What to do when family says no to care?

mscsrjhm · Aug 29, 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......

The POA has the authority. You say that you are all for following the rules, but by ignoring the POA, you are not following the rules.

We all know and have dealt with the dysfunctional families. Not our business.

If the POA and Dr. said do not send patient, and patient was a DNR....

Maybe I am not understanding the situation.

Are there other persons nurses there who would witness/co-sign the directive from POA and Dr.? If so, it would no longer be a potential "your word against theirs".

You can be in more trouble for NOT following POA and Dr. orders.

Havin' A Party!, ASN, RN · Aug 29, 2004

Agree with the last two posters on this.

mlolsonny · Sep 10, 2004

We have a Comfort Care Directive that the family signs when they are requesting limited care. It covers DNH, no antibiotics, no suctioning, no turning, etc. It's a checklist format so they can decide what they do and don't want. It's difficult to broach with some people, but when the end is near, we have to cover ourselves too.

It's a comfort to not only the family, but also the staff. It lets us know exactly what they expect from us on several issues.

Hellllllo Nurse, BSN, RN · Sep 10, 2004

To the Op-

Can't you call APS on this?

Explain the situation to them. Maybe they can advise you.

allnurses Guide · Sep 10, 2004

Try getting more comprehensive pain control for the chest pain. Have an MS order available, or GI cocktail (lots stronger than mere mylanta). If comfort measures are all you're "allowed", get all of them you can!

As far as the getting out of bed, try calling the state omsbudsmen, whose job it is to look out for elderly folks that aren't receiving adequate attention to their problems. If your social worker doesn't know her job well enough, the omsbudsmen certainly will.

ktwlpn, LPN · Sep 10, 2004

I don't understand the problem here-you have a clear DPOA/POA.....It is well within the families right to withhold any type of treatment..I have residents whose families want them up every day no matter what and others never want their loved one out of bed...It is not UP to ME....and I don't judge them or make any assumptions...Carrying out an advanced directive is a great gift to give to a resident and their family-but it often means that you as the nurse must surrender all control..that is hard for some of us..Isn't it possible that the resident is MORE comfortable IN the bed? And who knows what kind of family relationships these residents have had thought the years? Maybe they were the relatives from Hell-so what? That has no impact on the care we give them....Let their survivors count that money-good for them...I used to get SO upset over this type of scenario-until I experienced losses in my life and learned some lessons....We can't CONTROL anyone-we can only care for them to the best of our ability-it makes no sense to waste your positive energy in such a negative way-and it leads to burn out.....I have had end stage dementia residents fracture hips and stay at the nursing home with comfort measures---the key is pain control....Make sure you have some roxanol in your emergency med box......no one should have to suffer...And further more-if the POA has made a decision it is up to you to support it-if you knew the resident was not to be transported to the hospital you should not have asked her if SHE wanted to go...If that were my mother I would have your job for that...

hipab4hands · Sep 10, 2004

a family member came in angry because every since I have been at the Nursing Home, her mother has been out of bed everyday. She said her mother is old and dying and she wants her left in bed. This women has no actue disease. She has an old CVA which leaves her in a semi-vegatative state. Once again, the MD agreed that we would never get her out of be again.
_________
I hope that physician has his malpractice insurance paid up. Wait until the woman gets bedsores and/or pnuemonia. The daughter will be the first one complaining of poor care and hiring an attorney.

CapeCodMermaid, RN · Sep 11, 2004

We have a Comfort Care Directive that the family signs when they are requesting limited care. It covers DNH, no antibiotics, no suctioning, no turning, etc. It's a checklist format so they can decide what they do and don't want. It's difficult to broach with some people, but when the end is near, we have to cover ourselves too.
It's a comfort to not only the family, but also the staff. It lets us know exactly what they expect from us on several issues.

Your comfort care has a "no turning option"? I've been a nurse for more than 20 years and I've never heard of such a thing.

renerian, BSN, RN · Sep 11, 2004

I have read through all the posts. I do agree that if the patient has a POA and they don't want her OOB I can see that. If there is a DR. order I can do that. What I would not feel comfortable with is not turning. I think based on practice that would be negligent. I am not a lawyer so I cannot interpret that piece but I also have never heard of a DNR with "no turn specifications". Yes do remember if you notify the doc of chest pain and document request to send the person to ER and that request is denied, you are covered. Document it as such.

On another note, having been a POA I did set specifications in place to keep the stimuli as low as possible/ie)painful procedures and such. If I set care and doc agreed/ordered I would not have been happy at all if someone went against the orders for care. Use all the tools you have orders for/ie)mylanta, NTG and if those don't work, I would call and conference with the doc/document your request to send based on your assessment and interventions that failed and document your orders from the doc. This would cover your ethical debate legally but may not help your feelings of ethics personally. I think we all run into ethical debates for which there could be several different interventions based on our own thoughts. For ethics there is no right or wrong responses since frequently they are matters of individual thoughts/opinions.

Does that help?

renerian

pricklypear · Sep 11, 2004

I could understand the "no turning" if the patient was actively dying. I mean within hours of death. There is no point in moving them at that stage unless they are uncomfortable. To not repostition someone who could live days or weeks would seem to cause more potential discomfort secondary to pressure points, stiffness etc.. as mentioned in the above posts. I also agree with the posters who stress the importance of following POA wishes, no matter whether you agree or not. There is only so far that our advocacy can go. It's the hard part of nursing.

ktwlpn, LPN · Sep 11, 2004

a family member came in angry because every since I have been at the Nursing Home, her mother has been out of bed everyday. She said her mother is old and dying and she wants her left in bed. This women has no actue disease. She has an old CVA which leaves her in a semi-vegatative state. Once again, the MD agreed that we would never get her out of be again.
_________
I hope that physician has his malpractice insurance paid up. Wait until the woman gets bedsores and/or pnuemonia. The daughter will be the first one complaining of poor care and hiring an attorney.
If the resident is being kept clean,dry and repostioned she could live for YEARS without getting out of bed..(and many do) She will NOT get pneumonia or bedsores... In this case no one is saying leave her there flat on her back...as for the advance directives with the "no turning" option that is common in hospice...In the last day or so of life the repostioning can cause more discomfort in the actively dying patient....

hipab4hands · Sep 11, 2004

If the resident is being kept clean,dry and repostioned she could live for YEARS without getting out of bed..(and many do) She will NOT get pneumonia or bedsores....

"If" is the main factor here. We know how understaffed most LTC are. I get calls daily regarding geriatric patients in care facilities, who get minimal care. A lot of times, the families are not notified of their love ones condition until the patient needs to be hospitalized. In my experience, bed sores and pnuemonia are the two main factors for patients in care facilities being hospitalized.

Hopefully, the family will keep on top of the patients care, so she doesn't experieince these problems.