Palliative and End-of-Life Care: Precepts and Ethics for the Orthopaedic Population

Since the emergence of reports such as the National Consensus Project for Quality Palliative Care (2013) and the National Association of Orthopaedic Nurses Palliative Care Consensus Document (2005), there continues to be a growing recognition of the multiple adverse effects of serious illness and chronic conditions, as well as the potential benefits of receiving palliative or end-of-life care. As modern technology expands its ability to support life, ethical dilemmas may be encountered in the provision of palliative or end-of-life care. Through integration of the precepts of palliative care and consideration of the relevant ethical principles, orthopaedic nurses may best meet their patients\u27 comprehensive needs at an exceedingly difficult time

Clinical Observation Reflections from Students in an Interdisciplinary Palliative Care Course

The purpose of this study was to gain insight into how a brief clinical observation encounter contributed to students’ experiences in an interdisciplinary palliative care course. This course was required of all graduate nursing students and was available as an elective for medical and other healthcare professions students at a healthcare sciences university. The students were required to spend approximately 8 to 12 hours attending interdisciplinary team meetings or accompanying a team on rounds and patient visits. The students’ summary narratives of their observation experience were analyzed in this qualitative study that focused on six categories of feedback: (1) patients’ and families’ reactions, (2) communication issues with patients and families, (3) how the palliative care team speaks with the patient and family, (4) communication within the interdisciplinary team, (5) students’ reflections, and (6) students’ suffering. This study demonstrated that a clinical observation activity can be a valuable introduction to palliative care principles for healthcare students in an interdisciplinary course. Students benefited from gaining insight into family/practitioner communications regarding difficult issues, interdisciplinary roles and cooperation, and application of palliative care principles to clinical practice. Further research is required to identify appropriate interventions to deal with student distress resulting from such early career clinical encounters

A Framework for Integrating Oncology Palliative Care in Doctor of Nursing Practice (DNP) Education

Doctor of Nursing Practice (DNP) faculty play a critical role in preparing students to meet the complex needs of the nation as the number of cancer rates and survivors rise (National Cancer Institute, 2018) and as an unprecedented number of older Americans enter into the healthcare system with complicated comorbidities (Whitehead, 2016). Palliative care has dramatically expanded over the past decade and has been increasingly accepted as a standard of care for people with cancer and other serious, chronic, or life-limiting illnesses. Advanced practice registered nurses (APRNs) are recognized as important providers of palliative care (Walling et al., 2017). A 2-day course was held with support from the National Cancer Institute to enhance integration of palliative oncology care into DNP curriculum. The course participants (N = 183), consisting of DNP faculty or deans, practicing DNP clinicians, and students, received detailed annotated slides, case studies, and suggested activities to increase student engagement with the learning process. Course content was developed and delivered by palliative care experts and DNP faculty skilled in curriculum design. Participants were required to develop goals on how to enhance their school\u27s DNP curriculum with the course content. They provided updates regarding their progress at integrating the content into their school\u27s curriculum at 6, 12, and 18 months post course. Results demonstrated an increase in incorporating oncology palliative care in DNP scholarly projects and clinical opportunities. Challenges to inclusion of this content in DNP curricula included lack of: perceived time in curriculum; faculty educated in palliative care; and available clinical sites

A Retrospective Review of Sliding Scale vs. Basal/Bolus Insulin Protocols

Purpose The purpose was to assess the differences between subcutaneous basal/bolus and sliding scale insulin protocols in patients admitted with type 2 diabetes on non-critical care units. Methods A retrospective review of electronic medical records was conducted on a convenience sample of inpatients in a central-city teaching hospital. Results The findings were that basal/bolus protocols achieved American Diabetes Association glycemic targets on fasting, mean, and discharge blood glucoses. Conclusions This study provided insight into glycemic control and interdisciplinary education needs at this hospital. Evidence revealed that basal/bolus insulin protocols can achieve glycemic targets

A Review of Patients with Renal Disease Undergoing Vascular Access Surgery: Is Gray-scale Ultrasound Enough?

Background An adequate fistula or graft is essential to long-term survival and quality of life for patients with end-stage renal disease (ESRD) who are receiving hemodialysis because of its lower complication rates, lower costs, and prolonged patency. Use of duplex ultrasound for preoperative planning is currently recommended by the Kidney Disease Outcomes Quality Initiative for patients with ESRD with prior fistulas or grafts, central lines, pacemakers, and prior chest or arm surgery. The preoperative evaluation consisted of gray-scale ultrasound and physical examination in all patients with ESRD in this study. The current study determined the baseline data, including the type of vascular access, functional patency of access, associated morbidity, and preoperative demographics and comorbidities, including prior dialysis access. The primary objective was to determine the frequency of revision surgery, to identify the potential cases that may indicate the need for better assessments (eg, duplex ultrasound), and to improve fistula and graft success rates. Materials and methods A retrospective chart review of patients with ESRD who underwent native fistula or graft access creation in a 13-month time period from 2010 to 2011 was completed. Seventy-six surgical procedures were performed on 53 subjects. Included variables were age, race, gender, smoking status, body mass index, stage of chronic kidney disease at referral, previous central lines/pacemakers, fistulas, or grafts. Comorbidities identified included diabetes mellitus (DM), hypertension (HTN), and coronary artery disease (CAD). The types of access, location, maturation, infection, failure, or revision were noted. Continuous variables are shown in frequencies and mean. Categoric data were compared using chi-square analysis. Results During the 13-month study period, 76 surgical procedures were performed in 53 patients, with 39.6% of patients undergoing multiple surgical procedures. The majority of patients were male (98%) and white (58.5%), with a history of HTN (96.2%) and DM (64.2%). The mean age was 68 years, with most patients presenting in stage 5 chronic kidney disease (92.5%). Some 67.9% of patients had prior central lines or pacemakers; of those, 56.6% had previous fistulas or grafts. Negative significance was determined between the comorbidities DM/HTN/CAD alone or grouped as a cohort and multiple surgeries. Positive significance was found between multiple surgical procedures and those with prior access/ pacemaker/central line (chi-square [1, N = 53] = exact P = .04). Conclusions Patients with ESRD undergoing access creation presenting with prior central lines, pacemakers, or arm surgery (fistulas or grafts) were more likely to undergo multiple surgeries to obtain a functional graft or fistula for hemodialysis use than those patients with ESRD without prior central lines, pacemakers, or arm surgery (fistulas or grafts). Color duplex ultrasound should be considered as a standard for preoperative assessment in an effort to improve fistula or graft success rates

Anesthesia Preoperative Clinic Referral for Elevated Hba1c Reduces Complication Rate in Diabetic Patients Undergoing Total Joint Arthroplasty

Background: Diabetes mellitus (DM) is risk factor for complications after orthopedic surgery. Objectives: We tested the hypothesis that anesthesia preoperative clinic (APC) referral for elevated glycosylated hemoglobin (HbA1c) reduces complication rate after total joint arthroplasty (TJA). Patients and Methods: Patients (n = 203) with and without DM were chosen from 1,237 patients undergoing TJA during 2006 - 12. Patients evaluated in the APC had surgery in 2006 - 8 regardless of HbA1c (uncontrolled). Those evaluated between in subsequent two-year intervals were referred to primary care for HbA1c ≥ 10% and ≥ 8%, respectively, to improve DM control before surgery. Complications and mortality were quantified postoperatively and at three, six, and twelve months. Length of stay (LOS) and patients requiring a prolonged LOS (\u3e 5 days) were recorded. Results: Patients (197 men, 6 women) underwent 71, 131, and 1 total hip, knee, and shoulder replacements, respectively. Patients undergoing TJA with uncontrolled HbA1c and those with HbA1c \u3c 10%, but not those with HbA1c \u3c 8%, had a higher incidence of coronary disease and hypercholesterolemia than patients without DM. An increase in complication rate was observed in DM patients with uncontrolled HbA1c versus patients without DM (P \u3c 0.001); the complication rate progressively decreased with tighter HbA1c control. More DM patients with preoperative HbA1c that was uncontrolled or ≥ 10% required prolonged LOS versus those without DM (P \u3c 0.001 and P = 0.0404, respectively). Conclusions: APC referral for elevated HbA1c reduces complication rate and the incidence of prolonged hospitalization during the first year after surgery in diabetics undergoing TJA

Evaluation of a Primary Care Weight Loss Program

Nurse practitioners at a primary care clinic established a weight loss program to address high obesity rates among their African American patients. Interviews and a retrospective chart review were used to evaluate the weight loss program. Number of appointments was the only significant predictor of weight loss, and there was a strong positive correlation between total number of appointments and weight loss. The overall view of the program was positive. This description and evaluation of the program may be useful to nurse practitioners seeking to develop an individualized effective weight loss intervention for African Americans within a primary care setting

Supporting a Community of Individuals with Intellectual and Developmental Disabilities in Grieving

Individuals with intellectual and developmental disabilities are living longer and experiencing deaths among their family and peers, yet their grieving is not well recognized. Staff members who provide care for these individuals witness the aging and death of their clients, yet they also receive little preparation to work through issues surrounding bereavement for their clients and themselves. The End of Life Nursing Education Consortium developed a national initiative to improve end-of-life and bereavement care education. Recommendations from the End of Life Nursing Education Consortium were incorporated into a home care/hospice/community health course and practicum for second-degree BSN students. The following reports on an innovative clinical experience in which students developed a program to address the bereavement needs of individuals with intellectual and developmental disabilities and their staff

Embracing a Competency-Based Specialty Curriculum for Community-Based Nursing Roles

The Quad Council competencies for public health nursing (PHN) provide guidance in developing curricula at both the generalist and specialist level. However, these competencies are based on nursing roles in traditional public health agencies and community/public health is defined more broadly than official agency practice. The question arises as to whether community-based specialties require largely the same knowledge and skill set as PHN. The purpose of the competency cross-mapping project reported here was to (a) assess the intersection of the Quad Council competencies with four community-based specialties and (b) ensure the appropriateness of a Quad Council-based curriculum to prepare graduates across these four specialties (home health, occupational health, environmental health, and school nursing). This article details the multistep cross-mapping process, including validation with practice leaders. Results indicate strong alignment of community-based specialty competencies with Quad Council competencies. Community-based specialty-specific content that did not align well is identified, along with examples of didactic and clinical strategies to address gaps. This work indicates that a Quad Council-based curriculum is appropriate to prepare graduates in community-based specialties when attention to the specialty-specific competencies in the clinical setting is included. This work guides the development of a doctorate of nursing practice curriculum in PHN, encompassing the four additional community-based specialties

Community/Public Health Nursing Practice Leaders\u27 Views of the Doctorate of Nursing Practice

ABSTRACT Objectives: This paper presents thoughts of practice leaders in the community/public health nursing (C/PHN) specialty on advanced nursing practice (ANP) and the necessary educational preparation for such practice. Design and Sample: Practice leaders were engaged in conversations specifically focused on the Doctor of Nursing Practice (DNP) as preparation for ANP in their specialties, and asked to consider the benefits of, and challenges to, this educational program. Measures and Results: The resulting remarks were then assessed for themes by the interviewers and these are presented along with thoughts on the future of education for ANP. Conclusion: Overall, there was much agreement among the practice leaders interviewed about the importance of a broad skill set for ANP in the specialty. However, the practice leaders interviewed here also identified the practical challenges involved in educating nurses at the DNP level in the C/PHN specialty, as well as some concerns about the definitions of ANP for the future