1. Reigle, Juanita MSN, RN, ACNP-BC


Listening for the hidden questions of patients and families.


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"She's fine," answered the nurse when I called to ask about my 91-year-old mother, who'd been taken to the ED after a fall. After multiple prodding questions, I better understood my mother's condition. When I thought over the response I'd received as a family member seeking crucial information about a loved one, I was reminded of a situation years ago when I was a nurse on the cardiac care unit. We had been working all night to stabilize a critically ill woman. In the early morning hours, two family members entered the room where the resident and I were maintaining a vigil at the patient's bedside. One of the family members, aware of our efforts to keep her aunt's blood pressure at a level for adequate perfusion, meekly asked, "How's her blood pressure?" The resident glanced at the monitor and said, "It's fine." I looked at him and waited. When I realized that was his complete answer, I added, "Yes, her blood pressure is fine, but let me tell you why."

Figure. Juanita Reig... - Click to enlarge in new window Juanita Reigle, MSN, RN, ACNP-BC

I explained the purpose of the multiple iv medications that were stabilizing her aunt's blood pressure and the other equipment supporting this tenuous life. My purpose was not to take away hope; in fact, I conveyed the possibility that things would improve. My intent was, however, to frame the "fine blood pressure" with the understanding that the patient was unstable and quite ill. I wanted to acknowledge the question this family member was afraid to ask: "Is my aunt going to die?" I also wanted her to be able to relay to other family members, when asked "How is she?" not "She's fine," but "Her blood pressure is OK now, but she needs a lot of medications to keep her stable."


The spoken and unspoken messages we give patients and families are powerful. Imagine the family, having only heard that their relative's blood pressure was fine, corralled into a conference room two days later for a meeting to discuss withdrawal of treatment. But she was "fine" two days ago! No wonder families look bewildered and are resistant when they've never heard the real message we wanted to give them.


We are often reluctant to discuss the gravity of a patient's condition. I remember families proclaiming that their loved one was still alive years after a prognostication of imminent death. Perhaps we need to be clear that we are talking about a patient's current status, such as: "At this time, your aunt is very sick and relying on multiple medications to keep her alive." It is important to keep patients and their families aware of the state of their illness so that they can make informed decisions that are congruent with their goals of care. The truth can be difficult to deliver, but deceptive or evasive approaches to delivering it can hinder others from achieving emotional and spiritual peace.


We know the science of nursing well, immersing ourselves in the clinical details and complex diagnoses. The art of our profession is more subtle and revealed in how we demonstrate compassion and respect as we attend to the emotional and spiritual needs of patients and families. It is critical that we listen to the questions that are not being asked directly-and answer them with compassion and clarity. Our ability to communicate honestly and effectively is one of the reasons that nursing continues to be ranked as the most trusted profession. Many of us have seen the puzzled look on family faces after they hear conflicting information from the various specialists who have just finished poking and prodding their loved ones.


We need to relay the message that we have time to talk by sitting down, making eye contact, and listening. If we value this as part of the art of our profession, then hopefully our colleagues will support us as we take the time to be present with patients and families.


My mother wasn't fine. She had fallen and had focal neurological deficits. I was five hours away from her and determined to remain on the line until I had some answers. It should have been easier than that.