How do you handle needy patients and family?

[TheTruckGuy]

Question for y'all. How do you deal with patients and family that want/need updates. Like, legitimately some have serious issues going on, and I think they deserve an update, but they also ask a ton of questions, talk super slow, and sometimes make life hell for the nurses, but you're sitting in the middle of a dumpster fire of a shift?

Also, do you go and update every patient being discharged on results, diagnosis, answer questions, etc?

I had a horrible shift recently. Multiple strokes, brain bleeds, traumas, GI bleeds needing transfusion, and they just kept coming. Admitted 3 to obs, 8 to the floor, 2 to ICU, and 4 to stepdown. Then dealt with the normal BS that comes in. It was a night for me. Ended up staying 3 hours past shift to avoid turning over the 8 patients I got in my last 2 hours. Overall I was able to juggle the patient care ok. Had pretty good nurses. But the way our department is set up, family members can see me. And I had angry family members coming up to me asking for updates, and yelling at nurses because I hadn't updated them. I'm normally good about updating people, but I have my own workflow to get it done. When your workflow gets interrupted, it just compounds delays.

Also, being from the south, I was raised to not interrupt people, especially your elders. And most of my patients are way older than me.

Thanks for any tips.

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[Tenk]

Besides having the nurses update them (ie looks like a uti, looks like pneumonia, etc) there isn’t much else you can do. Lack of communication is very frequently cited as one of the top reasons of lawsuits so I personally think it’s always best to take time with explanations and always ask if they have any questions at the end. Does it suck when they do? Yup. Is it worth it in the long run? Absolutely.

 

[namethatsmell]

A few options to consider:

-family members (especially challenging ones) always get a big acknowledgment from me at the outset after I have patient introduce them. On way out of initial contact I almost always ask family if they have any questions… they normally ask one or maybe two, but you’d be surprised how they often become much more respectful after being given an opportunity to ask a question

-Whenever feasible, I forecast likely course of visit/dispo and potential decision points right up front. This heads off tons of questions/saves time of the back end of things

-set realistic expectations on when they will see you again next. “While it may seem calm here, things are very busy right now and once I have all the testing results back, I will come in as soon as I can to update everyone.” Or “If the X-ray of your ankle doesn’t show any broken bone or anything else acutely concerning, you won’t see me again but I’ll put the follow up plan/return precautions we just discussed and radiology report in the paperwork your nurse gives you before you go home.”

-if they are not letting you go, pause the conversation and say you need to step out of the room to check on the status of pt’s outstanding test, the callback from consultant, etc to keep their care moving forward

-if they really will not let you go, say that you have to step out to check on other patients and leave the room

* Do not forget that you have complete license to leave the room at any time and for any reason to do your job of running the department …and you don’t need to apologize to anybody for doing so (though it’s a-ok to do so if it’s your style)

While the above may seem like it’s more trouble than it’s worth, it saves so much time and hassle during/on the back end of the visit that it’s almost always worth it

 

[BoardingDoc]

Question for y'all. How do you deal with patients and family that want/need updates. Like, legitimately some have serious issues going on, and I think they deserve an update, but they also ask a ton of questions, talk super slow, and sometimes make life hell for the nurses, but you're sitting in the middle of a dumpster fire of a shift?

Whenever I have time and it fits into my workflow, I give critical updates as needed. No one gets a play by play. They get 1 update if there for a while, 2 at the most for the vast majority of patients and you already need to be sick as **** to get that many.

Also, do you go and update every patient being discharged on results, diagnosis, answer questions, etc?

Only if there's an unexpected outcome.

For every patient that I can guess the outcome with near certainly I will tell them: I think this is likely x. <Insert simple terms explanation of X>. I'm going to run some tests to make sure that I'm right though. If I am, we're going to <care plan here>. If I'm wrong, you're going to see me again and we'll chat (usually said with a sort of ominous tone, which makes them think that seeing me again will only happen if something bad is happening). Any questions about all of that before I go start your workup? <answer questions>.

This makes seeing them again unnecessary 98% of the time.

For actually sick people (and I mean proper sick) this obviously doesn't work and you'll need to go back in with some updates. That said, once you know what's going on and what the dispo is, you give the above speech so that you can stop coming back into that room ASAP.

 

[Groove]

I explain the treatment plan at the beginning along with my anticipated disposition. What I've found is that the majority of generated angst is from family members that simply want to know whether the pt is being admitted (so they can go home) or whether they need to wait around to take them home themselves. If it's a moderate to high risk chest pain and/or granny from the nursing home that looks ill, or pt with stroke like symptoms, etc.. I just let them know right off the bat that I anticipate admitting them to the hospital for X,Y,Z. I tell them the initial treatment plan and let them know that when everything is back, I'll update them. I try to circle back at least once to update them on the findings and re-iterate my plan to dc/admit. I also take that time to explicitly let the family know that it's ok to leave because the pt will likely be in the ED for hours waiting on a bed, etc.. I find that a lot of family members or friends of family feel bad for leaving and many times don't want to ask the pt whether it's ok for them to leave, so it alleviates some stress when I bring it up point blank and give them permission to leave letting them know that we have their number in the chart and can call and update them with any status change.

If they are WR patients, I let them know what tests I'm ordering and what I'm going to be doing in the background and I assure them that although they are sitting out in the WR, things are moving forward and I'll come find them when everything is back.

I take a WOW in most of my pt rooms and/or use the workstation in the pt rooms as much as possible because the pt perceives that I'm spending more time with them and technically I am. I also tend to mumble out loud what I'm ordering for them along with what medications I'm ordering, etc..

All of that won't take away the frustration of having to spend hours and hours in the ED but it helps. I do a lot of apologizing for wait times, etc.. as do most of us I'd wager. I don't really have any patience for the angry and rude patients. I have no problem cutting it off immediately and giving a terse apology for the wait times, letting them know I have no control over X,Y,Z and explaining that I have some very sick patients to attend to. I think most of us become experts at deescalation techniques over time so I rarely have a really nasty encounter like the above.

Get up and have a discharge discussion with each and every patient. It's frustrating for nurses to try and answer all the questions and try to read your brain simply from your exit care instructions. It's also often the most memorable discussion that the pt and family recollect and reinforces an overall impression of their care during that particular encounter.

 

[thegenius]

Question for y'all. How do you deal with patients and family that want/need updates. Like, legitimately some have serious issues going on, and I think they deserve an update, but they also ask a ton of questions, talk super slow, and sometimes make life hell for the nurses, but you're sitting in the middle of a dumpster fire of a shift?

Also, do you go and update every patient being discharged on results, diagnosis, answer questions, etc?

I had a horrible shift recently. Multiple strokes, brain bleeds, traumas, GI bleeds needing transfusion, and they just kept coming. Admitted 3 to obs, 8 to the floor, 2 to ICU, and 4 to stepdown. Then dealt with the normal BS that comes in. It was a night for me. Ended up staying 3 hours past shift to avoid turning over the 8 patients I got in my last 2 hours. Overall I was able to juggle the patient care ok. Had pretty good nurses. But the way our department is set up, family members can see me. And I had angry family members coming up to me asking for updates, and yelling at nurses because I hadn't updated them. I'm normally good about updating people, but I have my own workflow to get it done. When your workflow gets interrupted, it just compounds delays.

Also, being from the south, I was raised to not interrupt people, especially your elders. And most of my patients are way older than me.

Thanks for any tips.

For uncomplicated non-sick patients and sick ones where you know they will be admitted, I just tell patients during the initial H&P what's going to happen after I leave.
- i'm going to order tests, medicine, and you'll be discharged after the workup w/wo abx or treatment or whatever and you won't see me again unless something rare happens
- I'm going to order tests, medince, and going to admit you.

In both cases I tell them you won't see me again unless something really rare occurred or there is a weird finding on the workup.
I say it's busy and I wish I could spend more time, but I just can't. I'd say 90% of people understand this.

Hard to do with some presentations though.

Just tell patients and families the truth. "I would love to spend more time with you, but there are other patients patiently waiting hours for me and I need to see them now."

Just takes practice.

 

[WorkNoteEmergency]

I talk to every patient before I discharge them, no matter how busy it is. There are rare exceptions, the frequent flyers, etc. If it’s an in and out visit, means one visit from me, longer stays will get 2 visits, minimum. If it’s someone I know will be admitted, I go back in once after the first visit to explain test results. When the throughput is really slow, like long waits for CT reads, labs, consultant callbacks, I pop my head in to update. Nurses these days are hit or miss on this, so I’ve also gotten into the habit of checking on pain responses, so I don’t find out patient is 11/10 pain when I try to discharge.


On the other hand, for the most part I don’t do phone calls to family for info or updates.

 

[nVictus]

As always, it's case by case but I don't let anyone on shift kill my flow. Every shift is triaging most to least important tasks and needy families aren't on that list unless it helps my dispo. Sorry not sorry, the nurse can update you but s/he is probably hella busy too. But... usually I have time to update everyone.

 

[WildEMDoc]

Every time I have ever said "you won't see me again unless xyz" when I'm discharging a patient, they universally say to the nurse at the time of dc "the doctor hasn't told me the plan" despite me telling them the plan before. So basically that has lead to me going back once I hit the dc button to tell them everything is normal and its the same plan we talked about before.

I've always wanted to just have that one time conversation but short term memory of my patients hasn't worked in my favor.

Doesn't really happen that way on admits, so I can do just the one time talk. I think because the hospitalist comes to talk to them though.

 

[s/p epilepticus]

the way our department is set up, family members can see me

This is a problem

 

[RuralEDDoc]

You don’t interrupt people?
Problem solved. Interrupt frequently. Give everyone 15 seconds or so to drive their narrative then take control. It’s not rude, it’s essential. You gotta manage the chaos and sustain a career. Interrupt away.

 

[Rendar5]

With extremely rare exceptions, I see every patient two times. If they’ve got a clear disposition from the start, I let them know that as part of their plan on the initial visit To the room. I give them a very generous time estimate on how long to get tests and reassure I will be back to go over results.

The only time I don’t see them again is if they’ve got such a straightforward discharge I tell them the full distress instructions, and that if they do not see me again at all, the tests are normal, and that we are proceeding with the plan. Like they just want a head ct for a minor head injury. I tell them I don’t think there’s a bleed. I will double check the results and if negative will dc them to f/u with their doctor. And I will return if it’s positive to go over the results.

That said. It is rare that I don’t recheck with them. I see sometimes 3+/hr on a bad night and even if it’s a complete **** show I do this like dotting my i’s and crossing my t’s.

It’s proactive complaint protection. Most common patient complaint is no one spoke with me and I was just discharged. I would much rather take 1 minite to at least stop back in the room than take 5 minutes next week addressing complaints. If it’s more than a minute I fake having to answer an emergency call from a nurse and ask if they have any other questions before I have to see the emergency that I just got called to. (They can’t tell if my hospital phone buzzes or not). That last question is invariably a quick one or a simple thank you.

 

[blacknblue133]

“Touch it once”- from an EM education lecture I watched about efficiency. When I first see the patient, I set the expectation early. I tell them, “We are going to get bloodwork, urine, and a ct of your abdomen because I’m suspecting you have diverticulitis (or whatever you think they have), so I would like to get you pain medication. If all the work up is normal, we will discuss your results and I will likely discharge you home with medication or follow up with your pcp or gi (or whatever appropriate specialty). If we find something, I might have to consult my surgery colleagues”.
For obviously sick patients, I tell them from the outset “I think you need to be admitted because you are very sick possibly from your recent biopsy, pna etc. I will run some tests and X-rays, are you okay with admission?”.

Patients with positive results that need a consult in the ED get more updates.


Always start off upbeat and in charge so they sense you have a general direction. And you also can feel if they are the patient that will demand an admission for nothing or the potential social admits.

Same with orders- order everything at once and leave it.


The patients who are most needy tend to be pain related chief complaints.

 

[medninja]

The only covid restriction I miss is barring families from coming back with their relatives. I know it sounds cruel. What’s really cruel, though, is a relative proving their love by torturing me with endless non sequitur questions. Just kicking the tires of my tortured soul. It’s not as though I provide quality care only if whipped by your loving niece.

 

[CoolDoc1729]

I look at it like .. my job is to give everyone what they actually need, it’s nice if they are also “satisfied” but anymore my job is to find the critically ill subset of the waiting room, make a dispo on the rest, keep the adolescent psych boarders off the Geri psych boarders’ lawns, and generally maintain safety and order. I think it is crucial to tell people you’re going to admit them, if you’re definitely going to admit them.. most families are 90% less needy after that.

I need to get better at redirecting the true aimless rambling though. I will know if I am in heaven or hell the first time I ask a yes or no question - if the answer is a yes or no, I’ll know I made it to heaven, if the answer is an unrelated 8 minute soliloquy I’ll know I done f’ed up lol

 

[Rekt]

I hope you got paid for those 3 extra hours or I’d be finding a new job.

Lots of good advice but missing the core issue. You’re blaming yourself when it’s your hospital’s problem. You’re not appropriately staffed.

 

[emergentmd]

If your shift is not the exceptional day, then you need to get out. If you are staying 3 hrs late then you need to do something about this b/c its unsustainable. If you are taking charting home, figure out how to game the system so never leave with work to do/charting to finish. If you are continually being bugged by family, then you are doing something wrong.

You will always have the occasional needy family but holy cow I don't think I have had a similar shift in 20+ yrs and I have worked in some crummy places.

Typically education early on in the process will set expectations.

 

[wareagle726]

I see every discharged patient twice. I like to make sure I actually got the correct story the first time and love giving that "wow you look so much better after your xyz treatment!" and getting a smile which probably doesn't help but I like the idea of maybe they will remember in a good light. Especially for family with them. I also use this time to legitimately give the "time is part of the diagnostic process and I only see you for a snapshot etc..." By this time, most of the family are happy to take mom/dad home and I can honestly document I had good DC instructions.

As for admitted patients, unless you are truly dying or I am waiting on a family member, I pretty usually have a pretty good idea of the course from the get go and tell them they will be admitted(barring an unforeseen surgical process). As stated above, the family usually appreciates this.

If I get stuck in a room, I have the charge nurse "special" phone number in my favorites. I just call in on my watch(muted) and when they answer and I don't they page me overhead. It's an escape.

I have gotten somewhat battered over the past two years and the whole "I've been waiting TWWWOOOOO HOLLLEE HOUURS" has really irritated me. Usually Its a response like I'm sorry, there are 85 patients down here and only two of us. We are doing to best we can. Usually most people are shocked at those numbers and have some understanding.

One thing i love is the 5 stretcher beds just outside of the trauma rooms 1-5. They see all the action coming in. It's not uncommon that someone just gets up and says "I'm not sick enough to be here I'll just go home." I see those people immediately because they get bonus points for honesty lol.

 

[turkeyjerky]

It seems to me that a lot of times these requests for "updates" are the dumbest questions ever. A lot of hospitals seem to go out of their way to disempower nurses. Like, a tech'll come up to me saying the patient is asking to talk to me, I get up and go over there and they want a blanket or to know whether me-maw can have some water. I try my best to train staff to head this nonsense off. "I already talked to them, can you just let them know the XR is negative and she's getting discharged".

Patients being able to see your workstation is a real negative. My old shop was like this, it was infuriating--the doc was the easiest person for them to see, they would constantly approach our desk asking for anything. Got real good at telling them, "hold on for just a minute, I'll look for your nurse".

I find it useful to keep in mind that this type of scenario is really unique to the ER. There's nowhere else in the medical system where a patient can expect to speak to a doctor, and then 5 minutes later ask to have them come back in. People have to wait weeks to spend 15 min talking to their PCP. Patients on the floor see a doc once a day, if they're lucky. So if I get asked to update a patient, I don't feel bad about putting in at the bottom of my to-do list.

 

[RustedFox]

It seems to me that a lot of times these requests for "updates" are the dumbest questions ever. A lot of hospitals seem to go out of their way to disempower nurses. Like, a tech'll come up to me saying the patient is asking to talk to me, I get up and go over there and they want a blanket or to know whether me-maw can have some water. I try my best to train staff to head this nonsense off. "I already talked to them, can you just let them know the XR is negative and she's getting discharged".

Patients being able to see your workstation is a real negative. My old shop was like this, it was infuriating--the doc was the easiest person for them to see, they would constantly approach our desk asking for anything. Got real good at telling them, "hold on for just a minute, I'll look for your nurse".

I find it useful to keep in mind that this type of scenario is really unique to the ER. There's nowhere else in the medical system where a patient can expect to speak to a doctor, and then 5 minutes later ask to have them come back in. People have to wait weeks to spend 15 min talking to their PCP. Patients on the floor see a doc once a day, if they're lucky. So if I get asked to update a patient, I don't feel bad about putting in at the bottom of my to-do list.

I hide in the "doc box" instead of working in the main area for this precise reason. If I didn't, nothing would get done.

 

[n2b8me]

"How do you deal with patients and family that want/need updates.
Admitted 3 to obs, 8 to the floor, 2 to ICU, and 4 to stepdown.
8 patients I got in my last 2 hours.
I was raised to not interrupt people"

What I try to do:

• shotgun labs/xray from waiting room
• focused exam/physical in room to plan for dispo at the onset
• make myself seen and heard by ALL of the patients/families. including waiting room. everyone should know it's just me and I am working my tail off for all y'all.
• explain I wish I had more time to talk or explain then apologize then walk to the next one.

its like a restaurant sometimes, when we're dead you can have an appetizer and dessert, but when it's popping off then just one order and the check!

 

[GonnaBeADoc2222]

It seems to me that a lot of times these requests for "updates" are the dumbest questions ever. A lot of hospitals seem to go out of their way to disempower nurses. Like, a tech'll come up to me saying the patient is asking to talk to me, I get up and go over there and they want a blanket or to know whether me-maw can have some water. I try my best to train staff to head this nonsense off. "I already talked to them, can you just let them know the XR is negative and she's getting discharged".

Patients being able to see your workstation is a real negative. My old shop was like this, it was infuriating--the doc was the easiest person for them to see, they would constantly approach our desk asking for anything. Got real good at telling them, "hold on for just a minute, I'll look for your nurse".

I find it useful to keep in mind that this type of scenario is really unique to the ER. There's nowhere else in the medical system where a patient can expect to speak to a doctor, and then 5 minutes later ask to have them come back in. People have to wait weeks to spend 15 min talking to their PCP. Patients on the floor see a doc once a day, if they're lucky. So if I get asked to update a patient, I don't feel bad about putting in at the bottom of my to-do list.

Most patients who present to an ED for low acuity complaints self select for entitlement.

My response to nursing is "I will update them when I have an update to give."