AACN News—February 2003—Practice

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Vol. 20, No. 2, FEBRUARY 2003

The Power of One: Living Wills Help in the Transition From Curative to Palliative

By Benny Bolin, RN, ADN, MS
Ethics Work Group

Advance directives, which include living wills, medical powers of attorney and healthcare proxies, are legal documents that enable people to give instructions regarding their future medical care in the event they are unable to give or make healthcare decisions themselves. Through these documents, patients can delineate the types of treatments they want or don�t want when they are terminally or irreversibly ill or injured. If these wishes are medically appropriate, they can have a chance to be a part of the decision making, even when they can no longer make their wishes for care decisions known.

In addition to the fact that too many patients do not have living wills, two basic problems exist.

First, to avoid conflicts with survivors and potential lawsuits, hospitals, physicians and other members of the healthcare team too often allow families to override living wills. Nurses and other healthcare team members should be advocates for what is best for the patient, and allowing families to override living wills is not being a patient advocate. In fact, many states now have laws that require advance directives to be honored. Some states, for example Texas, even provide for criminal, civil or licensure penalties in cases where advance directives were knowingly not followed. However, because few, if any of these circumstances are reported, the legal ramifications are minimal. Nurses and other healthcare team members should be familiar with their states� laws regarding advance directives. A good Internet resource site for advance directives is http://www.lastacts.org.

The second problem with living wills is that they sometimes carry a "morale dis-ease" by creating morale problems or uneasiness in those caring for patients perceived as a "lost cause." Too often, we feel that we are failures if we cannot cure. Instead, we should consider the transition from curative to palliative care as an opportunity to help our patients and their families have as positive an experience as possible in this very difficult and emotionally trying time.

Our track record in providing care at the end of life is not optimal for many reasons, including fear of overmedicating and fear of going against the families. However, this should be a time when patients get the most basic care that nurses have to offer: comfort. We must ensure thdat patients under do-not-resuscitate orders do not become "do-not-treat" patients. We must understand how we can make their last days and hours comfortable and meaningful to them and their families and friends, such as moving them to a private room where the family can be in attendance and ensuring that pain is controlled.

We should also shift our nursing focus from sustaining life to emphasizing comfort. Making the shift from cure to comfort allows us to view our nursing care in more positive terms.

Acknowledging and honoring living wills can ease patients into this last phase of their life in a more comfortable and humane manner. Patients� families can find comfort that the patients were treated in the manner they desired, hopefully without suffering. The fact that patients have living wills and do-not-resuscitate orders should not cause nurses to avoid these patients or spend less time with them, but instead to increase the time, albeit with a different type and focus.

APNs Can Minimize Liability Exposure

By Lisa Kohr, RN, MSN, CPNP, MPH
Advanced Practice Work Group

Advanced practice nurses have successfully demonstrated their competency in managing sicker patients, implementing clinical pathways to decrease morbidity and costs, and expanding their practice domain to fit the needs of our specialty and institutions. Yet, as the scope of practice has grown, so has the risk for liability.

Because healthcare has changed so rapidly, legislation may not yet exist to address the newer healthcare modalities. For example, there are no laws governing the responsibilities of the APN involved in telemedicine.

As a result, many questions are unanswered. Should the APN be responsible for actions taken by the referring hospital in response to the telemedicine diagnosis? Will the APN be liable if mismanagement of the diagnosis causes complications? Who is responsible if there is a lack of compliance with the recommended follow-up?

E-mail triage is another black box when it comes to APN liability. What is the APN�s responsibility toward a patient who e-mails with complaints of an illness? Is the APN liable if the patient does not seek recommended treatment? Is the APN responsible if the patient does not fully disclose the symptoms or recent changes in his or her condition and suffers a complication? Are guidelines established for each site where the APN has privileges? Who covers cases after the APN leaves? What if the patient�s condition changes after the APN has written to discharge the patient?

Medicare billing and correct assignment of visits for APNs who are independently seeing patients are other hot liability topics. On-call and off-shift coverage can be a minefield unless appropriate guidelines are set. Questions regarding who is the emergency backup, which patients are covered during the off hours and whether staff nurses can accept telephone orders from an APN are just a few of the details that must be addressed to avoid the potential for liability.

In addition, many APNs could face increased patient loads, as well as moonlighting options, when the new law limiting residency hours goes into effect in July. Unless guidelines clearly establish the scope of the APN�s role and responsibility, these issues will expose the APN to liability.

Minimize Exposure
APNs can minimize their liability exposure by staying abreast of the latest legislative developments affecting their practice at the federal, state and local levels. This type of legislative information is available from a variety of sources, including the AACN Web site (www.aacn.org > Public Policy), or the Web sites of their state boards of nursing, state advanced practice council or their national association. Other strategies to limit liability risk include updating practice agreements and scope of responsibilities to accurately reflect current roles. In addition, ensuring compliance with yearly reviews of procedures and prescriptive authority, certification requirements and institutional agreements will decrease the potential of liability.

Lisa Kohr is a pediatric nurse practitioner with the Division of Cardiovascular-Thoracic Surgery at Children's Memorial Hospital, Chicago, Ill.

1. Survillo A, Levine A. Strategies to limit CNS malpractice liability exposure. Clin Nurse Specialist. 1993;7:215-220.
2. Buppert C. Avoiding Medicare Fraud, Part 1. The Nurse Practitioner. 2001;26:34-38,41,70-75.
3.Buppert C. Nurse Practitoner�s Business Practice and Legal Guide. Aspen, Colo: Aspen Publishers Inc; 1999.
4. Kleinpell R, Piano M. Practice Issues for the Acute Care Nurse Practitioner. New York, NY: Springer Publishing Co; 1998.

Sepsis Education Program Available

Eli Lilly Grant Underwrites Purchase Fee for CD-ROM

Identification and Management of the Patient With Severe Sepsis," AACN�s national sepsis education program for nurses, is now available in a self-paced CD-ROM format. Funded by an unrestricted educational grant from Eli Lilly and Company, this program is sponsored by AACN and is accredited for 5.0 contact hours of CE credit for single users.

Narrated by clinical expert Barbara McLean, RN, MN, CCRN, CCNS-NP, FCCM, the new program offers clinicians a comprehensive view of the latest information on the diagnosis and care of patients with severe sepsis.

The 170-page, audio/slide CD-ROM study guide includes pathophysiology of severe sepsis; identification of acute organ system dysfunction; antibiotics, source control and monitoring in severe sepsis, including investigational and new approved therapies; hemodynamic, ventilatory, renal and other aspects of care; and nursing care of patients with severe sepsis. Case studies are also included in the presentation.

To order this cutting-edge learning program for only the $7.50 shipping and handling fee, call (800) 899-2226 and request Item #004060. Quantities are limited.

Myth vs. Reality: Beta Blocking Agents Have Positive Effect on Heart Failure

By Elaine Steinke, RN, PhD
Chair, Research Work Group

Myth: Beta blocking agents should be avoided in heart failure patients.

Reality: Beta blocking therapy has a positive effect on both morbidity and mortality in HF.

Previously, the use of beta blocking therapy was debated, largely because of initial transient negative inotropic effects.1 However, the use of beta blocking agents has now been evaluated in more than 20 published placebo-controlled trials with more than 10,000 patients.2 These clinical trials clearly show that beta blocking therapy reduces both morbidity and
mortality in HF.

Its effectiveness holds true for both older and younger patients.1-3 A recent study of women with New York Heart Association functional Class II or higher HF who were treated with metoprolol revealed reduced mortality, cardiovascular hospitalizations and hospitalizations for worsening HF.4 These findings were also true for women with the most severe HF. In addition, long-term treatment with beta blocking agents improves the patient�s clinical status, lessens symptoms of HF and enhances an overall sense of well-being.2

Additional outcomes from clinical trials include a reduced need for hospitalization for cardiovascular causes and improvement in NYHA functional class, hemodynamic status, left ventricular ejection fraction, and signs and symptoms of HF.5 Recent trials, such as COPERNICUS, suggest that beta blocking agents improve outcomes for those with the worst heart failure, Class III and Class IV. Indications and Warnings

The 2001 ACC/AHA guidelines for HF suggest that, in patients with systolic HF, an angiotensin-converting enzyme (ACE) inhibitor be started, followed by a low-dose beta blocking agent, such as carvedilol or metoprolol, with a gradually increasing dose over 12 weeks.2 Because beta blocker therapy can potentially worsen HF, it is recommended that a period of treatment with standard therapy be initiated first and that evidence of clinical stability (no acute decompensation or fluid overload) be present before initiating a beta blocking agent.6 Beta blocking agents are started at low doses and slowly up-titrated, generally at two-week intervals. Careful evaluation of the patient, including assessment of worsening failure, is important. Evidence of worsening failure may require adding other medications or a reduction of the beta blocker dose. In addition, patients should be adequately diuresed and stabilized before therapy is initiated.

Beta blocking agents should be started early, even in patients with mild symptoms or those who are clinically stable. These patients are at risk for increased morbidity and mortality, and their condition may likely deteriorate over the next 12 months, even when treatment with digoxin, diuretics and ACE inhibitors has been initiated.2 Beta blocking agents have been used primarily for those patients with NYHA Class II or III and HF patients who don�t tolerate ACE inhibitors.5 Low-dose ACE inhibitors combined with beta blocking agents have improved both symptoms and mortality risk when compared with increasing the dose of ACE inhibitors.2 Clinical response to beta blocking agents is delayed, and it may take two to three months before effects are apparent. Because of the effect on morbidity and mortality, continuing beta blocker therapy is recommended, even if symptoms do not improve.

Beta blocking agents are contraindicated in patients with decompensated HF, cardiogenic shock, acute pulmonary edema, hemodynamic instability requiring IV inotropic support, bronchial asthma, second or third degree AV block, sick sinus syndrome without a permanent pacemaker, and severe hepatic or renal impairment.5

Patient Monitoring
Monitoring for patients taking beta blocking agents includes observing for clinical indicators of drug intolerance such as a heart rate below 55 beats per minute, symptomatic hypotension, dizziness or lightheadedness, or manifestations of worsening HF, such as shortness of breath, dyspnea, fatigue or weight gain. Beta blocking agents should not be discontinued suddenly, because reflex tachycardia and angina in those with coronary artery disease can occur.7 Serum digoxin levels should be monitored, because some beta blocking agents, such as carvedilol, can increase digoxin levels. Because beta2 adrenergic blocking agents may prevent the appearance of warning signs of acute hypoglycemia, blood sugar levels should be closely monitored in patients with diabetes.8 Additional side effects include erectile dysfunction in males, depression, lethargy, drowsiness, weakness, difficulty sleeping, anxiety, nasal congestion, abdominal distress, and cold hands and feet.8

Patients should be instructed to weigh daily to assess fluid status and report signs and symptoms of fluid overload. If patients experience medication side effects, separating the time of day medicines are taken, especially ACE inhibitors and beta blocking agents, may be helpful. Patients should be told that symptom improvement may not be noticed for weeks or even months and that medications should not be discontinued suddenly or without consulting their physician.

1. Gheorghiade M, Goldstein S. B-Blockers in the postmyocardial infarction patient. Circulation. 2002;106:394-398.
2. American College of Cardiology/American Heart Association [ACC/AHA] ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. Dallas, Tex: American Heart Association; 2001.
3. Stanley M, Prasun M. Heart failure in older adults: Keys to successful management. AACN Clin Issues. 2002;13:94-102.
4. Ghali JK, Pina IL, Gottlieg SS, Deedwania PC, Wikstrand JC. Metoprolol CR/XL in female patients with heart failure. Circulation. 2002;105:1585-1591.
5. Meghani SH, Becker D. B-Blockers: a new therapy in congestive heart failure. Am J Crit Care. 2001;10:417-427.
6. Heart Failure Society of America. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction�pharmacologic approaches. J Cardiac Failure. 1999;5:357-382.
7. Capriotti T. Current concepts and pharmacologic treatment of heart failure. MEDSURG Nursing. 2002;11:71-83.
8. McKenry LM, Salerno E. Mosby�s Pharmacology in Nursing, 21st ed. St. Louis, Mo: Mosby; 2001:484.

Practice Resource Network

Q: I am interested in the Instructor�s Resource Manual for the Core Curriculum, 5th edition. However, because of the cost, I would like to review this product in advance. I understand that it is a nonreturnable item.

A: The good news is that you can preview this product online at www.aacn.org > Bookstore > AACN Product Catalog > Specials & What�s New. Here you will find a link to sample pages, which include the full Table of Contents and samples of the Cardiovascular Instructor Outline, Cardiovascular Module Handout Index, the handouts and slides from the Cardiovascular Module.

Do you have a question related to your practice? Contact AACN�s Practice Resource Network at (800) 394-5995, ext. 217.


Apply by March 1 for Evidence-Based Clinical Practice Grant

AACN offers a variety of small and large research grants. March 1 is the deadline to apply for the Evidence-Based Clinical Practice Grant. This grant awards $1,000 to cover direct project expenses, such as printed materials, small equipment and supplies. Eligible projects can include research utilization studies, CQI projects and outcome evaluation studies. Collaborative projects are encouraged.

To find out more about AACN�s research priorities and grant opportunities, visit the AACN Web site. The grants handbook is also available from AACN Fax on Demand at (800) 222-6329, Request Document #1013.

Public Policy Update

Health Policy Outlook
When the 107th Congress ended in December, lawmakers had rejected virtually every significant healthcare proposal they had considered during the past two years. Included were efforts to expand insurance, better protect patients and curb the nation�s medical expenditures.

From patients� rights to generic medicines to changes in medical malpractice law, the lengthy list of unpassed bills reflects the polarization of the political parties.

Congress is closely divided and the agenda has been focused on a few core issues, largely the economy and national security.

Whether attention on health legislation will heighten in the new Congress, where the GOP controls both the House and the Senate, is up for debate. Many Republicans predict a smoother legislative path, but
policy analysts from both parties note that the Senate majority is slim and that the budget may have less room for expensive health proposals. However, despite the party differences, Congress can be
expected to make healthcare issues a priority in 2003.

President Bush has outlined a comprehensive healthcare agenda that proposes to create a system that puts the needs of patients first by helping all Americans obtain affordable healthcare coverage, helping patients get consistently high-quality care, and developing new treatments to keep patients healthy and prevent complications from diseases and strengthen the healthcare safety net. The president will back up this agenda with more than $300 billion in proposed funding.

Republicans say they are drafting a healthcare agenda that would "drastically reshape" how healthcare services are delivered. President Bush and congressional Republicans said that healthcare issues, such as a Medicare prescription drug benefit, tax credits for the uninsured and limits on damages awarded in medical malpractice cases will be a "high priority."

However, in enacting their agenda, Republicans will face several challenges that could force party leaders to consider scaling back their goals and "softening" their approaches. For example, as demands for new spending increase, the federal budget is running at a deficit. Republicans also must overcome the party�s "internal division" over the best ways to resolve some healthcare problems. Although the White House and Senate Republicans tend to agree on policy, the House often passes more partisan legislation, because it is easier for the GOP majority to control.

Improved Patient Care
The Department of Health and Human Services Advisory Committee on Regulatory Reform has issued its final report highlighting hundreds of specific recommendations for improving regulatory requirements across HHS agencies, including some that HHS has already moved to implement or address.

"One by one, we are removing the unnecessary barriers between patients and their doctors, nurses and other healthcare providers," said HHS Secretary Tommy G. Thompson. "By restoring common sense to our regulatory system, we are helping healthcare professionals spend more time caring for patients and less time consumed with paperwork."

The advisory panel of consumers, doctors, nurses and other professionals was established last year to help guide HHS� efforts to streamline unnecessarily burdensome or inefficient regulations that interfere with the delivery of and access to quality healthcare for Americans. Its final report urges a broad range of actions to reduce the potential for harm to patients that may result from unnecessarily complex, confusing and burdensome regulations. The panel made 255 recommendations to reduce potential obstacles to patients� access to care, reduce the time doctors and other healthcare professionals spend on paperwork, improve communication with consumers and improve the use of technology to promote quality care while ensuring patients have strong privacy protections.

Staffing Issues and Drug Errors
Distractions, increased workload and other staffing-related issues, including inexperienced or temporary staff, were the most frequent factors contributing to medication errors in 2001, according to a study by U.S. Pharmacopeia, Rockville, Md. Staffing issues were cited in 36% of medication-error reports in 2001, up from 27% in 1999, the first year that U.S. Pharmacopeia conducted its annual analysis. Among the other findings were:
� Distractions contributed to 47% of the 105,000 medication errors reported by 368 hospitals nationwide in 2001.
� Staff workload was cited in 24% of the reported errors.
� Approximately 61% of the errors affected patients, an improvement from the 69% in 2000. Of those, 2.4% were harmful or fatal. Fourteen deaths were reported, compared with three in 2000.

Demand for Beds and Services
The demand for beds in U.S. hospitals is projected to increase by as much as 46% in the next 25 years, according to a study published by Solucient, a healthcare business intelligence firm. This increase of an additional 238,000 beds is expected to result from long-term demographic shifts in the U.S. population, which could drive up demand for inpatient acute care through 2027. The new long-term forecasts also show that total acute care admissions are projected to increase by 13 million cases or 41% during the same period.

For more information about these and other issues, visit the AACN Web site.

Nurse Reinvestment Act Must Now Be Funded

Contact Legislators to Advocate for Their Support

As a member of the Americans for Nursing Shortage Relief coalition, AACN is pushing for funding of the Nurse Reinvestment Act, the main issue for nursing advocates in 2003.

The fact that the legislation was enacted in only a year�s time indicates the high priority that Congress has placed on addressing the nursing shortage. AACN hopes that the new Congress will maintain this focus in 2003 and act to fund this important piece of legislation to protect patients.

However, now that the elections are over and the NRA has been passed, the nursing shortage may likely be further down on the 108th Congress� priority lists. Nevertheless, nurse advocates will still have opportunities to draw attention to the shortage as Congress focuses on other issues, such as bioterrorism and small pox vaccinations.

Without funding, the programs included in the act to address recruitment, retention, nurse faculty education, public education about the profession and professional development for nurses cannot be implemented. AACN members are encouraged to ask their legislators to support funding of the NRA. AACN�s Legislative Action Center online can not only help members easily identify their congressional representatives, but also contact them directly via e-mail.

Enrollment Up
Enrollment in entry-level baccalaureate programs in nursing increased by 8% in Fall 2002, according to the American Association of Colleges of Nursing. However, the number of students in the educational pipeline is still insufficient to meet the projected demand for 1 million new nurses over the next 10 years. Total enrollment in baccalaureate nursing programs surveyed by the association was 116,099, up from 106,557 in 2001 but still lower than the 127,683 enrolled in 1995, the year enrollments began to dip.

Although the increase in enrollments is good news, substantially greater increases in the number of nurses available over the next five years will be needed. The most recent projections from the U.S. Bureau of Labor Statistics indicate that 1 million new and replacement nurses will be needed by the year 2010 and, according to a July 2002 report by the Health Resources and Services Administration, the number of states with a shortage of registered nurses is expected to grow from 30 in 2000 to 44 in 2003. In addition, the growing shortage of faculty is of significant concern for institutions trying to accommodate the increased interest in nursing as a career.

AACN will continue to advocate for legislation that benefits the nursing profession and seeks solutions to the nursing shortage.

In the meantime, efforts to address the shortage continue on a number of fronts. Below are examples of how the issue is being addressed at the state levels.

Addressing the Nursing Shortage


The Pennsylvania Higher Education Assistance Agency has announced the establishment of a nursing loan forgiveness program to help alleviate its nursing shortage. The agency expects to fund $13.3 million in loan forgiveness with proceeds from a series of bond-issue refinancings at no cost to taxpayers. To qualify, students must graduate from an approved professional nursing education program during or after 2003. Participants must also maintain employer-verified, full-time, continuous employment after graduation as a direct care nurse at an approved Pennsylvania healthcare facility or as a nurse educator in the Commonwealth for a minimum of one year and hold an eligible federal Stafford loan.


A coalition of Virginia-based private and public healthcare systems and organizations has announced the launch of the Virginia Partnership for Nursing�s campaign, "Nurses Change Lives." The campaign seeks to inspire students in kindergarten through 12th grade to consider a career in nursing. As part of the campaign, four different posters targeting specific age groups have been created for distribution to elementary, middle school and high school students across the state. In addition, a network of nurses will be developed to provide education about nursing opportunities. For more information, visit www.nurseschangelives.com.


More than 35 hospitals, 16 schools of nursing and 60 school districts in southeast Michigan have come together to launch "Nurse Now!," a five-year collaborative initiative to increase the number of academically qualified youth interested in nursing careers. Recently, more than 1,000 high school students had the opportunity to "Be a Nurse for a Day" at participating hospitals. Other campaign elements include a "Nurse Now!" career information kit for high school counselors, math and science teachers that includes posters and brochures, and a Nurse Ambassador program that makes nurses available for school and in-classroom presentations on a variety of topics. For more information, visit www.mihott.com.

Online Quick Poll

Does your unit use a standard monitoring lead for every patient regardless of diagnosis (for example, every patient monitored in Lead II)?

Yes 52%
No 48%

Number of Responses: 592

The AACN Online Quick Poll is a voluntary survey on a variety of topics and is not scientifically projectable to any other population. AACN presents these surveys to give our users an opportunity to share their opinions on particular topics. Participate by visiting the AACN Web site.

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