Recognize Interplay in Important Ethical Concepts|
By Kate Sullivan Collopy, RN, PhD, CCNS, CCRN
Ethics Work Group
Mr. Ferrare (pseudonym) was a 52-year-old who was admitted to the emergency department with an acute myocardial infarction of the anterior wall. Within 20 minutes, he sustained a full cardiac arrest. Although he was resuscitated, he suffered a significant hypoxic brain injury, manifested by aphasia, loss of gag reflex, significant short-term memory deficits and hemiparesis.
By applying the Synergy Model, Mr. Ferrare was determined to be moderately resilient. Because his health had previously been good, he had moderate reserves to deal with his present condition. Susceptible to myriad complications, he was highly vulnerable. He was unstable, with labile vital signs and inconsistent response to treatment. His condition was moderately complex, in that he had acute problems with multiple body systems and the trajectory of his illness was unpredictable.
Although Mr. Ferrare had many resources, including a strong family, a supportive social circle and adequate finances, he had minimal ability to take part in his care or his decision making. During his hospitalization, Mr. Ferrare’s family and healthcare team became increasingly aware that he was unable to fully understand his condition. Furthermore, it appeared unlikely that he would recover quickly. With the assistance of the hospital’s social worker, Mrs. Ferrare and her children sought to have her appointed as his legal guardian. This allowed her to gain access to financial resources such as investments that were needed to provide for his care.
A team of independent evaluators was named by the court to assess the patient. Both a psychiatrist and a neuropsychologist who examined the patient agreed with the assessment that Mr. Ferrare lacked the understanding to participate in important medical or legal decisions. Mr. Ferrare was declared legally incompetent and his wife was appointed his guardian. Within a few weeks, he had stabilized enough to be discharged to a combined rehabilitation/long-term care facility.
A year later, he was readmitted to the same ICU with pneumonia. It was noted that there had been very little neurological improvement. During this hospitalization, Mr. Ferrare became increasingly agitated during his tube feedings. He repeatedly tried to push the nurses away and covered his tube whenever they attempted to feed him. Both the staff and family were concerned about whether he was trying to express a desire to stop the tube feedings. They were conflicted between their wish to obey his request and their concern that he could not understand the implications of what he was asking. This posed an interesting ethical dilemma: Does a patient who has been declared legally incompetent have the capacity to make such an important decision?
Competency vs. Autonomy
Mr. Ferrare’s case illustrates the interplay between the important ethical concepts of autonomy, competency and capacity. Legal competence and autonomy are closely related, in that a competent person has the capacity for autonomy, and a competent decision is made autonomously.1
Our respect for a patient’s autonomy requires us to recognize his or her right to self-determination. However, we must first ascertain whether the patient is able to fully appreciate the implications of the decision. To do so, we begin with an evaluation of the patient’s competence.
Competence is often referred to as a “gatekeeper” because it determines whether an individual’s decisions should be sought or accepted.2 Reaching consensus on what is meant by competence can be difficult. However, Faden and Beauchamp3 stress that the core meaning of competence is “the ability to perform a task.” In the case of Mr. Ferrare, the task is to make an informed decision about discontinuing tube feedings.
It is important to understand that there is a difference between clinical capacity and legal competence. A patient who is temporarily confused following a mild traumatic brain injury may be legally competent, yet lack capacity, such as the ability to make sound decisions. Likewise, a 17-year-old patient may not have the legal competence to consent to a healthcare procedure, but may have the functional ability to do so.4
Investigating the Cause
Wettstein cautions that, though “competence is a necessary precondition to respecting patient choice, incompetence is not a sufficient condition to overriding it, contrary to much clinical and lay understanding.”4 In the case of Mr. Ferrare, we were obligated to thoroughly investigate his behavior during his tube feedings. Was he truly trying to express a desire to stop the feedings? Or did he find the feedings uncomfortable? Did he have pain at the insertion site?
A complete assessment determined that Mr. Ferrare was indeed attempting to tell us that he no longer wished to receive tube feedings. However, we also called in specialists to determine that his apparent choice was not influenced by treatable conditions such as pain or depression.
Although both the staff and family understood that the patient did not have the capacity to understand all the implications of his desire to stop the feedings, his wife and children believed that his wish should play an important part in their decision-making process. Ultimately, they chose to discontinue the feedings. After doing so, Mr. Ferrare was much less agitated, and his wife believed that he seemed “at peace.” He expired within a few weeks, with his family at his side.
1. Miller B. Autonomy. In W. Reich, ed. Encyclopedia of Bioethics (Revised Edition). New York, NY: Simon & Schuster Macmillan; 1995
2. Beauchamp TL & Childress JF. Principles of Biomedical Ethics. New York: Oxford. 1994.
3. Faden RR & Beauchamp TL. A History and Theory of Informed Consent. New York, NY: Oxford; 1986.
4. Wettstein RM (1995). Competence. In W. Reich, ed. Encyclopedia of Bioethics (Revised Edition). New York, NY: Simon & Schuster Macmillan; 1995
Myth vs. Reality: Talk About Sex With MI Patients
By Elaine E. Steinke, RN, PhD
Research Work Group
Mr. Hanes is a 67-year-old anterior myocardial infarction (MI) patient for whom you are caring in the CCU. He is post-PTCA with coronary stents in two vessels. Coronary risk factors include a strong family history of heart disease and stroke, a 12-year history of hypertension that has been treated with atenolol and an elevated cholesterol level that has been treated with Lipitor for the last four years.
Mr. Hanes is active in his church, walks at the local mall with his wife two to three times a week and travels frequently. He will be transferring to the cardiac step-down unit in a few hours.
Mr. Hanes is anxious about transferring out of the CCU and has questions about resuming his normal activities. One of the questions that he hesitantly asks you is related to sexual activity. Should you respond to Mr. Hanes or refer him to his physician?
Myth: Information on resuming post-MI sexual activity is not important to patients during their hospital stay and providing this information is not part of the nurse’s role.
Research has shown that patients with an MI believe that healthcare professionals, including nurses, should provide information on resuming sexual activity as part of their patient education.
The importance of sexual activity as a topic of post-MI education has been demonstrated in several studies.1-7 Subjects enrolled in one longitudinal study were questioned about the importance of specific areas of sexual counseling and when they would like to receive this information.7 All 14 items related to sexual activity were rated by subjects as important information to learn at two, four and six months post-MI. Many of the subjects indicated that they thought this information was important to learn while hospitalized, while others stated they could wait until after discharge. It would appear from these studies that resuming sex after a heart attack is an important concern for patients and their partners.
Nurses and other healthcare professionals have been reluctant to provide information regarding post-MI sexual activity. This is understandable, because few nurses receive education regarding strategies for approaching intimacy issues. In a study of nurses’ assessment and patient education practices regarding general intimacy issues, Matocha and Waterhouse8 found that few nurses routinely assessed sexual health, answered questions regarding sexuality or
listened to sexual concerns. This study also revealed that nurses infrequently provided information on breast self-exam, testicular self-exam, contraception, safe sex practices or sexually transmitted diseases. These findings suggest that
if nurses are unwilling to address sexuality-related issues during health-promotion activities, they would be even more unlikely to consider it during times of illness, such as MI.
Reasons identified in one study for not addressing patients’ sexual concerns suggest that nurses do not discuss sex because they do not perceive sexuality as a problem, feel that patients are too ill to discuss it or believe that it might cause anxiety for the patient.9 Studies report that less than 52% of nurses have ever offered to discuss sexual issues with MI patients.10 These studies suggest that, though nurses may agree that sexual issues are important to address with MI patients and feel some level of comfort in providing this information, they infrequently provide such counseling.11-12
There are many reasons to discuss sex. Patients often have fears about resuming sexual activity. They hear stories and see media portrayals of people having heart attacks during sex or in some dramatic fashion. Actually, the risk of MI during sex is low, and sexual activity has been reported as a likely contributor to MI in less than 1% of cases.13
The fact is that not discussing sex can increase patients’ anxiety. Patients often fear that sex may put a strain on their heart and that having an MI means an end to sexual activity. It is encouraging for patients to hear such a sensitive, but important topical activity discussed as part of gradual resumption of their other normal activities.
Patients with uncomplicated MIs are now frequently being discharged directly from the ICU setting, allowing little or no time for in-hospital education. Therefore, nurses across the healthcare continuum must be prepared to address sexual issues as part of the patient’s health instructions. Cardiac rehabilitation staff may be able to meet some of these education needs at the time of discharge. However, few ICU staff are prepared to meet the sexuality information needs of cardiac patients discharged on evening, night or weekend shifts. All critical care nurses must be competent and comfortable in providing this essential patient education information.
Following are recommendations for providing information on resuming intimacy after an MI and suggestions on how to discuss this topic:
1. Make your discussion as private as possible by closing curtains or doors, positioning yourself near the patient and talking in a normal tone of voice.
2. Begin your discussion with a more general topic, such as exercise, and then discuss sex as a component of exercise. Ask the patient if he or she is currently sexually active or plans to be in the near future.
If not, you don’t need to proceed with the counseling information. Let the patient know that you are available to answer questions they might think of later.
If the patient indicates he or she plans to be sexually active, ask about concerns. If the patient does not state a specific concern, proceed with your discussion. Patients often are unaware of what they should
consider in resuming sexual intimacy until you bring up each point.
3. Give the patient a copy of the information that accompanies this article. Let him or her review it and ask any additional questions. This may be the most comfortable way for both the patient and the nurse to
approach this topic.
Many of these discussion points for MI patients are common sense and can be adapted to other types of patients. Encourage all patients to openly discuss their sexual concerns with their physicians and to report any signs or symptoms of distress promptly.
Incorporating sexual counseling as part of your nursing practice can be very rewarding. Most patients are pleased that you made the effort to bring up this personal topic. Healthy sexuality is both a quality of life and health promotion issue. Who is better qualified to discuss such a sensitive and important issue than a knowledgeable, caring nurse?
The complete ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction are available online at www.americanheart.org/Scientific/ statements/1999/AMI/edits/jac1716pVII.htm#.
Patient education resources are also available online at
Sexual Intimacy After a Myocardial Infarction Patient Information
Resuming sexual activity or intimacy after a myocardial infarction (MI) can be frightening to many patients. Many fear that having an MI or heart attack means the end of normal sexual activity and that a regular sex life will be impossible.
However, research has shown that this is not necessarily true and that, with proper precautions, most patients are able to resume a normal and healthy, though slightly modified, sex life. Nevertheless, all patients should consult with their physician before engaging in sexual activity.
Following are some important discussion points that patients may want to discuss with their nurse or physician:
Prior to engaging in sexual activity
1. According to American Heart Association and American College of Cardiology guidelines,1 sexual intercourse can be safely resumed within approximately one to two weeks after an uncomplicated MI.
2. After a complicated MI, sexual activity should be resumed more slowly and gradually.
3. Your physician can tell you which category applies to you and advise you about how best to proceed.
4. Although you might not initially be able to engage in full sexual intercourse, other forms of less physical activities, such as kissing, touching, hugging and snuggling, may be resumed soon after an MI.
When you are ready to resume sexual activity:
1. To help minimize the emotional stress you might feel in resuming sexual activity, select a comfortable, familiar setting for your first intimate encounter.
2. Get plenty of rest prior to engaging in sexual activity. This might be best in the early morning or after a nap.
3. Find a comfortable position for sexual activity, perhaps including the use of pillows or alternate positions.
4. Avoid eating or drinking one hour prior to sexual intimacy.
5. Limit sexual intimacy to your usual partner to minimize emotional stress that can cause cardiac stress.
6. Be alert to warning signs during sexual activity, including chest pain, shortness of breath, rapid or irregular heart beat, dizziness, insomnia or extreme fatigue the day after sexual activity. If any of these
symptoms develop, report them to your physician as soon as possible and discontinue sexual activity.
7. If nitroglycerine has been prescribed by your doctor, use it for chest pain during sexual activity. If the nitroglycerine and rest fail to relieve the pain, stop sexual activity and notify your physician immediately.
8. Ask you physician about your medications and their potential side effects. Because a variety of drugs can cause sexual dysfunction, ask your doctor what side effects to expect with your medications. Report
any sexual problems or dysfunction promptly to your physician.
9. Avoid the use of recreational drugs because of their potential negative effects. Drug stimulants or cocaine may cause chest pain, or even MI. Marijuana can cause increased heart rate and oxygen use by the
heart. These substances may also cause sexual dysfunction.
10. Avoid sexual stimulation of the rectal area. This can cause activation of the vagus nerve that controls your heart rate and may lead to decreased cardiac performance and chest pain. If you want to resume
this type of sexual activity, discuss it with your physician.
Resuming normal sexual intimacy after an MI is possible with the proper precautions. It can be a source of important emotional support, love and sharing. With proper guidance, you can successfully reestablish sexual intimacy safely and without fear.
1. Gerard PS, Peterson LM. Learning needs of cardiac patients. Cardiovasc. Nurs. 1984;20:7-11.
2. Karlik BA, Yarcheski A. Learning needs of cardiac patients: A partial replication study. Heart Lung. 1987;16:544-551.
3. Hanisch P. Informational needs and preferred time to receive information for phase II cardiac rehabilitation patients: What CE instructors need to know. J Contin Educ Nurs. 1993;24:82-89.
4. Casey E, O’Connell JK, Price JH. Perceptions of educational needs for patients after myocardial infarction. Patient Educ Counseling. 1984;6:77-82
5. Moser DK, Dracup KA, Mardsen C. Needs of recovering cardiac patients and their spouses: Compared views. Int J Nursing Stud. 1993;30:105-114.
6. Steink EE, Patterson-Midgley P. Sexual counseling following acute myocardial infarction. Clin Nurs Res. 1996;5:462-472.
7. Steinke EE, Patterson-Midgely P. Importance and timing of sexual counseling after myocardial infarction. J Cardiopulm Rehabil. 1998;18:401-407.
8. Matocha LK, Waterhouse JK. Current nursing practice related to sexuality. Res Nursing Health. 1993;16:371-378.
9. Kautz DD, Dickey CA, Stevens MN. Using research to identify why nurses to not meet established sexuality nursing care standards. J Nurs Quality Assurance. 1990;4:69-78.
10. Shuman NA, Bohachick P. Nursing attitudes towards sexual counseling. Dimens Crit Care Nurs. 1987;6:75-81.
11. Steinke EE, Patterson-MIdgley P. Sexual counseling of MI patients: Nurses’ comfort, responsibility, and practice. Dimens Crit Care Nurs 1996;15:216-223.
12. Steinke, EE, Patterson, P. Sexual counseling of MI patients by cardiac nurses. J Cardiovasc Nurs. 1995;10:81-87.
13. Muller JE et al.. Triggering myocardial infarction by sexual activity: Low absolute risk and prevention by regular physical exertion. Determinants of Myocardial Onset Study Investigators. JAMA. 1996;275:1405-1409.
Answering the Call: Work Group Volunteer Cites Reward in Involvement
By Deborah Greenlaw, RNC, MS, CCRN, NP
Advanced Practice Work Group
Although I am an experienced critical care nurse and longtime AACN member who has filled a number of volunteer roles, I wanted to become more involved at the national level. Now, as a member of the Advanced Practice Work Group, I have found a great opportunity to share my perspective and to be mentored by veteran volunteers.
I already have realized many rewards in this involvement after meeting face-to-face with the full group for the first time in August in Costa Mesa, Calif. Our agenda topics ranged from the new CNS Scope and Standards to the 2002 Advanced Practice Institute and resources for advanced practice nurses.
How Did I Get Here?
I responded to AACN’s annual Call for Volunteers, which appears both in AACN News and on the AACN Web site at
http://www.aacn.org > Membership > Volunteer Opportunities. The varied volunteer opportunities that are available can be tailored to a member’s interests. For example, in addition to filling volunteer roles with my local chapter, I have been an NTI abstract reviewer, a special interest consultant and a member of the AACN Board Advisory Team at the national level.
According to the Call, applicants are reviewed for the potential contributions that they can make, as well as the knowledge, expertise and perspective that they might bring to a group. So, I asked myself: Do I really have anything valuable to contribute?
I recalled an article I had read titled “The Imposter Phenomenon in the Clinical Nurse Specialist” (Arena DM, Page NE. IMAGE: Journal of Nursing Scholarship. 1992;24:121-125). The article described successful individuals who feel inadequate with respect to their achievements. This phenomenon is particularly prevalent among high-achieving women who maintain a strong belief that they are not intelligent and, in fact, are convinced that they have fooled everyone who thinks otherwise. I could be the poster child for the “Imposter Phenomenon.” Nevertheless, I downloaded the volunteer application from the AACN Web site, wrote a cover letter and included my curriculum vitae. In May, I was notified that I had been appointed to the Advanced Practice Work Group.
What Do We Do?
My first communication from AACN was a congratulatory letter from then President-Elect Michael Williams, RN, MSN, CCRN, detailing my responsibilities as a member of the Advanced Practice Work Group. Group members bring their diverse expertise and perspective and ensure that AACN’s members are represented in the group’s work. Our charges include:
• Recommending resources to support the Scope and Standards for the Acute and Critical Care CNS
• Having input on the API for 2002 and 2003
• Writing articles for AACN News and other media to promote advanced practice nursing
• Carrying on the ongoing work of the previous work group
• Reviewing current resources that support advanced practice areas of the strategic plan and making recommendations
• Assessing feedback from special interest constituents’ discussion at the November AACN Board of Directors meeting
In addition to our meeting in August, our work is to be accomplished through conference calls and ongoing discussion of issues through the online database.
In mid-July, I received a welcoming letter from AACN Clinical Practice Specialist Linda Bell, RN, MSN. As the national office staff liaison, Linda is our first-line contact for questions or information regarding the Advanced Practice Work Group. She communicated the logistics of the group’s meeting in Costa Mesa, for which AACN took care of all travel needs. About two weeks before the meeting, I received a letter from work group Chair Alice Davis, RN, PhD, CNRN, along with the agenda and a variety of documents to review.
What Are the Rewards?
Already, I have experienced many rewards:
• My weekend roommate provided insights and encouragement on writing for publication.
• Over dinner, I had the opportunity to discuss the “how to’s” of writing for publication with the editor in chief of AACN Clinical Issues: Advanced Practice in Acute and Critical Care.
• In a small group setting, I met with the current president, president-elect and CEO of AACN to discuss AACN’s strategic plan and their ideas for AACN’s future.
• I conversed one on one with other AACN volunteers and national office staff.
• I developed new professional contacts and personal friends from across the nation.
• I had the opportunity to contribute to the organization of AACN and to critical care nursing.
• I enjoyed a fun weekend with wonderful people in a great location of our country.
Sharing the Experience: Participation Helps Build Confidence
Editor’s Note: In celebration of the 10th anniversary of the AACN Wyeth-Ayerst Nursing Fellows Program, AACN invited alumni mentors and fellows to share their thoughts about and experiences with the program. These accounts will be published in AACN News throughout this anniversary year.
By June Oliver, RN, CNS
Being a Wyeth-Ayerst fellow was a memorable experience that offered both personal and professional rewards. However, I probably would not have undertaken the challenge had it not been for my mentor, who affirmed my writing abilities and encouraged me to consider writing for publication.
Although I was not aware of the Wyeth-Ayerst program at the time, my mentor, thankfully, was well acquainted with it. I was a somewhat reluctant candidate for a publication attempt because I previously had had a short article I submitted for publication rejected twice. After the second rejection letter, I had filed the article and mentally assigned publication as an unreachable goal.
However, my mentor helped me put the rejection letters in perspective. Again affirming my abilities and potential, she pointed out that this program was designed especially for nurses like me. I still wasn’t sure I had anything to write about that would interest a large segment of nurses. Again, my mentor came to the rescue by enthusiastically pointing out two areas of recent personal involvement that would be worth sharing with a larger audience.
Bolstered by her confidence in me, I completed the program application. When our proposal was accepted, I was both elated and terrified. Now I had to produce a coherent, interesting piece of literature that nurses would actually read.
With a general framework in mind, but lacking specific details, I set about digging into the published research related to our subject. As I read and checked cross-references, I became intrigued about what I was learning. As I clarified what information was needed, help came from many sources. Our hospital librarian was extremely helpful in tracking down an article from 1960 that set the historical framework for the subject. As I constructed a tentative outline, it was invaluable for me to be able to confer with my mentor for instructions on mechanics as well as affirmation that I was “on target.” As the article took shape, I began to feel an ownership of the subject matter. Now I was forging ahead on my own enthusiasm, convinced that I did have something worthwhile to share.
When I mailed off the copy of the article, I thought my work was done. However, the next challenge came as the editors at the American Journal of Nursing gently guided me through the revision process. Because the message in the article had become part of me, letting go of sections that needed to be cut was not easy. With the help of the journal editors and my mentor, the final product still contained a clear and coherent theme.
My satisfaction and sense of accomplishment was complete when I saw the article in print. I was no longer tentative about my abilities. I was now proud of my accomplishment and humbled in recognizing the input of so many others in helping me get to that moment.
The Wyeth-Ayerst reception at the NTI was a wonderful capstone to the whole experience. The sense of celebration extended to all of us in the program far exceeded my expectations. The privilege of having my NTI expenses covered made me feel special. The convocation ceremony and dinner continued with the same spirit of celebration. It was truly enlightening and fun to meet many of the program sponsors, as well as other mentors and fellows. As we shared our publication stories, a bond of common understanding and appreciation seemed to grow.
Needless to say, my experience was truly enjoyable. Although I have not attempted publication again, I have gained a sense of confidence in myself and in the publication process. I am aware that I did not accomplish this alone and am grateful for the generosity of spirit that allowed my many helpers to share themselves and their resources with me.
Mentoring is a gift that I have received and hope to pass on to others so that they may benefit as I have. The Wyeth-Ayerst Nursing Fellows Program is a good way to do that.
Practice Resource Network
Q: A neurosurgeon at our facility wants the RNs to be responsible for flushing the intraventricular catheters as part of a troubleshooting procedure when there is a lost waveform or lack of cerebrospinal fluid drainage. Has a specific competency been developed for this skill and under what criteria are nurses taking responsibility for this intervention?
A: The new AACN Procedure Manual for Critical Care, 4th ed., includes a protocol specific to this issue. According to information for troubleshooting the intraventricular catheter (page 566) the “responsibility for pressure tubing change and flushing of intraventricular catheter systems vary according to institutional policy. Intraventricular catheter irrigation and manipulation is usually viewed as a physician responsibility in most institutions.” The manual can be obtained by calling (800) 899-2226 and requesting Item #128150, or by visiting the AACN Bookstore online at www.aacn.org > Bookstore. The price is $66 ($75 for nonmembers).
The May 1998 AACN VIP Survey (#11) addressed how institutions were handling the issue. Of the 1,000 demographically selected AACN members who received the survey, 140 or 14% completed and returned it. Only 10% reported instilling fluids or medication into a intraventricular catheter.
The typical survey respondent was a staff nurse who was older than 40 and bachelor’s prepared with more than six years of nursing and critical care experience. He or she worked in an adult critical care unit (predominately a combined ICU/CCU, ICU, surgical or cardiovascular surgical unit) at a nonprofit community hospital with more than 200 beds.
Another source of information on this topic is the American Association of Neuroscience Nurses, which has developed an excellent clinical guideline titled “Intracranial Pressure Monitoring.” This guideline is available online at
The deadline to apply for the AACN Clinical Inquiry Grant is Jan. 15, 2002.
This grant awards up to $500 to support research that focuses on one or more of AACN’s research priorities, which are:
• Effective and appropriate use of technology to achieve optimal patient assessment, management, or outcomes
• A healing, humane environment
• Processes and systems that foster the optimal contribution of critical care nurses
• Effective approaches to symptom management
• Prevention and management of complications
Funding from this grant may be applied to new projects or projects in progress. Interdisciplinary projects are especially invited.
To obtain grant application materials, call (800) 899-2226 and request Item #1013, or visit the of the AACN Web site at
Applications Available Online
Information and applications related to research grants offered through AACN are now available online to nonmembers as well as members. To access these materials, visit the AACN Web site > Clinical Practice > Research > Grants.
We All Want to Know
Has your employer found innovative ways to recruit or retain nurses? If so, how? Tell us about these strategies. We are all looking for ways to bolster our profession and enhance the quality of care we are able to provide for our patients. Send your comments to AACN News, 101 Columbia, Aliso Viejo, CA 92656; e-mail,
email@example.com; fax, (949) 362-2049.
AACN Online Quick Poll
As critical care nurses, we are aware of organ donation (heart beating) and tissue donation (nonheart beating). Are you aware of the procedure for nonheart beating organ donation?
Number of Responses: 647
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 at