The Power of One: Identifying Patient’s Needs Helps With Ethical Dilemmas
By Natalee J. Correll, RN, MN, CCRN
As critical care nurses and patient advocates, we are charged to support the difficult decisions made by our patients and their families.
However, when we disagree with a patient’s or family’s decision, we are challenged to examine our own values and belief systems as they relate to issues of quality vs. quantity of life. The following case study presents this type of situation, where the principle of patient autonomy collides with those of justice, beneficence and nonmaleficence.
Critical care nurses match the patient’s needs and characteristics with a specialized set of nursing competencies to create synergy. This is the “power of one,” because when we truly “know” our patients, we connect, and through that connection we can make a difference.
W.A. was back in the ICU, after having been on the step-down unit for a little more than three weeks. He previously had spent time in the ICU, the step-down unit and the medical-surgical unit. Nineteen of W.A.’s 53 days in the hospital had been in the ICU. This may seem like a long time. However, for W.A., this time was short, compared to his hospitalization for three months the previous winter. He had been home for only a week when his condition deteriorated, resulting in this latest hospitalization.
W.A. had been diagnosed with a bronchogenic carcinoma. As a result, he also had a host of complications, including acute respiratory failure, renal failure, subendocardial infarction with atrial fibrillation, diabetes mellitus, esophagitis, duodenal ulceration, gastrointestinal hemorrhage, coagulation defect and Clostridium difficile. His primary physician, a nephrologist, consulted his colleagues to assist in managing W.A.’s host of complications. Each consultant did the best he or she could to treat W.A., including bronchoscopies and eventually a tracheostomy, central line insertions, upper and lower endoscopies, and percutaneous endoscopic gastrostomy insertion and revisions. Eventually, the nephrologist conceded to W.A.’s disease process and declared the care to be futile.
The critical care staff got to know W.A. well. The nurses struggled with each complication. His nutritional status deteriorated, as he was unable to absorb calories, either parenterally or enterally. Because of muscle wasting, W.A. was able to sit upright only for brief periods at a time. Because he was 6-feet tall and barely 140-pounds, his legs could not bear his weight. W.A. did not tolerate turning on his sides without respiratory distress and, gradually, he developed stage III and IV pressure ulcers on his sacrum and both heels. Because of his poor nutritional state, these wounds resisted healing.
In spite of his illness and multiple complications, W.A. remained lucid. While at home between hospitalizations, his physician discussed treatment options with him. He asked W.A. whether, after his lengthy hospitalization and aggressive medical and nursing interventions, he would do it all again. W.A. felt strongly that withdrawing or limiting care was not only equivalent to giving up, but also contrary to his personal and religious beliefs.
During his second hospitalization, the nursing staff and other members of the healthcare team struggled with W.A.’s deteriorating condition. Because he grimaced in pain during physical and occupational therapy interventions, the physical therapy and occupational staff were unable to make progress and signed off his case. The dietitian was unable to provide enough calories to feed his withering frame. As a result, the nursing staff struggled with providing care that was in direct conflict with providing comfort. The critical care staff began to rotate after one or two shifts, saying they were unable to adequately care for W.A. because his condition was too overwhelming. Although patient care conferences helped refocus the team, the seemingly unattainable goals remained. W.A.’s physician repeatedly asked him if he wanted to continue aggressive medical and nursing interventions. Each time he answered, “Yes.”
Honoring the patient’s wishes is based on the principle of autonomy. As patient advocates, critical care nurses must make certain that a patient’s wishes are known. The question is whether providing aggressive medical and nursing care for a patient whose body is failing is in the patient’s best interest. Does the benefit outweigh the burden in accordance with the principle of beneficence? Or, are we honor-bound to prevent harm, as with the principle of nonmaleficence? Is providing aggressive medical and nursing interventions that utilize a multitude of resources for one patient fair allocation of resources, as with the principle of stewardship? Or, does this deny other patients, who respond to treatment modalities, access to these same resources? Do these questions support the principle of justice?
These are difficult questions. W.A. had a strong belief that he must fight and not give up. In caring for him, a few of the critical care nurses began to know him better. In line with the Synergy Model’s patient characteristics, the nursing staff would have found W.A. to be moderately stable for limited periods of time. He was highly complex, unpredictable, highly vulnerable and minimally resilient, which required support from the entire interdisciplinary team to keep him progressing toward small goals. W.A. would have many resources available to him, including strong family and social support of his wishes and readily available financial resources. However, he and his family were unable to participate in his care, and his social network could provide only moderate participation that was not consistently at the level required by his condition. Lastly, W.A. was fully able to participate in all of his decision making.
Considering the nursing competencies that would match W.A.’s patient characteristics, the critical care staff would find clinical judgment extremely important for managing the complexity of the situation in collaboration with other members of the healthcare team. In addition to the nursing competencies of systems thinking, clinical inquiry and facilitator of learning, the critical care nurse would rely on his or her competencies in advocacy and caring practices. It was important for the critical care nurse to gain W.A.’s trust that she or he supported his decision-making process and that his needs were being anticipated. The critical care nurses caring for W.A., in collaboration with the healthcare team, included him in all of the care-planning processes. In keeping with the principle of veracity, they told him the truth about his progress and regression with respect to the small treatment goals set by the group. The ethics consult team was asked on several occasions to assist in clarifying the patient’s wishes in relationship to code status and establishing treatment goals in line with the ethical principles.
W.A. lost his battle some 200 days after his initial admission to the ICU. He decided to have care withdrawn slowly, until he was receiving ventilatory support only at night and dialysis every other day. Using the Synergy Model to assess W.A.’s characteristics would have helped us to identify his needs sooner and assist the critical care staff in managing his care. The nursing competencies W.A. needed could have been identified and implemented. The caring practices and advocacy competencies were what he truly needed during his last days.
Toward the end, each nurse did use his or her “power of one” energies to provide comfort and to advocate for W.A.’s final wishes.
Natalee J. Correll, RN, MN, CCRN, is a clinical nurse specialist in the ICU/CCU at Queen of the Valley Hospital, Napa, Calif. She is a member of the AACN Ethics Integration Work Group.
Geriatric Corner: Evidence-Based Research Drives Pain Management for the Elderly
University of Iowa researchers have been awarded a $1.5 million federal grant to study the effectiveness of methods to translate scientific findings into nursing and medical care for older adults experiencing acute pain. The research team, led by Marita Titler, RN, PhD, FAAN, will study how to promote the use of evidence-based guidelines that are designed to improve pain management among older people. Titler is director of the Research Dissemination Core (RDC) of the Gerontological Nursing Interventions Research Center at the University of Iowa College of Nursing.
The guidelines for acute pain management among older adults are based on evidence from previous research that demonstrated their effectiveness. The upcoming study will help determine how to best facilitate the adoption of the guidelines among healthcare providers.
RDC also has many other research-based practice protocols that relate directly to the care of the older adult patient. These protocols can be obtained online at
, or by contacting the Gerontological Nursing Interventions Research Center, Research Dissemination Core, 4118 Westlawn, The University of Iowa, Iowa City, IA 52242-1100
The protocols include:
• Acute Confusion/Delirium
• Acute Pain Management
• Advance Directives
• Alzheimer’s Disease and Chronic Dementing Illness
• Bathing Persons with Dementia
• Detection of Depression in the Cognitively Intact Older Adult
• Family Involvement in Care (FIC)
• Hydration Management
• Identification, Referral, and Support of Elders with Genetic Conditions
• Individualized Music
• Latex Precautions
• Management of Constipation
• Music Therapy Programming for Individuals With Alzheimer’s Disease and Related Disorders
• Prevention of DVTs
• Prevention of Falls
• Prevention of Pressure Ulcers
• Progressive Resistance Training
• Prompted Voiding for Persons with Urinary Incontinence
• Split Thickness Skin Graft Donor Site Care
• Treatment of Pressure Ulcers
Do you have an age-related care story or idea? AACN wants to provide a vehicle for the sharing of information that can enhance practice for all members who provide care to the older population. Send information to AACN Clinical Practice Specialist, Justine Medina, RN, MS, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 448-5520; e-mail,
Justine.Medina@aacn.org, or call (800) 394-5995, ext. 401.
NP Declaration Promotes Role and Access to Care
AACN has signed on in support of a declaration developed by the Nurse Practitioner (NP) Think Tank. which met in Annapolis, Md., in March 2000 to discuss ways to advance the course of NP practice and facilitate access to NP care.
The meeting was convened by Carolyn Buppert, RN, JD, CRNP, an attorney and president of Better Life Health Care Systems, Annapolis, in response to limitations affecting the practice of nurse practitioners. Attending were NPs representing various areas of the profession, including clinical practice, education, research, administration and health policy.
The majority of AACN’s NP members practice in an acute care role, which requires a high degree of collaboration with all members of the healthcare team. AACN advocates for processes that promote mutual respect and collaboration in the care of acute and critically ill patients and believes the underlying tenets of the NP Declaration embrace these processes.
A background statement that accompanied the declaration noted that the ability of NPs to safely and effectively deliver comprehensive healthcare services has been documented in scientific studies for more than 35 years. Emphasized was the advanced academic and clinical experience NPs bring to the care of patients, the extensive services they provide in community and hospital settings and the important contributions they make to the nation’s health.
“The scope of advanced nursing practice is distinguished by autonomy to practice to the full extent of the expanding boundaries of nursing care,” the statement reads. “Within this context, an important hallmark of NP practice is the primacy of independent diagnosis and treatment decisions over the more dependent functions of traditional nursing.”
Nevertheless, the statement continued, NPs’ authority to provide care that is within the domain of nursing has not been uniformly reflected in professional practice acts. As a result, their scope of practice has been limited in many states to require physician supervision or formal collaboration, which contribute to rising healthcare costs and restrict access to care for all citizens.
The declaration reads:
Nurse Practitioners are experts in
Primary Care and a variety of
Nurse Practitioners are proven to
provide high quality, cost effective, ethical and compassionate care;
Nurse Practitioners provide a full
range of comprehensive health care;
Patients report a high level of satisfaction with care from Nurse Practitioners; and
Nurse Practitioners are Nationally
Be it resolved:
Patients must have access to Nurse Practitioners in the healthcare
Nurse Practitioners must be unencumbered from restrictive requirements that restrain their practice;
All payers must credential Nurse Practitioners as Primary Care Providers.
The full statement and the Nurse Practitioners Declaration can be obtained online in the Advanced Practice area of the AACN Web site at
AP Work Group to Develop CNS Scope and Practice Standards
The 2000-01 Advanced Practice Work Group will begin work this summer to develop a scope and standards of practice for the clinical nurse specialist (CNS) in critical care.
Under the direction of former AACN President Mary G. McKinley, RN, MSN, CCRN, as chairperson, the group plans to develop this document over the next year. By developing a Scope and Standards for the Critical Care CNS, AACN can actively support CNS members to delineate and communicate their role and contributions to patient care.
The scope and standards document will also support the CCNS certification exam, which is administered by AACN Certification Corporation for CNSs in acute and critical care, by enhancing its efforts to obtain states’ recognition of CCNS certification for this advanced practice role. CCNS certification in adult, pediatric and neonatal practice is available.
In addition to the critical care CNS scope and standards document, the Advance Practice Work Group will focus on several other areas. These include participation in and support of the Advance Practice Institute at AACN’s annual National Teaching Institute,™ developing resources to support advanced practice nurses in measuring and evaluating the outcomes of their care, and further delineating the CNS and ACNP roles. Both CNSs and ACNPs from a variety of practice settings serve on the Advanced Practice Work Group
For more information about the Advanced Practice Work Group, contact Kim Brown, RN, MSN, FNP, CS, CEN, (800) 394-5995, ext. 339; e-mail,
Submit Your Research or Creative Solutions Abstracts for NTI 2001
Submit your research and research abstracts or your creative solutions abstracts for AACN’s National Teaching Institute™ and Critical Care Exposition in 2001 in Anaheim, Calif. Sept. 1, 2000, is the deadline for submissions.
Presenters of selected abstracts receive a $75 reduction in NTI registration fees. All other expenses are the responsibility of the presenter, who can be either the first author or a designate of the author.
NTI 2001 is scheduled for May 19 through 24. Following is information about these abstracts:
Abstracts can focus on any aspect of critical care nursing research including reports of research studies or reports of research utilization. Only abstracts of completed projects will be accepted.
Abstracts reporting research studies must address the purpose; background and significance; methods; results; and conclusions.
Abstracts should focus on specific strategies and practice innovations that are used by nurses to solve difficult, unique or interesting problems in patient care, nursing practice, nursing management or nursing education. The creative solution must have been implemented, with outcomes evaluated.
Abstracts must address the purpose of the project and include a description of the creative solution, as well as evaluation and outcomes.
Accepted abstracts will be designated either as an oral presentation or as a poster presentation.
To obtain abstract forms, call (800) 899-AACN (2226), or visit the research area of the AACN Web site at
Deadlines Near to Apply for Nursing Research Grants
The deadlines to apply for several nursing research grants are approaching. Following is information about each of these grants:
Medtronics Physio-Control AACN Small Projects Grant
Cosponsored by Medtronics Physio-Control and AACN, this grant awards up to $1,500 to a qualified individual who is carrying out a project that focuses on aspects of acute myocardial infarction, resuscitation or sudden cardiac death, such as the use of defibrillation, synchronized cardioversion, noninvasive pacing and interpretative 12-lead electrocardiogram.
To be eligible, the applicant must be an active or affiliate member of AACN, who is not currently conducting a study funded by an AACN research grant.
To obtain application materials and instructions, call (800) 899-AACN (2226), or visit the research section of the AACN Web site at
http://www.aacn.org. Applications must be received by July 1, 2000.
AACN Clinical Inquiry Grants
These grants, funded by an anonymous donor, support projects that address one or more AACN research priority and that link to AACN’s vision. Selected projects will receive up to $250 each.
The principal investigator in the proposed study must be an RN, a current member of AACN, employed in a clinical setting and directly involved in patient care.
To obtain application materials and instructions, call (800) 899-AACN (2226), or visit the research section of the AACN Web site at
http://www.aacn.org. Applications must be received by July 1, 2000.
Agilent Technologies-AACN Critical Care Nursing Research Grant
Cosponsored by Agilent Technologies and AACN, this grant supports research conducted by a critical care nurse.
The total of $35,000 includes $33,000 for research and $2,000 for travel expenses associated with presentations of the study findings. The recipient may use up to $3,000 of the research award to purchase a personal computer, utility software and printer to support the study. Computer-related expenses should be included and justified in the project budget.
The grant is intended to support a well-defined, well-described research project. The award selection will be based upon the scientific merit of the project; scientific and professional background of the applicant; adequacy of facilities and resources available for the research; originality; and potential benefits to the care of critically ill patients.
The preferred topic for this grant is the information technology requirements of patient management in critical care. Because this grant is intended to support research that has direct clinical application to critical care nursing practice, proposals for basic science or animal studies are not eligible. Reviewers’ comments will not be provided to applicants.
To be eligible, the applicant must be both an RN and an active AACN member. The grant can be used to fund research associated with an academic degree.
To obtain application materials and instructions, call (800) 899-AACN (2226), or visit the research section of the AACN Web site (http://www.aacn.org). Proposals must be received by AACN by Sept. 1, 2000.
Vox Populi: AACN Online Quick Poll
Does your hospital have a mandatory overtime policy?
Don’t Know 5%
To what do you attribute the mandatory overtime?
Nursing Shortage 39%
Sick Calls 15%
Routine Short Staffing 36%
How often are you required to work mandatory overtime on your unit?
Excessively (once a week or more) 7%
Frequently (once every two weeks or more) 23%
Infrequently (once a month or less) 28%
Number of Responses: 804
The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. Participate by visiting the AACN Web site at