AACN News—November 2000—Practice

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Vol. 17, No. 11, NOVEMBER 2000


Informed Consent Does Not Need to be an Impossible Task

By Pamela Popplewell, RN, BSN

Member, AACN Ethics Work Group

Mr. J., an 82-year-old male, was admitted to a general surgical floor prior to surgery to remove a tumor, which was located at the base of his tongue and extended into his larynx. The planned procedure was a radical neck dissection, a partial glossectomy, a tracheostomy, placement of a feeding jejunostomy and a possible pectoralis flap.

Mr. J., who lived in an assisted-living facility, told his nurse that the only pleasures in life were sitting on his porch, drinking coffee, smoking cigarettes and watching the airplanes land at a small airport that was visible from his room. Although the reasons he could not have any food or beverage on the morning of his surgery were repeatedly explained to him, he was agitated because he could not have his breakfast and coffee. However, he did go downstairs to the smoking area for his “morning smoke.”

In reviewing the preoperative documents, the nurse noticed that, although both Mr. J. and his physician had signed the operative consent form, there was no witness signature. The nurse was concerned that Mr. J. did not understand the full extent of the surgery that was planned. When she questioned him about his knowledge he simply said, “They are going to remove a bump on my neck.” He did not seem to believe the nurse when she told him that he might never be able to drink coffee or smoke cigarettes following his surgery. He just kept repeating that he wished he could get the surgery over and have his coffee and breakfast. Was this informed consent? The nurse was not confident.

Mr. J.’s nurse notified the operating room staff that the informed consent had not been signed properly and paged the physician to express her concerns about Mr. J.’s understanding of the procedure. When the physician arrived, he discovered Mr. J. eating food that he had convinced another patient to give him. The physician then carefully explained to Mr. J. about his tumor and the planned surgery. Mr. J. said he wanted to talk to his sister, who often helped him make tough decisions.

Following a family conference, Mr. J. decided to go ahead with the surgery. He was able to state realistic expectations of his postoperative course and had a clear understanding of the consequences of nontreatment. The same nurse was on duty the day his surgery was rescheduled. As she readied him for the operating room, she was confident that his consent was truly informed and that his wishes for his care were being followed.

Regardless of the appearance of a positive outcome in this scenario, the road to ethical decision making is not always simple. In this situation, members of the operative team had been upset at the disturbance in their operative schedule. In fact, they were aggravated that the nurse had questioned the validity of the informed consent for their patient. Even the physicians indicated that they felt the nurse was trying to block appropriate treatment for the patient. However, after a discussion among the healthcare team members and a re-evaluation of the patient and his level of comprehension, the physician informed the nurse that her actions were clinically appropriate and ethically correct.

The ideal scenario of informed consent is one of respect for patient autonomy. It should represent a dialogue between the patient and healthcare provider that covers reasons for recommended treatment; options for alternative treatments; the benefits and burdens of all options; consequences of nontreatment; and possible outcomes and risks. The patient should have an opportunity to understand the information, ask questions, weigh the options and express a preference for treatment. Jonsen, Siegler and Winslade1 state: “As an ethical basis for the patient-physician relationship, informed consent refers to an encounter characterized by mutual participation, respect, and shared decision making.”

Unfortunately, in the hustle bustle world of healthcare where many patients have multiple care providers, a much more casual attitude of what constitutes informed consent is recognized as the norm. Physicians often refer to “consenting the patient” as if it is a procedure done to the patient, instead of a mutual exchange of information with the focus on respecting the wishes of the patient.

It is a sad truth that nothing is easy about informed consent. Physicians have the burden of explaining highly technical information to a person who may have little medical background or knowledge. Verifying comprehension of the presented material is difficult. In addition, there are often barriers to patient understanding. Language differences, hearing or visual compromise, anxiety, denial, fear and previously held conceptions or misconceptions about diseases and treatments are merely a few of these barriers.

There is a role for the nurse in the informed consent process. Nurses, who spend more time with patients than physicians, often have the opportunity to present and discuss practical information about surgical procedures, disease processes, outcomes and risks. In addition, patients frequently speak more frankly with nurses and are more willing to discuss doubts and fears with and ask more questions of nurses than doctors. This is a prime opportunity for the nurse to assess the degree of understanding the patient possesses and to provide feedback to the physician if there is a lack of comprehension.

This case uses the Synergy Model, in which the needs and specific characteristics of the patient drive the characteristics and competencies of the nurse. This patient could be described as minimally resilient, highly vulnerable, moderately stable and moderately predictable and as having moderate resources and moderate levels of participation, both in care and in decision making. Did the nurse competencies match this patient? The nurse employed a high level of clinical judgment, advocacy, collaboration and facilitation of learning. Thus, the needs of the patient and the nurse competencies synergized, and the outcome of this patient was optimized.

Informed consent does not need to be an impossible task. Careful listening skills; strong communication techniques; written, printed or video educational offerings; allowing nursing competencies to be driven by the needs of the patient; and the ethical groundwork of respecting patient autonomy are the proper places to start.

Reference

1. Jonsen A, Siegler M, Winslade W. Clinical Ethics. 4th ed. New York, NY: McGraw Hill; 1999.

Pamela Popplewell, RN, BSN, is a staff nurse in the surgical intensive care unit at the VA Puget Sound Healthcare System in Seattle Wash. She is a member of the hospital ethics committee, cochair of the nursing bioethics committee and a volunteer member of the AACN Ethics Work Group. She is currently enrolled in the master’s of nursing program at Seattle Pacific University.

Deadlines Near to Apply for Nursing Research Grants

AACN offers grants to AACN members for research or projects that are relevant to critical care nursing. The deadlines to apply for several of these grants are approaching. Unless otherwise specified, all grant proposals must be relevant to critical care nursing practice and should address one or more of AACN’s research priority areas and link with AACN’s vision. Following is information about each of these:

AACN Clinical Inquiry Grants for Projects

These grants provide awards of up to $500 each to qualified AACN members who are carrying out clinical research projects that will directly benefit patients or families. Interdisciplinary projects are especially invited. This grant may be applied to new projects, projects in progress or projects required for an academic degree. The funds may be used to cover direct expenses such as printed materials, small equipment and supplies, including computer equipment.

To qualify for a Clinical Inquiry Grant, the principal investigator must be a regular or affiliate member of AACN, employed in a clinical setting and directly involved in patient care.

Proposals must be received by Jan. 15, 2001.

Datex-Ohmeda-AACN Research Grant

This new $5,000 grant to study the issue of nutritional assessment in the critically ill patients is funded by Datex-Ohmeda.

Examples of study topics might include the impact of continuous metabolic monitoring; the assessment of the nutritional and metabolic condition of the critically ill patient; current practices of nutritional assessment of the critically ill patient; the use of the Harris-Benedict Equation vs. indirect calorimetry in nutritional assessment; and the evaluation of the accuracy or efficacy of continuous metabolic monitoring in the critically ill patient.

To qualify for this grant, the principal investigator must be a regular or affiliate member of AACN and not currently conducting a study funded by another AACN research grant.

Proposals must be received by Feb. 1, 2001.

AACN Critical Care Grant

This grant awards up to $15,000. Principal investigators must be current AACN members. The principle investigators cannot currently be conducting a study funded by another AACN research grant. The proposed research may not be used to meet requirements of an academic degree. The funds may be used to support project expenses and may include research assistant or secretarial support, equipment, supplies, and consultation assistance.

Proposals for this grant must be received by Feb. 1, 2001.

AACN Mentorship Grant

This $10,000 grant provides research support for a novice researcher who is working under the direction of a mentor with expertise in the area of proposed investigation. The novice researcher, who will be the principal investigator, may use the study to meet the requirements for an academic degree, though the mentor may not. The funds may be used to support project expenses and may include research assistant or secretarial support, equipment, supplies, and consultation assistance.

The mentor cannot serve as a mentor on an AACN Mentorship Grant in two consecutive years.

Proposals must be received by Feb. 1, 2001.

AACN Certification Corporation Grant

Up to four $10,000 grants are funded by AACN Certification Corporation to support research related to certified practice. Examples of eligible projects include studies that focus on continued competency; the Synergy Model; the value of certification as it relates to patient care or nursing practice; and credentialing concepts. The proposed research may be used to meet the requirements of an academic degree. Membership in AACN is not required to apply for this grant.

Proposals must be received by Feb. 1, 2001.

For more information about these and other AACN nursing research grants, or to obtain application materials, instructions and information regarding restrictions, call (800) 899-AACN (2226), or visit the "Research" section of the AACN Web site at www.aacn.org.

Research Work Group Promotes Evidence-Based Practice

Members of the 2000-01 Research Work Group are
(from left, seated) Karen Gaertner and Charlene
Winters and (from left, standing) Paula Lusardi,
Elaine Steinke, Linda Bucher, Eleanor Bond,
Debbie Brinker and Lyn Wooten.

By Charlene A. Winters, RN, DNSc, CS

Chair, AACN Research Work Group

A critical review of existing AACN research grants was initiated by the AACN Research Work Group (RWG) when it met in August 2000 to identify strategies to enhance AACN’s research activities. Group members also are continuing to build on work begun by the 1999-2000 RWG to identify and create evidence-based practice resources for use by critical care nurses.

Their recommendations will be submitted to the AACN Board of Directors in 2001.

The two-day meeting in August was cofacilitated by Justine Medina, RN, MS, AACN practice director; Barbara Mayer, RN, MS, AACN education director; and RWG Chair Charlene “Charlie” Winters, RN, DNSc, CS. The diversity, dedication and expertise of the RWG members provided for a productive meeting with a lively exchange of ideas.

The eight-member volunteer group includes representatives from education, management and clinical practice, who were appointed because of their commitment to research and research-based practice, their expertise in conducting and using research, and their knowledge of critical care nursing practice. In addition to Winters, members of the 2000-01 RWG are Karen Gaertner, RN, MSN, CCRN, Paula Lusardi, RN, PhD, CCNS, CCRN, Elaine Steinke, RN, MN, PhD, Linda Bucher, RN, DNSc, Eleanor Bond, RN, PhD, and Lyn Wooten, RN, MSN. Debbie Brinker, RN, MS, CCNS, is the group’s AACN board liaison.

The RWG is guided by the vision that critically ill patients and their families will have nurses who actively question their practice and base their practice on research. The group’s mission is to meet the needs of patients and families through a research agenda that promotes the creation of three cultures—inquiry (doing research), broad sharing (sharing research) and data-driven practice (using research). These three cultures are realized when no gap exists between research and practice.

The RWG facilitates the identification and utilization of AACN research priorities (see priorities below); provides input and direction for research and research-based practice initiatives and educational programming; and reviews processes through which abstracts and research grants are solicited, reviewed and selected for presentation, awards or funding. Each year, the group also selects the Distinguished Research Lecturer Circle of Excellence award recipient, as well as research abstracts for awards and presentation at AACN’s National Teaching Institute.

In addition to attending the face-to-face meeting in August, RWG members will participate in three conference calls during their one-year appointment. They also will use mail, e-mail and the volunteer discussion board on AACN’s Web site as needed to complete their work.

Charlene “Charlie” Winters is an assistant professor of nursing at Montana State University-Bozeman.

AACN Research Priorities

• Effective and appropriate use of technology to achieve optimal patient assessment,

management and /or outcomes

• Creation of a healing, humane environment

• Processes and systems that foster the optimal contribution of critical care nurses

• Effective approaches to symptom management

• Prevention and management of complications

Give Us Your Input

AACN leads other organizations in support of critical care nursing research through a research agenda that promotes research generation, dissemination and utilization. However, to create an environment where critical care nurses’ optimal contribution is based on research, the RWG members need your help. Let them know your thoughts and suggestions about creating a culture of inquiry, broad sharing and data-driven practice.

They can be contacted by e-mail at research@aacn.org, or by calling (800) 394-5995, ext. 377.

RWG members will also be on hand at the NTI May 19 through 24, 2001, in Anaheim, Calif., to introduce presenters and facilitate discussion of their work. If you attend the NTI, take time to give RWG members your input on ways AACN can better support critical inquiry and research-based practice.

For more information and resources that support evidence-based practice, visit the “Research” area of the AACN Web site at www.aacn.org, and watch for articles by the RWG in future issues of AACN News.

Nominations Due Dec. 1, 2000, for Distinguished Research Lecture Award

Dec. 1, 2000, is the deadline to submit nominations for the Distinguished Research Lecturer award for 2001. Part of AACN’s Circle of Excellence recognition program, the award will be presented to a nationally known researcher, who will deliver the Distinguished Research Lecture at the National Teaching Institute, May 4 through 9, 2002, in Atlanta, Ga.

The recipient will receive a $1,000 honorarium and complimentary registration, airfare and hotel accommodations for the NTI.

Candidates should be nurse researchers who are nationally recognized for publications, presentations and mentorship in research relevant to acute and critical care.

Candidates may be nominated by an AACN member, committee member, committee chairperson or member of the Board of Directors.

For more information about this award, call (800) 899-AACN (2226), or visit the “Awards” area of the AACN Web site at www.aacn.org.

Circle of Excellence: Excellence in Caring Practices

The AACN Excellence in Caring Practice Award is presented in honor of John Wilson Rodgers to recognize nurses whose caring practices are paramount in empowering acute or critically ill patients or their families. The recipients of this award received complimentary registration, airfare, and hotel accommodations for AACN’s National Teaching Institute and Critical Care Exposition in May 2000 in Orlando, Fla.

Following are excerpts from the exemplars submitted in connection with these awards:

 

Marcia DePolo, RN, CCRN, CNRN, TNCC, ONC

Springfield, Va.

Inova Fairfax Hospital

I first met Ellen in the trauma-medical-surgical ICU, where she had been transferred with a diagnosis of pancreatitis secondary to cholelithiasis. She had waited almost too long before seeking medical attention. She had been caring for her 12-week-old son Tyler and praying that her symptoms would dissipate.

During Ellen’s almost one month of hospitalization, she battled challenges of fever, acute respiratory distress syndrome, hypotension, immobility and nutrition. She had numerous setbacks amid miniscule triumphs. Any encouraging information her family had been told was certainly overshadowed by her appearance. Despite these setbacks, her condition improved. I am indebted to Ellen for what she taught me through her courage and perseverance.

Even after 20 years as a critical care nurse, I am amazed that I can never truly predict a patient’s outcome. Regardless of the fact that I work hard and intervene appropriately, and that I think positively and talk to my patients and their families, there is no certainty. I hope that what I do, or choose not to do for my patients matters.

In critical care, we often miss closure. I frequently wonder how a patient that I took care of is doing. When Ellen fully recovered, she visited me, which I will always treasure. She does not know this, but she visits me a little every day in my thoughts. It is a mixed blessing to be able to see how fragile life is and to be a part of helping others, regardless of the outcome. I am thankful for another day, every day that I have one.

 

Joanne Emerson

RN, BSN

Richmond, Va.

Medical College of Virginia

W.A., an 18-year-old military trainee, was admitted to us from a referring hospital with sepsis from five-lobe strep pneumonia. Because of a bad experience prior to the transfer, her mother, who was 5,000 miles from home, scared and alone, would not leave her daughter’s bedside. I knew we needed to find a way to gain her trust.

I signed up as an associate nurse for W.A., because I recognized that having a consistent nursing staff would be important in building that trust. Over the next three weeks, I spent a lot of time with the mother, explaining what I was doing and involving her in the care of her daughter. At the end of each day, I reviewed W.A.’s progress and explained what I anticipated would happen the next day.

Within the first week, I sensed that W.A.’s illness was not the only cause of her mother’s anxiety. I discovered that she needed to hug her daughter, but was afraid to because of the tubes and lines that were attached. I added “BIG hugs” to the nursing care plan. For the first time, W.A.’s mother smiled and relaxed a little.

I believe I made a difference and accomplished my goal of gaining the mother’s trust. Almost a year later, W.A. and her mother agreed to become e-mail pals with a family who was in a similar situation on our unit—still 5,000 miles away.

 

Kimberly A. Keane, RN, BSN

Richmond, Va.

Virginia Commonwealth University/Medical College of Virginia Hospitals

W. F., a 51-year-old man with acute lymphocytic leukemia, was awaiting a bone marrow transplant. He had received several rounds of chemotherapy before being admitted to us for acute respiratory distress, acute renal failure and neutropenia.

From the beginning, his prognosis was extremely poor and he quickly went into multisystem organ failure, which required high ventilator settings, high-dose vasopressors and continuous veno-venous hemodialysis. Although his family members had been updated daily on the gravity of his prognosis, they remained hopeful. The medical team had advised that, if W.F.’s condition did not improve, they would approach the family to discuss withdrawal of care.

On Christmas Day, one week after W. F. had been admitted, his blood pressure began to drop rapidly. Although the resident physician wanted to try different medications, I realized that W. F. was going to die despite our efforts. I urged the resident to inform the family members and to discuss “code” options with them. After talking to the attending physician, the resident asked me to help him talk to W.F.’s family.

I helped W.F.’s family members understand what we were up against, and they decided to have life-support withdrawn later that night. I felt I was instrumental in refocusing the care we were providing W. F. from doing everything in a futile situation to doing the most important thing—letting him die in peace with his family at his side.

 

Michael O’Melia, RN, CEN

Woburn, Mass.

Children's Hospital-Boston

The transport team and I met Rory on a dreary September night. The neonate was on 95% oxygen via hood and was in severe respiratory distress with a respiratory rate of 120 and had nasal flaring, grunting and profound chest retractions. His Spo2 was 88%. As we prepared to intubate him, his dad entered the nursery. We introduced ourselves and I explained our plan.

Before intubating Rory, we administered six micrograms of fentanyl. Shortly after, he became very difficult to ventilate. Acting quickly, I gave Rory a paralytic and, after an anxious minute, was able to ventilate him. High-peak inspiratory pressures were required to move his tiny chest. I knew that these high pressures would make the transport back difficult and dangerous.

We contacted our neonatal fellow and received permission to administer surfactant. I first took a few minutes to explain the procedure to his parents, assuring them that I would bring their son the next time they saw me.

The surfactant administration went well, and Rory’s lung compliance improved, I placed him in the isolette with his beanie baby “Twigs.” His parents were pleased at how comfortable he looked. They took a few photographs and kissed him.

Recently, I got a call from Rory’s mother. She thanked me for taking care of Rory, and told me that the few minutes I spent with them that night gave them the confidence they needed to trust me to care for their son. Her phone call is a reminder to me that every child I care for is somebody's son or daughter. This is something I will never forget.

 

Mechelle Williams, RN, MSN, ACNP-CS

Pearland, Texas

M.D. Anderson Cancer Center

Mr. C. was readmitted to our medical ICU only three weeks after being transferred out of the unit. He was reintubated and developing multi-organ failure in addition to his leukemia, which had not responded to chemotherapy. Mrs. C. and I had developed a good relationship during her husband’s previous stay in the unit, and she was well aware of Mr. C.’s poor prognosis.

During a family meeting, Mrs. C. indicated she did not want her husband kept on life support. We made sure Mr. C. was comfortable and removed all lines and tubes. He looked very peaceful and did not struggle. Mrs. C. lovingly stroked his cheeks and forehead. She kissed him repeatedly and told him how much she loved him, and that she and their son would be fine. I realized how honored I was to witness such a show of love and compassion. If only we could all leave this earth with the one we love kissing our face and whispering sweet words of love in our ears. I was very blessed to be present as Mr. C.’s soul passed on from this world.

I have been involved with many patients from whom life support was withdrawn. However, instead of only feeling sadness for the family members who are left behind, I have new insight regarding the event taking place. The patient is able to spend his last moments with the people that mean the most to him. The family members and loved ones are able to actively comfort the patient as he passes on and offer words of compassion and love. I feel a sense of honor and responsibility that I am present when these patients’ souls leave the earth for another place.

Vox Populi: Online Quick Poll

Do you have a living will or durable power of attorney for healthcare for yourself?

Yes 30%

No 70%

Number of Responses: 1,682

The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. Participate by visiting the AACN Web site at www.aacn.org.