Troubling mother-daughter dynamic
I'm a hospice nurse caring for an 82-year-old inpatient. Although she may have only a few months to live, she's alert and cognitively intact. Her daughter visits daily and sits for hours at her mother's bedside, gently adjusting the covers and pillows, swabbing her mother's mouth, and performing other personal care. I often hear her mother scold her, loudly, for “marrying that loser” and “ruining her life by dropping out of college.” Yesterday I was in the patient's room when she took a swipe at her daughter and told her to “get her sorry self” out of her room.
I'm tempted to talk with this patient about her behavior, especially after seeing her nearly assault her daughter. Is it right for me to initiate this type of conversation?–S.B., KAN.
If you haven't yet, share your concerns with the hospice team about this patient and the family dynamics you've observed. Consider that this may be a longstanding communication pattern between mother and daughter. Attempting to change deeply ingrained patterns like this may be counterproductive. On the other hand, reconciliation in relationships can be a valuable part of the dying process.
Your hospice chaplain and/or a family counselor can help assess the situation. Then with their insights, approach your patient and her daughter separately to gently discuss whether either of them has an ideal for the relationship at this point. What changes, if any, would be most meaningful to them? What do they hope for? Encouraging your patient and her daughter to reflect on these questions could be the first step in bringing about a meaningful reconciliation.
But don't be the Lone Ranger in this process. Draw on the insights and expertise of all the wonderful resource people on your hospice team for help.
Concealed medications raise concerns
Is there an ethical way that I can let my patient know that I don't think she's telling the truth? Glancing in her room from the hall, I saw her take two prescription containers from a small handbag and swallow a pill from each one. I was about to confront her when a surgeon stopped me to discuss another patient. By the time I returned to the patient's room, the handbag was out of sight and she was sleeping.
During medication reconciliation, she denied taking any prescription medications. How should I handle this?–M.V., WASH.
First, immediately assess the patient, including obtaining vital signs. If indicated, summon a rapid response team or a code team to treat a possible drug overdose.
If no immediate emergency exists, share your observations and concerns with the patient's healthcare provider, who may order a urine or serum drug screen to assess for the presence of substances that haven't been prescribed for the patient. Complete an event report according to facility policy.
Also inform your nurse manager and clarify facility policies that apply to this situation. Could your patient be using these prescription containers to conceal a dependence on illicit drugs? Because this is a common type of problem, many hospitals have a policy and procedure for searching patient's belongings. These policies legally balance the patient's rights with the hospital's obligation to protect the patient. Even if the drugs in the bottles are properly labeled, combining them with other medications administered during her hospitalization is potentially dangerous.
If administration decides to invoke the policy or if your manager wants to question the patient further, an “intervention” approach is best. Several people (often the unit manager, a security team member, healthcare provider, and an addiction counselor if appropriate) meet with the patient and discuss their concerns, informing her that she was observed taking medications from prescription containers concealed in her purse and not reported on admission. After explaining to the patient why self-medicating is dangerous for her and isn't permitted at the hospital, they'll let her know what actions could be taken, including searching her belongings, limiting visitors, assigning a safety companion, and initiating treatment for drug use or abuse as indicated.