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University of Iowa Nursing Faculty to Develop Web-based Course on End-of-Life Issues

University of Iowa College of Nursing faculty have received a grant to develop a Web-based course on end-of-life care. The goal of the new course initially will be to educate nursing and other health professional students at UI about issues surrounding care for older adults approaching death and for their families; it likely will be offered to practicing nurses and others in the future.


The 3-year $90,000 award comes from the John A. Hartford Foundation of New York and the American Association of Colleges of Nursing. Paula Mobily, PhD, associate professor of nursing at UI, is principal investigator for the project. Mobily also serves as education coordinator for the Hartford Center for Geriatric Nursing Excellence, which is based at the UI College of Nursing.


In addition to Mobily, UI nursing faculty involved in development of the course are Keela Herr, PhD, professor; Jo Eland, PhD, associate professor; Paula Forest, clinical assistant professor; Kristine Kwekkeboom, PhD, assistant professor; Meridean Maas, PhD, professor; Sheryl Miller, lecturer; and Deborah Schoenfelder, PhD, clinical associate professor. The project team also will ask faculty in other disciplines to contribute their ideas concerning course content.


Although health providers and the public have gained considerable awareness of end-of-life issues in recent years, reports and studies indicate older adults often don't receive adequate care at life's end. Mobily and her colleagues attribute this not to a lack of effective therapies but to the fact that many health professionals simply don't know the latest and best available practices. Management of pain and other symptoms, ethical and legal issues, and the needs of family caregivers all play important roles in caring for dying elders, Mobily said. Other key elements of the course content include the application of research evidence to support bedside care decisions and consideration of the role of interdisciplinary teams in caring for dying elders and their families.


"Students have a lot of interest in this," Mobily said, noting that some nursing students have formed an end-of-life interest group, "but to this point there haven't been any formal courses available." This will be the college's first stand-alone course on end-of-life care. Currently, end-of-life issues are covered as units within a gerontological nursing course, an oncology elective, and a gerontology practicum includes a highly sought-after hospice experience.


Mobily expects development of course content to take a year. After that, it will be offered to undergraduate and gerontology nurse practitioner students for credit. The course also will be available to students in related health fields.


Mobily said the course will continue after the 3-year funding period ends. She and her colleagues also plan to adapt it for practicing nurses and other health professionals. One group in particular that could benefit from Web-based instruction, Mobily said, is nurses who work in long-term care facilities, where staffing concerns and long distances limit the ability of nurses to attend off-site classes. The college also hopes to market the course statewide through the Iowa Association of Colleges of Nursing, and regionally to six universities affiliated with the Hartford Center for Geriatric Nursing Excellence. Project faculty will explore the possibility of national and international outreach as well, Mobily said.




Innovative Online Review Course to Improve Nursing Care for Elders Launched By Hartford Institute for Geriatric Nursing

The John A. Hartford Foundation Institute for Geriatric Nursing in the Division of Nursing at New York University's Steinhardt School of Education has announced a new, free-of-charge Internet review course to help meet the urgent need to enhance nursing competence in care for older adults. This course represents the first opportunity for nurses to review materials online at an individual pace to bridge the gaps in their skills in caring for older adults and to prepare to sit for the national certification examination in gerontological nursing that will validate their expertise.


Nearly half of the hospital beds in the United States are occupied by adults age 65 and older, yet fewer than 1% of the practicing registered nurses are certified in geriatrics, according Mathy Mezzy, EdD, RN, FAAN, director of the Hartford Institute. The online course, which prepares registered nurses to become certified as gerontological nurses by the American Nurses Credentialing Center of the American Nurses Association, reviews and summarizes key clinical information for the care of older adults, from the causes of aging, to pain management, to nursing home protocols. It also reviews the many financial, social, political, and cultural issues that affect nursing care for elders. The course is available free-of-charge on the Internet at The course takes an average of 6 to 8 hours to complete.


The basic features of the course include:


A Four-Module Design: The course is organized around four common older patient types that nurses encounter in their practice: healthy, frail, institutionalized, and dying aging adults. Each module includes a case study of an atypical patient in the population being reviewed.


Practice Questions: Practice questions in each module and a final review test set assist in examination preparation.


Self-Paced Study: The course is interactive and is designed for individual study at a flexible pace.



This course is recommended for practicing nurses, nurse educators, or nursing students who want to acquire fundamental knowledge of geriatric nursing care. Individuals completing the course may earn 9.6 contact hours of continuing education credit through the Center for Continuing Education in Nursing at NYU's Division of Nursing.


The online course content was developed from a 2-day Gerontological Nursing Certification Review Workshop created by national gerontological nursing experts as a pilot project of the John A. Hartford Foundation Institute for Geriatric Nursing at NYU. For more information about the online geriatric nursing review course, log onto the free course at; e-mail the Hartford Institute at hartford.ign@; or call Elaine Gould at 212-998-5568.


American Alliance of Cancer Pain Initiatives Urges Caution in Implementing State Prescription Monitoring Programs

In a July 2002 statement, the American Alliance of Cancer Pain Initiatives urged states to adopt balanced approaches when dealing with abuse and diversion of prescription pain medications so that such efforts do not harm patients who need the medicines to relieve their pain. Several states are considering new programs to track the prescribing and dispensing of controlled substances to prevent the drugs from being diverted to illegal uses.


"Prescription drug abuse is a serious problem in this country, but so is unrelieved pain. We must be careful so that efforts to address drug abuse and diversion do not make it more difficult for patients in pain to obtain necessary and appropriate medical care," said Robert Twillman, PhD, president-elect of the AACPI. Dr Twillman said that states must use caution to assure that regulations to track the prescribing patterns of physicians do not increase physician fear of investigation or discipline and make them more reluctant to prescribe controlled substances, such as opioids, to manage pain.


For many patients, opioid analgesics are the most effective way to treat pain, and currently 16 states have active prescription monitoring programs for controlled substances, including pain-relieving opioids like morphine, hydrocodone, and oxycodone. The programs collect information on the prescribing, dispensing, and use of prescription drugs. The information is intended to help regulators and law enforcement identify healthcare professionals and patients who may be diverting the medicine for nonmedical and illegal uses. The United States Congress recently approved $2 million for the US Department of Justice to help states establish prescription monitoring programs to address diversion.


In its statement the MCPI recommended:


* Fully utilize existing resources to identify sources of diversion, such as prescription data from the Medicaid Drug Utilization Review program, before enacting new and expensive programs that may adversely affect patient care;


* Involve a multidisciplinary medical review group in the development, review and evaluation of any diversion prevention and control program;


* Assure that prescription monitoring programs (a) are administered by the state agency regulating healthcare, (b) do not include special government-issued, serialized prescription forms that may deter physicians from prescribing the medications, (c) covers all controlled substances in Schedules II, III, and IV; and, (d) protects patient confidentiality;


* Encourage educational programs to address healthcare professionals' perceptions about prescription monitoring programs and minimize concern about regulatory scrutiny when prescribing and dispensing controlled substances as part of legitimate medical practice;


* Evaluate the impact of prescription monitoring programs on both patients needing controlled substances for legitimate medical purposes and the prevalence and incidence of drug abuse and diversion.



"It will take an ongoing, interdisciplinary strategy to comprehensively address these issues. Thoughtful, respectful dialogue needs to take place between law enforcement and the healthcare community before significant progress can be made," said Kandyce Powell, RN, MSN, president of the MCPI and director of the Maine Cancer Pain Initiative. The entire statement on prescription monitoring programs can be viewed online at For an overview of states' pain policies, visit


FDA Provides Marketing Clearance for Unique Antimicrobial Hydrofiber Wound Dressing

AQUACEL Ag, a unique antimicrobial wound dressing, has been cleared by the Food and Drug Administration for marketing in the United States for acute and chronic wounds, including partial thickness burns, surgical wounds, diabetic foot, and leg and pressure ulcers. AQUACEL Ag is indicated as an effective antimicrobial barrier that is potent, gentle on patients, effective in managing wound exudates, and helps reduce wound infection.


AQUACEL Ag is a primary wound dressing composed of sodium carboxymethylcellulose with ionic silver 1.2%. Ionic silver is made available at low but effective concentrations, killing a broad spectrum of pathogens including antibiotic resistant bacteria in the dressing. Pure (ionic) silver generally is regarded as a safe antimicrobial agent, and its use as a prophylactic agent and treatment of infections and other diseases dates back to 1000 BC when silver was used as a disinfectant to sterilize drinking water.


The gelling properties of Hydrofiber technology absorbs up to 20 times its weight in fluid and retains wound fluid by a hydrophilic action. Dressing fibers swell as they carry wound fluid, containing bacteria, away from the wound by vertical wicking. With hydration, a cohesive gel forms an intimate contact with the wound surface, minimizing dead space and providing a moist wound environment, which reduces traumatic and painful dressing removal by providing longer wear time.


"AQUACEL Ag has been developed to meet growing demands from doctors and nurses for an antimicrobial dressing that is potent, gentle on patients, and effective in managing wound exudates," says Michael Lydon, PhD, Vice President of Conva Tec Global Development Centre in North Wales, UK. AQUACEL Ag is manufactured and marketed by ConvaTec, a Bristol-Myers Squibb company specializing in ostomy and wound and skin care.


To learn more about Convatec, visit their Web site at




Last Acts Campaign and Kaiser Family Foundation Focus on TV Dramas

In two separate projects, the Robert Wood Johnson Foundation's Last Acts Campaign and the Henry J. Kaiser Family Foundation have explored content of popular TV shows dealing with and reflecting the attitudes toward health concerns and issues affecting Americans.


In June 2002, more than 250 television writers, producers, directors, and actors gathered in Los Angeles to discuss ways that television can best deal with the reality of death while still fulfilling its prime directive to attract and entertain a controlling share of the American audience. The event, billed as Life, the Last Act: Television's New Take on Death, was developed by The Last Acts Writers' Project and coproduced by the Academy of Television Arts and Sciences.


Panel members included five writers, actors, and creators from some of TV's most popular shows-ER, NYPD Blue, Scrubs, and CSI: Crime Scene Investigation. According to Writers' Project Director Bill Duke, the event's ability to draw major industry talent, both on the panel and in the audience, is a strong sign that Hollywood is open to exploring dying in America.


Panelists discussed the challenges inherent in portraying the typical dying experience in America today, an often-protracted process much different from TV's traditional treatment of death (either violent or peaceful) as swift. People spend more time dying these days, and frequently confront delicate issues such as when to stop seeking curative care or how to emotionally cope with life's end. David Milch, executive producer of NYPD Blue, calls this process "living into death."


It's a difficult reality for most humans, including TV writers. "My attitude towards death as a writer was that I didn't want to hear about it, except on my own terms," said Milch. But Milch said he grew personally from the experience of scripting the death of main character Bobby Simone (played by actor Jimmy Smits), which took place over the course of 5 episodes.


For several years, the Writers' Project has engaged with and offered TV writers seminars on the medical, ethical, and legal issues involved in dying. In the past, the project has influenced story lines on medical dramas such as ER and Chicago Hope, legal shows such as The Practice and Family Law, and even comedies such as HBO's Six Feet Under.


TV's popular hospital dramas also are regularly addressing such important national health policy issues as patient's rights, managed care, the right to die, and racial disparities in healthcare, according to Henry J. Kaiser Family Foundation study results, released in July 2002 at a forum called John Q Goes to Washington: Health Policy Issues in Popular Culture. At the same time, the study found that many of the most hotly debated national health policy issues such as prescription drug coverage for the elderly or coverage of the uninsured are not featured on these fictional shows.


According to the study, entitled As Seen on TV: Health Policy Issues in TV's Medical Dramas, an average of one scene per episode discusses a public policy on healthcare. Examples include a debate over whether it is legal to distribute clean needles to drug addicts on the NBC drama ER; an episode of the popular Lifetime show Strong Medicine in which a critically ill low-income patient doesn't have access to the prescription drugs she needs because her inner city neighborhood isn't adequately served by the major pharmacies; a story about a woman whose leukemia was misdiagnosed by her overworked and possibly careless HMO doctor on the now-cancelled ABC drama Gideon's Crossing; and an ER episode in which an HMO won't allow a woman with terminal breast cancer to be admitted to the hospital for pain management.


Overall, the study found the shows did not tilt either for or against the status quo in their depictions of these public policy issues. Approximately half of all scenes (48%) presented both sides of the issue in an evenhanded manner, while the rest were split between scenes that seemed to come out against the status quo policy (26%) and those that appeared to favor current policy (26%).


Shows frequently referenced many of the leading institutional players in health policy debates, such as hospital administrators, lawyers, government agencies, insurance companies, and HMOs. Of these, the only ones portrayed more negatively than positively were insurance companies, lawyers, and HMOs (all six references to HMOs over the season were negative).


A related survey by the Kaiser Family Foundation found that 4 in 10 adults surveyed (44%) said they had heard about the movie John Q, in which a young boy can't get the heart transplant he needs to survive because his insurance policy doesn't cover it and the hospital demands a $75,000 cash payment in advance. Among those who had heard of the movie, more than 7 in 10 said they believe insurers refuse to pay for treatments like those in the movie: 42% think it happens "a lot" and 30% "sometimes."


The movie John Q, released on video and DVD, was seen in theaters by an estimated 12 to 15 million viewers, earning more than $70 million in domestic box office receipts. Next year several new medical dramas are expected in the fall TV lineup, including Presidio Med on CBS (from the executive producer of ER, John Wells) and Meds on ABC, about two "renegade doctors" who are trying to take on the HMOs. ER and Scrubs (a hospital-based comedy) will both return to NBC in the fall. In May, the Showtime Network premiered the movie Damaged Care, a fictional movie that profiled a real-life managed care executive who went on to become an "outspoken critic" of the industry.


For more information on the Last Acts study, visit


For more information on the Kaiser Family Foundation study, visit




US News Factors Hospice and Palliative Care into Hospital Rankings

For the first time in US News and World Report 's history of ranking hospitals nationally, hospice and palliative care are included as criteria in the ranking methodology. Based in part on the Robert Wood Johnson Foundation's Last Acts Campaign's efforts, the magazine is now formally recognizing the importance of end-of-life care and pain management. Specifically, five specialties-cancer, geriatrics, heart and heart surgery, respiratory disorders, and rheumatology-include hospice and palliative care as structural variables.


To access the US News and World Report 2002 Hospital Rankings page, go to:


To learn about the ranking methodology US News and World Report used, visit:




New Web Site Offers Palliative and End-of-Life Care Information

The Nursing Leadership Consortium for End-of-life Care has unveiled a new Web site to allow nurses and other professionals to exchange information related to improving patient care at the end of life. The site features links to Last Acts'Precepts of Palliative Care; the bimonthly online journal, Innovations in End-of-Life Care; an overview of state pain policies; educational Web sites and software programs; and a list of resources including surveys, televised programs, and links to other hospice and palliative care organizations.


To visit the Nursing Leadership Consortium for End-of-Life Care Web site, go to: