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Making a Difference: Disclosure of
Medical Errors: An Ethical Dilemma
By Julie McNulty, RN, BSN, CCRN
Ethics Work Group
Dealing with medical errors is a challenging and
often emotionally charged issue. It is difficult for the patients and families,
as well as for the clinicians making the errors.
However, by using the power of one, nurses can
make a difference in their practice environments by encouraging their
organizations to have defined and ethical processes regarding disclosure of
medical errors. Participating in activities to create a culture of improving
patient safety is an ethical imperative for all healthcare providers.
Following are three case scenarios that
illustrate the dilemmas inherent in this issue:
Case #1: A 74-year-old woman is admitted with an
exacerbation of Hodgkin�s lymphoma and complications of chemotherapy. During her
hospital course, she develops signs of possible rectal cancer and requires a
diagnostic colonoscopy. During this procedure, her bowel is accidentally
perforated, which requires major abdominal surgery for repair. She subsequently
has a one-week, postoperative course in the ICU, including brief mechanical
ventilation and a prolonged need for total parenteral nutrition. Her total
hospital stay is 30 days. She is ultimately discharged and is able to continue
at her previous functional level. During this admission, the family and patient
do not seem to be aware of the reason for the surgery. The nurse feels
uncomfortable and questions the fact that the patient and family do not seem to
be fully informed. When she questions the surgeon, the response is that he will
tell them �when the time is right.� What should the nurse do? What options does
she have?
Case #2: The nurse is taking care of a
critically ill patient with sepsis and pneumonia. The patient requires
mechanical ventilation and is on sedation protocols with continuous infusion IV
versed requiring active titration to control agitation. On the night shift, the
nurse discovers that the versed drip is about to run out. No replacement drip is
available, so she consults references and mixes the drip herself. Because the
charge nurse is busy with an emergency, she is not available to double-check the
dosage. Inadvertently, the nurse has mixed double the concentration that the
patient was receiving previously. A half an hour after she hung the new drip,
the patient develops acute hypotension and requires fluid resuscitation and the
addition of a dopamine drip. The next morning, the family questions the reason
for the new IV medication. Assuming that the nurse already knows about the error
from the previous shift, what should she say to the family? Do you think the
family should be told about this error? If
so, how should they be told?
Case #3: Mr. X is a 64-year-old patient with a
long cardiac history and dysrythmias. He is admitted to the CCU with a history
of a recent syncopal episode and chest pain. He had an AICD implanted six months
ago, and there is no history of malfunction. Because he was assessed to be in
stable condition and acute myocardial infarction was ruled out, he is assigned a
float nurse. During the shift, the patient went into ventricular fibrillation
and the AICD fired normally. The patient was asymptomatic and remained asleep
during the episode. The float nurse did not witness the alteration in rhythm,
and the strip was not discovered or documented. During the next shift, the nurse
is reviewing the alarm history and discovers the dysrythmia and appropriate
response of the AICD. She promptly notifies the physician. Is this a medical
error? If so, what type? How should the nurse handle this discovery?
The medical errors represented in these
scenarios range from an unintended complication that resulted in an increased
length of stay to a near-miss event that caused no harm to the patient. One of
the difficulties with medical errors is that there is no clear-cut, workable
definition that can be applied in practice. The Institute of Medicine defines
error as �the failure of a planned action to be completed as intended or the use
of a wrong plan to achieve an aim.� Wu and colleagues define a medical error as
�a commission or an omission with potentially negative consequences for the
patient that would have been judged wrong by skilled and knowledgeable peers at
the time it occurred, independent of whether there were any negative
consequences.�1
In some instances, such as in case #2, the
medication error is clear. However, in case #3, whether an error occurred is
less clear. Smith and Forster2 have advocated adopting a classification system
for medical errors that: (1) focuses on intended acts only, (2) includes
intercepted mistakes or near misses (such as in case #3), (3) is not limited to
negligence, (4) uses a knowledge-based model as a mechanism for classification,
and (5) provides a practical standard for determining if a mistake occurred. A
good working definition is the first step in creating effective processes and
assisting the nurse in knowing how to proceed in situations where a medical
error is in question.
Once organizations have appropriately defined
medical error, they need to develop procedures for disclosure to patients and
families. Being up front and disclosing serious errors to patients and families
is common practice now. In fact, this attitude has been shown to increase trust
between healthcare providers and patients. Some organizations involve patients
and families in the analysis process, allowing them to assist in making
recommendations for improvement. The literature clearly describes the ethical
obligation to disclose serious errors to patients. In addition, JCAHO has new
regulations requiring disclosure of errors when they result in harm to the
patient. However, direction is less clear when the error is less serious and
does not harm the patient.
Nurses caring for patients must also feel
satisfied that the disclosure has occurred in an ethical manner. Staff benefit
from a chain of command and clear process to report errors. In case #1, where
the patient was not informed about a serious complication from an invasive
procedure, the nurse was uncomfortable with the lack of communication. In this
instance, the nurse could perhaps consult with the hospital�s risk manager and
ensure that the situation was under appropriate review.
Hebert, Levin and Robertson3 recommend a process
for disclosure. The process includes the need to disclose promptly, taking the
lead in disclosure (and not waiting for patients and families to ask), outlining
a plan to treat the harm and prevent recurrence, offering second opinions if
appropriate, offering follow up meetings, accepting responsibility and
apologizing and avoiding blame. Be prepared for strong emotions in these
meetings! In case #2, perhaps the nurse could coordinate a meeting with the
family, attending physician and risk manager to discuss the error and what is
being done to rectify it.
The solutions in case #3 are less clear cut.
Since there was no harm to the patient, is non-disclosure appropriate?
Recognizing the importance of creating an ethical environment that is free of
blame, the nurse could work with other staff and the manager to improve
processes and systems that possibly led to this near-miss event. Focusing on
improvements and not blame can help to drive out fear and improve care for
patients.
References
1. Rosner F, Berger J. Kark P, Potash J, Bennet
A. Disclosure and prevention of medical errors. Arch Intern Med. 2000;
160:2089-2092.
2. Smith M, Forster H. Morally managing medical
mistakes. Cambridge Quarterly of Healthcare Ethics. 2000. 9:38-53.
3. Hebert P, Levin A, Robertson G. Bioethics for
clinicians, disclosure of medical error. Canadian Medical Association Journal.
2001; 164:509-513.
Research Corner: NTI Spotlight on
Evidence-Based Practice
Barbara Drew
Evidence-based practice will be front and center
when Barbara J. Drew, RN, PhD, FAAN, receives the 2002 Circle of Excellence
Distinguished Research Lecture Award at AACN�s 2002 National Teaching Institute
and Critical Care Exposition in Atlanta, Ga. A nationally known researcher, she
is professor and vice chair of academic programs in the Department of
Physiological Nursing at the University of California, San Francisco, School of
Nursing.
In conjunction with the honor, Drew will present
the NTI Distinguished Research Lecture, which this year is sponsored by Philips
Medical Systems. Her topic is �Celebrating the 100th Birthday of the
Electrocardiogram: Lessons Learned From ECG Monitoring Research.�
NTI 2002 is scheduled for May 4 through 9.
A member of AACN for 28 years, Drew is
recognized internationally for her expertise in cardiac intensive care nursing
and electrocardiography. She has been an invited professor to Taiwan, Canada,
Mexico, Israel and Japan. In 1991, she was the recipient of the first Hewlett
Packard-AACN Critical Care Nursing Research Grant, which was applied to a study
that evaluated the diagnostic accuracy of a new ECG lead method and its
advantages for bedside cardiac monitoring. Philips Medical Systems was formerly
known as Hewlett Packard and then Agilent Technologies.
In addition to the prestigious Distinguished
Research Lecture, research oral and poster presentations are a popular
attraction at the NTI.
This year, participants will have the
opportunity to view the research posters with the experts during interactive,
�walking� Grand Rounds. Members of the AACN Research Work Group will be on hand
to explain how to critique and evaluate a poster presentation as they discuss
selected posters with their authors. Research oral presentations are also
scheduled each day.
For more information or to register for NTI
2002, call (800) 899-2226 or visit the AACN Web site. The discounted, early-bird
deadline to register is March 26.
Grants
The AACN-sponsored American Nurses Foundation
Research Grant awards up to $5,000 for studies that advance the practice of
nursing, promote health or prevent disease.
Applications are due at ANF by May 1.
The ANF Research Grants Program was founded more
than 40 years ago to encourage career development in research by nurses.
Additional information and applications are
available from the American Nurses Foundation/NRG00, 600 Maryland Avenue, SW,
Suite 100W, Washington, DC 20024-2571; phone, (202) 651-7298; e-mail,
anf@ana.org;
Web site,
http://www.nursingworld.org/anf.
Sharing the Experience: Program Offers
Benefits to Both Fellows and Mentors
Editor�s Note: In celebration of the 10th
anniversary of the AACN Wyeth Nursing Fellows Program, AACN invited alumni
mentors and fellows to share their thoughts about and experiences with the
program. These accounts will be published in AACN News throughout this
anniversary year.
The Fellow
By Virginia Fidrocki Mason, RN, PhD
University of Massachusetts/Memorial Health
Care
Being accepted into the AACN Wyeth Nursing
Fellows Program provided me a wonderful opportunity to research, write and
publish an article, something that I never would have done without the
encouragement of my mentor, Kathleen Miller. I urge others to consider applying
to be a part of this rewarding learning experience.
This program gave me the chance to work with
someone who I greatly admire, as well as to attend AACN�s 2001 National Teaching
Institute and Critical Care Exposition in Anaheim, Calif.
My mentor and I share an extensive, 20-year
background of caring for cardiac surgical patients. She is well published in the
area of cardiac surgical patients and is an excellent editor. I benefited
greatly from her knowledge of the processes involved in writing an article.
Kathleen is also on my dissertation committee for my PhD in nursing at the
University of Massachusetts Worcester-Amherst Collaborative Program.
Publishing an article is something everyone
suggests that you do. However, I have always managed to successfully avoid it.
With Kathleen�s encouragement, we applied for the Wyeth program and identified
three topics of interest to us: �Care of �Off-Pump� Cardiac Surgical Patients,�
�Cardiac Rehabilitation Versus Home Walking Programs� (my dissertation topic)
and �Optimizing Outcomes for Cardiac Surgical Patients� in the ICU (the one
chosen).
Having a mentor allows you to try a new
experience but to have guidance and support during the process. I asked Kathleen
to let me try to research the topic and attempt to write the first draft. She
then helped me to organize themes, add necessary interventions, omit needless
material and meet publication deadlines. Kathleen had me thoroughly prepared for
the editing process, including the need to rewrite the manuscript to improve
clarity. E-mail greatly enhanced the speed and ease of communication for
editing.
This experience may open doors for you. Soon
after the article was published, I interviewed for a job and was surprised when
the vice president of nursing said she had read the article, which I had listed
on my resume.
The 2001 NTI was my first AACN national
conference. It will not be my last! The celebration at the NTI was much more
than I expected. At the NTI, Wyeth and the American Journal of Nursing presented
us a plaque, a writing portfolio and a pen to encourage us to continue writing.
Meeting nurses from different parts of the country who have similar interests
and hearing about their writing experiences was wonderful.
The Mentor
By Kathleen H. Miller, RN, EdD, ACNP
University of Massachusetts Worcester
Participating in the AACN Wyeth-Ayerst Nursing
Fellows Program in critical care was an opportunity to mentor a colleague in the
art and science of writing a scholarly manuscript. My fellow, Virginia Fidrocki
Mason, was a motivated, enthusiastic fellow who was receptive to the suggestions
from the editor and me regarding the manuscript. The fact that both of us share
an interest in and commitment to quality care for patients undergoing cardiac
surgical procedures was particularly helpful.
In addition to the writing focus of the program,
Virginia and I discussed and worked on other issues related to leadership as
advanced practice nurses in the clinical setting.
I would encourage anyone who is interested in
mentoring to consider applying for this program. The experience is enriching not
only for the fellow but also for the mentor. We enter nursing because of our
desire to help others, and mentoring is simply an extension of this process. The
recognition by Wyeth, AACN and the American Journal of Nursing is truly
wonderful.
As advanced practice nurses, we must guide the
next generation of nurses into leadership roles in the profession. The Wyeth
Nursing Fellows Program provides the mentors the opportunity to teach the
fellows about this aspect of professional nursing.
Network to Promote Advanced Practice
Mentoring Relationships
By Sarah A. Martin, RN, MS, CCRN, PCCNP, CPNP
Advanced Practice Work Group
A mentoring network to support the development
of advanced practice AACN members, both personally and professionally, is being
established by the Advanced Practice Work Group. The plan is to create a
directory of interested members from within the diverse roles and work settings
of advanced practice nurses.
The mentoring relationship, whether developed
formally or informally, benefits both the mentor and the mentee. It is a
reciprocal relationship in which the experienced colleague who is guiding and
supporting the mentee�s personal and professional goals is also acquiring new
knowledge, insight and support. A mentor may be a role model, adviser, supporter
or friend. A mentee is a colleague who respects and values the guidance of the
mentor.
Precepting is not mentoring, though a mentor is
often a role model and may foster learning experiences. In business, mentoring
is used to develop individuals who have been identified as having potential to
move up through the corporate ranks. In nursing, mentor relationships are found
in a variety of settings, including at the bedside, among managers and
administrators, and in academia.
AACN members have the opportunity to participate
in mentoring opportunities, either as mentors or mentees, through the AACN Wyeth
Nursing Fellows Program. This collaborative program among AACN, Wyeth
Pharmaceuticals and the American Journal of Nursing pairs experienced authors as
mentors with a fellow or mentee who is publishing his or her first manuscript.
The articles are published in a special AJN supplement.
In addition, the AACN Mentorship Grant awards up
to $15,000 to support research done by a novice researcher, who works under the
direction of a mentor within an area of investigation in which both have a
mutual interest.
Additional information about participation in
this mentoring network will be available in the future as the mechanism is
developed. The goal is to allow nurses seeking a mentor to have direct contact
with advanced practice nurses who are willing to be a mentor.
As you consider your current role, think about
your opportunities to mentor or your need to establish a mentor. We will be
looking forward to meeting you through this program!
Suggested Reading
1. Bhagia J, Tinsley JA. The mentoring
partnership. Mayo Clin Proc. 2000; 75:535-537.
2. Katz SL. American Pediatric Society John
Howland Award 2000: acceptance. A mentor�s joys and responsibilities. Pediar
Res. 2001; 49725-727.
3. The American Heritage Dictionary. Dell
Publishing, New York, NY. 1983.
4. Rothstein JM. Mentor: another word, another
fashion statement. Physq Ther. 2000; 80:954-955.
5. Meigs J. Mentoring: building nursing�s future
now. AWHONN Lifelines. February/March 1999; 3:55-56.
Get PA Catheter Education Online
AACN has joined a group of other associations in
sponsoring a Web site (www.pacep.org) to provide a state-of-the-art educational
program on how to use the pulmonary artery catheter. Continuing education
credits are available through AACN for those who complete the lessons.
Called PACEP (Pulmonary Artery Catheter
Education Project), the program was designed to measure learning outcomes for
the end-user in the clinical environment. To facilitate participant progression
from novice to expert, topics are divided into four levels.
There is no fee to register for access to the
program online. Visitors can find out more about how the program works by
clicking on the �Lesson Demonstration� icon.
Other organizations collaborating on this
educational effort are the American Association of Nurse Anesthetists, American
College of Chest Physicians, American Society of Anesthesiologists, American
Thoracic Society, National Heart Lung Blood Institute, Society of Cardiovascular
Anesthesiologists and Society of Critical Care Medicine.
API Participants Can Enjoy the Best of
Both Worlds
Advanced practice nurses can literally enjoy the
best of both worlds when they register for AACN�s Advanced Practice Institute, a
part of the National Teaching Institute and Critical Care Exposition, May 4
through 9, 2002, in Atlanta, Ga.
More than 30 sessions tailored specifically to
the needs and interests of advanced practice nurses are offered, including
preconferences, and clinical and mastery sessions. In addition to skills
development and role delineation, this year�s API adds a focus on patient
management and pharmacology, for which continuing education credit is available.
In addition, API participants will be guests at
a special API reception, sponsored by Stryker Medical. They are also eligible to
attend all NTI sessions and events, including the Critical Care Exposition,
Network Night and the Participant/Exhibitor Event, featuring comedian Victoria
Jackson and the music of Hall and Oates.
All API sessions are scheduled at the convention
center, allowing convenient access to the NTI sessions, the Resource Center and
the exhibit hall.
For more information or to register for the API,
call (800) 899-2226 or visit the AACN Web site. The discounted, early-bird
deadline to register is March 26.
Practice Resource Network: Looking for
Resources to Evaluate Knowledge and Skills?
Q:
What resources are available to help evaluate
the knowledge and skills of novice nurses and new employees in critical care and
progressive care/telemetry/stepdown?
A:
The core competencies that require validation
for both novice nurses and new employees are knowledge, skills and critical
thinking. In addition, a nurse�s ability to communicate and collaborate
effectively can be assessed and validated through peer review and during
evaluation of the core competencies.
To evaluate basic knowledge, consider using the
�Basic Knowledge Assessment Tool� developed by Jean Toth at Catholic University
of America. This paper-and-pencil, multiple-choice test focuses on core clinical
knowledge in critical care. The sixth version of the BKAT was completed in 2001.
All versions of this tool have been tested for reliability and validity. Tools
that are appropriate for use in progressive care (BKAT-5S) and pediatric
intensive care (PEDS-BKAT) are also available, and a tool is currently under
review for use in the neonatal area. There is a minimal fee to obtain these
copyrighted materials. For more information, contact Toth at
toth@cua.edu.
Core skills and mandatory hospital requirements
should be systematically identified and routinely re-evaluated. Skills
validation is usually done by review of the procedure and having the nurse
perform a return demonstration. Two products in the AACN Resource Catalog may
help to identify the skills or procedures you want to assess. The recently
updated AACN Procedure Manual for Critical Care, 4th Edition (Item #128150), and
the companion product, �AACN Critical Care Procedures Performance Evaluation
Checklists� on CD-ROM, 2nd Edition (Item #128151), also include some advanced
practice procedures. Each procedure in the manual has a companion checklist on
the �Performance Evaluation Checklists� CD-ROM, which lists the critical steps
in performing the procedure. Each checklist is in a PDF format that can be
identified with the nurse�s name and additional information. The document can
then be printed and added to the employee file. These same resources can be used
to evaluate and validate the nurse�s skills regardless of unit assignment
because many of the skills will still be required as the patient moves along the
continuum from the ICU to the progressive care/telemetry/stepdown unit.
Critical thinking can be tested through case
studies or clinical simulations. There are multiple sources for case study
materials, including those in the AACN Resource Catalog. Examples are Case
Studies in Critical Care Nursing, 2nd Edition (Item #128622) and the ECG case
study programs that are available on CD-ROM. To find these resources, simply
search for �case studies� in the online bookstore at www.aacn.org > Bookstore.
The benefit of the case study format is the ability to individualize it to meet
the needs of the nurse in a variety of settings. It can also be used as a
sampling of the patient population of a unit.
Clinical simulations for critical care,
co-developed with Medi-Sim Multimedia, are also available on CD-ROM. In this
interactive format, the nurse responds to the patient�s needs and then receives
feedback and scoring. Available simulations include hemodynamic monitoring, the
cardiovascular system, hematology and endocrine, as well as for neonatal and
pediatric critical care. Continuing education credit is available for completion
of the simulations. For a demo disk and free preview, contact Lippincott
Williams & Wilkins at (800) 527-5597.
The process of completing these assessments will
generate data to help evaluate the ongoing learning needs and measure the
progress of the novice or new orientee. The goal of any orientation should be a
nurse with competencies to meet the needs of the patient and to provide care in
a safe and effective manner.
In the Circle: Award Cites Excellence in
Caring Practices
Editor�s note: The following excerpts are
from exemplars submitted in connection with the Excellence in Caring Practice
Award for 2001, a part of AACN�s Circle of Excellence recognition program.
Presented in honor of John Wilson Rodgers, this award recognizes nurses whose
caring practices embody AACN�s vision of creating a healthcare system driven by
the needs of patients and families by helping patients and families understand
and cope with illness; offering avenues or possibilities of understanding;
increasing control and acceptance of a difficult experience; and demonstrating
vigilance, persistence and commitment to the patient and family�s life or
well-being. These applicants will demonstrate how they have encompassed the AACN
Values and Ethic of Care in their work. The recipients received complimentary
registration, airfare and hotel accommodations for NTI 2001 in Anaheim, Calif.
Elizabeth Chelette, RN, MSN
Hildebran, N.C.
Carolinas Medical Center
Vonda had mentored and guided me when I was a
new nurse in a busy ICU. Little did I know that I would later be helping her
through her own grief and loss.
Vonda�s mother was a patient in our ICU when she
went into cardiac and respiratory arrest during dialysis. She has been
resuscitated, but was now in coma and near death. Although we deal with death
issues every day, today was different. This was the mother of our friend and
colleague. I volunteered to be her nurse.
Saying a silent prayer before entering the room,
I went to Vonda and said, �I will be taking care of your mom today, but I need
to cry with you before I can become your mom�s nurse.� So, I hugged my mentor,
my friend and my patient�s daughter and cried.
Later, I remembered that a young nurse had
commented on how awful it was to have a family member die in your unit. Five
years earlier, Vonda had planted seeds in one unsure, unconfident nurse, and the
fruits of her mentorship and leadership had come back full circle and in a way
she never thought possible.
This exceptional nurse had taught me that
critical care nurses could provide comfort while monitoring and assessing and
that what we gain when sharing experiences with people in their moments of joy,
their suffering and even their deaths is beyond measure.
Venita Dasch, RN, BSN, CCRN
Dallas, Texas
Zale Lipshy University Hospital
I am privileged to have spent most of my 30
years as a registered nurse caring for patients in critical care settings. Thus,
my observations of where we are as nurses are always balanced by where we have
been.
Although I have witnessed tremendous strides in
responsibility, independence and knowledge, I have also seen that some things
change little. The vernacular of the day might label a patient as difficult,
anxious or afflicted with altered coping skills. The nurse labels it �just plain
trouble.�
My patient was a study in trouble. Physically
frail but mentally sharp, she was dying of lymphoma. However, she would not give
up her daily tasks of faxing and letter writing. She was confined to an
isolation room, but demanded ownership of all that was in that room. She could
eat only small amounts, but insisted on specially prepared meals and juice and
coffee for her visitors. She was a savvy, experienced consumer of nursing care,
and she was unrelenting in her evaluation of the quality of that care.
However, this patient�s demands, though
annoying, were not the reason that our unit found her so disruptive and
threatening. This 78-pound patient challenged each of us daily to stretch our
boundaries of what a patient should legitimately demand of a nurse and what a
nurse should legitimately provide to a patient. I valued and admired her ability
to force me from my comfort zone, which was largely constructed of protocol and
policy.
Amy L. Prielipp, RN, BSN
Ann Arbor, Mich.
University of Michigan Health System
At 48 years of age, Charlotte was suffering from
her first heart attack and was in severe cardiogenic shock. She was accompanied
by her husband Bob and 12-year-old daughter Christina.
Charlotte was critically ill and had arrested at
home, which was some distance from medical rescue teams. Her daughter, who was
with her, had phoned for emergency help.
Through the first night and the following four
days, Charlotte�s heart began to recover. However, her neurological status
remained poor.
When the neurologists informed the family that
Charlotte�s normal brain function was unlikely to return, Bob made the decision
to withdraw support and to allow Charlotte to die peacefully. I spent a lot of
time talking with Bob and Christina, and was with Charlotte when she died.
As the bereavement coordinator for our unit, I
send cards to families of deceased patients. After sending a note to Bob and
Christina, I received a reply from Christina, thanking me for helping her and
her father through this difficult time. Her letter reminded me that the role of
a nurse is to support patients and families in any way necessary during times of
life and times of death. I use my experience with her to remember that, as
nurses, our courage is called upon in so many different ways to help both our
patients and their families through some of the most crucial times in their
lives.
Juan �Ray� Quintero, RN, MSN, CCRN
Yorktown, Va.
Virginia Commonwealth University Health
System
Karl, a 19-year-old patient, started with
flu-like symptoms that led to a syncopal event. Although he was being treated
with oral antibiotics, his respiratory status became compromised due to a
complete, solid consolidation of his right lung. Karl was eventually diagnosed
with arcanobacterium haemolyticum and given the prognosis of inevitable death.
I devoted myself to setting a plan of care into
action for the whole family. Part of this plan was to get the family completely
informed on diagnosis, interventions, medications, care issues, therapeutic
lines and tubes, and a quick course on medical terminology. This preparation
work helped their comfort level and they knew they were contributing to the
recovery of their son. Karl�s room was slowly transformed into a room of hope,
remembrances and special items. A special bear that was brought early in his
admission became his �care bear� and symbol of life.
Clinically, my greatest challenge came when the
attending doctor was considering performing a tracheostomy. Together, we
formulated a plan that would best control Karl�s pain and provide us with the
necessary orders for sleep. Within a week, the tracheostomy was cancelled and,
soon after, Karl was extubated.
I was privileged to have served Karl and his
family, who were a blessing to me in many ways. When people unite for a common
cause, the human spirit is triumphant. There are no losers, and the best rises
to the top.
Sally A. Urban, RN, ADN, AA, CCRN
Freshwater, Calif.
Mad River Community Hospital
An appropriate death is one that makes sense in
terms of the individual�s pattern of living and values and, at the same time,
preserves or restores relationships and is free of suffering as possible.
�Laura E. Berk
�Death, Dying and Bereavement� Development
Through the Lifespan
For a long time, I had considered writing an
article about an unforgettable experience with a patient and family. In the
criteria for the AACN Excellence in Caring Practice Award, I found my
motivation. Specifically, I was moved by the section that read �... acceptance
and triumph in a foreign, uncharted ... experience,� because that seemed to
closely resemble what we were able to accomplish with one patient.
In my role as an ICU manager/UR perspective, I
facilitated interactions and information between the healthcare team and the
patients and families. Through collaborative team efforts, including hospice
care, we were able to deliver what this patient wanted: to die at home.
We were able to orchestrate life support
withdrawal at home, something she chose and her family supported, as a discharge
plan from our ICU. This required commitment and flexibility on our part, as well
as discipline to keep our goal patient driven. In the end, we were able to give
this patient what she, and we, had hoped for: an appropriate death.
End-of-Life Videos Available in Both
Family and Professional Versions
Two videos titled �Compassionate Care in the
ICU: Creating a Humane Environment� are now available through AACN. Funded by an
educational grant from the critical care/surgery division of Ortho Biotech, each
version of the videos was produced in cooperation with the Society of Critical
Care Medicine.
One version is geared to families and the other
to professionals. Both are hosted by Mitchell Levy, MD, associate professor of
medicine at the Brown University School of Medicine, Providence, R.I., and chair
of the Robert Wood Johnson Critical Care End of Life Work Group.
The professional version, which features a
candid discussion of the complex psychological, emotional and legal issues
surrounding end-of-life care, is intended to help ICU practitioners begin
cultivating the compassionate skills needed to assist patients and loved ones.
The family version focuses on the complex
decisions faced in the ICU and the importance of advance planning and
communication. It also answers questions about the withdrawal of life support
and addresses the issues of pain and symptom management.
To order either of these videos, call the
Society of Critical Care Medicine at (800) 504-9334.
SCCM Nursing Award Cites Thunder Project
II Abstract
Thunder Project II Task Force Co-chair Kathleen
A. Puntillo (center) received the Nursing Specialty
Award from the Society of Critical Care Medicine
for an abstract she co-authored. Joining Puntillo were
AACN President-elect Connie Barden and President
Michael L. Williams.
Results of AACN�s Thunder Project II multisite
research study are finding increased exposure, most recently at the Society of
Critical Care Medicine�s annual meeting in San Diego, Calif.
An abstract titled �Practices and Predictors of
Analgesic Interventions for Adults Undergoing Painful Procedures� received the
society�s Nursing Special Award. Accepting the award was one of the authors,
Kathleen A. Puntillo, RN, DNSc, FAAN, who is cochair of the Thunder Project II
Task Force.
A total of 161 sites participated in the
research project, which studied the pain perceptions and responses of critically
ill patients to six commonly performed clinical procedures: tracheal suctioning,
nonburn wound care, drain removal, turning, femoral sheath removal and central
line placement. Data collection involved more than 6,000 patients and included
children as young as age 3, as well as adults.
Results were first reported at AACN�s National
Teaching Institute and Critical Care Exposition in May 2000 in Orlando, Fla.,
and have since been reported in the American Journal of Critical Care (10[4],
238-251) and in Critical Care Clinics of North America (13[4], 541-546.
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