What to do when family says no to care?

[juley0129]

I am resigning from my position at the Long Term Care Facility where I have been working for the last two months. They have had 4 DON's in the last year. I was already disgusted because they have no on call RN's and inadequate CNA staffing and I was having to go in to cover shifts on the weekend. (CNA's and Nurses). The day I put in my resignation was last Tuesday, when at a Care Plan Meeting, I called:the family member didn't want her mother sent to the Hospital anymore for chest pain because she is "old and has a demented mind". This women is ambulatory and eats a regular diet, but she has Alheimers Disease and is very confused. The daughter has Legal Papers saying she has power over medical decisions, but that doesn't include Emergency Care, Does it? The MD agreed with the daughter and said we wouldn't send her out to the Hospital anymore. Today, 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 don't think I am going to work until my resignation is up on Friday. What are your thoughts?

[mlolsonny]

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.

...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....

The actively dying are the only residents that I have seen that option used for. It is included only to cover our rears, just in case.

The LTCF that I work at wholeheartedly embraces the Hospice philosophy. We are taught from the beginning that death is a part of life and "it's ok to die." I'm sure we have all seen situations in which the death was such a blessing. 90%+ come in as DNR/DNI and our social workers are very good about helping the family members accept the inevitable.

BTW, I work on-call at another facility that is a polar opposite to my full-time facility.

[ktwlpn, LPN]

"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.

i am thankful to say that i don't work in a facility like that-we have a policy that states we must inform the first contact of any change in a residents condition or any med changes-we have all leanred that open communication with the loved ones is the key to a harmonious relationship....in this area a decubitus ulcer that developes in the ltc is a sentinel event and is reported to the dept of health.they do follow up investiagtions on these reports-we have had 2 ulcers develop at our 250 bed ltc in the past 3 yrs-the others came from home or acute care with them....often we are unable to reach the first contact when there is a change in their loved ones condition-we will leave messages asking them to call us back and they often neglect to do so...they are also invited to the quarterly ,yearly and "significant change" team meetings and many do not bother to attend.....nor do they visit regularly-but when they come in they are surprised at "mothers sudden change" there are many good ltcs.....

[ballet_enya]

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.

Yes, this is correct........I have had residents with do not hosp. the family did make the decision, one included no ER...that person had a bad heart problem that no surg. (not that she could live through surg) could help.....we did comfort measures in the facility when she had chest pain.......so........you as a nurse do not have the power or responsibility to over ride the family in this case.....you need to get ahold of some legal material and do some reading............

[ballet_enya]

about the lady staying in bed...........try to get the family to understand the importance of her being around others.........we don't know what can and is heard........if they have durable power for health care, i would have then sign a shared risk..making sure that they understand the dangers etc.........i have a lady now who is alert and she chooses to stay in bed all the time......up for showers only.........this is her choice........we have it care planned that way too.........

[snowfreeze, BSN, RN]

Educate, educate, educate. When that fails, do what is in the best interest of the patient and Document, document, document. Call the doctor and arrange an ethics meeting if needed.

End of life issues are difficult for some nurses and some families and of course for some patients.

Where I work there is a document in the front of the chart that tells us what the wishes are. I work in LTC, we deal with death a lot.

Comfort for everyone involved is an issue for me, patient first, nurse second, family and friends next then the rest of the world.

I document a lot more when there are 'issues' involved. These are usually family dynamics.

Be firm with your decisions and don't waver....It is tough with manipulative people who have practiced manipulative behaviors longer than you have been alive. But above all

BE A PATIENT ADVOCATE AND STICK BY THAT AND DOCUMENT IT. NO one can bite you very hard for that.

[Mister Chris, MSN, NP]

I am resigning ...........:the family member didn't want her mother sent to the Hospital anymore for chest pain because she is "old and has a demented mind". This women is ambulatory and eats a regular diet, but she has Alheimers Disease and is very confused. The daughter has Legal Papers saying she has power over medical decisions, ............... What are your thoughts?

Hello fellow dementia care and aged care workers - How many times have you heard this sort of story? My main answer is document everything, I mean everything - that is all that the relatives say and what you did. Right from the admission through to the end. This is extra and anoying work but it will see you through court - successfully.

I have been in a few positions where this sort of thing has happened and the worse did happen - but in the end it exposed the relatives for what they were doing, that is "Granny dumping" and most with big guilt complexes. It also exposed that maybe the MD could have intervened correctly and backed up the nursing staff!

I could say it is just part of the job - I should not be. So, educate where relatives agree to listen and document everything.

This thread seems to cover many fantastic answers, you could print it out and make good use of the information for the future.

Lets all keep well up on our nursing ethics (and document detail) and maybe we can by example change some relatives attitudes and also get through to some of the doctors?

Thanks for all your input You make I am sure a lot of nurses feel a little better and not entirely on their own.

Mister Chris.