1. Salladay, Susan A. RN, PhD

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An 80-year-old woman with chronic obstructive pulmonary disease and heart failure was admitted from a nursing home to our ICU. Her son and his wife were at her side. He told me that the discharge nurse at the nursing home told him to find a good hospice for his mother and asked me for information. I explained the hospice philosophy and gave him the names and brochures of several local organizations.

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The next day, the patient's intensivist asked why I'd recommended hospice for a patient who doesn't meet hospice admission criteria. Apparently this patient is seriously ill but not terminal. I explained the misunderstanding to the physician, then spoke with the family. They got angry and accused me of telling them the patient was dying.


Trying to straighten things out, I called the nursing home and spoke with the discharge nurse. She said the son had asked her about hospice, but she told him that it was too soon.


Now I'm wondering what's going on. Does this family want the patient to die, or hope she'll die soon? As her advocate, what should I do?-J.E., N.J.


Share your facts and concerns with the intensivist and make sure he's discussed the patient's treatment and prognosis with her and her family. Ask if you and another nurse, a social worker, or a chaplain can meet with the patient and her family to discuss concerns about her treatment and prognosis. This will help you assess "what's going on." For instance, her family may be preoccupied with thoughts of her impending death because she's said she wants to die. If that's the case, why does she feel this way? Could she be clinically depressed? Share your nursing assessment with her physician.


Or, perhaps the patient or her family is afraid she'll die in the hospital, or that technologies might prolong the dying process. Make sure they've received information about advance directives and explain how these protect patient rights.


Finally, the patient and her family may simply be confused about their options and fear the unknown. Follow up with them to explore what they understood or misunderstood and (if possible) why. Ideally, have the intensivist and other caregivers present so the patient and family hear the same message from everyone. Document your findings and address them in your patient's care plan and patient/family education.


If, after a thorough assessment, you still think this patient may be at risk because her family doesn't have her best interests at heart, follow hospital policy and procedure for reporting your concerns.