Expert Reasoning

We’ve all been there; a patient’s family that forces you to take a deep breath when you see them enter the unit. Some can be demanding, some questioning, some “overly concerned,” but how often do we discount what they are saying because of the way they communicate with us? That point was driven home with me this past week.

I started my new position as the Oncology Clinical Nurse in this unit. One patient had been admitted with increasing pain in her legs and back, as well as increasing fatigue. This woman was in her late 80s, and had a history of breast cancer many years ago, and a plethora of other medical conditions. From the nursing report we got, she had been admitted to another area hospital six times in the past five months with similar complaints. She left and went to an acute rehab facility on her last admission. At that facility she had a fall which, according to her and her family was the beginning of her recent decline. She was a pleasant woman really, she loved to talk and “tell her story,” and would laugh and joke with us each time we came into her room. She complained of pain, but was not very good at giving a good description of where the pain was the worse or how it felt.

Things were moving smoothly and then, the family came. They, too, were pleasant, but they were one of those families that had just enough knowledge to be dangerous. They requested every type of consult and evaluation they had heard about. Consults were made to neurology, rheumatology, and orthopedics, all of whom this patient had already been seeing on a routine basis. They told us that she had had an MRI and an EMG on previous admissions, but the records somehow could not be found. They asked about not giving her so much pain medication because they thought that was making her less awake, but they wanted her pain to be controlled. They requested “trigger point” injections that they had heard of, wondered if a PET or bone scan would be appropriate and thought maybe having a cardiologist come and see her just to make sure there was nothing wrong with her heart. It was overwhelming at times. There were three daughters, two of whom were there off and on most of the time, and each had their own ideas of what might be best. We dutifully explained all the tests and the reasons for them and tried to explain why certain consults were appropriate while others were not. It was exhausting having to go through this every time one of them would think of another option in the plan of care they thought might be appropriate. When her two sisters came in, it was the same thing. They were all reaching for anything they could to try and find an explanation for her decline and possible relief of her symptoms.

While speaking with the primary physician and the other nurse, we all formed the opinion that there was not much more that could be done and we would simply have to try our best to get her to an extended care facility by the end of the week. It was clear she could not live alone any longer and it was “obvious” that all that could be done medically had been done. To the credit of her physician, he gave in to appease the family and wrote many of the consults and ordered some of the tests. Then the consulting physicians came in and the story somewhat changed. It seems that this patient did indeed have a known compression fracture of her spine. The fall that she took at the rehab facility could very well have caused more damage. Neurologically, several medications had been added in an attempt to lessen her pain, some had been working and others could have very well made her more lethargic.

As the story unfolded, it appeared we had made the wrong judgment. There was a very good chance that there was something more that could be done. Ordering additional diagnostic tests was more than appropriate. I don’t know the end of this story. I think it is still to come. But I do know that I learned a very important lesson, once again. A good reminder for all of us. Never take anything for granted. Try not to let someone’s communication style override the fact that they could be right on target. If her family had not been as persistent in their attempts to find answers that made sense to them, we might never have found out about conditions that could be treated. Sometimes being the “experts” can hinder us more than allow us to accept questions that seem out of line to our sensible reasoning. I know that I will take this lesson that I have learned once again and keep it in mind the next time I encounter what appears to be an unreasonable request. I can only hope that if I ever need it, someone will be unreasonable on my behalf.