Vol. 20, No. 2, FEBRUARY 2003
The Power of One: Living Wills Help in the
Transition From Curative to Palliative
By Benny Bolin, RN, ADN, MS
Ethics Work Group
Advance directives, which include living wills, medical powers of attorney and
healthcare proxies, are legal documents that enable people to give instructions
regarding their future medical care in the event they are unable to give or make
healthcare decisions themselves. Through these documents, patients can delineate
the types of treatments they want or don�t want when they are terminally or
irreversibly ill or injured. If these wishes are medically appropriate, they can
have a chance to be a part of the decision making, even when they can no longer
make their wishes for care decisions known.
In addition to the fact that too many patients do
not have living wills, two basic problems exist.
First, to avoid conflicts with survivors and
potential lawsuits, hospitals, physicians and other members of the healthcare
team too often allow families to override living wills. Nurses and other
healthcare team members should be advocates for what is best for the patient,
and allowing families to override living wills is not being a patient advocate.
In fact, many states now have laws that require advance directives to be
honored. Some states, for example Texas, even provide for criminal, civil or
licensure penalties in cases where advance directives were knowingly not
followed. However, because few, if any of these circumstances are reported, the
legal ramifications are minimal. Nurses and other healthcare team members should
be familiar with their states� laws regarding advance directives. A good
Internet resource site for advance directives is
The second problem with living wills is that they
sometimes carry a "morale dis-ease" by creating morale problems or uneasiness in
those caring for patients perceived as a "lost cause." Too often, we feel that
we are failures if we cannot cure. Instead, we should consider the transition
from curative to palliative care as an opportunity to help our patients and
their families have as positive an experience as possible in this very difficult
and emotionally trying time.
Our track record in providing care at the end of
life is not optimal for many reasons, including fear of overmedicating and fear
of going against the families. However, this should be a time when patients get
the most basic care that nurses have to offer: comfort. We must ensure thdat
patients under do-not-resuscitate orders do not become "do-not-treat" patients.
We must understand how we can make their last days and hours comfortable and
meaningful to them and their families and friends, such as moving them to a
private room where the family can be in attendance and ensuring that pain is
We should also shift our nursing focus from
sustaining life to emphasizing comfort. Making the shift from cure to comfort
allows us to view our nursing care in more positive terms.
Acknowledging and honoring living wills can ease
patients into this last phase of their life in a more comfortable and humane
manner. Patients� families can find comfort that the patients were treated in
the manner they desired, hopefully without suffering. The fact that patients
have living wills and do-not-resuscitate orders should not cause nurses to avoid
these patients or spend less time with them, but instead to increase the time,
albeit with a different type and focus.
APNs Can Minimize Liability Exposure
By Lisa Kohr, RN, MSN, CPNP, MPH
Advanced Practice Work Group
Advanced practice nurses have successfully demonstrated their competency in
managing sicker patients, implementing clinical pathways to decrease morbidity
and costs, and expanding their practice domain to fit the needs of our specialty
and institutions. Yet, as the scope of practice has grown, so has the risk for
Because healthcare has changed so rapidly,
legislation may not yet exist to address the newer healthcare modalities. For
example, there are no laws governing the responsibilities of the APN involved in
As a result, many questions are unanswered. Should
the APN be responsible for actions taken by the referring hospital in response
to the telemedicine diagnosis? Will the APN be liable if mismanagement of the
diagnosis causes complications? Who is responsible if there is a lack of
compliance with the recommended follow-up?
E-mail triage is another black box when it comes to
APN liability. What is the APN�s responsibility toward a patient who e-mails
with complaints of an illness? Is the APN liable if the patient does not seek
recommended treatment? Is the APN responsible if the patient does not fully
disclose the symptoms or recent changes in his or her condition and suffers a
complication? Are guidelines established for each site where the APN has
privileges? Who covers cases after the APN leaves? What if the patient�s
condition changes after the APN has written to discharge the patient?
Medicare billing and correct assignment of visits
for APNs who are independently seeing patients are other hot liability topics.
On-call and off-shift coverage can be a minefield unless appropriate guidelines
are set. Questions regarding who is the emergency backup, which patients are
covered during the off hours and whether staff nurses can accept telephone
orders from an APN are just a few of the details that must be addressed to avoid
the potential for liability.
In addition, many APNs could face increased patient
loads, as well as moonlighting options, when the new law limiting residency
hours goes into effect in July. Unless guidelines clearly establish the scope of
the APN�s role and responsibility, these issues will expose the APN to
APNs can minimize their liability
exposure by staying abreast of the latest legislative developments affecting
their practice at the federal, state and local levels. This type of legislative
information is available from a variety of sources, including the AACN Web site
(www.aacn.org > Public Policy), or the Web sites of their state boards of
nursing, state advanced practice council or their national association. Other
strategies to limit liability risk include updating practice agreements and
scope of responsibilities to accurately reflect current roles. In addition,
ensuring compliance with yearly reviews of procedures and prescriptive
authority, certification requirements and institutional agreements will decrease
the potential of liability.
Lisa Kohr is a pediatric nurse practitioner with the Division of
Cardiovascular-Thoracic Surgery at Children's Memorial Hospital, Chicago, Ill.
1. Survillo A, Levine A. Strategies to limit CNS malpractice liability exposure.
Clin Nurse Specialist. 1993;7:215-220.
2. Buppert C. Avoiding Medicare Fraud, Part 1. The Nurse Practitioner.
3.Buppert C. Nurse Practitoner�s Business Practice and Legal Guide. Aspen, Colo:
Aspen Publishers Inc; 1999.
4. Kleinpell R, Piano M. Practice Issues for the Acute Care Nurse Practitioner.
New York, NY: Springer Publishing Co; 1998.
Sepsis Education Program Available
Eli Lilly Grant Underwrites Purchase Fee for
Identification and Management of the Patient With Severe Sepsis," AACN�s
national sepsis education program for nurses, is now available in a self-paced
CD-ROM format. Funded by an unrestricted educational grant from Eli Lilly and
Company, this program is sponsored by AACN and is accredited for 5.0 contact
hours of CE credit for single users.
Narrated by clinical expert Barbara McLean, RN, MN,
CCRN, CCNS-NP, FCCM, the new program offers clinicians a comprehensive view of
the latest information on the diagnosis and care of patients with severe sepsis.
The 170-page, audio/slide CD-ROM study guide
includes pathophysiology of severe sepsis; identification of acute organ system
dysfunction; antibiotics, source control and monitoring in severe sepsis,
including investigational and new approved therapies; hemodynamic, ventilatory,
renal and other aspects of care; and nursing care of patients with severe
sepsis. Case studies are also included in the presentation.
To order this cutting-edge learning program for only the $7.50 shipping and
handling fee, call (800) 899-2226 and request Item #004060. Quantities are
Myth vs. Reality: Beta Blocking Agents Have
Positive Effect on Heart Failure
By Elaine Steinke, RN, PhD
Chair, Research Work Group
Myth: Beta blocking agents should be avoided in heart failure patients.
Reality: Beta blocking therapy has a positive effect
on both morbidity and mortality in HF.
Previously, the use of beta blocking therapy was
debated, largely because of initial transient negative inotropic effects.1
However, the use of beta blocking agents has now been evaluated in more than 20
published placebo-controlled trials with more than 10,000 patients.2 These
clinical trials clearly show that beta blocking therapy reduces both morbidity
mortality in HF.
Its effectiveness holds true for both older and
younger patients.1-3 A recent study of women with New York Heart Association
functional Class II or higher HF who were treated with metoprolol revealed
reduced mortality, cardiovascular hospitalizations and hospitalizations for
worsening HF.4 These findings were also true for women with the most severe HF.
In addition, long-term treatment with beta blocking agents improves the
patient�s clinical status, lessens symptoms of HF and enhances an overall sense
Additional outcomes from clinical trials include a
reduced need for hospitalization for cardiovascular causes and improvement in
NYHA functional class, hemodynamic status, left ventricular ejection fraction,
and signs and symptoms of HF.5 Recent trials, such as COPERNICUS, suggest that
beta blocking agents improve outcomes for those with the worst heart failure,
Class III and Class IV. Indications and Warnings
The 2001 ACC/AHA guidelines for HF suggest that, in
patients with systolic HF, an angiotensin-converting enzyme (ACE) inhibitor be
started, followed by a low-dose beta blocking agent, such as carvedilol or
metoprolol, with a gradually increasing dose over 12 weeks.2 Because beta
blocker therapy can potentially worsen HF, it is recommended that a period of
treatment with standard therapy be initiated first and that evidence of clinical
stability (no acute decompensation or fluid overload) be present before
initiating a beta blocking agent.6 Beta blocking agents are started at low doses
and slowly up-titrated, generally at two-week intervals. Careful evaluation of
the patient, including assessment of worsening failure, is important. Evidence
of worsening failure may require adding other medications or a reduction of the
beta blocker dose. In addition, patients should be adequately diuresed and
stabilized before therapy is initiated.
Beta blocking agents should be started early, even
in patients with mild symptoms or those who are clinically stable. These
patients are at risk for increased morbidity and mortality, and their condition
may likely deteriorate over the next 12 months, even when treatment with digoxin,
diuretics and ACE inhibitors has been initiated.2 Beta blocking agents have been
used primarily for those patients with NYHA Class II or III and HF patients who
don�t tolerate ACE inhibitors.5 Low-dose ACE inhibitors combined with beta
blocking agents have improved both symptoms and mortality risk when compared
with increasing the dose of ACE inhibitors.2 Clinical response to beta blocking
agents is delayed, and it may take two to three months before effects are
apparent. Because of the effect on morbidity and mortality, continuing beta
blocker therapy is recommended, even if symptoms do not improve.
Beta blocking agents are contraindicated in patients
with decompensated HF, cardiogenic shock, acute pulmonary edema, hemodynamic
instability requiring IV inotropic support, bronchial asthma, second or third
degree AV block, sick sinus syndrome without a permanent pacemaker, and severe
hepatic or renal impairment.5
Monitoring for patients taking beta
blocking agents includes observing for clinical indicators of drug intolerance
such as a heart rate below 55 beats per minute, symptomatic hypotension,
dizziness or lightheadedness, or manifestations of worsening HF, such as
shortness of breath, dyspnea, fatigue or weight gain. Beta blocking agents
should not be discontinued suddenly, because reflex tachycardia and angina in
those with coronary artery disease can occur.7 Serum digoxin levels should be
monitored, because some beta blocking agents, such as carvedilol, can increase
digoxin levels. Because beta2 adrenergic blocking agents may prevent the
appearance of warning signs of acute hypoglycemia, blood sugar levels should be
closely monitored in patients with diabetes.8 Additional side effects include
erectile dysfunction in males, depression, lethargy, drowsiness, weakness,
difficulty sleeping, anxiety, nasal congestion, abdominal distress, and cold
hands and feet.8
Patients should be instructed to weigh daily to
assess fluid status and report signs and symptoms of fluid overload. If patients
experience medication side effects, separating the time of day medicines are
taken, especially ACE inhibitors and beta blocking agents, may be helpful.
Patients should be told that symptom improvement may not be noticed for weeks or
even months and that medications should not be discontinued suddenly or without
consulting their physician.
1. Gheorghiade M, Goldstein S. B-Blockers in the postmyocardial infarction
patient. Circulation. 2002;106:394-398.
2. American College of Cardiology/American Heart Association [ACC/AHA] ACC/AHA
Guidelines for the Evaluation and Management of Chronic Heart Failure in the
Adult. Dallas, Tex: American Heart Association; 2001.
3. Stanley M, Prasun M. Heart failure in older adults: Keys to successful
management. AACN Clin Issues. 2002;13:94-102.
4. Ghali JK, Pina IL, Gottlieg SS, Deedwania PC, Wikstrand JC. Metoprolol CR/XL
in female patients with heart failure. Circulation. 2002;105:1585-1591.
5. Meghani SH, Becker D. B-Blockers: a new therapy in congestive heart failure.
Am J Crit Care. 2001;10:417-427.
6. Heart Failure Society of America. HFSA guidelines for management of patients
with heart failure caused by left ventricular systolic dysfunction�pharmacologic
approaches. J Cardiac Failure. 1999;5:357-382.
7. Capriotti T. Current concepts and pharmacologic treatment of heart failure.
MEDSURG Nursing. 2002;11:71-83.
8. McKenry LM, Salerno E. Mosby�s Pharmacology in Nursing, 21st ed. St. Louis,
Mo: Mosby; 2001:484.
Practice Resource Network
Q: I am interested in the Instructor�s Resource
Manual for the Core Curriculum, 5th edition. However, because of the cost, I
would like to review this product in advance. I understand that it is a
A: The good news is that you can preview this
product online at www.aacn.org > Bookstore > AACN Product Catalog > Specials &
What�s New. Here you will find a link to sample pages, which include the full
Table of Contents and samples of the Cardiovascular Instructor Outline,
Cardiovascular Module Handout Index, the handouts and slides from the
Do you have a question related to your practice?
Contact AACN�s Practice Resource Network at (800) 394-5995, ext. 217.
Apply by March 1 for Evidence-Based Clinical
AACN offers a variety of small and large research
grants. March 1 is the deadline to apply for the Evidence-Based Clinical
Practice Grant. This grant awards $1,000 to cover direct project expenses, such
as printed materials, small equipment and supplies. Eligible projects can
include research utilization studies, CQI projects and outcome evaluation
studies. Collaborative projects are encouraged.
To find out more about AACN�s research priorities
and grant opportunities, visit the AACN Web site. The grants handbook is also
available from AACN Fax on Demand at (800) 222-6329, Request Document #1013.
Public Policy Update
Health Policy Outlook
When the 107th Congress ended in December, lawmakers
had rejected virtually every significant healthcare proposal they had considered
during the past two years. Included were efforts to expand insurance, better
protect patients and curb the nation�s medical expenditures.
From patients� rights to generic medicines to
changes in medical malpractice law, the lengthy list of unpassed bills reflects
the polarization of the political parties.
Congress is closely divided and the agenda has been
focused on a few core issues, largely the economy and national security.
Whether attention on health legislation will
heighten in the new Congress, where the GOP controls both the House and the
Senate, is up for debate. Many Republicans predict a smoother legislative path,
policy analysts from both parties note that the
Senate majority is slim and that the budget may have less room for expensive
health proposals. However, despite the party differences, Congress can be
expected to make healthcare issues a priority in
President Bush has outlined a comprehensive
healthcare agenda that proposes to create a system that puts the needs of
patients first by helping all Americans obtain affordable healthcare coverage,
helping patients get consistently high-quality care, and developing new
treatments to keep patients healthy and prevent complications from diseases and
strengthen the healthcare safety net. The president will back up this agenda
with more than $300 billion in proposed funding.
Republicans say they are drafting a healthcare
agenda that would "drastically reshape" how healthcare services are delivered.
President Bush and congressional Republicans said that healthcare issues, such
as a Medicare prescription drug benefit, tax credits for the uninsured and
limits on damages awarded in medical malpractice cases will be a "high
However, in enacting their agenda, Republicans will
face several challenges that could force party leaders to consider scaling back
their goals and "softening" their approaches. For example, as demands for new
spending increase, the federal budget is running at a deficit. Republicans also
must overcome the party�s "internal division" over the best ways to resolve some
healthcare problems. Although the White House and Senate Republicans tend to
agree on policy, the House often passes more partisan legislation, because it is
easier for the GOP majority to control.
Improved Patient Care
The Department of Health and Human Services Advisory
Committee on Regulatory Reform has issued its final report highlighting hundreds
of specific recommendations for improving regulatory requirements across HHS
agencies, including some that HHS has already moved to implement or address.
"One by one, we are removing the unnecessary
barriers between patients and their doctors, nurses and other healthcare
providers," said HHS Secretary Tommy G. Thompson. "By restoring common sense to
our regulatory system, we are helping healthcare professionals spend more time
caring for patients and less time consumed with paperwork."
The advisory panel of consumers, doctors, nurses and
other professionals was established last year to help guide HHS� efforts to
streamline unnecessarily burdensome or inefficient regulations that interfere
with the delivery of and access to quality healthcare for Americans. Its final
report urges a broad range of actions to reduce the potential for harm to
patients that may result from unnecessarily complex, confusing and burdensome
regulations. The panel made 255 recommendations to reduce potential obstacles to
patients� access to care, reduce the time doctors and other healthcare
professionals spend on paperwork, improve communication with consumers and
improve the use of technology to promote quality care while ensuring patients
have strong privacy protections.
Staffing Issues and Drug Errors
Distractions, increased workload and other
staffing-related issues, including inexperienced or temporary staff, were the
most frequent factors contributing to medication errors in 2001, according to a
study by U.S. Pharmacopeia, Rockville, Md. Staffing issues were cited in 36% of
medication-error reports in 2001, up from 27% in 1999, the first year that U.S.
Pharmacopeia conducted its annual analysis. Among the other findings were:
� Distractions contributed to 47% of the 105,000
medication errors reported by 368 hospitals nationwide in 2001.
� Staff workload was cited in 24% of the reported
� Approximately 61% of the errors affected patients,
an improvement from the 69% in 2000. Of those, 2.4% were harmful or fatal.
Fourteen deaths were reported, compared with three in 2000.
Demand for Beds and Services
The demand for beds in U.S. hospitals is projected
to increase by as much as 46% in the next 25 years, according to a study
published by Solucient, a healthcare business intelligence firm. This increase
of an additional 238,000 beds is expected to result from long-term demographic
shifts in the U.S. population, which could drive up demand for inpatient acute
care through 2027. The new long-term forecasts also show that total acute care
admissions are projected to increase by 13 million cases or 41% during the same
For more information about these and other issues,
visit the AACN Web site.
Nurse Reinvestment Act Must Now Be Funded
Contact Legislators to Advocate for Their Support
As a member of the Americans for Nursing Shortage
Relief coalition, AACN is pushing for funding of the Nurse Reinvestment Act, the
main issue for nursing advocates in 2003.
The fact that the legislation was enacted in only a
year�s time indicates the high priority that Congress has placed on addressing
the nursing shortage. AACN hopes that the new Congress will maintain this focus
in 2003 and act to fund this important piece of legislation to protect patients.
However, now that the elections are over and the NRA
has been passed, the nursing shortage may likely be further down on the 108th
Congress� priority lists. Nevertheless, nurse advocates will still have
opportunities to draw attention to the shortage as Congress focuses on other
issues, such as bioterrorism and small pox vaccinations.
Without funding, the programs included in the act to
address recruitment, retention, nurse faculty education, public education about
the profession and professional development for nurses cannot be implemented.
AACN members are encouraged to ask their legislators to support funding of the
NRA. AACN�s Legislative Action Center online can not only help members easily
identify their congressional representatives, but also contact them directly via
Enrollment in entry-level baccalaureate programs in
nursing increased by 8% in Fall 2002, according to the American Association of
Colleges of Nursing. However, the number of students in the educational pipeline
is still insufficient to meet the projected demand for 1 million new nurses over
the next 10 years. Total enrollment in baccalaureate nursing programs surveyed
by the association was 116,099, up from 106,557 in 2001 but still lower than the
127,683 enrolled in 1995, the year enrollments began to dip.
Although the increase in enrollments is good news,
substantially greater increases in the number of nurses available over the next
five years will be needed. The most recent projections from the U.S. Bureau of
Labor Statistics indicate that 1 million new and replacement nurses will be
needed by the year 2010 and, according to a July 2002 report by the Health
Resources and Services Administration, the number of states with a shortage of
registered nurses is expected to grow from 30 in 2000 to 44 in 2003. In
addition, the growing shortage of faculty is of significant concern for
institutions trying to accommodate the increased interest in nursing as a
AACN will continue to advocate for legislation that
benefits the nursing profession and seeks solutions to the nursing shortage.
In the meantime, efforts to address the shortage
continue on a number of fronts. Below are examples of how the issue is being
addressed at the state levels.
Addressing the Nursing Shortage
The Pennsylvania Higher Education Assistance Agency
has announced the establishment of a nursing loan forgiveness program to help
alleviate its nursing shortage. The agency expects to fund $13.3 million in loan
forgiveness with proceeds from a series of bond-issue refinancings at no cost to
taxpayers. To qualify, students must graduate from an approved professional
nursing education program during or after 2003. Participants must also maintain
employer-verified, full-time, continuous employment after graduation as a direct
care nurse at an approved Pennsylvania healthcare facility or as a nurse
educator in the Commonwealth for a minimum of one year and hold an eligible
federal Stafford loan.
A coalition of Virginia-based private and public
healthcare systems and organizations has announced the launch of the Virginia
Partnership for Nursing�s campaign, "Nurses Change Lives." The campaign seeks to
inspire students in kindergarten through 12th grade to consider a career in
nursing. As part of the campaign, four different posters targeting specific age
groups have been created for distribution to elementary, middle school and high
school students across the state. In addition, a network of nurses will be
developed to provide education about nursing opportunities. For more
information, visit www.nurseschangelives.com.
More than 35 hospitals, 16 schools of nursing and 60
school districts in southeast Michigan have come together to launch "Nurse
Now!," a five-year collaborative initiative to increase the number of
academically qualified youth interested in nursing careers. Recently, more than
1,000 high school students had the opportunity to "Be a Nurse for a Day" at
participating hospitals. Other campaign elements include a "Nurse Now!" career
information kit for high school counselors, math and science teachers that
includes posters and brochures, and a Nurse Ambassador program that makes nurses
available for school and in-classroom presentations on a variety of topics. For
more information, visit www.mihott.com.
Online Quick Poll
Does your unit use a standard monitoring lead for every patient regardless of
diagnosis (for example, every patient monitored in Lead II)?
Number of Responses: 592
The AACN Online Quick Poll is a voluntary survey on a variety of topics and is
not scientifically projectable to any other population. AACN presents these
surveys to give our users an opportunity to share their opinions on particular
topics. Participate by visiting the AACN Web site.