To the Editor:

In 1984, I wrote the following in the January/February edition of the Journal of Enterostomal Therapy: "Stomas are intentional outcomes of surgical intervention for the treatment of disease or injury. Having an ostomy results in an identity crisis of image and function."

A quarter of a century later finds me questioning whether or not WOC nursing has shortchanged the extant ostomy population as evidenced, in part, by the range of experiences shared by posters on the UOAA Internet-based ostomy discussion forums. If one were to consider this venue as a window to the state of the ostomy populace today, one could then assume-always a dangerous endeavor-that a lesson to be learned from the readings of the posts can be that some ostomates are still getting short shrift with some important levels of ostomy-focused teaching and care. It is not unusual or unexpected that not all patients' needs are being met; however, I believe it unacceptable that some very basic needs remain unmet. The trend away from acute care focus and locus of ostomy teaching and learning should be anticipated and embraced by WOC nurses who remain invested in the care and needs of the ostomy client.

I cannot and do not expect to put the genie back into the bottle now that WOC nursing has expanded its professional role beyond ostomy care. I would, however, expect that ostomy care remain a primary focus of current WOC nursing practice. Sadly, I believe, this expectation is to be unfounded as I witness members of WOCN choosing their nonostomy subspecialties as part of their certification goals. While this choice benefits the practitioner, it leaves the ostomy patient at risk since the typical ostomate is unaware of the devolving nature of WOC nursing practice. In the patient's mind, the role and focus of the WOC nurse include ostomy. Either the WOCN Society has succeeded in encapsulating correctly the expectations for ostomy expertise in the minds of the ostomy populace and health care practitioners who request WOC nursing care or they may be the victims of unwarranted expectations. In either case, the outcomes are at risk when WOC nurses are not willing or able to satisfy such expectations for the ostomy patient.

In a more personal vein, it is beginning to really annoy me whenever I read or hear about the excuses individual practitioners make as to why they can or cannot do certain things for patients in certain settings. As I have said and written so many times before in the WOCN ostomy discussion forum, institutions and bureaucracies do not make decisions, people do!! If a policy is not helpful to the patient, then a responsible individual must make the appropriate decision to meet a patient's needs. It is that simple!!!!

I recall making some predictions in 2003 during the South Jersey Chapter of the UOA 25th anniversary meeting and dinner that WOC nursing will likely not be able or willing to meet the fuller needs of the ostomy population and the burden will fall back increasingly to the lay organizations. Specifically, I said the following, "Every ostomate must become 'expert' in their own knowledge and care and convey this knowledge to all who are involved in their well-being. As the ETs/WOCNs become increasingly diversified and less involved in ostomy matters, their voices and influence for ostomy issues will diminish; therefore, the lay groups must reassert their representative role. There are no free lunches!! Learn to live with the expectations that ostomy care will cost something and be prepared to pay as needed. The continued emphasis upon third party support is not always helpful and is in fact becoming increasingly costly and harmful."

I went on to say that "The responsibility for future needs will fall back to the ostomate. As the ostomy and ET/WOCN populations age the burden and responsibility of care will revert to the patient not the professional caregiver. The average age of ETs is late 40s-and by now well into the late 50s-and the percentage of skilled ostomy ETs, who tend to be older than their peers, is diminishing. Thus, by the time the typical ileostomate reaches 'old age' they will be true dinosaurs and without the benefit of skilled ostomy ETs/WOCNs, who will have either retired or died off."

I hate being right about things going poorly. My hope, still, for WOC nurse is that I may be proven wrong in my increasingly bleak assessment of the future expectations of the ostomy population.

Mike D'Orazio (ET, retired)

Broomall, Pennsylvania