End-of-Life in Acute Care

In today’s society, we have seen many great advances in medicine, science, and technology that have resulted in an aging population with chronic illnesses. Often times, these issues require frequent or prolonged acute care admissions. With this in mind, choices need to be made that involve discussing end-of-life care goals with patients and their families. As nurses, we must work hard to provide high value end-of-life care for these patients in the acute care setting when death is near.
Although many patients would prefer to die at home, the truth is a majority will die in acute care settings and other healthcare institutions. Over the years, end-of-life care in acute care settings has taken great stride in the implementation of specialty practices such as palliative care.1 However, in a healthcare organization that does not benefit from such a specialty, how is end-of-life care provided?
The first step in being able to plan and provide good end-of-life care is for the patient, family, and nursing staff to accept that death is the outcome.1 Next, all active life sustaining medications should be discontinued. These medications would include but not limited to: intravenous fluids, antibiotics, insulin, steroids, and blood pressure medications, but intravenous access should be maintained in order to administer end-of-life medications. Typically, in the acute care setting before transition to hospice is made, or if the patient is awaiting a hospice bed, the standard appropriate medical procedure for transitioning a patient to end-of-life care is started. A morphine bolus and/or relaxant such as Ativan is administered. These medications are given in end-of-life cases in order to decrease anxiety that the patient may experience as well as ease any feeling of breathlessness. It is very important to remember that the administration of these medications is not to promote death, but to aid the patient with the symptoms that often accompany dying.
Next, a continuous morphine drip which should be titrated for patient comfort is initiated. Often times, medications to aid with the patient’s secretions (such as levsin) is administered. Basic nursing care such as mouth care, turning, and repositioning of the patient should also be continued.
With life, comes death. As good as a healthcare professional may be, we, as a profession have yet to keep anyone from dying. We have kept people alive longer, but everyone dies at some point. Much of this understanding should not be when, but how. As a profession, when a patient’s care transitions to end-of-life care, we are not failing them. We often times begin to fail the dying patient when the health care team does not provide what the patient needs. If the outcome of the disease process or admission is death, then as a health care system, we are failing that patient by not providing a death for them that is good. Curing everyone is simply impossible, but what we can do as a profession and as patient advocates, is to provide a death that is comfortable for the patient’s final life journey.
Bloomer, M., Moss, C., & Cross, W. (2011). End of life care in acute hospitals: an integrative literature review. Journal of Nursing and Healthcare of Chronic Illnesses, 3(3), 165-173.  

William Pezzotti, MSN, RN, CRNP, AGACNP-BC, CEN 
Acute Care NP at Penn Medicine Chester County Hospital
Adjunct faculty at Drexel University, College of Nursing and Health Sciences​

Posted: 5/11/2015 5:23:06 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Patient Safety

Moral Distress

When I think about moral distress, I’d describe it as a gnawing, distraught feeling born of perceived injustice.  The underlying catalysts are highly variable and include lack of essential resources necessary to provide the standard of care to patients, interpersonal or inter-professional conflict, especially involving ethically challenging situations with patients, families, providers, or co-workers, as well as errors and disturbing treatment decisions. It encompasses a constellation of emotions that nurses have likely felt since the dawn of our profession. If left to fester without effective intervention, moral distress can lead to disillusionment, disenchantment, and even disengagement with the nursing profession. 
Over 30 plus years of practice, I’ve not only observed moral distress in colleagues, but have experienced it personally on several occasions. Until relatively recently, I didn’t have a name for it. My earliest memories of what I’d now term moral distress typically stemmed from being a party to treatment decisions that I simply couldn’t fathom -- they involved care that was either too aggressive (and seemingly abusive) for patients who simply had no hope for any type of recovery, or care that was not aggressive enough in patients who did. These were the days before evidence-based care pathways or palliative care services existed. I felt outraged that the hospital I worked for at that time didn’t seem to address these issues with the medical staff. A nurse, seasonedand hardened by her own years of enduring ethically challenging assignments, brushed off my distress as reality shock. “Just do what’s ordered; that’s our job,” she advised. But my own professional framework wouldn’t allow me to be satisfied with that advice since I felt the patients deserved so much more.  As this situation recurred repeatedly, I felt something had to change, but I didn’t know how to affect change at that point in time. Simply being mad wasn’t constructive.
Sadly, the way many nurses, especially ones in their formative years, handle this type of challenge is by jumping ship in their search for calmer seas or greener pastures. The true reality shock, in my opinion, is that no sea is always calm or pasture always greener. The secret is learning how to cope with resilience and fortitude, and at the same time, derive strategies to tackle the root causes of the situations that lead to moral distress in an effective manner. 
Mentoring and supportive relationships are essential among colleagues, nursing educators, and leaders to help individuals in the throes of moral distress to sort out their feelings, identify the causative factors, plan the resolution, and regain their own healthy emotional balance. Sometimes employee assistance programs are the best options to help nurses deal with the emotional toll in highly sensitive and confidential matters when discussions with colleagues or leaders wouldn’t be conducive to the open dialogue needed to sort out feelings and develop potential solutions.
For nurse leaders, listening and observation skills are key to identify problem situations and the impact they have on the staff. Ongoing vigilance and diligence are necessary to deal with the issues in our healthcare facilities that cause moral distress in nurses. Frankly, these issues should be very visible in the priority scheme of all healthcare leaders.  The solutions aren’t always straightforward, quick or easy, but they are essential to preserving quality and safety in patient care, as well as nursing itself as a long-term career choice.

Linda Laskowski-Jones, RN, MS, ACNS-BC, CEN, FAWM
Editor-In-Chief, Nursing2015

Posted: 5/10/2015 6:25:55 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

An Ethical Perspective on Elder Abuse

Nurses have a duty to report and to protect vulnerable populations including older adults. Yet it can be difficult for nurses to intervene successfully or to feel that they have made a difference in clients’ lives when older adults choose to stay in abusive situations. Abuse in the family and intimate partner abuse are often complicated because older adults are struggling with conflicting social, cultural, religious, or other pressures to continue living with their abusers (Finfgeld-Connett, D. 2014). In order to prevent harm to your clients at risk for abuse, nurses must carefully assess the ethical implications from the perspective of older adults, and then develop the best plan to intervene.

Social and Cultural

When deeply rooted cultural stigma about broken families exists, women may endure decades of abuse to portray an image of family unity rather than taking assistance to ensure their own personal safety (Finfgeld-Connett, D. 2014). As most abuse occurs in families, some older adults feel shame, guilt, or fear over reporting their relatives to the authorities (Olson & Hoglund, 2014).


Think about the dilemma of having a client with a lifelong religious devotion and a deep commitment to his/her marital vows when the relationship is abusive. There are reports of elders whose spiritual advisors have encouraged them to remain in abusive relationships rather than to leave (Finfgeld-Connett, D. 2014).


Low income contributes to the risk of abuse (Dong & Simon, 2014) and complexity of assisting elders who are abused. Some elders who have been abused feel trapped and unable to leave the relationship because of guilt over dependency of their spouse for shared income or fear for their own ability to provide for themselves (Finfgeld-Connett, D. 2014).

Nurses Role in Suspected Abuse

  • “provide an accurate assessment of abuse and risk factors for abuse;
  • clearly and objectively document assessment findings;
  • report suspected incidents of abuse and participate in investigation as appropriate;
  • provide support and referrals for clients experiencing potential or actual abuse; and
  • implement strategies to prevent elder abuse.” (Olson & Hoglund, 2014)
Just remember that safety comes first. If there is a situation when a client is in eminent danger or has been injured, there should be immediate action to obtain treatment and to remove weak or disabled individual to a safe location.  In non-urgent situations, nurses should take steps to help their clients to seek support from the community including counseling services, religious organizations, senior centers, or support groups to reduce their risk for being abused.
For more information, on risk factors and protective factors related to elder abuse, go to http://www.cdc.gov/violenceprevention/elderabuse/riskprotectivefactors.html.

Free Article:

Elder Abuse: Speaking Out for Justice 


Dong, X. & Simon, M.A. (2014). Vulnerability Risk Index Profile for Elder Abuse in a Community-Dwelling     Population. Journal of the American Geriatric Society, 62:10–15, doi: 10.1111/jgs.12621
Finfgeld-Connett, D. (2014). Intimate partner abuse among older women: Qualitative systematic review. Clinical Nursing Research, 23(6) 664–683.
Olson, J.M. & Hoglund, B.A. (2014). Elder Abuse: Speaking out for justice. Journal of Christian Nursing, 31(1):14-21 DOI:1097/CNJ.0000000000000028

Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director, Lippincott Continuing Education
Wolters Kluwer, Health Learning Research & Practice

Posted: 5/9/2015 6:31:36 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Informed Consent: An Ethical Way of Nursing

As nurses, we deal with informed consent a lot—on admission to a hospital/clinic or before a procedure/surgery. Nurses typically are assigned the task of obtaining and witnessing written consent for healthcare treatment. I’ll never forget admitting to our busy psychiatric unit a young mother who’d been found unresponsive after a drug overdose. She’d been taken to the emergency room to stabilize, and her young child taken into protective custody. Now on the locked psych unit, she was terrified to sign the consent form for admission and treatment, afraid for herself and her child whose whereabouts she did not know. I repeatedly explained what I knew about her child, treatment plan, and consent process, including that she did not have to sign the admission consent. However, if she did not sign, her admitting psychiatrist would request, and be granted, a “court hold” to admit her involuntarily. If she signed as a “voluntary” admission, it would suggest she was cooperating with treatment.
I knew it was in her best interest to sign, but understood it was her decision. The goal of informed consent is to assure patient autonomy. My patient didn’t have a choice of treatment alternatives, but she did have a choice to be admitted voluntarily or involuntarily. I felt ethically compelled to preserve that choice.
After almost an hour of listening, supporting, and explaining, I needed to give medications to other patients. My plan was to offer this woman a hot shower to help calm her and give time to process what was happening. Then, if she still could not sign the consent, I would explain I had to inform her psychiatrist, and we would proceed with a court hold.
When I stepped out of the room, I told my supervisor my plan. She hastily went to the patient, stuck the form and a pen in front of her, saying, you need to sign this NOW! My patient complied, tears streaming down her face.
I’ve since thought a lot about informed consent. I’ve worked in med-surg, cardiac rehab, intensive care, medical research, and psychiatry. In all settings, nurses are on the front lines of assuring patients truly are giving informed consent.

What is involved in informed consent?

Legally, this requires that the patient, or his/her surrogate, is informed of the risks, benefits, and alternatives to a treatment. A signature on the consent form provides legal documentation of consent.
Ethically, consent is about patient autonomy, meaning the patient understands and freely agrees to the treatment.
Consent may be withdrawn at any time. Healthcare providers must accept and support refusal or withdrawal of consent even if they disagree with the patient. 
The consent process can be affected by complexity of the treatment, patient condition and ability to understand information, and if treatment is emergent or elective.

What can nurses do to improve informed consent?

Think about consent as a process to assure patient understanding and agreement, not just signing a form.
Informed consent should be a collaborative activity between the physician, nurse, and patient. The physician should have obtained consent before the nurse has the patient sign a form.  
Nurses can offer what we do best—patient teaching, as we check patient understanding and obtain written consent. Where possible, use the teach-back method, asking the patient to repeat back what he/she understands. However, our teaching cannot take the place of prior physician / patient shared decision-making.
Assess for paternalism – from the physician, from yourself. We understand so much more than the patient and are trying to help, but we cannot pressure or tell a patient what to do.
Consenting to treatment is scary. As much as possible, obtain consent in a quiet and calm setting, with time to answer questions.

What about informed consent for nursing interventions?

Although we normally don’t obtain written consent for nursing interventions, such as holistic care using mind-body practices or spiritual therapeutics, we still must assure patients’ informed consent.
A critical topic we discuss frequently in Journal of Christian Nursing is spiritual care. How do we assess for spiritual needs and appropriately respond? What ethical guidelines must be followed when offering spiritual care? A comprehensive article discussing informed, ethical, and non-coercive spiritual care that could be applied to other holistic nursing interventions is, “Spiritual Care: Evangelism at the Bedside?,”by nurse researcher and spiritual care expert, Elizabeth Johnston Taylor. Take a look at this free article and discover principles for ethical nursing interventions.
This Nurses Week, remember that informed consent is a way of nursing each of us needs to live out as we offer our patients ethical practice and quality nursing care!
Barry, M. J. (2012). Shared decision making: Informing and involving patients to do the right thing in health care. Journal of Ambulatory Care Management, 35(2), 90 – 98.
Cook, W. E. (2014). “Sign here:" Nursing value and the process of informed consent  
Plastic Surgical Nursing, 34(1), 29-33.
Menendez, J. B. (2013). Informed consent: Essential legal and ethical principles for nurses. JONA's Healthcare Law, Ethics, and Regulation, 15(4), 140-144.

Kathy Schoonover-Shoffner, PhD, RN
Editor, Journal of Christian Nursing

Posted: 5/8/2015 4:56:36 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Patient Safety

Ouch! Safely keeping patients pain-free

A few weeks ago my husband was in the emergency room with a broken rib, which resulted from a fall. His nurse was very attentive to his need for pain management. He had never had morphine before and after his second dose, he asked the nurse “How much of this will you give me?” Her reply was, “As much as it takes to safely control your pain.” What a great answer!

It isn’t always this easy when it comes to pain management. I’ve shared a story previously about a patient in our ICU, whose family member, who happened to be a nurse himself, wouldn’t allow us to treat his sister’s pain. It was a challenging case, and ultimately, our hospital’s ethics committee was consulted.

The position of the American Society for Pain Management Nursing (ASPMN) and the International Nurses Society on Addictions (IntNSA) is “that every patient with pain, including those with substance use disorders, has the right to be treated with dignity, respect, and high-quality pain assessment and management.” As nurses, we have a responsibility to make ethically sound decisions when it comes to pain management. But, how do we do this?

Be familiar with related ethical standards

  • Beneficence is the duty to do what's good for the patient while considering his or her wishes. Nonmaleficence is the duty not to harm patients. The challenge here is to achieve pain control while ensuring patient safety.
  • Justice refers to fair treatment for all. This can be tricky because pain can't be measured objectively and we must rely on a patient’s self-report.
  • Autonomy requires us to respect, support, and advocate for patients, even when it goes against our own beliefs.

Be aware of barriers to effective pain management

  • Sometimes patients aren’t able to communicate about their pain. Whether the patient is non-communicative, there is a language barrier, or the patient finds it difficult to describe the pain they are experiencing, use your knowledge and skills to perform a thorough history and physical assessment.
  • Time constraints can get in the way of assessing and managing a patient’s pain. Do your best to actively listen to the patient, plan, and collaborate with other team members.
  • Sometimes cost is an issue and certain modalities aren’t covered by a patient’s insurance. If this is not in your realm of knowledge, consult with a colleague who is familiar with the financial aspects of pain management.

Set goals and make a pain management plan

  1. Assess your own beliefs and think about your past experiences.
  2. Remember that every patient is unique.
  3. Tailor your patient and family education appropriately.
  4. Encourage patients to become active partners in controlling their pain. Remind them that pain control aids recovery.
  5. Actively listen to the patient’s self-report of pain.
  6. Be alert to fears related to reporting pain. For example, patients might not report pain for fear of having to undergo more procedures.
  7. Consider asking about burning, aching, tightness, discomfort, or throbbing. Research shows that to minimize their pain, elders may not use the word ‘pain.’
  8. Take cultural differences into account.
  9. Use pain scales that are appropriate for the patient.
  10. Ask the patient what level of pain would be satisfactory.
  11. Explain the difference between pain elimination and pain control; completely eliminating pain while maintaining safety is not always realistic.
  12. Work with the patient to set ‘functional goals’ – for example, being able to walk down the hall and back.
  13. Consider non-pharmacologic methods, such as lighting, positioning, distraction techniques (music, guided imagery), relaxation techniques (breathing, progressive muscle relaxation), and advanced complementary modalities (massage, biofeedback).
  14. Monitor the patient for medication adverse reactions, contraindications, and interactions.
As nurses, we are well-positioned and obligated to advocate for safe pain management. Remember to listen, collaborate, plan, and evaluate!


Diallo, B., & Kautx, D. (2014). Better Pain Management for Elders in the Intensive Care Unit. Dimensions of Critical Care Nursing, 316-319.
Oliver, J., Coggins, C., Compton, P., Hagan, S., Matteliano, D., Stanton, M., . . . Turner, H. (2012). American Society for Pain Management Nursing Position Statement: Pain Management in Patients With Substance Use Disorders. Journal of Addictions Nursing, 210-222.
Quinlan-Colwell, A. (2013). Making an Ethical Plan for Treating Patients in Pain. Nursing2013, 64-68.

Lisa Bonsall, MSN, RN, CRNP
Clinical Editor

Posted: 5/7/2015 4:40:44 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

A Tale of Two Patients

In 1859, Charles Dickens wrote the book, "The Tale of Two Cities," which was a comparison of life in London and Paris and compared life of the aristocracy versus life of the peasantry in those two cities. Throughout my 30 plus years of being a nurse and nurse practitioner, I have watched and participated in the ethical dilemmas nurses and other healthcare providers encounter on a day to day basis. I have spent the majority of my professional nursing career in acute and critical care. As a nurse practitioner, my role is different than when I was a nurse; however, the issues I face are the same as all nurses in regards to ensuring patients receive optimum care that improves quality of life, not necessarily extending it.  This brings me to, "The Tale of Two Patients."

A few weeks ago I took care of two patients; two patients with similar stories, both had end-stage COPD and both were admitted to the ICU for a COPD exacerbation. Both patients received similar treatment, and both patients continued to deteriorate simply because their disease had progressed beyond recovery.  As a nurse, I was always taught to focus on quality not quantity of life, and quality of life is defined by the patient, not the healthcare professionals or the family.

The first patient had an advanced directive and had obviously communicated well with her family. They were all in agreement the patient should not be intubated, and instead, be placed on hospice and made comfortable. There was great peace among the patient, her family members and the entire nursing and healthcare staff. They rejoiced in the fact the patient had lived a full life and could now go on to a better place to be with her husband who had passed two years prior. Everyone agreed -- following the patient's advanced directive and making her a do not resuscitate was the right thing to do.

The second patient did not have an advanced directive, and had never spoken to her family about her wishes. Despite numerous attempts to discuss the patient's prognosis with the patient and her family, the family insisted everything be done and the patient capitulated to their demands. The patient was intubated and placed on a ventilator. Everyone knew the patient would never come off the vent and would eventually die in the ICU. After several days, the patient went into multiorgan failure and the family finally agreed that the patient should be allowed to die in peace. The patient was placed on a morphine infusion for comfort and died with the family still fighting over her. There was great sorrow in the eyes and hearts of everyone taking care of her. Nurses are about quality care, and even though the patient eventually died comfortably, everyone knew the situation could have been avoided if the patient had discussed her wishes with her family and her primary care provider and had an advanced directive.

As nurses, we see the ethical importance of doing what our patient's want; we are their advocates and their voice even in their most desperate hour. Healthcare professionals have an obligation to speak with their patients before the patient is in a life-threatening situation. The first time a discussion occurs should not be when the patient is critically ill and facing no chance of recovery. Quality of life must be defined by the patient and no one else. In this day and age, the tale of two patients should not be a story we tell in healthcare.

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC
Chief Nurse
Wolters Kluwer
Health, Learning & Practice
Nurse Practitioner, Critical Care Services
Penn Medicine Chester County Hospital
Adjunct Faculty
Drexel University
College of Nursing & Health Sciences

Posted: 5/6/2015 4:43:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Ethics in Nursing – Upcoming blog series

We face ethical issues and make related decisions – or help others to do so – every day. As we focus on nursing ethics for National Nurses Week, we will be bringing you daily blog posts related to nursing ethics. We have some guest blog authors lined up to cover ethical topics important to nurses, including informed consent, advance directives, moral distress, horizontal violence, pain management, elder abuse, and end-of-life issues. We hope that you’ll join this important conversation with us. Have a great week everyone!

Posted: 5/4/2015 6:55:46 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

YOUR Words about Nursing

Last week, we asked nurses on Facebook, twitter, LinkedIn, and Google+ to share words that describe nurses and what we do. Here's the result! Any more to add? 

Posted: 4/29/2015 8:37:06 PM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Inspiration

How to Celebrate National Nurses Week 2015

National Nurses Week runs from May 6 through May 12, ending on Florence Nightingale’s birthday. Every year, NursingCenter hosts a variety of celebrations, ranging from discounts on continuing education activities, journal articles, and nursing eBooks, to special giveaways, blog posts, and more. 

This year,  the American Nurses Association has given National Nurses Week the theme, “Ethical Practice, Quality Care,” and we are gearing up to bring you the same great week of celebrations as a special thank you to all of our members. 

Be sure to check our National Nurses Week page each day that week for discounts, activities, and blog posts. 

We will be developing an exciting CE Collection around topics dealing with “Ethical Practice, Quality Care.” 

Don’t forget to register for any of our free nursing newsletters, as we will be gifting a variety of offers to our newsletter members.

As a bonus, there are two Lippincott conferences running during National Nurses Week this year, the National Conference for Nurse Practitioners and the Lippincott Clinical Nursing Conference.  Both nursing conferences are being held in Philadelphia. 

Stay tuned for more information on how to celebrate National Nurses Week with NursingCenter. 

Posted: 4/7/2015 2:30:48 PM by Cara Gavin | with 0 comments

Categories: Inspiration

Gender pay gap in nursing – are male nurses worth more?

The salary gap, in general, is upsetting. For some reason, I just didn’t expect it to exist in nursing. In a profession that is predominantly female (according to a 2011 census report, only 9.6% of nurses are male), it really never occurred to me that such a discrepancy in pay was realistic. The results of recent research published in the Journal of the American Medical Association demonstrate that pay inequality not only exists in nursing, but is quite significant.

Here are some highlights from the research letter, which looked at two large data sets (the National Sample Survey of Registered Nurses [1988 to 2008] and the American Community Survey [2001 to 2013]) to assess salary trends by gender:

  • Male RN salaries were higher than female RN salaries every year, with an overall annual difference of $5,148. 
  • In ambulatory care, the salary gap was $7,678; in hospitals, it was $3,873. 
  • With the exception of orthopedics, male nurses out-earned female nurses in every specialty with the gap ranging from $3,792 in chronic care to $17,290 for nurse anesthetists. 

Like many others, I find these results discouraging. However, I am hopeful that nurses will be encouraged to speak up about our worth and engage in salary negotiations. I also am hopeful that employers will recognize these inequities and examine their pay structures. 

What’s missing in this research is the reason for this gap in pay. Care to share your thoughts on this? 

Posted: 3/25/2015 10:09:12 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Education & Career

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