families that have guardian services come in and take over. They also probably would be standing over her dying body counting her money. Would one consider this resident abuse of some sort? Are you familiar with the rules when you are standing in court accused of neglectfull nursing practices, letting a patient die or not seeking proper care .You and I both know families go with the side that produces the most money ,whether it be let moma live or let moma die.....

Let me add one more thing here I am all for following the rules, family wishes and what have you. And this has only come up once in my career, and hope to never deal with this BS again. The decision I made was send the resident to the hosptial because she was asking me to go. I more than anything am for making sure the resident is safe and well cared for. Most of these families dont surface until they think they are headed to the will reading ,or just making sure the patient is dead. I had one last week look at his moma (whom had just died) and said "Well I swear" looked at his wife and said "Lets go to the bank".

It doesn't sound like any of you know the rules. When a person is incapable of making decisions for themselves (ie, in Alzheimer's), their power of attorney's wishes are taken just like they were the patient's, as long as they are fully aware of the consequences, understand what they are doing, etc. Failure to follow their orders can result in malpractice which sucks for everyone. The only thing that can be done is to counsel the patients family and hope they make the right decision. You can't forcibly treat anyone. It doesn't seem right, but that's the way things are.

juley0129 · Aug 25, 2004

Thanks so much! The medical Director is the MD who keeps agreeing with the families. I have sat down with this lady about getting her mom up. She is very adament about leaving her in bed. She came once before when she was up and said something to be and I explained why we get her up and she seemed ok, but yesterday when the MD was there and she was up, she went balistic. I am just glad it's almost over. Thanks again.

My thought is this , These are the families that you want to run over!!!!! These little people have little to do as it is what is it going to hurt to get her out of bed. I am a alzheimers nurse and have worked in LTC a while. Have you as the nurse sat down with this family one on one and explained what happens when you stay in bed to long ,bed sores muscle deteriation etc..... There is such thing as a patient refusing to stay in bed... Talk to that damn dumb doctor and get that order dc'd. Well guess what about the heart patient , I one time had a patient have chest pain just like yours sent her to the ER ,they said it was heart burn . The son came to me the next day and said " Dont send her out anymore for chest pain cause it's probably just heartburn". Guess what this fat nurse told him. "Mr. SO and SO reguardless of how you feel about your mother having chest pain, if she has it she is going by ambulance to the ER for a evaluation PERIOD!" I futher explained that the one time I didnt send her ,she would have the big one. Then who would be at fault ,that's right me!!!!! I am not qualified to say yes she is having one or no she is not. My job is to evaluate the S/S and make a educated assessment, which includes the decision ,YOUR GOING TO THE HOSPITAL. I wish that once the families came gave me admission info they would leave and come back only when we do the D/C. I feel for ya hon good luck!!!

NYCRN16 · Aug 25, 2004

Rules Rules Rules,
Your not telling me anything about the rules I dont know. But you tell me the rules on how I am going to explain to the BON after I have let my patient die in front of me of a MI ,why I did not react with emergency care. Is this ethical, do you know a better way to handle this type of situation? This patient Im speaking of told me they wanted to go to the ER ,yes I do work in a alheimers facility. Yes ,she had a POA and he did not want her sent out again. But my admin set his *** straight real fast. These are the kind of families that have guardian services come in and take over. They also probably would be standing over her dying body counting her money. Would one consider this resident abuse of some sort? Are you familiar with the rules when you are standing in court accused of neglectfull nursing practices, letting a patient die or not seeking proper care .You and I both know families go with the side that produces the most money ,whether it be let moma live or let moma die.....
Let me add one more thing here I am all for following the rules, family wishes and what have you. And this has only come up once in my career, and hope to never deal with this BS again. The decision I made was send the resident to the hosptial because she was asking me to go. I more than anything am for making sure the resident is safe and well cared for. Most of these families dont surface until they think they are headed to the will reading ,or just making sure the patient is dead. I had one last week look at his moma (whom had just died) and said "Well I swear" looked at his wife and said "Lets go to the bank".

I agree with you that it is dispicable that some families do not care about the patient, and are just interested in any inheritance that they have coming to them. We as nurses must be advocates for the patients, but the families also have the right to refuse care in some cases. However, please understand that your license will NOT be revoked if you are put in a situation where you think a patient should go to the hospital and the doctor refuses to send the patient, as long as you CYA. For example, if the patient c/o chest pain, and you go assess the patient, take vitals and report to the MD everything that is going on with the patient (and document that you did so), and then MD says not to send patient to hospital, do XYZ instead, and something happens to the patient, then YOU as the nurse are not responsible for the poor outcome. If by some chance that the family decides to sue and you have to go to court, you will have thoroughly documented that you reported the patients change in condition to the MD, recommended that they get sent out, and followed any orders that MD gave you at that time, which did not include sending patient out. There you go. You did what you were obligated to do legally. If the patient does not have a DNR/DNI order, you can almost bet your last dollar that the doctor will provide the order to send the patient out, and you wont even be put in this situation. You have said that you are afraid that you will watch the patient die and not provide emergency care. What kind of emergency care can you render to a patient who is DNR/DNI?? It is a terrible feeling to see a patient with advance directives deteriorate in front of you and know that there is not much you can do, but this is a choice that the patients and thier families made. I have seen this in both the nursing home and the ER. That patient that you send out to us who is in severe respiratory distress who has orders not to be intubated will deterorate in front of us, just as he would in front of you. We can place oxygen via mask and give nebs just like they could in the nursing home. I would rather my family member have comfort measures in place and pass in thier own bed in a nursing home than in the ER as a patient that nobody knew. Maybe some of the families feel that way, although sadly, I am sure that a lot of them are just waiting for that payout. In a worst case scenerio the patient will go into cardiac arrest, but since you cannot perform CPR, what can you do? If they are deteriorating and you want to do something for them, provide comfort measures. Give them oxygen, pain meds, ect. Document that you did so. This will provide the patient with care they deserve, and cover yourself legally.