Ethical Considerations in Critical Care Nursing, Exams of Nursing

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CHapter 1-4 223

American Association of Critical-Care Nurses - Founded in 1969 Largest specialty organization in the world with over 100,000 members American Association of Critical-Care Nurses Mission - Assist acute and critical care nurses to attain knowledge and influence to deliver excellent care Values American Association of Critical-Care Nurses - An ethic of care that focuses on compassion, collaboration, accountability, and trust Create a health care system driven by patient's and family's needs in which critical care nurses make their optimum contributions SCCM - more geared towards doctors ensure high-quality care for all critically ill patients Vision: SCCM - The vision of the SCCM is to have care to all critically ill patients provided by an integrated team of professionals directed by an intensivist (physician who has education, training, and board certification in managing critically ill and injured patients). Membership in the SCCM is open to all providers in critical care, including physicians, nurses, respiratory therapists, and pharmacists. Critical Care Certification - Validate knowledge

Promote professional excellence Help nurses to maintain up-to-date knowledge AACN Certification Corporation oversees - CCRN, CCRN-E, and PCCN certification synergy model for patient care - Needs of patients and families drive to practice more critical the patent is the more qualified nurse the pt will get AACN Critical Care Certification Bedside practice - CCRN: Adult, Neonatal, and Pediatric PCCN for those working in step-down units CNML Critical Care Managers and Leaders AACN Critical Care Certification Advanced practice - ACCNS Acute and Critical Care Clinical Nurse Specialist ACNPC-AG Acute Care Nurse Practitioner AACN Critical Care Certification Subspecialty certification - CMC Cardiac medicine CSC Cardiac surgery Synergy model of practice - Give the new grad the most stable patient and the 20 year vet the most ill Although the synergy model is more than 20 years old, it remains relevant. Each patient and family is unique, with a

varying capacity for health and vulnerability to illness. Patients who are more severely compromised have more complex needs, and nursing practice is based on meeting those needs. Communication for patient and family - Communication for patient and family Framework to guide critical care nursing (7) - BOX 1.1 Competencies of Nurses Caring for the Critically Ill pg 3 Clinical judgment and clinical reasoning skills Advocacy and moral agency in identifying and resolving ethical issues Caring practices that are tailored to the uniqueness of the patient and family Collaboration with patients, family members, and healthcare team members Systems thinking that promotes holistic nursing care Response to diversity Facilitator of learning for patients and family members, team members, and the community Clinical inquiry and innovation to promote the best patient outcome Nurse assignment - most acute patient= most experienced nurse Continuity of care you get the same pt for all your shifts.

Reasons for good communication - Keeps the family in a good mood. Always honest never false reassurance. Lack of ------- is a principal complaint when families are dissatisfied with care. Facilitate communication by providing a simple, honest report of the patient's condition, free of -------. - communication / medical jargon Scheduled family ---------- provide a similar opportunity to facilitate--------. Family ----------- may be held at the bedside or in a conference room, depending on the space available and family needs. If possible, hold a preconference among team members to ensure that consistent messages are delivered during the family ------. - conferences / communication /conferences/ conference. ------------- communication is a strategy to improve the patient experience, a focus in today's healthcare delivery - Patient-centered a strategy for encouraging nurses to assess concerns before providing more information, especially when discussing stressful issues with patients and families. - Ask-Tell-Ask, a tool that encourages information sharing in challenging situations. - Tell Me More ------------ is also essential for delivering safe patient care. Many adverse events are directly attributable to faulty communication - Effective communication ---------------often occur during handoff situations, when patient information is being transferred or exchanged - Communication breakdowns Barriers to Effective Handoff Communication (4) -

Physical setting: background noise, lack of privacy, interruptions Social setting: organizational hierarchy and status issues Language: differences between people of varying racial and ethnic back- grounds or geographic areas Communication medium: limitations of communications via telephone, email, paper, or computerized records versus face to face SBAR - Situation Background Assessment Recommendation AACN standards of professional practice (9) - Systematically evaluates the quality and effectiveness of nursing practice Evaluates own practice in relation to professional practice standards, guidelines, statutes, rules, and regulations Acquires and maintains current knowledge and competency in patient care Contributes to the professional development of peers and other healthcare providers Acts ethically in all areas of practice Uses skilled communication to collaborate with the healthcare team to provide care in a safe, healing, humane, and caring environment

Uses clinical inquiry and integrates research findings into practice Considers factors related to safety, effectiveness, cost, and effect in the planning and delivering care Provides leadership in the practice setting for the profession Meta-analysis is the most accurate for research T/F - T looks across the board of research to tell us what is the most ACCURATE medication reconciliation - A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery. throw it in a bag and document if taking= keep, if not=throw it away includes: drug name dose frequency route purpose Diversity - You need to be culturally competent ask what they prefer National Patient Safety Goals (15) -

• Use at least two methods of patient identification

• Ensure correct patient identification for blood transfusions Improve Communication Among Healthcare Providers
• Report important results of tests and diagnostic procedures on a timely basis Use Medications Safely
• Label all medications and containers, including syringes and medicine cups
• Reduce harm associated with administration of anticoagulants
• Reconcile medications across the continuum of care Use Alarms Safely
• Ensure that alarms are audible and respond to them in a timely manner Prevent Infection
• Comply with guidelines for hand hygiene
• Implement evidence-based guidelines to prevent infection with multidrug-resistant organisms
• Central line-associated bloodstream infections
• Surgical site infections
• Catheter-associated urinary tract infections Identify Safety Risks
• Assess patients for suicidal risk Prevent Complications Associated With Surgery and Procedures

• Conduct a preprocedure verification process to ensure that surgery is done on the correct patient and site
• Mark the correct procedure site
• Perform a"time-out" before the procedure to ensure that the correct patient, site, and procedure are identified The Joint Commission National Patient Safety Goals - Communication Medication safety Reduce infections Reconcile medications when patient comes in you go over all meds and put them in the computer Harms Targeted for Reduction -
  1. Adverse drug events

2. Infections -Catheter-associated urinary tract infections (CAUTI) -Central line-associated bloodstream infections (CLABSI) -Ventilator-associated pneumonia (VAP) -Surgical site infections
3. Injuries from falls and immobility
4. Obstetric adverse events
5. Pressure ulcers
6. Venous thromboembolism (VTE) prophylaxis; prevention of PE Aging workforce - getting too old for this To accommodate this growing workforce, hospitals are focusing their attention on redesigning the environment with a focus on ergonomics, ease of use, and safety.

Unit design and patient care - noise reduction acoustical tiles conference rooms Adequate lighting Natural lighting night-day synchronization Sensory Overload - Light always on. at night get all you PM care done by 10 pm to let patient sleep Noise Loss of privacy Multiple caregivers Multiple people in and out of unit and room Lack of nonclinical physical contact can be detrimental to a patent. need to use touch when caring for a patient. never hug your patient. Emotional and physical pain lot of stress and emotional pain. imagine if they are the breadwinner or caregive and they are stuck in the ICU Sensory Deprivation - Increased perceptual disturbances Visitors should be allowed

Photos patients family photos so you can see what the patient looked like before they came to you Soothing music is good play near the patient no earbuds Lighting should be off when they are sleeping pull the curtain or close the door Communication and unresponsive patients - You communicate to the best of your ability and then you guess. give them choices so you are able to stay in control Lack of communication is the principle complaint when families are dissatisfied with care (pg. 22) Family centered care (everything family pg. 20-24) - important because family affects the pt in critical care nurse needs to focus on treating the family as well with communication and education since they are experiencing crazy stress with their fam in the ICU Family conflicts - an illness in the fam can bring up underlying conflicts with the members Family support (5) - families have reported that they need info on the pt, assurance, stay near the pt, be comfortable, and having support fams are tired, stressed, and wanting constant updates on their pt to relieve the stress, educate the fam on the interventions with stress reduction and coping if the fam is demanding, disruptive, or expects you to watch their loved one at all times they just feel a loss of control or PTSD from prior critical care experience we can encourage our fam to report if the pt experiences any changes build a relationship of trust and respect with the fam

we can ask fam to help with oral care, ROM, repositioning, hygiene to help them feel that they have a purpose Family assessment - always assess culture/spirituality of fam and pt assess primary language (may need an interpreter, absolutely no children of the pt should be interpreting) ask these questions what are your specific religious and spiritual practices? what are your beliefs about illness and death? what is most important to you and your family at this time? assess the fam and learn the roles each person plays, interact with them, lean their coping strategies, and socioeconomic probs once fam assessment is done, chart and share with healthcare team Visitation - Allow visitors at your discretion. studies show that visiting has no effect on pt and if there is its positive can decrease ICP and BP and increase HR kids are still up in the air when it comes to visiting Functional status and quality of life - transfer off of the ICU can be super stressful for fam and pt fam may experience relocation stress may feel abandoned or lose security because the other unit will not be higher level of care like ICU

education for fam and pt is NEEDED so when they go home they know what to do educate, set up appointments, and use teach back PICS - PICS (post intensive care syndrome): critical illness survivor that experiences disability and weakness, psychiatric pathologies, and cognitive disturbances may need therapy post discharge with PICS Communication with non-English speakers - Always use a translator never use a child ensure understanding Sharing information - Provide information to family members in a variety of formats. ask pt if they member is ok to receive info make sure the healthcare team if sharing the same info to the pt and fam Family coping methods - Disbelief, denial Anger Adaptation - Ability to respond to a stressor with good coping skills Stress and coping strategies- deep breathing exercises to help them relax. if we see negative coping strategies, we need to address that. what is causing that reaction? VALUE Mnemonic - -Value what the family tells you -Acknowledge family emotions

-Listen to family members -Understand the patient as a person -Elicit questions from family members Promoting change in practice - eICU has reduced hospital stays and mortality rate pg 2 encourage EBP be willing to learn about new and updated practices Family presence - can be present during CPR or invasive procedures because research shows there's positive effects and increased knowledge of pt family can be asked to leave if there is no space in room, violate pt confidentiality, not enough staff to help fam, increased stress on health team, and increased stress for fam being present helps fam to remove doubt about the pts condition, witness that everything possible was done, decrease their fear about what is happening to their loved one Advance directives - Documentation associated with PSDA o Advance directive o Durable power of attorney (DPOA)- only covers their healthcare o Durable power of attorney for healthcare (DPOAHC) o Living will- possible DNR (need to read because can be full code) o Do not resuscitate (DNR) autonomy - Right of self-determination concerning medical care Beneficence: - Duty to prevent harm, remove harm, and promote the good of another person

Nonmaleficence: - Not to intentionally inflict harm Justice: - Fair distribution of health care resources Veracity - Truthfulness Fidelity: - Faithfulness to commitment Confidentiality: - Respect for right to control information Resuscitation (pg. 33) Goals - Preserve life restore health relieve suffering limit disability respect the individual's decision, rights, and privacy Medical futility - Situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient's health condition, or a lack of attainable goals of care. Legal and organizational definitions may vary, and much controversy exists. Nothing else we can to and can't do more for the pt (happens w/ cancer pt)

Persistent vegetative state - A permanent irreversible unconsciousness condition that demonstrates an absence of voluntary action or cognitive behavior or inability to communicate or interact purposefully with the environment Moral distress - occurs when the nurse knows the ethically appropriate action to take but is unable to act on it or when a nurse acts in a manner contrary to personal and professional values key issue affect the workplace Cause nurses to be sick more often, suffer burnout, and disengage from their work environment Post brain death - Initiate call with organ procurement organization (OPO) when you know they are dying They'll determine if pt is eligible to donate organs and will come ASAP to collect them and harvest their organs if they are and are pronounced dead Time of death - don't let them marinate get two nurses or a doctor ASAP 2 nurses cn call it or 1 nurse nd nurse manager or one doc can come DNR - Do not resuscitate (DNR) orders o Prevent initiation of life-sustaining measures let them die DNR Influenced by - Goals of care § Comorbidities

· Doctors will look at these when DNR is given. § Pace of clinical decline § Availability of surrogate T/F DNR is the same as withdrawal of life-sustaining treatment - F Before we withdrawal care we need the DNR Living will - a witnesses written document or oral statement voluntarily executed by a person the expresses the person's instructions concerning life-prolonging procedures Ethics consultation - Purpose is to improve the process and outcomes of patient care by helping identify, analyze, and resolve ethical problems Ethics consultation should be used when - should be used when issues cannot be resolved among the healthcare team, patient, and family disagreement on aggressive treatment like CPR family wanting a vent for pt but doctor and nurse consider it futile family wants to make decisions on behalf of ill pt ill pt is incapacitated and does not have surrogate decision maker or advance directive Ethical Dilemma warning signs - Emotionally charged

• Significant change in patient's condition
• Confusion about facts
• Hesitancy about the correct set of actions
• Deviation from customary practice

o Off label uses of drugs (Viagra)

• Need for secrecy regarding proposed actions o Don't keep secrets for drs! Criteria for brain death - when there's no blood flow in your brain (what she said in class) -Cessation of brain function -Including function of the cortex and the brainstem -Flat or inactive EEG -Absence of brainstem responses -Absence of spontaneous respirations when ventilator assistance is withdrawn -Evaluated two times by different physicians Withdrawal of care - Discontinuation of life-sustaining therapies in a terminally ill or persistently vegetative patient Withholding of treatment - a decision not to initiate treatment or medical intervention for the patient Withholding food, ABX, not intubating them when they should be intubated. CAN'T WITHHOLD PAIN MEDS. withheld therapies include - blood, vasopressors, abx, blood products, dialysis, and nutritional support; deactivating heart device terminal weaning - when the ventilator is taken out and the nurse determines what exactly is needed med wise to promote comfort Palliative care -

Alleviation of distressing symptoms (palliation) o Antiemitics, pain meds, palliative surgery Caregiver organizational support - Respite care can help caregiver burnout. End of life and culture - ask about their cultural wishes know their religious beleifs and wishes (if they want a chaplin or pastor, if they want prayers said) accommodate for their wishes (fake candles instead of real ones) whites less aggressive while black and hispanic more aggressive End of life decision making - dr and family meeting to discuss options go based on the pt's will and advanced directive, not on their family make sure the family doesnt feel guilty for carrying out the patient's wishes. make sure patients don't die alone. Pharmacological management - o IV benzodiazepines for anxiety o IV morphine for dyspnea and pain o Guidelines for pharmacological interventions for end-of-life § Titrate for comfort Dyspnea Management - Treat primary cause, relieve psychological distress that accompanies symptoms o Opioids § anyone o Anticholinergics § Pt with lots of secretions

o Bronchodilators § COPD pts o Sedatives § Titrate for effect to what will produce comfort o Corticosteroids § COPD o Oxygen therapy § anyone o Diuretics § CHF to pull fluid o Antibiotics § Pneumonia or others Nausea & Vomiting Management - Antiemetic agents o Prochlorperazine (Compazine) (OLD) o Ondansetron (Zofran) (most common) o Dexamethasone (Decadron) § Anti-inflammatory but affects vomiting mechanism o Metoclopramide (Reglan,) Restlessness & Agitation Management - Assess for pain, urinary retention, constipation, other reversible cause

• Treat underlying cause
• Pharmacologic agents

o Haloperidol (Haldol)= for anxiety or agitation Palliation(pg. 41) Elements of Palliative Care - o Early identification of end-of-life patients o Pain management as "fifth vital sign" o Pharmacological and nonpharmacological interventions to: § Relieve pain § Control anxiety § Control other distressing symptoms

• Hospice - Interdisciplinary approach to facilitate quality of life and peaceful death o Neither hastens nor postpones death o Six months or less to live · Try not to give food or water when dying because their bowels are not functioning as well Palliative - Philosophy of care for individuals with life-threatening illness o Prognosis may be greater than 6 months