AACN News—January 2000—Practice

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Vol. 17, No. 1, JANUARY 2000

Hospital Sessions Promote Discussion of End-of-Life Issues

By Theresa E. DeVeaux, RN, BSN, CCRN
Public Policy Adviser, Region 4

The boundaries between life and death are not as clear as they once were, because modern technology provides the means to keep a patient alive indefinitely.

In an institutional setting, patients’ families may be too apprehensive and distressed to pursue value preferences. Many do not understand that they have the right to participate in making decisions about treatment.

The fear of prolonging death in this high-tech environment has led to the development of laws to guide healthcare decisions. Personal philosophy, spirituality and values can become entangled, further complicating a stressful situation.

Critical care nurses are confronted daily with the reality that a patient probably will die and with questions that challenge their own values. Physicians, who are trained to preserve life at all costs, experience great difficulty advising end-of-life treatment for a patient. These conflicts raise questions such as whether only the consequences for the patient should be considered or whether the effect on the family, as well as the healthcare professionals should be considered, collectively.

At North Arundel Hospital in Glen Burnie, Md., the ethics committee has provided an opportunity for staff to discuss their concerns by offering lunchtime roundtable sessions. The sessions are primarily intended to increase awareness of advance directives and to promote better understanding of the role of the healthcare provider in supporting a patient’s end-of-life decisions.

The committee, which is comprised not only of nursing, medicine, social work and administration representatives, but also of community members, selects a case to present that highlights a particular ethical issue. Although the cases are taken from actual patient admissions, anonymity is maintained.

The 90-minute sessions, which are open to all of the hospital’s healthcare providers, are well-attended. Because lunch is provided, staff members can attend during their breaks. Evaluation comments frequently include requests for more sessions and suggestions for future case presentations.

At each session, one committee member summarizes the case history and prepares questions to help stimulate discussion. Examples of issues include starting or stopping enteral tube feeding, beginning or ending dialysis, discontinuing ventilator support and pain management of the dying patient. The hospital attorney is also a committee member and attends to provide clarification of laws or terminology.

Ethics committee representatives explain that they are available to consult on particularly difficult patient situations or to address concerns. At least twice a year, the committee arranges for guest speakers who have expertise in ethical issues at evening meetings that are open to the community.

In keeping with the AACN priority issue for humane, healing and ethical care, end-of-life care has been identified as an association initiative. The initiative action plan includes continued efforts to develop educational resources for nurses and consumers to present and teach end-of-life options.

Patient education is an important role for nursing. Many patients are reluctant to begin a discussion of advance directives, preferring instead to have the healthcare provider initiate the discussion. Nursing interactions result in special relationships with patients and their families and are associated with a high level of trust. This unique relationship facilitates the initiation of a discussion related to advance directives.

As patient advocates and caregivers, nurses have an opportunity to assume a major role in this important area of healthcare.

One of the educational resources that can enhance this role is a publication titled Discovering Your Beliefs About Healthcare Choices: A Guide to Living Wills and Durable Powers Of Attorney, which is designed to lead and teach groups about this important aspect of healthcare. Discovering Your Beliefs About Healthcare Choices is included in the AACN Resource Catalog. To obtain a catalog, call (800) 899-AACN (2226), or order online through the AACN Web site at  http://www.aacn.org.

Additional information about this and other public policy initiatives is also available through the AACN Web site, or by calling Public Policy Specialist Janice Weber, RN, MSN, CCRN, (800) 394-5995, ext. 508; e-mail, janice.weber@aacn.org.

A Nurse’s Strength Can Help Pull a Patient Through

Ronna Carlton, RN, ADN, CNRN, is a staff nurse in the ICU/CCU at Methodist Medical Center, Oak Ridge, Tenn. She received a 1999 Excellence in Clinical Practice Award, cosponsored by 3M Healthcare. Following are excerpts from the exemplar that Carlton submitted in connection with her award, which is part of AACN’s Circle of Excellence recognition program. For more information about Circle of Excellence awards, call (800) 899-AACN (2226), or visit the AACN Web site at  http://www.aacn.org.

By Ronna Carlton

Our eight-bed unit was quiet when the call came from the emergency department. My patient was to be a 34-year-old man with inferior myocardial infarction (MI) and tissue-type plasminogen activator (t-PA) infusing. Hanging from the IV poles when he was brought to the unit were the last portion of t-PA, heparin and nitroglycerin—all infusing into three different sites.

Mr. X’s vital signs were good, and the monitor showed sinus rhythm, though the ST-segment was still elevated. As I obtained his admitting history, I monitored his vital signs and assessed his level of chest pain.

Mr. X told me about his involvement in Little League Baseball. He and his wife had no children of their own, and considered the young players “their kids,” he said. He was anxious about the game scheduled for the next day, and asked me whether I thought he would be out of the hospital in time to attend. I told him I thought it was unrealistic to expect to be discharged in time. I explained to Mr. and Mrs. X that he would be in the hospital for a few days and might have to undergo a heart catheterization. Throughout this, he continued to comment about “his boys.”

As we talked, the t-PA dosage was completed, and I gave him a couple more doses of morphine to alleviate his continued chest discomfort. The nitroglycerin drip was at an extremely high dose level, and I was concerned that he continued to experience pain.

After the t-PA had been finished for about 30 minutes, I noticed that Mr. X’s ST-segments were elevating. His pain was increasing, even though his heart rate and blood pressure remained stable.

After giving Mr. X the sixth dose of morphine, I told his wife that I suspected his heart attack was extending, which could mean that he could expect to be taken to another facility for a heart catheterization. I paged the doctor and quickly did an ECG, which confirmed that the MI was extending. After receiving transport orders, I gave Mr. X a bolus of heparin and another dose of morphine for his pain.

He became more anxious and was having difficulty accepting what was happening. I explained that the heart catheterization would hopefully intercede and prevent further damage to his heart. He held my hand tightly and asked me not to leave him. I promised I would take care of him.

Transferring Mr. X to the stretcher was difficult, because he refused to let go of my hand and insisted that I accompany him in the ambulance. After assessing the situation, my supervisor gave approval for me to go with him.

During the trip, Mr. X kept asking me if he was going to be all right. Sensing his anxiety, I did something I had never done before. I told him that he would be all right. I knew it was something he needed to hear. As soon as he heard that, he loosened his grip on my hand and became visibly more relaxed. Mr. X’s wife was waiting at the hospital when we arrived. He smiled and told her, "The nurse says I’ll be OK. I’ll see you soon."

As the procedure was about to begin, Mr. X squeezed my hand one last time and said, "Thank you." Holding back tears of my own, I reassured him and said I expected to see him soon.

I left the lab and sought Mr. X’s wife in the waiting room. I hugged her and asked that she let me know how things went.

Mr. X had triple bypass surgery that night. I learned from the doctor that he came through the surgery fine.

When I arrived at work several months later, a coworker told me I had had a visitor earlier in the day, who said he would return the following morning. I didn’t give it much thought until a nurse from the step-down unit called to say she had sent someone back to see me. As I hung up the phone, Mr. X walked through the door, carrying a basket of flowers and a gift. He wore a T-shirt that read: "I survived ’96." Below that were the words: "I had a guardian angel."

Mr. X said the flowers were from his wife. I then opened the gift from him. It was a plaque that read: "Some people come into our lives and quickly go. Some stay for a while and leave footprints in our hearts, and we are never ever the same." With tears in my eyes, I hugged Mr. X.

I was deeply touched by the experience of meeting Mr. X and his wife, helping them through a difficult time, calming their fears and seeing Mr. X after he pulled through. I realized that, as nurses, we sometimes have to transfer our own will and own strength to our patients and families to enable them and us to make it through.

Geriatric Corner: Test Your ‘Aging IQ’

The Specialty Nursing Activities Partnership Program (SNAPP) of the Hartford Institute for Geriatric Nursing brought its conference resource center to AACN’s 1999 National Teaching Institute" and Critical Care Exposition in New Orleans, La., in May.

SNAPP offers associations like AACN assistance in educating their members in the essentials of geriatric nursing. Given a burgeoning older population, it is fair to say that every nurse will provide nursing care to older adults in the course of his or her career.

At the NTI, 725 of the nurses who visited the SNAPP booth completed the Aging IQ Quiz, developed by the National Institute on Aging. The 20-question quiz addressed common themes and issues associated with aging. Seventy-one percent (71%) of the nurses who took the quiz missed more than two questions; 32% missed more than four questions; and 2% answered all the questions correctly.

The quiz is re-created here. The answers and the rationale for the correct choices will appear in the February issue of AACN News. Enjoy assessing your "aging IQ."

Aging IQ Quiz
Answer "True" or "False."
1. Baby boomers are the fastest growing segment of the population. True False
2. Families don’t bother with their older relatives. True False
3. Everyone becomes confused or forgetful if they live long enough. True False
4. You can be too old to exercise. True False
5. Heart disease is a much bigger problem for older men than for older women. True False
6. The older you get, the less you sleep. True False
7. People should watch their weight as they age. True False
8. Most older people are depressed. Why shouldn’t they be? True False
9. There is no point in screening older people for cancer, because they can’t be treated. True False
10. Older people take more medications than younger people. True False
11. People begin to lose interest in sex at about age 55. True False
12. If your parents had Alzheimer’s disease, you will inevitably get it. True False
13. Diet and exercise reduce the risk for osteoporosis. True False
14. As your body changes with age, so does your personality. True False
15. Older people might as well accept urinary accidents as a fact of life. True False
16. Suicide is mainly a problem for teenagers. True False
17. Falls and injuries "just happen" to older people. True False
18. Everyone gets cataracts. True False
19. Extremes of heat and cold can be especially dangerous for older people. True False
20. You can’t teach an old dog new tricks. True False

Be sure to check the answers in the " Geriatric Corner" in the February issue!

AACN will continue to provide age-related practice information in this "Geriatric Corner." Do you have suggestions regarding content? Has the practical information presented been useful to you? Have you made changes to your practice because of this information? We want to hear from you. Contact AACN Clinical Practice Specialist, Justine Medina, RN, MS, at (800) 394-5995 ext. 401; fax, (949) 448-5520; email, Justine.Medina@aacn.org.

Practice Resource Network: Frequently Asked Questions

QHelp! I feel burned out and don’t want to work in a hospital setting any longer. The ICU where I am employed just keeps getting busier. The patients are sicker, and the staff is smaller and more upset. I have been a critical care nurse for seven years, and never thought that I would ever feel this way. I often leave work in tears and dread coming to work the next day. Where do I go from here?

AThe feelings and frustrations you express are, unfortunately, all too common among critical care nurses. By evaluating these difficult issues, you can not only help yourself, but also the profession of nursing. Retrospectively, most nurses can identify points in their lives in which burnout played a major role. The fact that you are recognizing this and working your way through it is transformational, though not fun or easy.

Because we work in the high-adrenaline environment of a critical care or emergency department, we are accustomed to conditions that would bowl over the average citizen, let alone the average nurse. Nurses who function well in these situations tend to be bright, motivated, self-sacrificing and tremendously caring. Rightfully, they also tend to be proud of themselves and their expertise.

So, what happens when the well goes dry, whether that be because of personal struggles, workplace agonies or simply the inability to get our own well filled? Suddenly, the cases on which we once thrived become our undoing, making it difficult to even think. This is burnout, of which all caregivers are at risk.

The deep soul searching that comes from these difficult parts of our lives makes us better people and, in turn, better nurses. For each person who struggles with these issues, the answer is very personal. Some nurses may decide to change careers; others seek new avenues or perspectives that can restore the passion for their careers.

With the progressing nursing shortage, the conditions you described in your facility are common. Patient acuity is up, while staffing numbers, as well as experienced resources, are down. As nurses, we must pull together and support each other. Do you have any colleagues, mentors or friends you can call on to support you? Now is also a great time to contact an Employee Assistance Program (EAP), if your employer offers one. Calls to an EAP are generally confidential and it is likely you will speak with someone who has dealt with nursing issues in the past.

When was your last physical? Hypothyroidism and anemia are medical conditions that can drastically affect how a person deals with stress, as well as energy levels. Your primary care provider can also act as a sounding board, confidante or referral source.

Be gentle with yourself. You cannot overcome your feelings or resolve your doubts quickly. Your emotions are normal; your feelings are valid. Concentrate on things in your life that bring you joy, both on and off the job. Two books that could help you are What Color is Your Parachute and How Not to Go Home From Work Exhausted by Ann McGee-Cooper.

Although the second one is business-oriented, it relates to any profession.

Journaling is another means to work through these types of issues. Writing down your thoughts and emotions can help sort through the confusing maze. People often tend to focus on their mistakes or on what they did not accomplish. Yet, it is important to applaud all that you have done and the ways you have made the world better.

Remember that there is no right or wrong in this situation, only the discovery of what is best for you. We often hear of that elusive "peace that transcends understanding." The closer we get to that, wherever that may be in nursing, is where we will do our most important work.

In addition to caring for yourself, you should identify individuals or processes in your facility that can help bring about a positive change. Being able to step back and gain some objectivity is important. Through objectivity, creative solutions can often be developed. Elicit the assistance of your middle management to find the best way or channel to address problems.

Grants Focus on Nursing Research

Following are nursing research grants for which application deadlines are approaching. For application materials, call (800) 899-AACN (2226) or visit the AACN Web site at  http://www.aacn.org. Click on "Research" under the "Departments" area. For more information, call the AACN Practice and Research Department at (800) 809-2273.

Critical Care Research Grant
This grant provides for one award of up to $15,000 to a nurse investigator who is actively involved in acute and critical care nursing practice. The study selected must be relevant to critical care nursing practice.

The principal investigator must be both an RN and a current AACN member. The proposed study may not be used to meet the requirements for an academic degree.

Proposals must be received by Feb. 1, 2000.

Mentorship Grant

Cosponsored by AACN and Mallinckrodt Inc., this grant awards up to $10,000 to a novice researcher to work with an experienced research mentor on a study that is relevant to critical care nursing practice.

The novice research applicant, who must be an RN and current member of AACN, should have only limited or no experience in the area proposed for investigation. The research funded may be used toward an academic degree.

The mentor must have research expertise in the area proposed for study by the novice researcher. The mentor cannot be designated as a mentor on another AACN mentorship grant for two consecutive years and cannot be conducting the research toward an academic degree.

Proposals for this grant must be received by Feb. 1, 2000.

AACN Certification Corporation Research Grant
These grants, funded by AACN Certification Corporation, provide up to $10,000 each for four studies related to certified practice. Examples of eligible projects are studies that focus on continued competency; the Synergy Model; the value of certification as it relates to patient care or nursing practice; and credentialing concepts. The proposed research may be used to meet the requirements of an academic degree.

Although AACN members are encouraged to apply for this grant, AACN membership is not required. However, if all other factors are equal, AACN member applications will be given preference.

Proposals must be received by Feb. 1, 2000.

AACN Data-Driven Clinical Practice Grant
This grant provides six awards of up to $1,000 each year for studies that stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute or critical care nursing practice.

The principal investigator must be both an RN and a current AACN member, and cannot be currently conducting a study funded by another AACN research grant. Proposed studies may be used to meet the requirements of an academic degree.

Applications must be received by March 1, 2000.

New Preceptor Materials Available

From Staff Nurse to Preceptor, the revised edition of the popular Preceptor Development Program, is now available from AACN.

The instructor’s manual (Item #120500) can be purchased for $27 for members ($45 for nonmembers). The preceptor handbook (Item #120550) is priced at $8 for members ($11 for nonmembers).

The new Preceptor Training Program for Professional Heathcare Staff, is modeled after the successful program for nurses. This program is designed for other licensed, support staff and ancillary personnel.

The instructor's manual (Item #120560) is available for $29 for members ($45 for nonmembers). The preceptor handbook costs $8 for members ($11 for nonmembers).

Quantity discounts are also available. Shipping and handling charges are in addition to the above prices.

To order, call (800) 899-AACN (2226), or order online through the "Bookstore" area of the AACN Web site at http://www.aacn.org. AACN Resource Catalog orders placed during January 2000 receive a complimentary educational tool valued at $12. However, supplies are limited.

Vox Populi: AACN Online Quick Poll

What is the typical nurse/patient ratio in your critical care unit?

1:1 to 1:2 40%
1:2 to 1:3 29%
1:3 to 1:4 27%
> 1:4 27%

Number of Responses: 2,497

The AACN Online Quick Poll surveys a variety of topics. Participate by visiting the AACN Web site at  http://www.aacn.org.

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