Guidelines Aimed at Improving Practice
Around End-of-Life Care. Effort Is Multidisciplinary
By Mary E. Holtschneider, RN, BSN, MPA
AACN Board of Directors
Caring for patients at the end of life poses a
variety of challenges for both family members and healthcare providers. More
than eight years ago, the cardiac care unit at Duke University Hospital, part of
the Duke University Health System in Durham, N.C., undertook an effort to
incorporate into daily practice the best measures for helping families cope
through the end-of-life process of their loved ones. The results of this initial
effort are now woven into the daily practice and culture of the unit.
Data collected on the CCU between 1995 and 1996
indicated an increase in the number of deaths that involved withdrawal of life
support. In response, the unit ethics committee examined not only its own
practice, but also that of other hospital CCUs. Confronted by a lack of
consistency, the committee turned to the literature, but found little written.
Recognizing the opportunity to improve practice, Rebecca Johnson, RN, BS, the
CCU�s nurse clinician and ethics committee chair, formed a multidisciplinary
task force to confront the issues surrounding patients, family members and staff
during end-of-life care. Nurses, physicians, pharmacists, respiratory
therapists, chaplains and social workers came together to develop unit
guidelines to improve this process.
Johnson emphasizes that these guidelines are not
protocols, policies or procedures. Instead, they are a framework from which
individualized plans of care can be uniquely designed for each patient and
family situation. The guidelines focus on several key objectives, including
consistent management of pain, dyspnea and anxiety during withdrawal; effective
and compassionate ventilator weaning; effective and consistent communication
among all team members, including the family; and effective pharmacological
�The guidelines were neither a complex nor
dictatorial document, but rather served as a catalyst for change in unit
culture. Even staff members usually resistant to change and structure have come
to embrace this legally and ethically sound format for end-of-life care,� said
Wanda Bride, RN, clinical operations director for cardiology at Duke Heart
Two ethical principles, adjusted care and double
effect, are cited in the unit guidelines and often referred to by all
disciplines when discussing withdrawal of support. Adjusted care refers to the
approach of providing individualized care for a dying patient where the focus is
on alleviating pain, fear and suffering. Double effect refers to the ethical
principle of accepting a less than desirable effect in order to achieve an
ethically desirable one. For example, morphine causes respirations to diminish
as the dose is increased to alleviate pain. This nonintended effect of
respiratory depression is necessary to achieve the goal of effective pain
relief. Because the intent of using morphine is to alleviate pain and not to
diminish respirations, it is ethically permissible.
Because including the family in discussions is
integral to providing a peaceful death, family conferences are a key part of the
guidelines. Ethical principles are discussed with the family members if
appropriate to their individual situations. Topics outlined for discussion
include time and sequence that the withdrawal will occur, assurance that
families will have liberal access to their loved ones and preparation for the
sights and sounds of death.
According to Johnson, �Consistency is the key to
trust. An essential component to a smoothly running process is ensuring that
each person on the team is fully aware of and supports the proposed plan of
care. Only when this occurs, can we remain in harmony with the family and
patient. Recognizing that this is not always the case, an algorithm for conflict
resolution, which includes all team members, the patient, and the family, is
included in the guidelines.�
With respect to pharmacological management,
pharmacists helped develop guidelines for morphine and lorazepam, the
recommended drugs to decrease pain, anxiety and the sensation of air hunger. The
nursing and medical staff did not previously have a consistent approach to
managing these drips.
According to CCU pharmacist Van Blalock, RPh, �For
too long, we were more focused on the caregiver issues in the end-of-life
setting than the patient. Questions involving the legality and ramifications of
the medications being used were in the forefront of thought. We were missing the
important concept of death with dignity and without pain.
�By involving the families in conversations and
informed decision making and properly documenting doses with pain assessments,
the use of medications for patient comfort in the end-of-life setting is now
viewed as compassionate, responsible care for our patients. It�s really a matter
of doing �the right thing.�"
Ongoing education regarding pharmacotherapy is
essential. For example, new resident physicians who rotate through the unit
often write an order for a �Morphine IV drip, keep respirations above 12.� These
residents are quickly educated by the multidisciplinary team that the goal of a
morphine drip in end-of-life care is comfort and that respirations are not a
limiting factor, as guided by the concept of double effect.
Effective ventilator weaning and airway management
are also addressed in the guidelines. Respiratory therapists were vital to the
development of the guidelines and the ongoing implementation.
These processes are now an integral part of the
unit�s culture. All new staff are educated about these guidelines and ethical
principles as part of their orientation.
Cory Miller, RN, BSN, a 17-year CCU staff nurse and
preceptor, states, �Teaching these guidelines to new staff is equally important
to teaching about CVVHD, Swans, balloon pumps and other technological
interventions. It is also important to teach new staff how to talk to the
�Before the guidelines, many nurses were
uncomfortable with withdrawing support because there was no framework. Nurses
would wonder if they were doing things correctly and legally, and would have to
walk new residents through the process. With the guidelines, there is a greater
sense of confidence in taking these challenging patient assignments.�
Focus on Families
Another aspect of end-of-life care that the CCU
staff focuses on is family visitation and participation.
�For those who want to visit and participate,
visitation becomes a crucial part of helping the families through the
end-of-life process. It provides them with a �reality orientation� that the
family member is indeed dying, in spite of all the medical interventions,
nursing interventions, and all the prayers. Families are not only encouraged to
visit, but to help provide care if they are able,� Johnson explains.
In addition, families have the option of witnessing
codes and are supported by a chaplain or other staff member outside the room.
�I have never seen a family member be litigious when
they have witnessed a code. In fact, one woman once called her husband�s code,
saying that, �It is time to stop.� For those family members who do not witness
the code, we invite them back into the room before it is totally cleaned up.
This allows them to see �reality� of everything that was done for their loved
Liz Stokes, RN, BSN, a staff nurse who has worked on
the unit for a year and has been involved with many patients requiring
end-of-life care, echoes Johnson�s remarks.
�The family is truly part of the team. Once they see
all we are doing for their loved one, it is very comforting for them,� she says.
Stokes also describes a recent situation in which
the husband of a 47-year-old patient refused to withdraw support for his wife.
�He felt that withdrawing support would be �letting
go,� and he was not ready to say those words. When the husband witnessed the
final code situation and saw that we were doing all we could do, he was finally
As far as plans for the future, Johnson states that
she would like to better formalize the teaching of ethical principles for new
staff members. Although staff is oriented to ethical principles and the
guidelines, much of the current ongoing teaching is done informally on patient
rounds and whenever there is opportunity. The unit is also dealing with cultural
issues as they treat increasing numbers of patients from diverse backgrounds and
�We truly attempt to �rise above� our previous
practice by incorporating the entire family into the team by encouraging them to
assist with the end-of-life care and the decision-making process, and thus
allowing each patient a death with comfort and dignity,� Johnson comments.
CNS and NP: To Blend or Not to Blend
By Kristine Peterson, RN, MS, CCRN, CCNS
Advanced Practice Work Group
How do clinical nurse specialists and nurse
practitioners maintain their nursing identity and increase understanding of
their roles? What is the best use of these scarce advanced practice resources?
Can you blend the skills of an NP and a CNS into one role?
To better understand this emerging issue for
advanced practice nursing, let�s listen in on a hypothetical conversation among
a group of nurses discussing this issue.
Are These Roles Different?
Janet, an ICU staff nurse, is enjoying lunch with a
group of advanced practice nurses. Mary is an experienced critical care CNS.
Susan is a CNS who is one of the leaders in the national CNS association. Liz is
an acute care nurse practitioner. And, Anne is practicing in a dual NP-CNS role.
As Janet listens to their conversation about work,
she observes, �All of you are advanced practice nurses, but you all are doing
different things. Is that your choice or are they just assignments?�
Mary explains: �We actually are not all in the same
role, so that accounts for some of the differences you see.�
Janet probes further. �I see Anne and Liz doing more
what the physicians do, like writing orders, but I don�t see you or Susan doing
that. You do more education. Then again, I see Anne doing that as well.�
4 Distinct Roles
Liz tries to end the confusion: �There are four
distinct roles that are advanced practice nursing�nurse anesthetists, nurse
midwives, clinical nurse specialists and nurse practitioners. Mary, Anne, Susan
and I are all CNSs or NPs. In fact, Anne is practicing in a dual NP-CNS role.
These two roles are closer in function than the other two APN roles.
�If you look at the official definitions, however,
they are quite different. An NP is an advanced practice nurse who assesses and
manages both medical and nursing problems and has prescriptive authority.1 A
CNS is a master�s-prepared nurse and an expert in
clinical nursing with a specialty focus who advances the practice of nursing
through innovative, cost-effective nursing interventions that are based in
theory and evidence.�2
Susan interjects: �Although both practice groups are
based in the scope of practice as defined by their RN licenses, they diverge at
the advanced practice level. An advanced nursing practice role extends nursing
practice into the medical domain to some extent. The NP is an independent
practitioner functioning chiefly in the medical domain, while the CNS is an
independent practitioner functioning chiefly in the nursing domain. The CNS
assesses patients from the nursing perspective and uses advanced knowledge to
identify problems amenable to nursing care.�2
Mary adds, �The CNS ensures that staff is able to
carry forward with the nursing care and works with the system to ensure
appropriate staff support is available, such as equipment, education and
resources needed to deliver care. NPs concentrate on managing care for
individual patients. The CNS may see individual patients, but does so in the
nursing domain and through the staff nurse. We serve the nurses so they may
better serve the patients.�
Anne explains, �My role came about because the
physicians needed an expert nursing clinician to follow some of the patients
with more complex needs. It was a bit of a rocky road at first, because there
were communication and control issues. As the medical staff became more
comfortable with the role, they relaxed and let me do my thing. I think it
helped pave the way for other NPs into the system.
�Because I was a CNS first, they were comfortable
with me, and got used to the idea of a nurse managing patients. That helped
introduce NPs into other areas of the system. I think that is one of the
advantages of having a blended role.
�There are other reasons this is happening, though.
For instance, APRNs are a scarce resource, and hospitals especially have learned
the value of their skills, so they will hire in a way that gets them what they
need. Care needs are becoming more complex. Nurses, administrators and nurse
managers all recognize the value of multiskilled APNs serving as resources.
Cutbacks are another reason, I suppose.�
Both roles sound interesting to Janet, who asks for
�Graduate school in nursing is the key to developing
entry-level skills,� says Anne. �I was working as a CNS, got comfortable with
CNS practice and then added the NP practice elements later. The practice role
you choose will determine which skill sets you need to hone.�
But Mary disagrees. �As we were working with the
state board of nursing to develop criteria for advanced practice roles, it
became clear that the requirements for a CNS and NP are very different. You need
a master�s in nursing, but you need the preparation for the specific role as
well. The CNS needs content in the competencies for CNS practice. The NP needs
content that includes NP competencies, such as clinical assessment, pharmacology
and advanced physiology. Because the competencies are different, the education
is different. Your state may add certification in your specialty or a second
license to practice as a CNS as well.�
�Of course, the NP needs to pass a certification
exam for entry into the role,� states Liz.
�You don�t want just anyone to be able to call
themselves a CNS,� says Mary. �The person must understand CNS practice, and the
competency content is not only critical but also different from other ANP
training. It is important for title protection and public protection to have
specific requirements to practice as a CNS or in any advanced practice role. If
you want to do a dual role, you need both preparations.�3
Filling a Dual Role
�That�s what I like about the dual role,� says Anne.
�The APN rounds on each unit with the team, identifies care needs, addresses the
needs (through team or by using prescriptive privileges), and serves as a
resource to both medical and nursing staff. In this role, you can identify
system issues that may affect patients� needs and staff education needs. You
provide education as necessary. You then bring this knowledge to the table at
administrative meetings and incorporate research findings into practice by
sharing them with nursing staff. The APN follows patients as part of the
caseload. Of course, the disadvantage is obvious, you can spread the
practitioner too thin.�
�Well, I agree it can be overwhelming. But, I think
the danger of being overloaded is seen more when you spread the practitioner
over more than one position versus over more than one type of practice,� says
Anne. �I like my role. A dual role gives you more learning experiences and more
variety. You also have more career choices because of the diversity of skills.
There is less chance of getting �rusty� because you maintain skills in a variety
of realms. Having an APN who has a broad repertoire benefits both patients and
staff. It�s kind of like �one stop shopping� rather than have to call a CNS and
an NP to manage a patient.�
1. What Is a Nurse Practitioner. American College of
Nurse Practitioners. Accessed on 3/17/2004.
2. Certification and Regulation of Advanced Practice
Nurses. American Association of Colleges of Nursing. Accessed on 3/17/2004.
3. NACNS Statement on Clinical Nurse Specialist
Practice and Education. 2nd ed. National Association of Clinical Nurse
Specialists. Accessed on 3/17/2004.
July 1 is the deadline to submit applications for
funding by the AACN Small Grant Program. Following is information about the
grants that are available:
AACN Clinical Inquiry Grant
Five $500 awards are available to qualified
individuals carrying out clinical research projects that directly benefit
patients or families. Interdisciplinary projects are especially invited.
End-of-Life/Palliative Care Small Projects Grant
One award of $500 is available annually. Eligible
projects may focus on: any age group, patient education, staff development, CQI
projects, outcomes evaluation projects or small clinical research studies. A
broad range of topics may be addressed, including bereavement, communication
issues, caregiver needs, symptom management, advance directives and life support
Medtronic-Physio-Control Small Projects Grant
One award of $1,500 is available. Funds will be
awarded for projects involving patient education, competency-based education,
staff development, CQI, outcomes evaluation or small clinical research studies.
Topics should focus on aspects of acute myocardial infarction, cardiac
resuscitation, sudden cardiac death, use of defibrillation, synchronized
cardioversion, noninvasive pacing or interpretive 12-lead electrocardiogram.
Collaborative projects involving interdisciplinary teams, multiple nursing
units, home health, subacute and transitional care or other institutions and
community agencies are encouraged.
Is Your Unit a Beacon of Critical Care
Applications are now being accepted for AACN�s new
Beacon Award for Critical Care Excellence to recognize exceptional critical care
units. For more information, visit our website.
Public Policy Update
Election Politics to Complicate Congress
The election-year session of Congress picks up where
the last one left off. Democrats and Republicans appear to agree on little
beyond the extent to which partisanship has made lawmaking difficult.
Legislators will have to put aside their differences long enough to deal with
several inescapable issues during the second session of the 108th Congress.
In the mix are bills to cap medical malpractice
lawsuits and to create a fund of more than $100 billion, financed by businesses
and insurance companies, to pay asbestos victims. Senate Democratic Leader Tom
Daschle said top Democratic priorities this year include raising the minimum
wage, passing a mental health parity bill, getting a good higher education bill
and rewriting the enacted Medicare bill.
Bush�s Approval Rating Falls on Healthcare Issues
President Bush�s approval rating for his handling of
healthcare issues dropped 11 percentage points over the past year, falling to
35% at the beginning of this year from 46% a year ago, according to a Gallup
Group survey of 1001 adults. The survey, conducted between Jan. 19 and Feb. 1,
found that 57% of adults disapproved of Bush�s work on healthcare, compared with
44% a year ago. The remainder had no opinion. The Bush administration had hoped
the Medicare reform law, signed late last year, would cement Bush�s position as
a healthcare leader. However, Democrats criticize the law as a giveaway to drug
makers and HMOs. A new estimate has raised the law�s 10-year price tag $139
billion from the previous estimate to $534 billion.
ANA Endorses Kerry for President
The American Nurses Association has endorsed Sen.
John Kerry (D-Mass.) for president in the 2004 election. Saying that nurses�
interests would be better addressed if Kerry was elected president, ANA cited
the need for dramatic improvements in the nation�s healthcare system, as well as
continued support for RNs and their role in healthcare.
In the Senate, Kerry co-authored the Nurse
Reinvestment Act and other nursing workforce development programs. He also
co-authored the ANA-backed mandatory overtime bill known as the Safe Nursing and
Patient Care Act (S. 373) and opposed the repeal of strong ergonomic protections
that were passed during the Clinton administration.
Although AACN bylaws prohibit the organization from
endorsing candidates for political office, AACN encourages all members to
register to vote and become involved in the political process and will continue
to endorse issues of concern to critical care nurses, the profession and the
industry. For more information on the elections and candidates and to register
to vote visit our website.
RNs Now Top Workforce Demand Projections
For the first time, registered nurses top the U.S.
Bureau of Labor Statistics list of occupations with the largest projected
10-year job growth. Nurses have been on the list for some time but never as No.
1. The bureau�s latest projections put the demand for registered nurses at 2.9
million in 2012, up from 2.3 million in 2002. However, the total number of job
openings, reflecting job growth and the need to replace nurses who have left the
industry, will be more than 1.1 million from 2002 to 2012, the bureau said.
President Bush�s fiscal 2005 budget proposal allocates $147 million for nursing
education programs, including provisions of the Nurse Reinvestment Act.
Although AACN is pleased with the $5 million
increase in this tight budget year, it is also concerned that funding levels are
still inadequate to meet the growing demand for nurses. AACN is joining others
in the nursing community in requesting an increase of $205 million for FY05
nursing funding and will continue to pursue building on the $15 million funding
increase in FY03 and the $30 million increase received in FY04 to ensure that
the nation�s growing need for nurses is met.
Senator Frist Introduces Healthcare Disparity
Senate Majority Leader Bill Frist (R-Tenn.) has
introduced legislation to close the healthcare gap by improving data collection
and analysis on disparities, funding outreach programs, promoting training of
minorities in the health professions, and making cultural competency part of the
training of healthcare professionals. Closing the Health Care Gap Act of 2004
(S. 2091) also contains measures to standardize measures of quality healthcare.
Joining Frist in announcing the legislation was Sen. Mary Landrieu (D-La.), who
expressed hope that the measure can be combined with one proposed by Senate
Minority Leader Tom Daschle (D-S.D.) to get bipartisan action on the issue.
IOM Recommends Strategies for Diversifying
A report by an Institute of Medicine panel
recommends strategies for achieving greater diversity among health
professionals. Titled �In the Nation�s Compelling Interest: Ensuring Diversity
in Health Professions,� the report considers the benefits of greater racial and
ethnic diversity, and identifies institutional and policy-level mechanisms to
garner broad support among health professions leaders, community members and
other key stakeholders to implement strategies to increase the proportion of
minority students training for careers in healthcare. The report is available
online at www.iom.edu > Reports.
More States Bar Forced Overtime
West Virginia and New Jersey have joined the state
of Washington in banning mandatory overtime at healthcare facilities, except in
emergencies. Covered are workers who provide patient care or clinical services.
AACN believes that mandatory overtime is not an
acceptable means of staffing a hospital, because it may place nurses and their
patients at increased risk of being involved in medical errors. Instead, nurses
should be able to decide whether working overtime will affect their ability to
care safely and effectively for patients.
FDA Releases Report on Counterfeit Drugs
Healthcare providers may be better prepared to
protect patients from counterfeit drugs, thanks to a report by the Food and Drug
The report addresses growing concerns about the
threat to consumers posed by counterfeit drugs. Though counterfeiting is not now
widespread in the U.S. drug market, the FDA is investigating more cases of such
activity, often involving well-organized criminal operations working to
introduce finished drug products that resemble legitimate drugs but may contain
only inactive ingredients, incorrect ingredients, improper doses or be otherwise
contaminated. The report outlines a multilevel collaborative approach to the
problems, including an emphasis on the use of new technologies to increase
security, adoption of secure business practices by all participants in the drug
supply chain, education of consumers and healthcare professionals and
collaboration with foreign stakeholders.
Drawing on information from a task force�s six-month
review of the problem, the FDA also encouraged the drug industry to use tiny
radio frequency tags on drug packages to track the medicine from factory to
AACN supports a stepped-up communications effort
called the Counterfeit Alert Network. This public-private network will educate
and inform key stakeholders, including consumers, of this growing threat to
patient safety and serve to protect many from fraud and possible harm as a
result of counterfeit drugs. The FDA Counterfeit Drug Task Force final report is
available online at www.fda.gov > Hot Topics.
New Survey Benchmarks Healthcare Recruiting
Healthcare recruiters and human resources decision
makers have a new national survey with which to benchmark their key recruiting
indicators. Bernard Hodes Group, a New York City-based healthcare recruitment
and communications company, has released its survey reflecting responses from
151 recruiters and other HR experts and offering insight to recruitment metrics
among acute care hospitals (80% of respondents), long-term care, home care and
other facility types.
Following are some of the findings:
� Nurses are the third most expensive of the
healthcare professions studied at $2,651 cost-per-hire. Direct costs, such as
recruiters� salaries, media, collateral materials,and postage, are included.
On-boarding or replacement costs are not.
� RNs had the highest turnover rates of all the
professionals studied (15.5%). The respondents said the average number of
full-time equivalent RNs at their hospital is 416.
� In the hardest-to-fill category, critical care-ER
nurses topped the list with a mean of 3.97, followed by operating room/postanesthesia
care unit, oncology and then medical-surgical.
� Although most employers (83%) offer employee
referral bonuses, only 44% reported offering them in all categories. Fifty-nine
percent said they offered employee bonuses for RNs.
� Fifty-nine percent of respondents indicated that
they offer sign-on bonuses for new hires. The bulk of those (45%) are for RNs.
� Combining nursing and allied health, the most
frequent employer offering to healthcare workers was tuition to attend offsite
programs, with 89% offering those; followed by paid time off to attend offsite
educational programs (67%), paid time off (65%) and student scholarships (49%).
Study Shows Health Benefits Worth More Than Money
Each additional dollar spent on healthcare services
has produced between $2.40 and $3 in tangible gains in healthcare over the past
20 years, according to a study by a coalition of the nation�s leading health
organizations. The report, titled �The Value of Investment in Health Care:
Better Care, Better Lives,� reveals that without this investment, in the year
2000 alone, there would have been 470,000 more deaths, 2.3 million more people
with disabilities, and 206 million more days spent in the hospital. It is hoped
that the report, published Jan. 28 by the Value Group, provides sufficient
evidence to insert the value of investing in healthcare into discussions as
lawmakers address rising healthcare costs.
Public Policy Snapshot
Hospital Capital Projects Include Major IT Plans
About 72% of hospital and health system chief
financial officers plan to purchase digital radiology systems in the next five
years, with another 64% investing in computerized physician order entry systems,
and 61% planning other major IT systems, according to a survey by the Healthcare
Financial Management Association.
Nearly three of four hospitals expect their capital
spending to increase in the next five years. Overall, hospital capital spending
will increase 14% annually during the next five years, compared with 1% annual
increases from 1997 to 2001.
Technology projects were the most commonly cited
capital projects, with about half of hospital and health systems planning to
devote capital to increasing emergency and operating room capacity.
The report, which includes 460 hospital and system
CFOs, is based on research by HFMA and PricewaterhouseCoopers. GE Healthcare
Financial Services provided funding for the report.
For more information about these and other issues,
visit our website.
Practice Resource Network
Q: Are there specific guidelines for monitoring
neuromuscular blocking agents and using the peripheral nerve stimulator and the
A: The goal of administering NMBA is to provide the
minimum depth of paralysis that is clinically appropriate for the patient, using
the least amount of drug. Monitoring the patient�s neuromuscular response is
important to decrease avoidable side effects, such as premature return of
spontaneous movement, prolonged paralysis and delay in recovery.
Traditional physical assessment methods to monitor
the depth of neuromuscular blockade include observing skeletal muscle movement
and respiratory effort. Electronic methods include use of the ventilator
software to detect spontaneous ventilatory effort and transcutaneous delivery of
current using the peripheral nerve stimulator.
However, the physical assessment and use of the
ventilator software are fraught with difficulties, making the train-of-four the
easiest and most reliable method available for monitoring the level of NMB.1
Studies have demonstrated that monitoring the depth of NMBA using PNS and
train-of-four has resulted in lower doses of NMB drugs and faster recovery of
neuromuscular function once the drug has been discontinued.
In 1995, the Society of Critical Care Medicine and
the American College of Critical Care Medicine published the first clinical
practice guidelines for sedation, analgesia and neuromuscular blockade in the
critically ill patient. In 2004, they joined with the American Society of
Health-System pharmacists to develop new guidelines on the sustained use of
sedatives, analgesics and NMBAs in the critically ill adult.
The �Clinical Practice Guidelines for Sustained
Neuromuscular Blockade in the Critically Ill Adult Patient� recommends that
patients receiving NMBA should be assessed clinically and by using train-of-four
monitoring, with a goal of titrating the NMBA to achieve one to two twitches.2
The guidelines are available online at www.sccm.org
> Professional Resources > Guidelines.
Adequately assessing the depth of paralysis to avoid
complications or adverse effects when administering NMBA is important. The AACN
Procedure Manual for Critical Care includes a comprehensive procedure for the
use of peripheral nerve stimulators in association with the administration of
NMBA.3 This procedure will be useful in developing or reviewing current policies
regarding the monitoring of patients on NMBA.
1. Rudis MI, Sikora CA, Angus E, et al. A
prospective, randomized controlled evaluation of peripheral nerve stimulation
versus standard clinical dosing of neuromuscular blocking agents in critically
ill patients. Crit Care Med. 1997;25(4):575-583.
2. Murray, MJ, Cowen J, DeBlock H, et al. Clinical
practice guidelines for sustained neuromuscular blockade in the adult critically
ill patient. Crit Care Med. 2002;30(1):142-156.
3. Lynn-McHale DJ, Carlson KK, eds. AACN Procedure
Manual for Critical Care (fourth edition). WB Saunders Co; St Louis Mo:2001.