It is hard to believe that this marks the end of my first year as the Editor of JONA Law. I am finding this position to be one in which I routinely interact with people whom I believe are the best and brightest of the nursing profession. Despite the ongoing issues nurses face in terms of patient load, job security, and pay, it heartens me to meet nurses who are committed to making the profession better for other nurses and for our patients. I would like to take this opportunity to recognize those board members who have been with JONA Law now for the entire time it has been in publication: Mark Barabas, Ed Beard, Marcia DeWolf-Bosek, Nancy Brent, Diane Huber, Hussein Tahan, and Deborah Terry. These folks are largely responsible for what you see between the covers with each issue. Their insight and feedback have been invaluable both to me and to the authors whose work you have read in this journal over the last 5 years. Simply put, without the volunteer efforts of the board, this journal would not be in existence. Since I am writing this letter at the beginning of December, gifts and giving are on my mind. This coming year, consider what you can do as a volunteer to help other nurses. I promise you will find it to be an activity that will give you back as much as you put into it.

This issue presents a fantastic article regarding medication error prevention, a real must-read for everyone these days, and you can knock off some CEUs for reading it. We also have an interesting study regarding mandatory CEU requirements. There were many interesting and important cases published this summer, and our Legal Briefs column gives you an executive summary of these rulings.

We received the following letter in response to an article regarding DNR orders published last year; the author's response follows. As always, we appreciate your feedback.

As part of the study of do-not-resuscitate (DNR) orders written by physicians without the consent of patients or their surrogates, Lisa Anderson-Shaw describes a review she conducted at the University of Illinois Medical Center.1 She says that the study was raised by questions of whether some patients would be more likely to have DNR orders put in place this way and whether or not an ethics consultation was involved. I collaborated with Anderson-Shaw in interpreting the findings of that review and in making an earlier public presentation of results.

Anderson-Shaw has failed to note serious limitations of the review. She says that for the period October 1999 to April 2000, 110 DNR orders were written at the medical center. In fact, she does not know that this is an accurate number because she relied on nursing staff to forward a copy of any DNR orders to her, and there is no way to know whether this was done in each case. There was, moreover, a computer failure during this period, and certain DNR tracking records were not produced. Anderson-Shaw did not conduct a review of all patient records at the medical center during this period to confirm the accuracy of the numbers she reports. More DNR orders might have been written, and some of those might have been unilateral DNR orders.

The findings of this review in any case do not offer any inkling of whether certain kinds of patients were more likely to have unilateral DNR orders written for them or whether an ethics consult would have changed the decisions made. Despite various statements about the usefulness of these findings, Anderson-Shaw does not either report that the findings of her review were used to allay the-apparently unfounded-concerns voiced by nursing staff. This is extremely surprising since Anderson-Shaw says that they were originally the reason she undertook the study.

Timothy F. Murphy

(October 7, 2003)

Author's Response

Thank you for the opportunity to respond to the October 7, 2003 letter to the editor from T. Murphy regarding my recent article "The unilateral DNR order - one hospital's experience".

The following is my response:

My recent article in JONA's Healthcare, Law, Ethics and Regulation titled "The unilateral DNR order-one hospital's experience (2003:5;42-46)" is intended to show the process of institutional policy review and the important role that nurses have in this process. I do not suggest that the medical record review of DNR orders at my institution was in any way inclusive of all such orders written during the time frame reported. As Murphy points out, there are limitations in information systems that prohibit such inclusive data review.

The point of my article is to highlight the importance of listening to nursing staff concerns when drafting important institutional policy, using the unilateral DNR order policy revisions at my institution to illustrate this point. I make no assertions as to the kinds of patients who may be more likely to have unilateral DNR orders as this was not the purpose of the article.

Nurses are an extremely valuable resource when developing policies, in general, but even more so when the policy in question is controversial or poses ethical dilemmas. Murphy states that the findings of my review "were used to allay the - apparently unfounded - concerns voiced by nursing staff." To this I would say that any policy concerns voiced by nurses should not be automatically discounted as unfounded, but rather should be pursued in a logical review process so that concerns may be validated or not, as determined by thoughtful review and consideration.

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