Raising concerns about palliative sedation
Thank you for publishing "Is Palliative Sedation Right for Your Patient?" (August 2011).* The authors did a good job of explaining the concepts, and I do believe this treatment option is indicated in rare cases of intractable pain that can't otherwise be treated. Because I'm a pro-life nurse, I'll always consider it to be "terminal" sedation.
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I witnessed a situation recently in which a woman, age 80, experienced a massive cerebral hemorrhage. She was given terminal sedation for 5 days in ICU. Shortly before she died, the nurse came in three times to administer I.V. bolus doses at 10-minute intervals. When I asked the nurse what she was doing, she told me the medication was hydromorphone and said, "It won't be long now."
With the economic uncertainty in our healthcare system, healthcare providers need to be aware of the potential for a "slippery slope" related to end-of-life care.
Paul Arnstein, PhD, RN, FAAN, replies: We agree with many of your points and join you in the value that you place on human life. In our practice as clinical nurse specialists in ethics and pain, we've found that many people are uncomfortable with the dying process and want it to be as short as possible. As we point out in our article, the deliberate termination of life by another person, even to ease the patient's suffering, is never justifiable. When anyone says or does things that implicitly or explicitly resemble euthanasia, we must have a conversation with them. Intent matters, and it must be clear that we don't want to stop life; we want to halt the suffering. Done properly, with the intent to alleviate intractable pain, palliative sedation may actually allow patients to live longer.
The authors state that "[a]s appropriate, the treatment team expands to include specialists in pain, palliative care, psychiatry, spiritual care, and other disciplines." We suggest including the nurses involved in the care of the patient, as well as a social worker, in the palliative care team. Often their insights into family dynamics can greatly assist in the process and discussion, enhancing the outcome. The decision to use palliative sedation is one of the most difficult that care providers have to make, and representatives of all specialties should be involved.
An ounce of prevention
I must respond to "Hypertensive Emergency" (Action Stat, August 2011).* In the scenario described, a patient experienced a hypertensive emergency after surgery because he'd decided on his own to stop taking his antihypertensive medications 1 week before surgery. I believe this situation shouldn't have occurred in the first place.
The patient should have been instructed about his medications by his healthcare providers days before the surgery and been given printed instructions. On the day of surgery, the pre-op nurse should have asked him if he'd followed the instructions and what medications he'd taken or held. After surgery, the receiving nurse should have asked him again what medications he'd taken that day as part of the medication reconciliation process.
Medication errors, including oversights such as this one, cause unnecessary complications and even deaths. The event described could have been easily prevented.
"The Physics of Flushing: The Science Supporting Why We Do What We Do" (I.V. Rounds, August 2011)* was helpful, but I'd like to bring a couple of points to your attention. In the discussion of syringe-induced reflux, the authors indicated that the catheter tip is compressed. That's not accurate-it's actually the rubber gasket on the syringe plunger rod that's compressed. When pressure on the plunger rod is released, this gasket expands, pulling blood back into the catheter lumen.
Also, I'd like to remind nurses that small quantities of medication shouldn't be measured in a small syringe, then transferred to a larger syringe just for the purpose of using a larger syringe. The Institute for Safe Medication Practices has warned against syringe-to-syringe drug transfer, as do the 2011 Infusion Nursing Society standards.1,2
Because the article doesn't address this issue, nurses might think that they should be transferring these small-quantity drug doses. The first flush of the catheter is for the purpose of assessing patency. After demonstrating a lack of resistance and seeing a blood return, the nurse can and should use the appropriate-size syringe to give the medication.
-MARJORIE ATKINSON, MSN, RN
-CHUCK ATKINSON, LMSW, AHPC-SW
-PATRICIA GAIL BATSON, MSN, RN
-LYNN HADAWAY, MED, RN-BC, CRNI
-MATTHEW MCKENZIE, MBA
West Chester, Pa.
1. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011; 34(1 suppl):S60. [Context Link]
Timely attention to staffing
Thanks to Eugene Litvak and Linda Laskowski-Jones for "Nurse Staffing, Hospital Operations, Care Quality, and Common Sense" (Editorial, August 2011),* which gave the important concept of patient throughput the attention it needs. I've been studying this a lot in the last year here at my hospital, and I think many other potential fixes could yield significant results. Keep up the good work!
* Individual subscribers can access articles free online at http://www.nursing2011.com. [Context Link]