AACN News—March 2002—Practice

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Vol. 19, No. 3, MARCH 2002

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.

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.


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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