Archive for the ‘palliative care’ Category

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On Euphemisms and Learning to Be Present

November 28, 2011

By Alicia Marie Hinton, who is a BSN student at the College of New Rochelle School of Nursing in New Rochelle, NY. This is her first post for this blog.

by grepsy, via flickr

My senior year preceptorship was an assignment on a palliative and acute care unit at a busy medical center. When I received the assignment, I prayed that no patient of mine would die during my time on the unit. Every nursing student is afraid of their first patient death. Simulation and course work prepare students in various ways for this experience, but nothing can really prepare you for the emotions you’ll feel. Some students experience a patient death during an undergraduate nursing program, but for others it may not happen until their first year or two working as an RN. I hoped to never endure it, but knew it was inevitable.

During report, working alongside my preceptor, I listened anxiously to the status of the various patients. Since my first day on the unit, I’d practiced my therapeutic techniques and researched different cultural needs pertaining to the death of a patient. I felt culturally competent and well informed about what a nurse should do when a patient dies, but I couldn’t shake my fear. What would I say to the family? Would they value my presence?

Finally, during morning rounds on my third day on the unit, I was told that a certain Mr. P wasn’t doing too well and might “expire” that day. Our focus would be to provide comfort for him and his family.

How did they know he was to “expire”? Was that the politically correct term for dying? I was familiar with “passed away,” “deceased,” or “gone to a better place.” But the word “expire” didn’t feel right. I’d cared for Mr. P since his admission and interacted daily with his family, and news of his impending death hit me hard, increasing my anxiety about how I’d respond when it happened. While I was anxious about my own feelings about the patient’s death, I was preoccupied with my ability to comfort that family. Read the rest of this entry ?

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Addressing Traumatic Injury in Older Adults

November 18, 2011

By Sylvia Foley, AJN senior editor

Frank Jones, age 83, arrives at a local trauma center after falling down a flight of stairs in his home. Initially diagnosed with two fractured ribs, a fractured ulna, and a fractured tibia, he’s admitted to the ICU.  At first, things seem to go well—his electrolytes and bloodwork appear to be within normal limits, and his vital signs are stable. But the next day he becomes increasingly unstable. What’s going on?

Stairs by spivvo, via Flickr

Trauma is currently the seventh leading cause of death in older adults—and older adults are more likely to suffer complications and die than are younger ones. But as author Christine Cutugno points out in this month’s CE, “The ‘Graying’ of Trauma Care: Addressing Traumatic Injury in Older Adults,” advanced age isn’t a predictor of trauma outcome. Many trauma-related complications are preventable.

What guides current care? While standards of care for geriatric patients and for trauma patients exist, as yet none have been specifically developed for and tested in geriatric trauma patients. Until that happens, Cutugno writes, “nurses will need to be guided by measures known to prevent iatrogenic complications in other patient populations.”

To that end, Cutugno first reviews common mechanisms of traumatic injury in older adults and discusses the effects of aging and comorbidities. She points out that older adults usually have poorer physiologic reserves and are less able to maintain homeostasis. Their compensatory responses may be inadequate. The drugs taken to manage many comorbidities can mask warning signs. In short, it can be challenging for nurses to recognize when a geriatric trauma patient is in trouble. Read the rest of this entry ?

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Toward a Less Painful Death: ICD Deactivation at End of Life

October 14, 2011

By Sylvia Foley, AJN senior editor

A few years ago, in a letter to the editor of another journal, an NP described how one of her patients, a man on home hospice care, had suffered 33 shocks as he lay dying in his wife’s arms. The source of those shocks, his implantable cardioverter-defibrillator (ICD), reportedly “got so hot that it burned through his skin.” The device that had been implanted to save his life caused this man and his wife great distress in his final hours. Device deactivation at the end of life is an option; but in this case, apparently, it had never been discussed.

Stories like this one helped to inspire the research reported in this month’s CE feature, “Deactivation of ICDs at the End of Life: A Systematic Review of Clinical Practices and Provider and Patient Attitudes,” by James Russo.

Lightning by snowpeak, via Flickr

ICDs, standard treatment for people at risk for life-threatening cardiac arrhythmias, work to restore normal rhythm by delivering a high-energy, painful electrical shock. The devices are so effective that people with ICDs often die from causes other than heart disease. But once a person with an ICD begins actively dying, as in the case above, the device may cause needless pain and prolonged suffering. So it’s essential for providers and patients to talk about the possibility of deactivation, well in advance of such crises.

Russo, the coordinator of the pacemaker clinic at the Department of Veterans Affairs Medical Center in New York City, wanted to better understand why providers and patients weren’t discussing this possibility and to find ways to promote more timely discussions. Read the rest of this entry ?

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What One Thing Will Make Today Better for You?

September 12, 2011

As I entered Mr. Ricker’s room, I remembered that the night nurse had mentioned that his wife had been with him overnight. I knocked very lightly and opened the door a crack. The two of them were cuddled up closely in the bed.

“What One Thing Will Make Today Better for You?” That’s the title of the Reflections essay in the September issue of AJN, in case you thought a genie had materialized out of the steam from your afternoon coffee mug. A simple question, but one that author Susan Goff has used since the 1970s with her patients. Sometimes the answer is surprising—that is, sometimes we shouldn’t assume we know what patients want . . . or need. Sometimes, in the case of the patient she describes in this essay, there’s something that should trump NPO. We hope you’ll read the essay and let Susan know your thoughts in our comments section below.—JM, senior editor


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Return on Investment: A Nurse’s Mother Makes Her Wishes Clear

August 10, 2011

By Margaret Gallagher, BSN, RN. Margaret is a cardiovascular nurse currently working in Georgia. This is her first post for this blog.

Fly Away / jenny.nash712, via Flickr

My parents believed it was their obligation to educate their children. My sister and I both walked out with a college diploma and no debt. Susan went to a state university for her pharmacy degree, but I fell in love with a private nursing school. So my mother spent her inheritance on her own alma mater’s archrival because it was where I wanted to go. Mom got what she paid for, however, as I graduated with a BSN that has done more than just keep the roof over my head.

Shortly after I passed my boards, I planned a trip to visit my parents. I got report for my last shift, then walked in on a shouting match. My patient lay comatose between his two adult sons. Awareness of my presence brought a thick silence, followed by the younger son muttering an “excuse me” as he bulldozed his way out. After a pause, the remaining son searched my face as he began to speak.

“The doctors just told us today that Dad’s never going to get better than this. They asked us how far we wanted them to go.” He bit his lip. “I’m the oldest, so it will fall on me. But I don’t know what to tell them. I never heard him say how he felt. Dad never liked to talk about that sort of thing. I don’t know what to do.”

His eyes drifted to his father’s face, then back to mine. He blinked back the tears, “I only know that, no matter what I decide, I will never know if it was the right choice.”

I knew that this would haunt him for the rest of his life. I don’t remember what I told him. I do remember the voice in my head telling me not to ever have to utter those words.

It’s been a quarter century, but I can still see my parents, sitting at the kitchen table that next afternoon. I told them about my patient’s son. I mentioned that I knew they didn’t like to talk about that sort of thing either. I promised I’d never bring it up again if they would just tell me what they would or wouldn’t want if I ever had to be asked. Read the rest of this entry ?

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Bearing Witness: April’s ‘Art of Nursing’ and Cover Art

April 14, 2011

By Sylvia Foley, AJN senior editor

In “Palm Sunday,” the poem featured in this month’s Art of Nursing, nurse and poet Rachel Betesh evokes the prolonged anguish of those who tend the dying. A man lies “sick and stained” in a bed, leaves his food untouched, and “hardly speaks anymore.” His wife and sons lament “the sin of the too-long moment”; time does not heal, but gapes like an “open wound between sickness and dying.”

A lesser poem might have slipped into sentimentality. But Betesh’s characters are a lively, indomitable bunch. “Pop!” the man’s sons say, visiting; you can feel their vigor. His wife remembers a baked potato he’d once given her, and her response: “You gonna marry me or what?” Indeed, it’s through witnessing, hearing the family’s stories, that the nurses can offer some comfort. They cannot heal the man, but they can “pack the wound, and listen.” (Art of Nursing is always free online—just click through to the PDF file.)

Windows and Doors by Paula Giovanini-Morris

This month’s cover art, a work of embroidery by nurse and fiber artist Paula Giovanini-Morris, explores the concept of memory and illustrates its mechanisms, the neurons and synapses through which the brain registers, encodes, and retrieves events. The piece, titled “Windows and Doors,” was prompted by another kind of witnessing: the artist’s visits to her mother, who was suffering from the early stages of dementia.

AJN senior editorial coordinator Alison Bulman spoke with Giovanini-Morris, who explained, “As I watched [my mother] search for words to express herself and attempt to recall recent events, I was struck by a sadness, realizing that in a short period of time the mother I knew might be replaced by someone who had no idea who I was.” Giovanini-Morris also acknowledged that she faces the possibility that she might eventually suffer from dementia herself. For more on this artist and her work, read this month’s On the Cover.

If you’re interested in submitting your own work to Art of Nursing—we consider visual art, very short “flash” fiction, and poetry—send me an email (sylvia.foley@wolterskluwer.com) for more information.

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‘A True Art’: Strategies for Feeding Patients with Dementia

April 1, 2011

By Sylvia Foley, AJN senior editor

The fork and the spoon, by Jordan Fischer via Flickr

Feeding difficulties in people with dementia are common, but the way such difficulties manifest can vary widely, and there is no single, one-size-fits-all solution. Nurse researchers Chia-Chi Chang and Beverly L. Roberts open their April CE article, “Strategies for Feeding Patients with Dementia,” with some disturbing statistics that make clear the scope of the problem:

People with dementia constitute roughly 25% of hospital patients ages 65 and older and 47% of nursing home residents. And more than half of them lose some ability to feed themselves, which puts them at high risk for inadequate food intake and malnutrition. Patients who are unable to eat independently must rely on caregivers to assist them . . . Unfortunately, caregivers may be unable to identify the various types of feeding problems that accompany dementia or unaware of the feeding practices required to address them.

In an earlier literature review published in the Journal of Clinical Nursing, Chang and Roberts evaluated three tools used to assess feeding difficulties in people with dementia, then created a conceptual model depicting such difficulties, contributing factors, and outcomes. Now, in this CE article, the authors take their work a step further. Read the rest of this entry ?

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Turkey, Sweet Potatoes, and Living Wills

November 24, 2010

By Christine Moffa, MS, RN, AJN clinical editor

by controltheweb/via Flickr

When I was growing up, my family spent Thanksgiving dinner at my grandmother’s house. She was a star in the kitchen, with cooking and baking skills beyond compare. However, while she made a chocolate cream pie to kill for, her knack for turning every conversation into a newsfeed of various neighbors’ illnesses, symptoms, and near-death experiences, if not actual deaths, stood out more. She did this so much that my brother began referring to her as Grandma Kevorkian.

It turns out that death-and-dying discussions on Thanksgiving might not be such a bad thing, according to Engage with Grace, a nonprofit organization that promotes end-of-life discussions. In 2008 they launched a blog rally timed with Thanksgiving weekend, for bloggers to get the word out about end-of-life discussions. The idea is to have the conversation when most of the family members are together, and the Thanksgiving holiday is a perfect fit. There’s a five-question tool available on the site that can be used as a conversation starter, as well as other resources.

While talking about these topics could potentially clear a room, it’s a lot worse to be sitting at a family member’s bedside in the ICU and not knowing what to choose for them because they didn’t let you know in advance.

For additional information on end-of-life discussions and options, see the AJN articles “Life-Support Interventions at the End of Life: Unintended Consequences,” by Shirley A. Scott, MS, RN, CT, and “Stopping Eating and Drinking,” by Judith K. Schwarz, PhD.

And if you raised this topic at your Thanksgiving meal this year, or at another opportune moment, write in and let us know how it went.

Happy Thanksgiving!

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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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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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