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Case 2 - The case of the "difficult family"
You may read or listen to this case:
You are a member of the team on a floor that often cares for people at the end of their lives. The ward is especially busy at this time and, as is usual now, staffing is short.
One of the families on the unit is becoming increasingly challenging. The family is gathering to care for and spend time with their mother as the end of her life draws near. This woman has been widowed for 20 years and has 6 adult children, 4 of whom are in attendance at various times of the day and week. They never seem to be there all at the same time and often come after work or on the weekend. It is starting to feel to the team that they are all expressing different opinions/desires about end of life care for their mother.
One possibility is a team meeting. The team has recently restarted full team meetings each week to review the people receiving care on the floor. In the past these meetings were cancelled because everyone felt too busy. The team now knows that the time spent meeting together does result in better care from improved communication. They have also started using 5 or 10 minutes of the time to talk together about the stresses of doing this kind of work and the effect of budget cuts and short staffing. If nothing else they feel less alone and are coming to know one another as people and not just as roles on the team.
The team physiotherapist is concerned about mobility and impending skin breakdown. She also mentions the risk of DVT and compromised respirations from being slouched in bed all day.
The ward clerk expresses that phone calls from various family members are taking up too much time at the desk, and that the family members are taking their frustrations and fears out on the people answering the calls.
Representatives from nursing note that the patient seems very agitated at times though her pain seems well controlled and she is generally lucid. The nurses are concerned that the situation seems to be escalating and jokes that maybe the family needs their meds increased.
The resident physician who is new on the service says -- rule out metabolic causes of agitation, increase medications to increase sedation at night and get a psych consult.
The cleaning staff are not invited to participate in the team meeting but one longstanding member of the housekeeping staff is clearing old coffee cups from the table and windowsill in the room during the meeting. She listens with interest.
After the meeting the cleaner tells the charge nurse, who she knows because their children were in a play together last year, that this woman’s husband died in intractable pain of pancreatic cancer and that her youngest son is HIV positive. He had a period of time living on the street and experimented with injection drug use after being abused by clergy around the time of his father’s death.
The charge nurse looks at the cleaner with great surprise and learns that on the weekend after her children left, this woman was crying in her room and requested that her room not be cleaned. She thought the cleaner looked friendly and though she never said much she always smiled and was respectful. The patient invited the cleaner, a woman whom she had seen almost every day of her long admission, to sit with her for a few minutes.
The charge nurse thanked her profusely and invited her to the next team meeting. On checking the cumulative patient profile she realized that neither spiritual care nor social work had been involved in the care of this patient. They had both been absent from the team meeting so their lack of involvement went unnoticed by the rest of the team.
After meeting with the patient on a number of occasions and providing instruction in relaxation techniques the social worker also had the opportunity to meet a few of the children. Everyone breathed a sigh of relief when the social worker arranged a family meeting. At the meeting the woman and her family were able to express:
hope for an opportunity for reconciliation with son
frustration at not having all information available
difficulty with not being able to meet with members of the care team - never seeing the team all together made them feel like they were getting different opinions and inconsistent information
The team was able to understand this and expressed their appreciation for meeting with all of the family members at once. Both the team and the family appreciated having everyone together.
One of the children who was most able to come to the hospital during the working day was appointed as contact for the family and the social worker was appointed primary contact for the family when questions or confusion arose. They were relieved to know that they could access the input of all team members through the social worker.
This case is not really the case of the ’difficult family’ but rather the case of the missing information.