Archive for September, 2010

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In Her Own Words: Pakistani Flood Victim Focuses on Providing Essential Medical Help to Others

September 30, 2010

Yesterday we posted here on the threats facing medical aid workers in unstable countries, with a special focus on the work of the international aid organization Merlin in Pakistan following this summer’s catastrophic flooding. Today we publish a first-person account by Azra Habib, a Lady Health Worker who has been working for Merlin’s diarrhea treatment unit (DTU) in the flood-affected Charsadda district of Khyber Pakthunkhwa. She, like many health workers, has opted not to focus on the potential risk she faces or her own family’s losses, but instead on the immediate need for basic health care services.—Jacob Molyneux, senior editor/blog editor

Azra Habib at a Merlin Diarrhea Treatment Unit in Pakistan

I’ve recently taken a new post as a Lady Health Worker for a diarrhea treatment unit (DTU) at the Charsadda District Hopital in KPK. After the floods there were many villages in the district with no clean water, and the demands on this specialized ward can be extreme. Having lost everything, many people don’t have the resources to get transport to the hospital. Often, by the time they get here, patients are moderately or severely dehydrated and need to be admitted. There are 40 beds but we’ve had as many as 189 patients arrive on the ward in a day.

A toddler recovering from dehydration brought on by acute watery diarrhea

Early one morning, not long after I started my position here, I was about to sign off from my night shift duty. A woman came in, crying out with a child not yet three years old in her arms. She was screaming, “He is not moving, he is not responding.” He had been suffering from diarrhea for two days. When the doctor saw him, he noted that his condition was grave and we started immediate treatment: an IV line to restore his fluid loss and antibiotics to treat his infection.

The boy had lost his father and 5-year-old sister in the flood. This meant that his mother had no one else left. I asked if I could take care of the child and continue my shift rather than sign out, and the doctor allowed me to do so. So I put in all my efforts to his recovery and the child started to respond in the evening. He remained in the DTU for five full days, and when he fully recovered he was discharged.

Noshad Ali holds his 2-year-old grandson, Mohammad Faizan, who is recovering from severe dehydration brought on by acute watery diarrhea

A very personal catastrophe. I wanted to make sure he survived because I know what it means to lose everything and to be left with heavy responsibilities. Prior to the floods in Pakistan, I worked for five years in my village, Banda Malahar, as a health worker. At the same time, I was close to finishing my nursing and midwifery studies. I was in the process of taking my third-year nursing exams when the floods hit and destroyed the area where I live. That day, I was on my way to the city to take exams when I saw water was fast approaching on the motorway. As the bus driver backtracked, I saw all the bee boxes from the nearby farms, floating in the water. I suddenly forgot about my exams and started to worry about my home.

I couldn’t reach my family by phone, but I’d heard on the radio that all of Khyber Pakhtunkhwa had been affected by flash floods. When I finally reached my elder brother by phone the next day, he told me that the whole village had been swept was away by water and there was nothing left. He told me that my sisters-in-law and their children found refuge in a school, while my three brothers were living in a tent on the motorway. He told me that our parents refused to leave the house. So we had no idea if they had survived. I was horrified by the news and felt very restless.

Only silence. Eight days after the flooding started, I finally found my parents. They had found shelter in a school. A week later we returned to Banda Malahar, which was washed away. There was nothing left, only silence. I was standing in ankle-high muddy water and debris. We took the household items we could salvage and what we could find to pitch up a tent to live in. Neighboring families began returning, pitching tents in the footprint of where their homes had once been.

Now everyone is developing severe skin infections, or coming down with diarrhea and malaria, which my sister has also contracted. Living conditions prior to the flood were very poor and now they’ve gone from bad to worse. The floodwaters took everything we had; even my elder brother’s beekeeping business is finished. Read the rest of this entry ?

Posted in children's health, human rights, infection control, international nursing, nursing perspective, public health nursing | Tagged , , , , , , | 3 Comments »

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The Grave Dangers Facing Medical Aid Workers in ‘Insecure’ Regions

September 29, 2010

I recently heard from Jacqueline Koch, a senior communications officer with the global medical aid group, Merlin. As described in a recent AJN photo-essay on Merlin’s work in Gaza (for the best view, click through to the PDF version), the organization partners with local health organizations and trains health workers to provide care in response to natural and man-made disasters. Ms. Koch has now shared with AJN a first-person account of one Pakistani woman’s experiences working with flood victims, which includes a description of that worker’s own family’s suffering as a result of the flood. This account, which will appear tomorrow along with several photos, is prefaced below by Ms. Koch, who provides context for Azra Habib’s story. The security issues raised by Ms. Koch are frightening, in that we now see an already taxing kind of health care work becoming even more perilous because of the threat of physical attacks like the murder of 10 medical aid workers in Afghanistan back in August.—Jacob Molyneux, senior editor/blog editor

A toddler recovering from dehydration brought on by acute watery diarrhea in Merlin's DTU in Charsadda.

‘Senseless but simple.’ In Pakistan, alongside a breadth of man-made and natural disasters, there are many occupational hazards and cruel ironies, especially for aid and health workers. It’s senseless but simple: delivering aid, providing medical care, and saving lives can potentially make you a target.

For any Pakistani national health worker who is working for an international nongovernmental organization (INGO), the danger multiplies. Not only can they themselves be threatened, but so can their parents, siblings, spouses, children, and extended families. They face armed attacks, death threats, robbery, kidnapping for high ransom, and the very real possibility of murder.

Many must navigate these dangers by refraining from visiting nearby family, living in close proximity of their offices, and hiring guards to escort their children to and from school. When working in the field, many opt to leave hats and jackets with INGO logos and ID cards behind, alongside their BlackBerries and anything else that might identify them. They have little choice but to dramatically alter the rhythm of their lives in order to save lives—including their own. But these measures are not always foolproof.

Not just in Pakistan. Merlin, an international medical aid organization, recently published a report outlining the impact of violence, conflict, and insecure environments on health workers, who are central to achieving the United Nations Millennium Development Goals. For those delivering essential health care in fragile or conflict-affected states, it is “A Grave New World.”

As one female health worker in Pakistan in conflict-affected Swat Valley (and who asked for anonymity) noted:

“The militants were against family planning, saying women must stay in the home. As a Lady Health Visitor, I was suspected of providing family planning and therefore at risk. During the militant regime, I could not reach women, I couldn’t meet my patients. If someone knew what my job was, they would have cut me to pieces. I often think about it, I think about my children, because my job is something my family needs. My family needs my job to survive. But I had to stop working here during the regime. I left. While I was away, I thought about my patients, I thought about those who I left behind and who didn’t have anyone to care for their health.” Read the rest of this entry ?

Posted in children's health, human rights, infection control, international nursing, public health nursing | Tagged , , , , , , , , , , , | 4 Comments »

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Why Didn’t Physicians Know What Nurses Know?

September 27, 2010

By Shawn Kennedy, AJN interim editor-in-chief

A recent post on our blog highlighted the experience of AJN’s associate editor Amy Collins in trying to get someone to diagnose the underlying reason for acute confusion in her grandmother. Over a two-week period, Amy’s grandmother was seen by various private and ED physicians, none of whom seemed to have an adequate diagnosis or a suggestion for treatment. Finally, nurses suggested that a urinary tract infection (UTI), fecal impaction, or some other infection might be a factor. It was a fecal impaction and yet none of the five physicians who previously evaluated Amy’s grandmother had thought about or assessed for it.

What the nurses said. Amy’s post generated many comments, both on the blog and on our Facebook page. What was interesting to me was how many nurses knew to first check for a UTI, electrolyte disturbance, or fecal impaction as a reason for confusion. Here are a few samples:

“Though not conclusive, in every case I have seen a change in cognition or behavior it was either a UTI or fecal impaction. I work in home health as a CNA and I am a nursing student.”

“The first thing I think to check is infection (UTI) with elderly, confused patients.”

“I’m a senior nursing student…and this material is on our exam that we are taking Friday. With acute confusion, always check for UTI and constipation.”

“Possible UTI. Possible dehydration &/or  constipation. Poor nutrition. All can (and do) manifest as “altered mental status.” Think I’d start with those, and then evaluate further for more complex issues.”

“I would check for fecal impaction, that tends to be a common tendency especially in long term care facilities and a urine sample for UTI.”

So why did none of the physicians who saw Amy’s grandmother think of those potential causes? Is it that none were astute in geriatric medicine, or is it that it’s easier to dismiss the rantings of an older woman as dementia and move on to a “more interesting” case? Was it a case of what one commenter suggested—“simply lazy health care”?

Some resources. Or might it perhaps be that nurses are ahead of physicians in working with the aged?  The John A. Hartford Foundation, which is “dedicated to improving health care for older Americans,” has funded educational programs for nurses through the Hartford Institute of Geriatric Nursing at New York University College of Nursing (you may be familiar with the Nurses Improving Care for Healthsystem Elders [NICHE] program); has fostered leadership building through the Building Academic Geriatric Nursing Capacity initiative with the American Academy of Nursing; and also supports nine Hartford Centers for Geriatric Nursing Excellence. And AJN was pleased to be a partner in the How to Try This series on geriatric assessment (a practical series of articles and videos on recognizing and treating common conditions among the elderly). There are also programs for physicians and social workers. Let’s hope people take advantage of them—it’s painfully apparent that the need is urgent.


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Posted in nursing perspective, patient safety, Shawn Kennedy, AJN editor-in-chief | Tagged , , , , , | 1 Comment »

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When Delirium Is Mistaken for Dementia

September 23, 2010

We hope you had a chance to read “No Country for Old Women,” yesterday’s moving post by AJN associate editor Amy Collins, in which she described the failure of multiple providers to assess and treat the underlying cause of her grandmother’s rapid acceleration of already existent dementia symptoms (or what were assumed to be dementia symptoms).

It so happens that several years ago we ran an article on a frequently undiagnosed condition in older adults; the article was called “Delirium Superimposed on Dementia.” Maybe this is why two of our nurse editors were able to point Amy in the right diagnostic direction as to possible hidden causes of her grandmother’s crisis. Here’s an excerpt from that article:

A systematic review . . . found that prevalence rates of delirium in people with dementia ranged from 22% among older adults who lived in the community to 89% in hospitalized patients . . .  It’s more difficult to recognize delirium in people with dementia than in those without because of overlapping symptoms, difficulty in ascertaining baseline mental status and the acuteness of symptoms, and the tendency to attribute symptoms of delirium to a worsening of dementia symptoms.4 Yet early recognition is essential in order to determine and treat underlying causes; institute interventions to maintain safety; [and] restore prior cognitive function and improve short- and long-term outcomes.

The article gives a useful algorithm for recognizing as well as managing this condition. There’s also a video which discusses the condition and shows a nurse working with an actual patient (you have to enter your e-mail address to get to it). Reading Amy’s account of her grandmother’s experience, one can’t help wondering if any of the physicians who assessed her had ever even heard of this condition, or knew to look for it. With older patients more and more the norm in hospitals, it’s time for nurses to lead the way in educating others about this condition so it no longer goes unnoticed. As the authors point out, “acuteness, fluctuation, inattention, and altered level of consciousness are not normal in people with dementia, and their presence should trigger further assessment and treatment.”—JM, senior editor/blog editor

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No Country for Old Women

September 22, 2010
By Amy M. Collins, associate editor

by Ann Gordon, via Flickr

For the past few weeks, my family has been living a health care nightmare. My 85-year-old grandmother, physically fit and as beautiful as an old-time movie star, but suffering from the first stages of Alzheimer’s disease, had a major meltdown. Her assisted living facility called to say she was harassing the residents and staff, claiming her belongings had been stolen, shouting at people at random, and even calling the police. Clearly not equipped to handle this level of agitation, the facility turned to us to pick her up and keep her for a few days.

The week that followed proved arduous—nobody seemed to know what to do with her. Her GP was at a loss, suggested that we bring her to the ED. Her neurologist prescribed Seroquel (after having to tackle and physically restrain her from the subsequent episode of screaming and pounding her fists on the wall, we called to tell the neurologist that the pill wasn’t working; he said to give her more; four pills later, she was still mildly agitated.) This went on for over a week. She came to live with us, where we listened, exhausted, to constant chatter that didn’t make sense. The talking never stopped—her voice grew hoarse with it and she didn’t sleep. She couldn’t feed or dress herself. We tried to see a geriatric specialist. He wasn’t available, so we were passed on to his assistant, a PA, who suggested that, at 85, my grandmother had developed bipolar disorder.

We finally brought her to the ED, where she was left alone for eight hours babbling away, only for a psychiatrist to come into her room at night, after she’d finally fallen asleep, to give her Haldol. We refused to let him. The psychiatrist suggested admitting her to the psych ward, but there weren’t any beds. This meant she could be shipped anywhere in New York State. We left the ED frustrated and angry.

What were we to do? A family friend and nurse said we shouldn’t be dealing with this alone, that my grandmother needed to be “controlled.” But nobody else would deal with her. She was being passed around from physician to physician, each diagnosis more outlandish than the last. Nobody believed that despite her dementia, she wasn’t crazy. One physician even suggested perhaps she’d hidden her psychosis all these years with drink. (Problem with that diagnosis: she never drank.) Read the rest of this entry ?

Posted in nursing perspective, patient perspective | Tagged | 11 Comments »

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What Nursing Independence? And Other Notes from the Nursosphere…

September 21, 2010

Here’s some stuff we’re reading online this week:

In one of the health systems that I interface with nurses can no longer document that they held a patient’s medications based on ‘nursing judgment’. Such an instance might be when a patient had hypotension from pain medication and thus the morning anti-hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something like ‘Tylenol’ on a patient’s medication record ordered for fever could not be administered by the nurse for a headache if the patient requested it because that would be ‘practicing medicine without a license’.  A nurse cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for diabetes education, etc., etc., without an order from the supervising physician.

That’s from a smart, if somewhat depressing, blog post at Nurse Story called “Independent Nursing Practice: Reality or Still the ‘Physician’s Hand’?” The writer, Terri Schmitt, goes on to wonder just how nurses can carve out areas of independent practice, even in the most basic matters. Good questions.

And here’s a question of interpretation raised by an incident in Colorado involving a nurse and the policeman who stopped her for speeding:

When Colorado Springs cardiac nurse Miriam Leverington was stopped for speeding, she grumbled to the police officer.

“I hope you are not ever my patient,” she reportedly told him.

What happened next has become a topic of widespread debate in Colorado and on the blogosphere. The police officer, Duaine Peters, complained to the hospital where Ms. Leverington worked that her comment amounted to a threat, suggesting she might give him poor care should he ever become her patient.

The hospital fired the nurse, and now the nurse has countered with a lawsuit. She says she was merely exercising her right to free speech — and expressing her hope that she never see the policeman again.

Much ado about nothing? Are we going out of our way a bit too often lately in our zeal to make people pay for casual, if ill-advised, acts of speech? Or did this nurse cross a line?

For some quick takes on where we are with health care reform implementation, here’s a roundup from Kaiser Health News—which in general has done a great job keeping us abreast of what’s actually happening with this issue, as well as the range of opinions being tossed about. Here’s an excerpt.

Six months after passage of the federal health reform law, major provisions will kick in that supporters say will make it easier for Americans to get and keep health insurance. … Among the major changes: Insurance companies will no longer be able to cancel policies because someone becomes sick, set lifetime caps on coverage or deny insurance to children with pre-existing conditions. … In addition to enabling young people to remain on their parents’ policies up to age 26, several other major provisions kick in on Thursday.


The various nursing blogs are a little quiet today. Since palliative care has been in the news a great deal lately, this might be an appropriate time to note that Pallimed: A Hospice and Palliative Medicine Blog just celebrated post #1,000 with a list, partially excerpted below, of tips for a successful palliative care consult:

  1. Assume nothing, ever. 
  2. Always talk to the team first.
  3. Respond to emotion with emotion. 
  4. 75% of what we do is showing up and shutting up.  
  5. Tame the beast inside who just wants to talk, talk, talk.
  6. Don’t just do something, stand there.
  7. Acute symptoms = acute meds.  (That is – don’t jack around with long-acting/continuous meds for out of control symptoms without first actually making someone comfortable with bolus/immediate-acting meds.)  This is a variation of the idea behind:
  8. NO DRIPS ‘TITRATED FOR COMFORT.’
  9. ‘Good work’ describes a process, not an outcome.
  10. Palliative care is just good medicine.

Pallimed is an excellent and thoughtful site, even if the focus may be somewhat more toward the MD perspective than the nurse perspective. It is also hosting the medical blog roundup Grand Rounds this week, if you’d like to do some interesting Internet browsing with a shrewd and useful tour guide. (And the latest Change of Shift, the regular nursing blog roundup, can be found at the nursing blog Emergiblog. We appreciate the mention of a recent post from this blog!)—JM, blog editor

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A Nurse Cartoonist Worth Checking Out

September 17, 2010

Drawing on Experience is a blog run by a student who’s been completing an accelerated BSN program in nursing and who illustrates his education and personal life with remarkably subtle and witty cartoons. Hat tip to a recent Change of Shift blog roundup at Emergiblog for letting us know about his work. It would be wrong to reproduce this artist’s work here without permission, and he might not like it, so I’m just including a really really tiny version of a recent cartoon illustrating his induction into the nursing honor society. It links back to his original Web site, where you can see this and many other cartoons in full, legible size (and of course, upon request, we’ll gladly remove the thumbnail image here!).

Click image to go to artist's site and see larger version

What makes this artist’s work so much fun? The tongue-in-cheek, martial-arts-disciple-and-wise-man narrative? The humility and sense of pleasure in life’s ironies and challenges? The quality of line? The attention to apparently trivial details? The way his mini-narratives play with genre conventions? At any rate, it’s a welcome addition to the nursosphere; I don’t see any contact info on this artist’s blog, but we hope he’ll find time to continue (and consider letting us publish one of his drawings on the blog or in AJN).—JM, senior editor/blog editor

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Posted in male nurses, nursing perspective, nursing students, professional identity | Tagged , , , , , , | 1 Comment »

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I Simulate, Therefore I Am…

September 16, 2010

One after another, the student nurses pump the hand sanitizer dispenser and approach the bedside. They turn the patient’s name band to check his birth date and full name and say, in that singsong manner typical of young adults, “Good morning, Mr. Johnson, I’m your nurse today. How are you feeling?” The patient is a manikin called SimMan, short for simulation man, and I’m his voice. Hidden behind a one-way mirror, I also control SimMan’s physiological responses to the students’ interventions. My goal is to replicate the essential aspects of a clinical situation in order to prepare the students to encounter them in a living patient.

That’s the start of the September Reflections essay, written by a nursing instructor who experiences a curious role reversal as he plays the patient in a simulation exercise. Read the rest of it here, and let us know what you think.—JM, senior editor/blog editor

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After the Angels: In Search of A ‘Knowledge-Based’ Professional Identity

September 14, 2010

If you’re looking for angels, you’ve come to the wrong place. So says GuitarGirlRN in her latest blog post.

One stereotype of nursing (and it’s perpetuated by nurses as well as by those not in the medical or nursing fields) that bothers me is that of nurses as “angels of mercy.”

We’re expected to smile while up to our elbows in bloody shit and vomit, be pleasant to rude and sometimes violent people, put up with crap from doctors, managers, patients, their families, nurse techs, and janitors yet keep our cool, never cry, never sweat, never lose our tempers with each other, always be prepared and be right there when we are needed.

by shioshvili/via Flickr

Her point is that nurses are human; they do the best they can with scant resources, but they aren’t superhuman. They aren’t saints, they have lives of their own, and they can’t always be all things to all people. Back in 2005, noted author Suzanne Gordon wrote, with Sioban Nelson, an article for us called “An End to Angels.” In it, they presented the idea that nursing is a profession with a serious image problem, one that undercuts recruitment efforts and ill prepares new nurses for the reality of their work. The arguments in the article are subtle and thought provoking, and impossible to summarize. Here, anyway, is the introduction:

Nurses often disagree on the causes of and possible solutions to the current nursing shortage. Mandatory staffing ratios versus Magnet hospitals? Sign-on bonuses for nurses versus more unionization of RNs? The aging of the nursing workforce versus working conditions? Still, most nurses agree that the profession needs a contemporary image to attract new recruits and reinforce the idea that nursing is a profession grounded in science, technology, and knowledge. To present a modern image and solve the crisis, dozens of different groups have produced advertising campaigns and promotional messages to attract new recruits to the profession.

A close analysis of the words and images used in these campaigns reveals that, instead of creating a modern, accurate version of today’s nurse, many simply repackage nursing’s traditional stereotype of women born to be good, kind, and self-sacrificing-not educated to provide care based on science and practical skill. Although many studies-conducted by nursing, medical, and public health researchers-have documented the links between nursing care and lower rates of nosocomial infections, falls, pressure ulcers, deep-vein thrombosis, pulmonary embolism, and death, most promotional campaigns are conspicuous for their failure to promote these data. Even when ads feature a mix of men, women, and minorities, what is often communicated is a sexist, archaic message: nursing is virtuous work.

The subtitle of Gordon and Nelson’s article is “moving away from the ‘virtue script’ toward a knowledge-based identity for nurses.” So, five years on, how is the nursing profession doing with this? Do you feel you have a “knowledge-based” professional identity? Is that how patients, physicians, nursing instructors, administrators, your friends and family, and the general public see you?—JM, senior editor

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Posted in healing/holistic, media depictions of nursing, nursing perspective, nursing shortage, patient perspective, professional identity | Tagged , , | 4 Comments »

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Maybe Palliative Care SHOULD Go to the Dogs

September 13, 2010

By Shawn Kennedy, MA, RN, AJN interim editor-in-chief

Sam in his hospice quilt

Last week, we took Sam, our ailing 14-year-old Labrador Retriever, on what became his last trip to the vet. Sam had been diagnosed with bone cancer in February after we noticed the right half of his head enlarging. Because of where the tumor was, it was inoperable. We felt that at his age chemotherapy wasn’t a realistic option, and we didn’t want the last few months of his life to be bad ones.

His veterinarian, who’d treated Sam since his puppy days, supported the decision, saying she would make the same choice for her dog. And so we spent the last few months adjusting doses of steroids and pain meds to enable him to live as normally as possible. For Sam, “normal” was being able to greet all comers to our door, to be the leader on his walks, to be smack in the middle of where his family was. (If people were in the basement and on the second floor, he would lie equidistant from where everyone in the house was. If we were in the same room, he sat, front legs crossed in his “elegant dog” pose, where he could see us all.)

So last month, when we saw that he would no longer get up to greet visitors or his family; was reluctant to go on walks (he did, but with a great sigh and lots of panting after even the shortest walk); and, finally, stayed in a corner of the back hallway, no longer making the effort to be part of the family, we realized Sam’s quality of life was diminishing. It became abundantly clear when he wouldn’t eat his normal food or even cookies, his favorite, that Sam was suffering.

When we took him to the vet, secretly my husband and I were hoping the vet would give us a different regimen that would restore Sam to the dog of a few months ago. But the vet pointed out that, at most, any measures we could take would only gain us another few weeks—and there was no guarantee of even that. She also asked us about our motives. Clearly, prolonging Sam’s life meant prolonging his discomfort. It became obvious that “keeping him going” would be only for our benefit and not for Sam’s. And so we decided it was time to say goodbye.

The technician brought out a quilt for Sam to lie on, and we fed him cookies and petted him and talked to him while the vet gave him a large dose, an overdose, of sedative. It was all very peaceful, and we were grateful for the support and guidance of the vet and her staff in helping us let Sam go.

I couldn’t help contrasting Sam’s death with Theresa Brown’s story of her oncology patient in her recent opinion piece, “A Dying Patient is Not a Battlefield.” Yes, I know Sam was a dog, and I’m not advocating euthanasia, but I am advocating that people deserve a good death and shouldn’t be cajoled into decisions for the benefit of others.

I worked as a chemotherapy nurse during graduate school, and I remember discussions with patients who made treatment decisions they really didn’t want to make but made anyway—because they didn’t “get” that things were not going to get much better, or they didn’t want to let their families down or, worse, felt they “owed it” to the physicians and staff who were working hard to keep them alive. What messages are we giving to patients and to families if they feel they owe us anything? What happened to what we learned from the work of Cicely Saunders or Florence Wald in creating hospice care? What happened to those of us who are charged to be advocates for our patients? Brown’s piece is a reminder to make sure our patients have the right information to make informed decisions, and then to listen and support their decisions.

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Posted in ethical issues, healing/holistic, pain control, palliative care, patient perspective, Shawn Kennedy, AJN editor-in-chief | Tagged , , , , , | 6 Comments »

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