DNA Reporter - December 2021
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<strong>DNA</strong><br />
REPORTER<br />
CONSTITUENT MEMBER OF ANA<br />
Volume 47 • Issue 1<br />
<strong>December</strong> <strong>2021</strong>, January, February 2022<br />
Inside This Issue<br />
The mission of the Delaware Nurses Association is to improve healthcare in Delaware by the advancement<br />
of nursing. Quarterly publication distributed to approximately 6,700 RNs and LPNs in Delaware.<br />
Guest Editor<br />
End of Life Care Considerations in<br />
Palliative Care and Death with Dignity<br />
Joint Policy Statement Adopted by<br />
the Delaware Nurses Association<br />
PAGE 11<br />
Delaware LPN Leadership<br />
PAGE 13<br />
Suzette M. Flores, DNP, BSW, APRN, NP-C<br />
Dr. Suzette Flores is currently<br />
an inpatient palliative care<br />
consultant at Bayhealth Sussex<br />
Campus Hospital. Dr. Flores<br />
has over 30 years of healthcare<br />
experience in the areas of<br />
social work, geriatric psychiatry,<br />
neurosurgery, cardiology, long<br />
term care, and palliative care.<br />
She is board certified in adult<br />
care by the American Academy<br />
of Nurse Practitioners (AANP).<br />
She earned a Bachelor’s Degree<br />
in Social Work from Michigan Suzette M. Flores<br />
State University (MSU), a Bachelor’s Degree of Nursing from the<br />
University of Delaware (U of D), a Master’s Degree of Science<br />
in Nursing and a Doctorate Degree of Nursing Practice from<br />
Thomas Jefferson University (TJU). Dr. Flores has membership<br />
with the Delaware Medical Reserve Corps, Delta Gamma<br />
Sorority, Alpha Eta Society-Thomas Jefferson University,<br />
Sigma Theta Tau International Society of Nursing-Delta Rho<br />
Chapter, on the Delaware Nurses Association (<strong>DNA</strong>) Advocacy<br />
Committee, on the Delaware Cultural Advisory Committee,<br />
and has been involved ongoing with the Delaware Coalition of<br />
Nurse Practitioners (DCNP). She currently serves as Chair of the<br />
Nominating Committee for the DCNP. Dr. Flores is the recipient<br />
of the 2019 AANP Advocate State Award for Excellence. Dr.<br />
Flores may be reached at suzette_flores@bayhealth.org.<br />
Having worked in palliative care, end of life discussions<br />
and end of life care planning can be difficult and<br />
uncomfortable for patients and their families, as well as for<br />
healthcare providers with preparation, let alone without<br />
preparation. All too often, patients and their families do<br />
not think about death and dying until they are confronted<br />
with that possibility.<br />
Death with Dignity is a topic to be considered in our<br />
fast paced technologically evolving medical environments<br />
in which we may be able to keep ourselves going for<br />
prolonged periods of time. Prolongation of life may not<br />
come with improvement in health, and it may not lead to<br />
improvement in our quality of life, although it may be life<br />
sparing.<br />
Every death experience is unique to a person and their<br />
family. What would constitute a good death experience<br />
for you? What would dignity at the end of your life look<br />
like? What would be most important to you at this time?<br />
According to the Institute of Medicine (1997), a good<br />
death is “one that is free from avoidable distress and<br />
suffering, for patients, family, and caregivers; in general<br />
accord with the patients’ and families’ wishes; and<br />
reasonably consistent with clinical, cultural, and ethical<br />
standards” (p. 24).<br />
Traditionally, it was the patient’s physician who<br />
determined what end of life care should look like. This<br />
trend has since shifted to give patient’s autonomy or selfdetermination<br />
to direct their own medical treatments in<br />
end of life care. The concept of self-determination or Death<br />
with Dignity is that a terminally ill patient should determine<br />
their own end-of-life decisions and determine how much<br />
pain and suffering they should endure based upon their<br />
personal beliefs and values, and what a good death may<br />
mean to them (“Death with Dignity Acts,” n.d.).<br />
In Delaware, Title 16, Health and Safety, Regulatory<br />
Provisions Concerning Public Health, Chapter 25.<br />
Health-Care Decisions, section 2502, the right of selfdetermination<br />
states that “any legal adult, who is mentally<br />
competent has the right to refuse medical or surgical<br />
treatment if such refusal is not contrary to public law”<br />
(“The Delaware Code Online,” n.d.).<br />
The legal rights to self-determination in Delaware, may<br />
be expressed as cognizant decisions to forgo or not initiate<br />
life-saving treatments. In my inpatient hospital practice,<br />
discussions center around the risk versus benefit of<br />
Guest Editor continued on page 4<br />
Index<br />
current resident or<br />
Presort Standard<br />
US Postage<br />
PAID<br />
Permit #14<br />
Princeton, MN<br />
55371<br />
Meet the 2022 <strong>DNA</strong> Board of Directors.................. 2<br />
Executive Director’s Report.............................. 3<br />
COVID-19 Pandemic Through the Lens<br />
of an Inpatient Palliative Medicine Provider............. 6<br />
Community-Based Palliative Care:<br />
High Quality and Cost Effective........................ 7<br />
Palliative Care: Including Nursing in Early Intervention... 8<br />
Non-beneficial Treatment at the End of Life............. 9<br />
Using Respiratory Distress Observation<br />
Scale (RDOS) at End-of-Life..........................10-11<br />
Policy Statement on Dissemination<br />
of Non-Scientific and Misleading<br />
COVID-19 Information by Nurses ...................... 11<br />
Results of Delaware Nursing Dialogue –<br />
Advocacy Prioritization................................ 12<br />
Retirement Readiness Checklist........................ 12<br />
Delaware Licensed Practical Nurse Leadership......... 13<br />
Documenting nursing assessments<br />
in the age of EHRs ...................................14-15<br />
New, Renewing, & Returning Members...............15-16
Page 2 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />
REPORTER<br />
OFFICIAL PUBLICATION<br />
of the<br />
Delaware Nurses Association<br />
4765 Ogletown-Stanton Road, Suite L10<br />
Newark, DE 19713<br />
Phone: 302-733-5880<br />
Web: http://www.denurses.org<br />
The <strong>DNA</strong> <strong>Reporter</strong>, (ISSN-0418-5412) is published quarterly every<br />
March, June, September and <strong>December</strong> by the Arthur L. Davis<br />
Publishing Agency, Inc., for the Delaware Nurses Association,<br />
a constituent member association of the American Nurses<br />
Association.<br />
EXECUTIVE COMMITTEE<br />
President: Leslie Verucci, , MSN, APRN, ANP-BC<br />
President-Elect: Stephanie McClellan, MBA,<br />
MSN, RN, CMSRN, NE-BC<br />
Secretary: Jacqueline C. Armstrong, DNP,<br />
MSN, APRN, FNP-BC, PMHNP-BC<br />
Treasurer: George Zangaro, PhD, RN, FAAN<br />
Director-at-Large, Clinical Nurse: Ramona Negron, BSN, RN<br />
DIRECTORS<br />
Membership Growth Directors<br />
New Castle County: Kathy Neal, PhD, RN<br />
Kent County: Sharon Mills-Wisneski, PhD, RN<br />
Sussex County: Candace Hamner, MA, BA, RN<br />
Professional Development Director<br />
Sandra Nolan, PhD, RN, HN-BC<br />
Advocacy Director<br />
Annamarie Flick, MSN, RN-BC, NE-BC<br />
Editorial Director<br />
Karen Panunto, EdD, MSN, RN<br />
EXECUTIVE DIRECTOR<br />
Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN<br />
executivedirector@denurses.org<br />
ORGANIZATIONAL AFFILIATES<br />
Oncology Nursing Society-Delaware Diamond Chapter<br />
communities.ons.org/delawarediamond<br />
Delaware Organization of Nurse Leaders<br />
www.delawareone.org<br />
Delaware Emergency Nurses Association<br />
www.de-ena.org<br />
Delaware State Affiliate of the American College of Nurse-Midwives<br />
http://delaware.midwife.org/<br />
Delaware Coalition of Nurse Practitioners<br />
https://dcnpweb.enpnetwork.com/<br />
Subscription to the <strong>DNA</strong> <strong>Reporter</strong> may be purchased for $20 per year,<br />
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in this publication express the opinions of the authors; they do not<br />
necessarily reflect views of the staff, board, or membership of <strong>DNA</strong> or<br />
those of the national or local associations.<br />
Editorial Director<br />
Karen L. Panunto, Ed.D, MSN, RN<br />
The <strong>DNA</strong> <strong>Reporter</strong> welcomes unsolicited manuscripts by <strong>DNA</strong><br />
members. Articles are submitted for the exclusive use of The <strong>DNA</strong><br />
<strong>Reporter</strong>. All submitted articles must be original, not having been<br />
published before, and not under consideration for publication<br />
elsewhere. Submissions will be acknowledged by e-mail or a selfaddressed<br />
stamped envelope provided by the author. All articles<br />
require a cover letter requesting consideration for publication. Articles<br />
can be submitted by e-mail to Christopher E. Otto, MSN, RN, CHFN,<br />
PCCN, CCRN at executivedirector@denurses.org<br />
Each article should be prefaced with the title, author(s) names,<br />
educational degrees, certification or other licenses, current position,<br />
and how the position or personal experiences relate to the topic of<br />
the article. Include affiliations. Manuscripts should not exceed five (5)<br />
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mailing address, telephone number where messages may be left,<br />
and fax number. Authors are responsible for obtaining permission to<br />
use any copyrighted material; in the case of an institution, permission<br />
must be obtained from the administrator in writing before publication.<br />
All articles will be peer-reviewed and edited as necessary for content,<br />
style, clarity, grammar and spelling. While student submissions are<br />
greatly sought and appreciated, no articles will be accepted for the sole<br />
purpose of fulfilling any course requirements. It is the policy of <strong>DNA</strong><br />
<strong>Reporter</strong> not to provide monetary compensation for articles.
<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 3<br />
Executive Director’s Report<br />
Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN<br />
Executive Director<br />
executivedirector@denurses.org<br />
or 302-733-5880<br />
The meaningful recognition of<br />
nurses is a heavily researched area<br />
of nursing practice with several<br />
notable outcome improvements<br />
when successfully applied to<br />
professional practice settings.<br />
The American Association of<br />
Critical-care Nurses’ framework<br />
for healthy work environments<br />
includes meaningful recognition<br />
and defines it as, “Nurses<br />
Christopher E. Otto<br />
must be recognized and must<br />
recognize others for the value each brings to the work of<br />
the organization” (American Association of Critical-care<br />
Nurses, <strong>2021</strong>). Meaningful recognition can decrease nurse<br />
burnout and increase compassion satisfaction for nurses<br />
(Kelly & Lefton, 2017). Additionally, meaningful recognition<br />
increases the nurses’ self-perception, pride, and often<br />
reconnects nurses with their “why” (Lefton, 2014).<br />
Recognizing nurses includes all nurses, Licensed<br />
Practical, Registered, and Advanced Practice Registered<br />
Nurses. Research supports the positive impact of<br />
meaningful recognition for Licensed Practical Nurses by<br />
reducing burnout (Kim et al., 2020). The Delaware Nurses<br />
Association has provided recognition for Delaware’s nurses<br />
for decades and continues to evolve existing programs.<br />
We believe in the power of nurse recognition to combat<br />
burnout, increase professional role satisfaction, and<br />
promote a positive image of nursing. Recognizing nurses<br />
at the state level facilitates increased public awareness and<br />
perception of the unique contributions, qualifications, and<br />
service nurses make. By recognizing nurses statewide, the<br />
Delaware Nurses Association can uplift the characteristics<br />
of exceptional nurses and further define the essence of our<br />
profession. On behalf of the Delaware Nurses Association<br />
Board of Directors, I am proud to share the following<br />
evolving advancements for statewide nurse recognition.<br />
Joint Committee on Nursing Recognition<br />
In partnership with our organizational affiliate, the<br />
Delaware Organization for Nursing Leadership, we<br />
established a Joint Committee on Nursing Recognition<br />
to expand, implement, and evolve statewide nursing<br />
recognition programs and partnerships. The newly<br />
forming committee comprises 13 voting, volunteer<br />
members that represent all three nursing licensure levels<br />
and Delaware counties. Additionally, volunteer members<br />
come from numerous practice settings including academia,<br />
private practice, schools, the state, hospitals, and more.<br />
Partnerships and broad nursing representation set this<br />
committee up for success in providing meaningful<br />
statewide recognition. The committee will begin meeting<br />
monthly after the new year.<br />
Delaware Today Top Nurses<br />
The Delaware Nurses Association has partnered with<br />
Delaware Today Media to recognize Delaware’s Top<br />
Nurses for nine years. Starting in 2013, the program has<br />
now grown to recognize all Delaware nurses. Voting is<br />
conducted November-January annually and winners are<br />
selected by a panel of peers, now the Joint Committee<br />
on Nursing Recognition. Every Delaware nurse is eligible<br />
to nominate and be nominated. This is a statewide peer<br />
recognition program, so only nurses may nominate.<br />
Winners and honorees are recognized annually during<br />
May to coincide with nurse’s week. They are provided<br />
recognition in the May edition of Delaware Today and with<br />
a sponsored reception. Nominations for 2022 Delaware<br />
Today Top Nurses are accepted until January 3, 2022.<br />
The DAISY Foundation<br />
The DAISY Foundation is an established and highly<br />
recognized non-profit that exists solely to recognize<br />
nurses for their extraordinary compassion and skill. They<br />
deliver meaningful recognition internationally and across<br />
the nation. Numerous international, national, and state<br />
Celebrating Delaware’s Nurses<br />
associations support The DAISY Foundation and their<br />
incredible work. The Delaware Nurses Association and<br />
Delaware Organization for Nursing Leadership, with the<br />
generous support of Rhoades & Morrow LLC, is proud<br />
to become the first state nursing association to partner<br />
directly and provide DAISY awards to nurses.<br />
There are several existing DAISY-partner organizations<br />
in Delaware: Bayhealth, Beebe Healthcare, ChristianaCare,<br />
Encompass Health, Nemours, Silver Lining Healthcare,<br />
St. Francis Hospital, and University of Delaware. Nurses<br />
working for one of the above employers are already and<br />
remain eligible to be nominated and recognized by their<br />
employers. This new partnership does not change existing<br />
programs; any nominations received at the <strong>DNA</strong> for a<br />
nurse working at an existing partner will be forwarded to<br />
that DAISY coordinator. The Delaware Nurses Association<br />
encourages all eligible nurse employers/organizations to<br />
partner directly with The DAISY Foundation to recognize<br />
as many extraordinary nurses as possible.<br />
Our mission at the Delaware Nurses Association and<br />
Delaware Organization for Nursing Leadership is to provide<br />
extraordinary nurses with this prestigious recognition.<br />
Whether you work in a school, prison, public health, private<br />
practice, medical aid unit, surgery center, etc., you are now<br />
eligible to become a DAISY honoree. We will work with<br />
local media, members, partners, schools, and employers<br />
to raise awareness of this program and exponentially grow<br />
nominations. Patients, families, colleagues, nurses, leaders,<br />
and all are encouraged to submit nominations for their<br />
extraordinary nurses. The nomination form is live and can<br />
be accessed at http://www.daisynomination.org/<strong>DNA</strong>.<br />
Because of the generous support of Rhoades & Morrow<br />
LLC, we will be offering nurse employers free posters and<br />
window clings (in addition to online, self-print materials) to<br />
place in their practice settings to increase awareness and<br />
nominations for this honor.<br />
The nominations will be blinded and reviewed by the<br />
Joint Committee on Nursing Recognition and honorees<br />
selected for various categories (direct care nurse, team,<br />
leader, lifetime achievement, health equity, faculty, and<br />
students). Honorees will be vetted, approved, and presented<br />
with their recognition during a surprise presentation at<br />
their practice setting. Becoming a DAISY honoree provides<br />
nurses with pride, gratitude, and a plethora of benefits<br />
and continued opportunities. Speaking personally, it is<br />
still a career highlight when I and my colleagues in the<br />
Cardiovascular Critical Care Complex were presented with a<br />
DAISY Team Award in June 2018. We were nominated by<br />
the family of a patient we cared for, and it remains one of<br />
my most cherished nursing memories.<br />
We are humbled and excited to bring this<br />
meaningful recognition to all Delaware nurses and<br />
continue building the legacy and history of both<br />
The DAISY Foundation and the profession of<br />
nursing.<br />
Additional Specialized Awards and More<br />
Another focus of the Joint Committee on Nursing<br />
Recognition will be to uplift and celebrate Delaware’s<br />
notable nurses that contributed to the profession here<br />
and nationally. The committee will explore custom awards<br />
named after Delaware’s most influential and noted nurses.<br />
These awards will continue to uplift and celebrate nurse<br />
contributions in specific areas of the profession, such as<br />
advanced practice leadership and government relations/<br />
advocacy. We will also partner with our organizational<br />
affiliates, state specialty nursing associations, to generate<br />
awards for the many nursing practice specialties and elevate<br />
exceptional nurses from all areas of the profession.<br />
Just because the committee has already been selected<br />
doesn’t mean you can’t contribute. Through Delaware<br />
Nursing Dialogue, social media, and other communications<br />
the joint committee will be engaging all nurses in defining,<br />
promoting, and providing meaningful statewide nurse<br />
recognition. Why not start now? Have an idea? Send<br />
it to us using email, contactdna@denurses.org. On this<br />
topic, and all matters affecting Delaware nurses, we are<br />
continuously open to your feedback and suggestions.<br />
We are excited to bring these advancements forward<br />
for Delaware’s nurses. The volunteerism and generosity<br />
of members, organizational affiliates, and partners is<br />
what makes these programs possible. Membership is<br />
not required to be nominated, to nominate, or to be<br />
recognized; however, we hope you will consider sharing<br />
your support in the best way possible – become a <strong>DNA</strong><br />
member. With a large, diverse, and continuously growing<br />
membership, <strong>DNA</strong> can bring Delaware nurses more value,<br />
advocacy, solutions, and more.<br />
References<br />
American Association of Critical-care Nurses. (<strong>2021</strong>). Meaningful<br />
Recognition. Retrieved from https://www.aacn.org/<br />
nursing-excellence/healthy-work-environments/meaningfulrecognition.<br />
Kelly, L. A. & Lefton, C. (2017). Effect of meaningful recognition<br />
on critical care nurses’ compassion fatigue. American Journal<br />
of Critical Care. 26(6), 438-444. doi: 10.4037/ajcc2017471<br />
Kim, L. Y., Rose, D. E., Ganz, D. A., Giannitrapani, K. F., Yano, E.<br />
M., Rubenstein, L. V., & Stockdale, S. E. (2020). Elements of<br />
the healthy work environment associated with lower primary<br />
care nurse burnout. Nursing Outlook. 68(1), 14-25. doi:<br />
10.1016/j.outlook.2019.06.018<br />
Lefton, C. (2014). Beyond thank you: The powerful reach of<br />
meaningful recognition. American Nurse. Retrieved from<br />
https://www.myamericannurse.com/beyond-thank-you-thepowerful-reach-of-meaningful-recognition/.
Page 4 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />
Guest Editor continued from page 1<br />
treatment options and willingness to pursue or not pursue.<br />
How a patient understands their choices influences the<br />
care they receive in end of life care, and options should be<br />
well laid out to our patients for informed decision making.<br />
Treatment decisions in end of life care include<br />
resuscitation in the form of CPR or intubation, palliative<br />
sedation for intractable pain, refusal of artificial nutrition<br />
and hydration via tube, refusal of life saving surgery,<br />
refusal of blood products, refusal of antibiotics, refusal<br />
of chemotherapy or radiation therapy, and refusal for<br />
initiation of or stopping of hemodialysis. These decisions<br />
to stop or not initiate treatments generally result in a<br />
death that would have naturally occurred without the<br />
intervention of medicine.<br />
I have observed that patients nearing the end of<br />
their life may make decisions to continue treatments<br />
inconsistent with their personal preferences based<br />
upon lack of information regarding the impact on their<br />
healthcare outcomes. This unwanted care has led to<br />
increased psychological distress and increased utilization<br />
of health care resources that may offer little therapeutic<br />
benefit or impact on quality of life and may leave their<br />
loved ones without the ability to have closure.<br />
In 1997, Oregon was the first state to legalize aid<br />
in dying. Since that time, Washington, D.C, California,<br />
Colorado, Hawaii, Maine, New Jersey, Vermont,<br />
Washington, and most recently in <strong>2021</strong>, New Mexico<br />
has followed suite. Although Montana does not have a<br />
dedicated law, in 2009, its supreme court supported that<br />
nothing in Montana’s State Law prohibited a physician<br />
from honoring the wishes of a competent terminally ill<br />
adult to be able to hasten their death. Only New Jersey<br />
and Hawaii currently allow nurse practitioners to prescribe<br />
end of life medications (“Death with Dignity Acts,” n.d.).<br />
Death with Dignity is the underlying concept of<br />
Delaware’s House Bill 140 (HB140), with Representative<br />
Paul S. Baumbach as the primary bill sponsor. This <strong>2021</strong>,<br />
the Delaware Death with Dignity Act, HB 140, was<br />
assigned to the House Health & Human Development<br />
Committee on the final day of the session, just before<br />
the Delaware General Assembly adjourned (“Death with<br />
Dignity Delaware,” n.d.).<br />
House Bill 140 would allow another option in end<br />
of life care, and would permit a terminally ill patient<br />
with six months or less life expectancy who is an adult<br />
resident of Delaware (age 18 and above) to request and<br />
self-administer medication to end the individual’s life in<br />
a humane and dignified manner if both the individual’s<br />
attending physician/advanced practice registered nurse<br />
(APRN) and a consulting physician/advanced practice<br />
registered nurse (APRN) agree on the individual’s diagnosis<br />
and prognosis and believe the individual has decision<br />
making capacity, is making an informed decision, and is<br />
acting voluntarily (“Delaware General Assembly,” n.d.,<br />
House Bill 140). House Bill 140 has safeguards built in to<br />
protect the public and providers when considering this as<br />
an option. It would be up to the healthcare institution and<br />
individual practitioner to consider and decide how they<br />
would respond to HB140 based on legal, ethical, moral,<br />
and personal values.<br />
The American Nurses Association (ANA, 2019) as<br />
cited in the ANA Position Statement, stated the hallmarks<br />
of end-of-life care include respect for patient selfdetermination,<br />
nonjudgmental support for patients’<br />
end-of-life preferences and values, and prevention and<br />
alleviation of suffering. Death with Dignity should be<br />
viewed as medical aid to those dying with a terminal illness<br />
(OJIN, 2019). It is not considered suicide, assisted suicide,<br />
homicide, or euthanasia, and would offer another option<br />
in end of life care planning to existing hospice care and<br />
comfort care provided under palliative care. The ANA<br />
2019 position statement recommends that nurses have<br />
knowledge on the current environment for medical aid<br />
in dying and remain objective if patients wish to discuss<br />
medical aid in dying, thus preserving self-autonomy and<br />
dignity in making end of life health care decisions (OJIN,<br />
2019).<br />
States that have Death with Dignity Laws provide<br />
another option suited to meet end of life preferences<br />
in those suffering with a terminal illness. The role of the<br />
nurse is to listen, to be an advocate for their patient’s<br />
needs, and to ensure continuation of care based on the<br />
patient’s personal preferences. Only our patients can state<br />
their wishes for their end of life care planning and tell us if<br />
medical aid in dying would be in their best interest.<br />
This edition of the <strong>DNA</strong> <strong>Reporter</strong> is focused on how<br />
palliative care may improve quality of life and preserve<br />
dignity in end of life care. The first step is to recognize<br />
the need to have end of life care discussions to share<br />
our thoughts on how we want to spend our final days<br />
and to revisit one’s medical wishes as health changes.<br />
Heather Milea, MSN, FNP-BC, AGACNP-BC, PCCN,<br />
CHFN, highlights how the Covid epidemic impacted<br />
patient’s quality of life in end of life care. Ginna Keil,<br />
MSN, FNP-BC demonstrates how community palliative<br />
care is high quality and cost effective when shifting the<br />
focus from active disease treatment to comfort care.<br />
LaTonya Mann, DNP, FNP-BC, OCN discusses that early<br />
intervention of palliative care with the assistance of<br />
nursing leads to a better quality of life for those living<br />
with cancer. Kiernan Quay, DNP, APRN, FNP-C relays<br />
that non beneficial treatment in end of life care may not<br />
equate with quality of life. Karin Cooney-Newton, MSN,<br />
RN, APRN, ACCNS-AG, CCRN presents an effective<br />
objective tool for end of life care that can promote<br />
comfort and alleviate suffering for patients and their<br />
families in end of life care.<br />
References<br />
ANA Position Statement: The nurse’s role when a patient<br />
requests medical aid in dying. (2019). OJIN: The Online<br />
Journal of Issues in Nursing, 24 (3). https://www.doi.<br />
org/10.3912/OJIN.Vol24No03PoSCol02<br />
Death with Dignity. (n.d). https://deathwithdignity.org Retrieved<br />
7/20/<strong>2021</strong>.<br />
Death with Dignity, Delaware. (n.d.). https://deathwithdignity.<br />
org/states/delaware/<br />
Death with Dignity Acts. (n.d.) https://deathwithdignity.org/learn/<br />
death-with-dignity-acts Retrieved 8/11/<strong>2021</strong>.<br />
Delaware General Assembly, House bill 140. https://legis.<br />
delaware.gov/BillDetail?LegislationId=79026 Retrieved<br />
10/7/<strong>2021</strong><br />
Institute of Medicine. (1997). Approaching death: Improving care<br />
at the end of life. Washington,D.C: National Academy Press.<br />
The Delaware Code Online (n.d). Title 16 Health and Safety,<br />
Regulatory Provisions Concerning Public Health Chapter<br />
25. Health-Care Decisions, section 2502. http://delcode.<br />
delaware.gov/title16/c025/ accessed 7/1/<strong>2021</strong>.
<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 5
Page 6 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />
COVID-19 Pandemic Through the Lens of an Inpatient Palliative Medicine Provider<br />
Heather M. Milea, MSN, FNP-BC, AGACNP-BC, PCCN, CHFN<br />
Heather M. Milea is currently a nurse practitioner on the palliative<br />
care team at Christiana Care Hospital where she has worked for<br />
over twenty years with an acumen in family medicine, advanced<br />
heart failure, and cardiology. She is a graduate of the University of<br />
Delaware’s undergraduate baccalaureate nursing program and Master<br />
of Science in Nursing program with a concentration in family nurse<br />
practitioner. She completed a post-master’s graduate degree at the<br />
University of Pennsylvania in adult gerontology acute care. Heather<br />
has been recognized as one of the <strong>2021</strong> top nurse practitioners by<br />
Delaware Today, is a member of the Delaware Coalition for Nurse<br />
Practitioners, and serves on the palliative team wellness committee<br />
and transition team at Christiana Care Hospital. Heather may be<br />
reached at hmilea@christianacare.org.<br />
Heather M. Milea<br />
The COVID-19 pandemic systemically obstructed the delivery of traditional<br />
healthcare, particularly impacting our chronically ill and frail patients. Healthcare<br />
delivery for the hospitalized, critically ill COVID-19 cohort was challenging because<br />
of the complex symptom management, rapid physical decline, high mortality,<br />
and increased intensive care utilization (Rosa et al., 2020). As the virus infiltrated<br />
Delaware, this problem was further aggravated as our healthcare organizations<br />
followed the isolation strategies established by other institutions: significant<br />
restrictions in visitation, limiting the flow of providers in and out of rooms, and<br />
segmenting COVID-19 patients from other patient populations. Despite the obvious<br />
public health need to reduce transmission of the respiratory pathogen, an illconsidered<br />
byproduct was the social isolation, severing our instinct to be present<br />
with loved ones during a serious illness. With the isolation increasing our patients’<br />
suffering and our efforts to provide holistic care frustrated, care delivery models<br />
had to be radically revised as the palliative medicine team innovated and tested our<br />
processes in real time. As the expression goes, we were “building the plane as we<br />
flew.”<br />
Palliative Medicine During a Pandemic<br />
Palliative medicine providers are holistic by virtue of the discipline. Through<br />
disease counseling and goals of care for acute, chronic, or traumatic health<br />
problems, palliative medicine’s foundational ethos is to improve quality of life<br />
both inside and outside the biomedical realm, as well as reduce the burden of<br />
symptoms related to disease states. The diverse team of inpatient palliative care<br />
service providers including physicians, nurse practitioners, physician assistants,<br />
social workers, nurse navigators, and palliative chaplains collaborate to add<br />
robust, holistic care. Communication prowess is one of the revered skillsets among<br />
palliative providers, especially during end-of-life care (Pattison, 2020). The World<br />
Health Organization’s (WHO) 2018 ethical principles in humanitarian contexts<br />
strongly advocate for access to palliative care to minimize suffering and, by the<br />
United Nations International Health Regulations’ own definition of “public health<br />
emergency of international concern,” the COVID-19 pandemic would most certainly<br />
qualify.<br />
As the pandemic disintegrated traditional healthcare delivery, inpatient palliative<br />
care consults for COVID-19 patients surged. Among the significant symptom burden<br />
of a hospitalized COVID-19 patients, anxiety and loneliness may be among the<br />
most hidden and difficult to resolve, even in optimal healthcare scenarios. In an<br />
environment where care teams and resources were burdened, and intensivists and<br />
nurses occupied the limited bedside to provide care, the palliative medicine team<br />
had to reinvent how to expedite care for this vulnerable, often frail, population. That<br />
revitalized care model was discovered in what originally gave our team strength: our<br />
multidisciplinary teamwork.<br />
Multidisciplinary Palliative Medicine Team and Virtual Management<br />
To bridge the gap of visitor restrictions, our team implemented off-the-shelf,<br />
consumer technology (i.e., iPads) equipped with videoconferencing platforms<br />
in COVID-19 rooms and at nursing servers. The care team worked “virtually” for<br />
inpatient visits, allowing for high-touch care in limited-touch environments. Trained,<br />
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medical language translation specialists and cultural consults were brought on to<br />
provide culturally competent care. The palliative medicine team now had an option<br />
to facilitate our exacting, rapport-dependent care for our patients and family,<br />
extending our ability to supply support and connection.<br />
Unfortunately, despite institutional support for the technology program,<br />
family stakeholders did not have universal access to platforms for virtual<br />
visits, forcing many difficult conversations to take place via telephone. In this<br />
context, the absence of important, nonverbal cues diminished the quality<br />
of interaction, especially regarding difficult, end-of-life communications.<br />
Vulnerable stakeholders had to trust a medical team to help with emotionally<br />
overwrought decisions without the comfort of connecting to their loved ones.<br />
Serious Conversations<br />
“Ordinary” critically ill scenarios can limit time to have meaningful<br />
healthcare conversations on the values and wishes of the patient. The often<br />
precipitous decline that can happen with COVID-19 hospitalized patients<br />
further compacted the time to prepare patients and their care circle. Often,<br />
that involved standing outside an ICU room of a COVID-19 patient struggling<br />
with fear, providing through the glass a calm voice of comfort, an ear to<br />
listen, or a provider who could treat symptoms of air hunger, anxiety, or even<br />
claustrophobia.<br />
The palliative medicine team elected to implement best practices from<br />
COVID-19 conversation guides. VITALtalk (n.d.), a nonprofit social impact<br />
organization for clinicians, encouraged early and clear communication, as<br />
well as exploring patient goals and making care recommendations based<br />
on those stated goals. For the team, discussions with the patient and their<br />
support system regarding prior advance care planning documents, anticipatory<br />
guidance of swift clinical deterioration, and code status ensued immediately<br />
into a hospitalized patient’s COVID-19 course. With those that were fortunate<br />
to survive the acute phase of their inflammatory-related respiratory failure,<br />
the palliative medicine team counselled patients on the trajectory of the longterm<br />
sequalae of COVID-19, including fibrotic lung disease, coagulopathies,<br />
cardiomyopathies, debility, and failure to thrive. The work was a delicate<br />
balance of active listening and support to spouses, children, and care circles<br />
physically separated from their sick family members. For patients that passed<br />
without a loved one near, our nurses held their hands.<br />
End-of-life Care for COVID-19 Patients Amidst a Global Pandemic<br />
Suffering, end-of-life COVID-19 patients are most treated for dyspnea,<br />
restlessness, anxiety, and delirium, along with significant spiritual and<br />
psychosocial needs. Dyspnea and delirium are among the most common<br />
symptoms in dying patients with COVID-19 and, despite attempts at managing<br />
underlying cause of dyspnea, refractory dyspnea and hypoxia may persist<br />
(Sun et al., 2020). The Center to Advance Palliative Care (n.d.) developed<br />
crisis protocols for managing common symptoms associated with COVID-19,<br />
which our team follows. Opioids are the treatment choice for refractory<br />
dyspnea and as-needed dosing is safer and more effective compared to an<br />
opioid infusion. Non-pharmacologic interventions include sitting the patient<br />
in either an upright or, in some instances, prone position. The decision in<br />
favor of COVID-19 ventilation focuses on limiting lung damage and mitigating<br />
aerosolization of the virus. In circumstances where continuing aggressive<br />
care was futile or where goals of care dictated de-escalating or withdrawing<br />
ventilation support, the ICU and palliative teams initiate end-of-life discussions<br />
to guide a compassionate withdrawal of care with an emphasis on a dignified<br />
passing. Preparing the family is imperative; expectations, suggestions, and<br />
exploration of their concerns are important to ameliorate prior to withdrawal<br />
of care. Hospice resources for family and their care circle is robust, not only<br />
during their hospice care, but also in bereavement support that extends after<br />
their loved one’s passing.<br />
The palliative team’s principle is to provide physical, spiritual, and<br />
psychosocial comfort for our patients and their extended care circle. During<br />
the COVID-19 pandemic, the collaboration with primary and specialty services<br />
complimented the front-line workers who were brave enough to support our<br />
community. Moreover, just as we do for patients, the palliative medicine team<br />
offers safe haven to support colleagues without prejudice. There have been<br />
far too many tragic losses related to COVID- 19 and, as a society, we share a<br />
collective and complicated grief that we have not yet begun to unpack.<br />
References<br />
Center to Advance Palliative Care (n.d.). COVID-19 rapid response resources hub. https://<br />
www.capc.org/covid-19/<br />
Pattison, N. (2020). End-of-life decisions and care in the midst of a global coronavirus<br />
(COVID-19) pandemic. Intensive and Critical Care Nursing, 58. https://doi.org/10.1016/j.<br />
iccn.2020.102862<br />
Rosa, W.E., Meghani, S.H., Stone, P.W. and Ferrell, B.R. (2020). Opportunities for nursing<br />
science to advance patient care in the time of COVID-19: A palliative care perspective.<br />
Journal of Nursing Scholarship, 52(4), 341-343. https://doi.org/10.1111/jnu.12570<br />
Sun, H., Lee, J., Meyer, B. J., Myers, E. L., Nishikawa, M. S., Tischler, J. L., & Blinderman, C. D.<br />
(2020). Characteristics and palliative care needs of COVID-19 patients receiving comfortdirected<br />
care. Journal of the American Geriatrics Society, 68(6), 1162–1164. https://doi.<br />
org/10.1111/jgs.16507<br />
VITALtalk (n.d.). COVID Ready communication playbook. https://www.vitaltalk.org/wpcontent/uploads/VitalTalk_COVID_English.pdf<br />
World Health Organization (2018). A WHO guide: Integrating palliative care and symptom<br />
relief into the response of humanitarian emergencies and crises. https://apps.who.int/iris/<br />
bitstream/handle/10665/274565/9789241514460-eng.pdf
<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 7<br />
Community-Based Palliative Care: High Quality and Cost Effective<br />
Ginna Keil, MSN, FNP-BC<br />
Ginna Keil earned her Associate of Arts Degree in General<br />
Studies in 2002 followed by her Associates of Science Degree<br />
in Nursing in 2006 from Wor-Wic Community College.<br />
Ginna was a registered nurse in the State of Maryland<br />
and Delaware for 13 years with nursing experience in the<br />
emergency department, women and children’s health,<br />
and neonatal intensive care settings. Ginna furthered her<br />
education by receiving her Bachelor of Science Degree in<br />
Nursing and graduated with her Master of Science Degree<br />
in Nursing from Wilmington University in 2018. Certified<br />
by the American Academy of Nurse Practitioners, Ginna<br />
practices as a Family Nurse Practitioner in the State of<br />
Delaware. Ginna currently is employed with Delaware<br />
Hospice and provides Palliative and Hospice services in the Ginna Keil<br />
community setting. Professional achievements include member of the Phi Theta<br />
Kappa-Honor Society, Daisy Award Recipient, Maternal Child Award, Nursing Service<br />
Excellence Awards, and Delaware Hospice Star Award. Ginna may be reached at<br />
gkeil@delawarehospice.org.<br />
Widely known among healthcare providers are the challenges today’s<br />
Healthcare system face secondary to an expanding aging population who<br />
suffer serious illness compounded by multiple medical comorbidities.<br />
According to data provided by the Center to Advance Palliative Care (CAPC,<br />
2015), there are at least 12 million adults and 400,000 children in the United<br />
States living with a serious illness and by the year 2030, people aged 85<br />
and over are expected to double to 8.5 million. The Delaware Healthcare<br />
Association (DHA, 2019) reported that emphasis on disease specific treatments<br />
have become commonplace rather than holistic treatment that addresses<br />
the needs of patients and their caregivers. In many cases, this focus has<br />
led to fragmented and burdensome care with inadequate management of<br />
symptoms resulting in unnecessary suffering. It is, therefore, a system that<br />
is unsustainable in terms of poor quality and high cost. The question then<br />
becomes, ‘how does the Healthcare system meet the needs of this growing<br />
population while still delivering high quality and financially sustainable care?’<br />
(CAPC, 2015).<br />
A potential solution may lie in the specialty of palliative care medicine which<br />
has been growing in popularity globally over the last two decades. What is<br />
palliative care? With a unique holistic approach that is both patient and<br />
family centered, the Center to Advance Palliative Care (2019) explained that<br />
the design of palliative care is to anticipate, prevent, and manage physical,<br />
spiritual, social, and psychological aspects of health and improve the quality<br />
of life for patients, families, and caregivers throughout their illness trajectory.<br />
Furthermore, based on patient need rather than diagnosis, any individual<br />
regardless of age who are diagnosed with a serious illness may receive<br />
palliative care services alongside curative treatment. Although services may<br />
be initiated at any stage of the illness trajectory, implementation in the early<br />
stages of the disease process have resulted in improved patient care outcomes.<br />
As leaders in healthcare recognize the impact that cost effective and<br />
high-quality palliative care have on patients, caregivers and healthcare<br />
organizations, services are now available in 94% of hospitals with more than<br />
300 beds and available in 72% of hospitals with more than 50 beds (Center<br />
to Advance Palliative Care, n.d.). Inpatient palliative care consultation is<br />
associated with a reduction in healthcare costs with a total savings of more<br />
than $1.3 million for a 300-bed community hospital and more than $2.5<br />
million for the average academic medical center (Cruz-Oliver, 2017).<br />
Expansion of palliative services is a Healthcare necessity and should be<br />
offered on every level and across all settings in efforts to meet the many<br />
needs of Americans living with serious illness compounded by multiple medical<br />
comorbidities (CAPC, <strong>2021</strong>). Hospitals and health systems are now extending<br />
palliative services into community settings including but not limited to<br />
physician offices, ambulatory clinics, cancer centers, skilled nursing facilities,<br />
and patient homes. In addition to hospitals and health systems, service<br />
delivery is provided by primary care physicians, specialty practices, private<br />
companies, home health aid agencies, and hospices (CAPC, n.d.). Palliative<br />
care is multidisciplinary and includes a team of dedicated medical, nursing, and<br />
allied health professionals. The comprehensive role of the palliative care team<br />
throughout the trajectory of the patient’s illness includes but is not limited to<br />
expert pain and complex symptom management, provision of psychological,<br />
spiritual, and emotional support, medication management and monitoring,<br />
and the completion of advance health directives. The palliative care team<br />
works collaboratively with specialists in the community that allows for<br />
coordination of care. As the trajectory of illness progresses, locations as well<br />
as wishes of the patient and their caregivers may change. Community based<br />
palliative care allows for consistency across transitions (CAPC, <strong>2021</strong>).<br />
Community based palliative care allows for a reach to patient populations<br />
that neither fit hospice eligibility nor are hospitalized and are stable enough to<br />
reside in the community setting. Many individuals suffering from serious illness<br />
and chronic medical conditions experience mobility issues with functional<br />
limitations that do not allow travel to office settings or are burdensome.<br />
Often, it is the preference of many individuals suffering from chronic medical<br />
conditions to remain at home while coping with their serious illness.<br />
The National Coalition for Hospice and Palliative Care (NCHPC, 2018)<br />
explained that with disease progression, the emphasis shifts from active<br />
treatment of the disease to treatment that promotes comfort with an improved<br />
quality of life. Anticipatory guidance is provided regarding disease process,<br />
progression, and strategies for management in efforts to optimize quality<br />
of life. They further explained that palliative care providers facilitate patient<br />
autonomy, by providing access to information and choice regarding their care.<br />
Palliative care in the home setting promotes the development of a trusting<br />
rapport and fosters feelings of support and connectivity. This allows for<br />
sensitive conversations of how individual values, preferences, ethnicity, culture,<br />
and spiritual beliefs play a role in their healthcare (NCHPC, 2018).<br />
The Center to Advance Palliative Care, (<strong>2021</strong>) recognizes that there is strong<br />
evidence that implementation of community based palliative care services<br />
results in compassionate, affordable, sustainable high-quality care, and is<br />
associated with reduced nonbeneficial emergency department visits and<br />
hospitalizations. Reduced hospital readmissions may lead to reduced penalties<br />
for hospitalized patients with serious chronic illnesses.<br />
Where do hospitals in the State of Delaware stand regarding equitable<br />
access to palliative care services? Delaware Healthcare Association (DHA, 2019)<br />
President & CEO Wayne A. Smith stated, “Delaware hospitals are proud to<br />
lead the nation in providing access to quality palliative care for our friends and<br />
neighbors” (para. 3). Delaware hospitals were leading the nation in 2019 by<br />
providing individuals living with a serious illness equitable access to palliative<br />
care services according to the 2019 State-by-State Report Card on Access<br />
to Palliative Care in Our Nation’s Hospitals (DHA, 2019). The integration of<br />
palliative care services promotes the high quality and financially sustainable<br />
care needed to meet the physical, spiritual, social, and psychological needs of<br />
patients and their caregivers who suffer serious illness. Leaders in Healthcare<br />
nationwide must strive to integrate palliative care medicine into healthcare<br />
systems and ensure that patients from all populations and across all settings<br />
receive this invaluable service.<br />
References<br />
Center to Advance Palliative Care. (2015). A guide to building a hospital-based<br />
palliative care program. file:///C:/Users/ginna/Downloads/the-capc-guide-tobuilding-a-hospital-palliative-care-program.pdf<br />
Center to Advance Palliative Care. (<strong>2021</strong>). Concepts of community-based palliative care<br />
program design 101: Learner’s Guide. file:///C:/Users/ginna/Downloads/conceptsof-community-based-palliative-care-program-design-101-learners-guide.pdf<br />
Center to Advance Palliative Care. (2019). Key findings on the perceptions of palliative<br />
care. https://media.capc.org/recorded-webinars/slides/1lessAudience_Research_<br />
Webinar_Aug_8-2019_FINAL.pdf<br />
Center to Advance Palliative Care. (n.d.). The case for community-based palliative<br />
care: A new paradigm for improving serious illness care. file:///C:/Users/ginna/<br />
Downloads/the-case-for-community-based-palliative-care.pdf<br />
Cruz-Oliver D. (2017). Palliative Care: An Update. Missouri Medicine, 114(2), 110 –115.<br />
Delaware Healthcare Association. (2019). Delaware receives top “A” grade on access<br />
to palliative care in our nation’s hospitals. https://deha.org/News/Press-Releases/<br />
Delaware-Receives-Top-A%E2%80%9D-Grade-on-Access-to-Pallia<br />
National Coalition for Hospice and Palliative Care. (2018). National Consensus Project<br />
for Quality Palliative Care. https://www.nationalcoalitionhpc.org/ncp<br />
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Page 8 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />
Palliative Care: Including Nursing in Early Intervention<br />
LaTonya E. Mann, DNP, FNP-BC, OCN<br />
Dr. Latonya Mann earned<br />
her Licensed Practical Nurse<br />
degree from Salem Community<br />
College, Associate Degree in<br />
Nursing from Gloucester County<br />
College, Bachelors in Nursing<br />
from Immaculata University,<br />
Master’s Degree from University<br />
of Delaware, and Doctorate in<br />
Nursing Practice from Wilmington<br />
University. She is a board certified<br />
Family Nurse Practitioner. Dr.<br />
Mann is Past President for<br />
Delaware Diamond Chapter LaTonya E. Mann<br />
of Oncology Nursing Society and a member of the Delaware<br />
Nurses Association, Delaware Coalition of Nurse Practitioners,<br />
and Sigma Theta Tau International Honor Society of Nursing.<br />
Dr. Mann brings over 35 years of experience in various<br />
settings of nursing including medical-surgical, intensive care,<br />
home infusion therapy, palliative care, and oncology nursing.<br />
She presently works as a Nurse Practitioner with the Medical<br />
Oncology team at Bayhealth Cancer Center. Dr. Mann may be<br />
reached at LaTonya_Mann@bayhealth.org<br />
The Center of Advanced Palliative Care (CAPC, <strong>2021</strong>)<br />
defines palliative care as:<br />
Specialized medical care for people living with a serious<br />
illness. This type of care is focused on providing relief<br />
from the symptoms and stress of the illness. The goal<br />
is to improve quality of life for both the patient and the<br />
family. Palliative care is provided by a specially-trained<br />
team of doctors, nurses and other specialists who work<br />
together with a patient’s other doctors to provide an<br />
extra layer of support. Palliative care is based on the<br />
needs of the patient, not on the patient’s prognosis. It<br />
is appropriate at any age and at any stage in a serious<br />
illness, and it can be provided along with curative<br />
treatment. (para. 2)<br />
Palliative care teams work alongside a patient’s team<br />
of specialists to provide symptom and communication<br />
expertise, emotional support, assistance with medical<br />
decision making, and assistance with end-of-life care and<br />
bereavement support when appropriate (Finn et al., 2017).<br />
Palliative care can be provided in a variety of settings,<br />
including inpatient hospital consultation, outpatient<br />
clinics, assisted living and long-term care facilities, and<br />
even home-based care. The most familiar mode of<br />
palliative medicine delivery is inpatient-based services<br />
that may involve a single practitioner or a consultant<br />
palliative care medicine team. These medical providers<br />
are available throughout the entire hospital setting, from<br />
Vacancy Announcement<br />
Adjuncts and Part-time Teaching Positions<br />
Department of Nursing<br />
Wesley College of Health & Behavioral Sciences<br />
Part time Adjunct positions-lecture and clinical areas: maternal/<br />
newborn nursing, medical/surgical nursing, mental health nursing, child<br />
and family nursing, community and/or public health nursing.<br />
Full time faculty positions-Clinical Practitioner, Maternal/Newborn<br />
Nursing Faculty, Medical/Surgical Nursing Faculty, Mental Health Nursing<br />
Faculty, Child and Family Nursing Faculty.<br />
Full time Staff positions-Skills Lab Coordinator-<br />
Required:<br />
• Delaware State University Masters of Science in Nursing with a focus<br />
on the area applying for<br />
• Current unencumbered RN license in the state of Delaware<br />
• Current clinical nursing experience<br />
• Teaching experience in higher education preferred<br />
• Simulation experience preferred<br />
Special Instructions: Interested applicants must apply online at DSU<br />
website: www.desu.edu. If invited for an interview, provide resume/<br />
curriculum vitae and three (3) professional references with contact<br />
information.<br />
Apply for this posting only if you are interested AND qualified for the<br />
position in the Department of Nursing. It is important that you specify<br />
your area of clinical expertise and interest in your cover letter in order to<br />
be considered as a viable adjunct/part-time candidate.<br />
DSU is an equal opportunity, Title IX Employer and does not discriminate against persons<br />
on the basis of race, religion, national origin, sexual orientation, gender, marital status,<br />
age or disability.<br />
the emergency department and intensive care unit to a<br />
rehabilitation unit if appropriate (Thomas et al., 2019).<br />
Early Integration<br />
Although there are current guidelines to advocate<br />
early integration of palliative care and research that show<br />
its benefits, there are several barriers to palliative care<br />
referrals. The most common is the misperception that<br />
palliative care is only associated with end of life. However,<br />
most patients accept palliative care intervention without<br />
a loss of hope. The ENABLE and ENABLE II studies<br />
showed decreased depression in patients who received<br />
palliative care, providing evidence that palliative medicine<br />
consultations should not be postponed until failure of<br />
therapy, symptom crisis, or end of life (Thomas et al.,<br />
2019).<br />
As healthcare providers, nurses struggle every<br />
day on what words to choose to deliver bad news to<br />
patients. Many providers wrestle with how to begin the<br />
conversation and knowing the appropriate time to discuss<br />
prognosis. Many have little training on how to deal with<br />
the patient and caregiver emotions. This is due to the<br />
limited training and education in palliative care. According<br />
to Sedhom et al. (2020), oncologists give bad news to<br />
patients an average of 35 times a month, yet few have<br />
training or mentorship in communication skills. Oncologists<br />
are more medicine oriented and fellows report receiving<br />
more coaching on how to perform bone marrow biopsies,<br />
a technical skill, than on how to conduct a family meeting.<br />
Word choice may feel trivial compared with the plethora of<br />
other things that need to be learned. Yet, words influence<br />
medical decision making and have implications for patient<br />
care (Sedhom et al., 2020).<br />
Nursing in Early Intervention<br />
Nursing is a profession within healthcare focused on<br />
the care of individuals, families, and communities so they<br />
may attain, maintain, or recover optimal health and quality<br />
of life. For the fifteenth consecutive year, the Gallup poll<br />
has ranked nursing as the most trusted profession, and<br />
nurses as the professionals who uphold the highest ethical<br />
obligations in establishing community relationships of trust<br />
according to society needs and desires.<br />
Nurses look after patient’s most intimate needs<br />
during their most vulnerable times, and they do so with<br />
compassion. While it is the provider who manages the<br />
overall treatment plan, nurses are the ones who carry it<br />
out. It is the nurse ninety-nine per cent of the time that the<br />
patient and family members interact with in the hospital<br />
setting. Patients know when they call for help, it is their<br />
nurse who will carry out their needs with compassion.<br />
Nurses draw on this trust by advocating for their patient’s<br />
healthcare needs. Patients are more likely to listen to the<br />
advice of their nurse and trust they will advocate for their<br />
overall well-being. When the patient has a poor health<br />
prognosis, patients rely on their nurse who has cared for<br />
them during their hospital stay to tell the truth and help<br />
them to make informed decisions about their healthcare.<br />
For these reasons, it would be to the patient and families’<br />
benefit to have bedside nurses more engaged in family<br />
meetings.<br />
According to Goehring (2017), there are several reasons<br />
a family meeting would be requested by the healthcare<br />
team. Most often there is a decline in the patient’s<br />
medical condition or prognosis and further goals of care<br />
discussions are necessary. There may also be a need for<br />
further discussions about DNR and DNI status as well<br />
as other life sustaining methods such as feeding tube<br />
placement, blood transfusions, and artificial hydration. For<br />
an effective family meeting with an oncology patient, it<br />
would be very beneficial to request the attendance of<br />
the bedside oncology nurse. The oncology nurse can<br />
provide updates on the patient’s medical status, assist<br />
patients with interpreting information, and answer<br />
questions or concerns the patient and loved ones may<br />
have during and post family meeting.<br />
Palliative care for Patients with Advanced Cancer<br />
The role of engaged and involved bedside nurses is<br />
critical to the integration of palliative care for patients<br />
with advanced cancer. A survey was performed<br />
to assess nurses’ perspectives on palliative care<br />
communication. It involved distributing a 46-item<br />
survey via email in 2013 to bedside nurses working<br />
in ICUs across five academic medical centers of the<br />
University of California. The survey was sent to 1791<br />
nurses; 598 (33%) responded. Most participants<br />
reported that their engagement in discussions of<br />
prognosis, goals of care, and palliative care was very<br />
important to the quality of patient care. A minority<br />
reported often discussing palliative care consultations<br />
with physicians (31%) or families (33%); 45% reported<br />
rarely or never participating in family meeting<br />
discussions. Participating nurses most frequently<br />
cited the following barriers to their involvement in<br />
palliative care communications: need for more training<br />
(66%), physicians not asking their perspective (60%),<br />
and the emotional toll of discussions (43%). The<br />
article concluded that ICU bedside nurses see their<br />
involvement in discussions of prognosis, goals of care,<br />
and palliative care as a key element of overall quality<br />
of patient care. Interventions are needed to ensure that<br />
nurses have the education, opportunities, and support<br />
to actively participate in these discussions (Boyle et al.,<br />
2017).<br />
Despite the evidence for a fundamental need for<br />
palliative care services in the practice of oncology,<br />
integration of these medical specialties remains a<br />
clinical challenge. Palliative care has a wide and<br />
significant role in providing palliative care services to<br />
inpatient and outpatient settings. An effective palliative<br />
care and oncology nurse collaboration improves<br />
patient care and QOL. Further research in the role of<br />
integrating the bedside nurse may improve patient and<br />
caregiver outcomes. To stay on top of the profession<br />
and to stay advanced in the field, nurses are expected<br />
to take professional development courses to help<br />
them carry out their duties to the best of their ability.<br />
Taking a course in palliative care would be highly<br />
recommended to assist with goals of care discussions.<br />
References<br />
Boyle, D. A., Barbour, S., Anderson, W., Noort, J., Grywalski,<br />
M., Myer, J., Hermann, H. (2017). Palliative care<br />
communication in the ICU: Implications for an oncologycritical<br />
care nursing partnership. Seminars in oncology<br />
nursing. 33(5) 544-554.<br />
Center to Advanced Palliative Care (CAPC). (<strong>2021</strong>). https://<br />
www.capc.org/about/palliative-care<br />
Ferrell, B., Meyer, J., O’Neil-Page, E., Cain, J., Herman,<br />
H., Mitchell, W., & Pantilat, S. (2016) ICU Bedside<br />
nurses’ involvement in palliative care communication:<br />
A multicenter survey. Journal of Pain Symptom<br />
Manage. Mar; 51(3):589-596.e2. https://doi: 10.1016/j.<br />
painsymman.2015.11.003.<br />
Finn, L., Green, A. R., and Malhotra, S. (2017). Oncology and<br />
palliative medicine: Providing comprehensive care for<br />
patients with cancer. Ochsner Journal, <strong>December</strong>;17 (4)<br />
393-397.<br />
Glajchen, M., Goehring, A. (2017). The family meeting in<br />
palliative care: The role of the oncology nurse. Seminars<br />
in Oncology Nursing; 33 (5): 489-497.<br />
Milton, C. L. (2018). Will nursing continue as the<br />
most trusted profession? Ethical overview.<br />
Nursing Science. Jan; 31 (1): 15-16. https://<br />
DOI: 10.1177/0894318417741099<br />
Sedom, R. Sedhom, R., Gupta, A., Von Roenn, J., & Smith, T.<br />
J. (2020). The case for focused palliative care education<br />
in oncology training. Journal of Clinical Oncology :<br />
official journal of the American Society of Clinical<br />
Oncology, 38(21), 2366–2368. https://doi.org/10.1200/<br />
JCO.20.00236<br />
Thomas, T. H., Jackson, V. A., Carlson, H., Rinaldi, S., Sousa,<br />
A., Hansen, A., Kamdar, M., Jacobsen, J., Park, E. R., Pirl,<br />
W. F., Temel, J. S., Greer, J. A. (2019). Communication<br />
differences between oncologists and palliative care<br />
clinicians: A qualitative analysis of early, integrated<br />
palliative care in patients with advanced cancer. Journal<br />
of Palliative Medicine. 22 (1), 41-49.
<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 9<br />
Non-beneficial Treatment at the End of Life<br />
Kiernan Quay, DNP, APRN, FNP-C<br />
Dr. Kiernan Quay is an inpatient Palliative Care Nurse<br />
Practitioner at Beebe Healthcare located in Lewes, DE.<br />
She obtained her BSN at Johns Hopkins University in<br />
2009, her MSN and DNP at the Medical University of<br />
South Carolina in 2017. She previously worked in the<br />
settings of acute care, medical-surgical, trauma, and<br />
family medicine. Dr. Quay is a board certified Family Nurse<br />
Practitioner. She is a member of the bioethics, readmissions,<br />
advanced practice provider, and bylaws committees<br />
at Beebe Hospital. She is an eight-time DAISY award<br />
nominee and has twice received honorable mention for<br />
Delaware Today Top Nurses. Dr. Quay may be reached at<br />
Kquay@beebehealthcare.org.<br />
Kiernan Quay<br />
Non-beneficial treatment (NBT) affects over a third of patients at end of life (EOL)<br />
(Cardona-Morrell et al., 2016). The shift from beneficence to autonomy coupled with<br />
a dramatic increase in easily accessible medical information can lead patients and<br />
surrogates to expect to be apprised of all options, including those not recommended and<br />
some not even mentioned, regardless as to whether the treatment could lead them to<br />
achieve their overall goals of care (GOC) (Macauley, 2018). This explosion of autonomy<br />
leads to increasingly complex cases where care being asked for at the end of life may be<br />
incredibly aggressive while not improving quality of life. Conflicts can arise when patients<br />
insist on inadvisable care. Some patients may have a nothing-to-lose mindset regarding<br />
interventions such as cardiopulmonary resuscitation (CPR). There is much to lose, even<br />
at the EOL. Non-beneficial treatment at EOL can lead to significant distress whether<br />
that be emotional, spiritual, physical, or financial. States often have vague legislation<br />
that attempts to offer some protection to providers who refuse to offer treatments. It is<br />
difficult to identify care that would be classified as futile with complete accuracy unless<br />
there is no true physiologic benefit (e.g., CPR in patients with substantial, irreparable<br />
head trauma). Every patient is unique, so determining if there is any chance of success<br />
is difficult, and perhaps even harder to determine the exact probability. While there are<br />
avenues for addressing requests for NBT, there may be overall less distress suffered by<br />
patients, families, and staff if NBT requests are prevented at the outset.<br />
Non-beneficial treatment at EOL, and particularly aggressive interventions such as CPR,<br />
may cause substantial distress to those providing and receiving care. One may think there<br />
is no harm in receiving or performing CPR. A nothing-to-lose mentality fails to recognize<br />
the potential for harm and ignores the responsibility to do no harm (Macauley, 2018).<br />
Cardiopulmonary resuscitation often contributes to broken ribs, internal organ damage,<br />
and the likelihood of a compromised quality of life if there is return of spontaneous<br />
circulation. Healthcare staff may experience moral distress while performing CPR at<br />
patients’ EOL. Providers may feel they are stuck in an impossible situation when they are<br />
concerned that the risk of CPR may be greater than the benefit, yet they feel obligated to<br />
fulfill patient requests. Despite significant scientific advancements, the median in-hospital<br />
adult cardiac arrest survival rate remains at 18% (Meaney et al., 2013).<br />
Per Pope (2017), when states have legislation that attempt to address NBT, they are<br />
often vague and tend to use the problematic futility terminology or reference standards<br />
such as medically ineffective or generally accepted healthcare standards. Delaware Title<br />
16, Chapter 25, section 2501 (m) defines medically ineffective treatment as any medical<br />
treatment to a reasonable degree of medical certainty, a medical procedure that will not<br />
prevent or reduce the deterioration of the health of an individual, or a medical procedure<br />
to prevent the impending death of an individual (The Delaware Code Online, n.d.). Vague<br />
legislation coupled with the nearly impossible task of deciding what is futile leads to<br />
providers being appropriately reluctant to refuse to offer treatments.<br />
At the hospital level, a bioethics committee can review cases and provide guidance<br />
on how to resolve ethical dilemmas that arise between patients and providers. Beebe<br />
Healthcare’s committee is comprised of providers, nurses, non-clinical staff, and<br />
community members. The provider who requests the consultation can accept or decline<br />
the committee’s recommendation.<br />
In addition to bioethics committees, some hospitals have a specific policy that outlines<br />
a precise process to address NBT requests. Beebe Healthcare does not currently have a<br />
NBT policy. While policy specifics vary, they must clearly define NBT to avoid treatment<br />
decisions being made based on personal values (Macauley, 2018). The policy should<br />
encourage the involvement of the Palliative Care team, if not already engaged, and the<br />
bioethics committee. Policies outline next steps if the dispute remains unsolved despite<br />
involvement of both groups. If the provider decides to limit, withdraw, or withhold NBT,<br />
the patient should be permitted to request a second opinion. If the second opinion<br />
concurs with the first, the provider must discuss the options for transfer to another<br />
provider, or another facility if appropriate, and the option to seek legal counsel (Macauley,<br />
2018). If after a reasonable period, transfer to another facility is not practical, nor has<br />
any legal action been filed, care may be unilaterally withheld or withdrawn based on the<br />
institution’s policies and procedures (Macauley, 2018).<br />
Ideally, conflicts are resolved before care is unilaterally withheld or withdrawn. With<br />
the assistance of Palliative Care teams, conflicts are avoided by implementation of early<br />
and ongoing GOC discussions prior to involving a bioethics committee and perhaps<br />
working through a NBT policy sequence.<br />
Early involvement of palliative care is advised as complex GOC discussions typically<br />
require a significant degree of rapport to be successful, and a patient-centered approach<br />
requires more than simply listing options and deferring to the patients’ choices (Macauley,<br />
2018). Palliative Care teams need to have ongoing, extensive discussions with patients to<br />
identify the patients’ values, beliefs, and what is of most importance to them in their<br />
lives. A significant portion of time is spent explaining acute and chronic medical issues<br />
and how those interact to create a prognosis. From there, individual treatment options<br />
are evaluated to determine if they may help patients progress towards their goals or<br />
lead them astray. For example, a full code status is inconsistent with the desire to die<br />
peacefully at home.<br />
Palliative Care teams are a key component to avoiding and solving requests for NBT.<br />
Patients and providers may become ensnared in vague laws and futile terminology.<br />
Engaging patients early in GOC conversations assists patients in determining if medical<br />
interventions are truly beneficial. The greatest satisfaction for patients and healthcare<br />
staff alike may come when patients are listened to, patients make decisions based on<br />
reality, and unnecessary distress is avoided.<br />
References<br />
Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016). Nonbeneficial<br />
treatments in hospital at the end of life: A systematic review on extent of the<br />
problem. International Journal for Quality in Health Care, 28(4), 456-469. doi:10.1093/intqhc/<br />
mzw060<br />
Macauley, R. C. (2018). Ethics in Palliative Care: A complete guide. Oxford University Press.<br />
Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenon, J., de Caen, A. R., Bhanji, F., Abella, B.<br />
S., Kleinman, M. E., Edelson, D. P, Berg, R. A., Aufdeheide, T. P., Menon, V., Leary, M., & on<br />
behalf of the CPR Quality Summit Investigators, the American Heart Association Emergency<br />
Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care,<br />
Perioperative and Resuscitation. (2013). Cardiopulmonary resuscitation quality: Improving<br />
cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement<br />
from the American Heart Association. Circulation, 128,417-435. https://doi.org/10.1161/<br />
CIR.0b013e31829d8654<br />
Pope, T. M. (2007). Medical futility statues: No face harbor to unilaterally refuse life-sustaining<br />
treatment. Tennessee Law Review, 1-81. https://ssrn.com/abstract=989662<br />
The Delaware Code Online. (n.d.). https://delcode.delaware.gov/title16/c025/<br />
We are currently hiring:<br />
• RN Triage (Odenton)<br />
• Staff RN (All ages continuing care)<br />
• RN MD PCP Nurse for Population Health<br />
If you have a passion for community health, we invite you to join our team.<br />
When you work for THC, you will be employed by a premier healthcare<br />
organization that continually strives for high quality, professionalism and<br />
service excellence.<br />
For more information about nursing opportunities at THC, please<br />
visit: www.totalhealthcare.org or<br />
email Michelle at: mlane@totalhealthcare.org
Page 10 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />
Using Respiratory Distress Observation Scale (RDOS) at End-of-Life<br />
Karin Cooney-Newton, MSN, RN, APRN,<br />
ACCNS-AG, CCRN<br />
Karin Cooney-Newton is a<br />
Pulmonary Clinical Nurse<br />
Specialist at Bayhealth Medical<br />
Center at both the Kent Campus<br />
in Dover, DE, and the Sussex<br />
Campus in Milford, DE. She<br />
is a BSN graduate of Widener<br />
University, and earned her<br />
Masters at Wesley College.<br />
Karin’s clinical expertise is within<br />
critical care for 33 years where<br />
her passion for end-of-life<br />
improvement is ongoing. She<br />
has presented on compassionate<br />
extubation using an objective<br />
respiratory distress observation<br />
Karin Cooney-<br />
Newton<br />
tool nationally at the National Teaching Institute & Critical<br />
Care Exposition, regionally at TRENDS, and locally at<br />
Nursing Research conferences. She has worked as adjunct<br />
faculty at Wesley College for 10 years; and is co-author<br />
of a chapter in Innovative Strategies in Teaching Nursing<br />
published by Springer April, 2020. Karin may be reached at<br />
karin_cooney-newton@bayhealth.org.<br />
End of life (EOL) patient care can be an extremely<br />
stressful experience for not only the patients, but<br />
also, their families, and the healthcare team. When<br />
training to become a nurse, the focus is largely on<br />
helping patients survive acute episodes and to assist<br />
in restoring their health. Unfortunately, not all patients<br />
are able to fully recover, or return to their desired<br />
quality of life. In 2010, 29% of deaths occurred in the<br />
hospital, and the average terminal admission lasted 7.9<br />
days according to the New England Journal of Medicine<br />
(Blinderman & Billings, 2015). The healthcare team<br />
must transition these patients from restorative care to<br />
palliative care. It is considered one of the most difficult<br />
and important aspects of nursing practice (Truog et al.,<br />
2008).<br />
Optimal pain and symptom management is a priority<br />
for patients and families at EOL. Bender et al. (2017)<br />
stated that surveys of patients and family members, as<br />
well as prospective and retrospective studies revealed<br />
gaps in the quality of care for symptom management<br />
at EOL. These gaps included inadequate pain and<br />
symptom control, and delays in the evaluation and<br />
management of dyspnea (Bender et al., 2017).<br />
Uncontrolled symptoms at EOL adds distress for<br />
patients and their families, as well as compromises the<br />
patient’s quality of life.<br />
When further life-sustaining treatment is deemed<br />
futile, and/or is no longer achieving the patient<br />
and family’s goals of care, the family may choose<br />
to discontinue further treatment. Within the ICU<br />
setting, compassionate extubation (CE) is the<br />
termination of mechanical ventilation and withdrawal<br />
of an artificial airway to avoid prolonged suffering<br />
at EOL. Some patients who are conscious are able to<br />
report dyspnea, but others being withdrawn from<br />
the ventilator are critically ill, cognitively impaired,<br />
or unconscious and unable to self-report dyspnea.<br />
These patients may or may not be able to experience<br />
respiratory distress depending on the severity of<br />
unconsciousness (Campbell et al., 2015). The ability to<br />
experience unrelieved dyspnea continues until death.<br />
These patients near death are vulnerable to be under<br />
recognized and under treated for respiratory distress.<br />
Conversely, a patient runs the risk of being over<br />
treated, which leads to over sedation and unintentional<br />
acceleration of death (Campbell & Templin, 2015).<br />
Unanticipated respiratory distress is a common<br />
complication of CE and one of the most challenging<br />
symptoms for healthcare providers to control for<br />
their patients. This can be an extremely distressing<br />
experience for patients, as well as their families and the<br />
healthcare team.<br />
The use of the Respiratory Distress Observational<br />
Scale (RDOS) at EOL can assist with patient comfort<br />
and decrease stress of the family and healthcare<br />
providers. RDOS is an objective assessment that can<br />
guide the CE process, as well as withdrawal of noninvasive<br />
ventilation device (NIVD), or high-flow nasal<br />
cannula (HFNC). It is an objective tool used to assess<br />
the nonverbal, adult patient for the presence and<br />
intensity of respiratory distress. There are 8 variables<br />
(heart rate, respiratory rate, restlessness, paradoxical<br />
breathing, accessory muscle use, grunting at end<br />
expiration, nasal flaring, look of fear) with numeric<br />
values which are totaled together to obtain the RDOS<br />
score. Scale scores can vary from 0 indicating no<br />
distress to 16 indicating the most severe distress. The<br />
goal is a score
<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 11<br />
of withdrawing life-sustaining measures in the clinical<br />
setting (Campbell et al., 2015).<br />
RDOS not only can be used within the hospital<br />
setting but could be used in the home during hospice/<br />
palliative care. Dr. Campbell initiated the RDOS-<br />
Family as a guide for the family caretaker who has<br />
the around-the-clock responsibility to ensure patient<br />
comfort at EOL (Campbell & Templin, 2014). Educating<br />
family members of patients with dyspnea to use a<br />
standardized patient assessment could increase family<br />
confidence with dyspnea caregiving. Knowledge of<br />
how to assess and manage dyspnea (especially with<br />
the heart and lung disease palliative/hospice patients)<br />
can be initiated using RDOS. This in turn, can improve<br />
patient and family outcomes, with a goal of decreasing<br />
acute hospital admissions where a nonpreferred site of<br />
death could occur (Campbell & Templin, 2014). During<br />
the pilot study, Dr. Campbell found that further testing<br />
would need to be completed including more education<br />
on variables that require more nursing experience that<br />
appeared to be underreported by family members<br />
(Campbell & Templin, 2014).<br />
To summarize, EOL can be a stressful experience for<br />
patients, families, and the healthcare team. Patients<br />
near death are apt to be under recognized and under<br />
treated for respiratory distress. Patients also run the risk<br />
of being over treated, which may lead to over-sedation<br />
and unintentional acceleration of death Using RDOS at<br />
EOL can help alleviate distress and assists to validate<br />
the need for medication titration for comfort during<br />
EOL care.<br />
Although EOL care is challenging and emotionally<br />
exhausting for all those involved, helping patients die<br />
peacefully can be as rewarding as saving a life. Thom<br />
Dick, an EMT paramedic and author, summarizes it<br />
best: “You’re going to be there when a lot of people<br />
are born, and when a lot of people die. In most every<br />
culture, such moments are regarded sacred and<br />
private, made special by a divine presence. No one<br />
on Earth would be welcomed, but you’re personally<br />
invited. What an honor that is” (T. Dick, personal<br />
communication, September, 8, <strong>2021</strong>).<br />
References<br />
Bender, M. A., Hurd, C., Solvang, N., Colagrossi, K., Matsuwaka,<br />
D., & Curtis, J. R. (2017). A new generation of comfort<br />
care order sets: Aligning protocols with current principles.<br />
Journal of Palliative Medicine, 20(9), 922–929. https://doi.<br />
org/10.1089/jpm.2016.0549<br />
Blinderman, C. D., & Billings, J. A. (2015). Comfort care for<br />
patients dying in the hospital. New England Journal of<br />
Medicine, 373(26), 2549–2561. https://doi.org/10.1056/<br />
nejmra1411746<br />
Campbell, M. L. (2016). AACN Webinar: Caring practice:<br />
Evidence-based terminal ventilator withdrawal. AACN.<br />
Campbell, M.L. (2018). Ensuring breathing comfort at the end of<br />
life: the integral role of the<br />
critical care nurse. American Journal of Critical Care, 27(4), 264-<br />
269. doi:https://doi.org/10.4037/ajcc2018420<br />
Campbell, M. L., & Templin, T. N. (2014). RDOS-Family: A guided<br />
learning tool for layperson assessment of respiratory<br />
distress. Journal of Palliative Medicine, 17(9), 982–983.<br />
https://doi.org/10.1089/jpm.2014.0145<br />
Campbell, M. L., & Templin, T. N. (2015). Intensity cut-points for<br />
the respiratory distress observation scale. Palliative Medicine,<br />
29(5), 436–442. https://doi.org/10.1177/0269216314564238<br />
Campbell, M. L., Yarandi, H. N., & Mendez, M. (2015). A twogroup<br />
trial of a terminal ventilator withdrawal algorithm:<br />
Pilot testing. Journal of Palliative Medicine, 18(9), 781–785.<br />
Dick, T. (2018). People care: Perspectives and practices for<br />
professional caregivers. (3rd ed). EMS World.<br />
Downar, J., Delaney, J. W., Hawryluck, L., & Kenny, L. (2016).<br />
Guidelines for the withdrawal of life-sustaining measures.<br />
Intensive Care Medicine, 42(6), 1003–1017. https://doi.<br />
org/10.1007/s00134-016-4330-7<br />
Mularski, R. A., Campbell, M. L., Asch, S. M., Reeve, B. B., Basch,<br />
E., Maxwell, T. L., Hoverman, J. R., Cuny, J., Clauser, S. B.,<br />
Snyder, C., Seow, H., Wu, A. W., & Dy, S. (2010). A review<br />
of quality of care evaluation for the palliation of dyspnea.<br />
American Journal of Respiratory and Critical Care Medicine,<br />
181(6), 534–538. https://doi.org/10.1164/rccm.200903-<br />
0462pp<br />
Truog, R. D., Campbell, M. L., Curtis, J. R., Haas, C. E., Luce,<br />
J. M., Rubenfeld, G. D., Rushton, C. H., & Kaufman,<br />
D. C. (2008). Recommendations for end-of-life care in<br />
the intensive care unit: A consensus statement by the<br />
American College of critical care medicine. Critical Care<br />
Medicine, 36(3), 953–963. https://doi.org/10.1097/<br />
ccm.0b013e3181659096<br />
Zhuang, Q., Yang, G. M., Cheung, Y. B., & Neo, S. H. (2018).<br />
Validity, reliability, and diagnostic accuracy of the respiratory<br />
distress observation scale for assessment of dyspnea in<br />
adult palliative care patients. Journal of Pain and Symptom<br />
Management. https://pubmed.ncbi.nlm.nih.gov/30391404/
Page 12 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />
Advocacy<br />
Results of Delaware Nursing Dialogue – Advocacy Prioritization<br />
Annamarie Flick, MSN, RN-BC, NE-BC,<br />
Advocacy Director<br />
The Delaware Nurses<br />
Association recently launched<br />
Delaware Nursing Dialogue,<br />
an ongoing inquiry series<br />
for all Delaware nurses to<br />
participate in and contribute to<br />
the advancement of nursing in<br />
Delaware. Delaware Nursing<br />
Dialogue will feature a variety of<br />
topics focused on the profession.<br />
The first survey in the series<br />
Annamarie Flick<br />
focused on advocacy and<br />
legislative efforts. These results were recently presented<br />
to the Advocacy Committee and Board of Directors. I am<br />
happy to share them back with you.<br />
Demographics<br />
• There were 194 nurses that participated in the annual<br />
advocacy priorities survey.<br />
o 68% are RNs, 29% are APRNs, and less than 1%<br />
each were LPNs and nursing students.<br />
o 70% of respondents had over 20 years’ experience.<br />
o 66% of respondents are members in the Delaware<br />
Nurses Association.<br />
o 54% of respondents live in New Castle County.<br />
o 37% of respondents work in the hospital setting.<br />
Advocacy Prioritization<br />
• Provided a list of 11 critical topics in nursing<br />
advocacy/policy, respondents ranked them in<br />
highest to lowest priority as below.<br />
o Safe Staffing<br />
o Wellbeing of the Nursing Workforce<br />
o Workplace Violence<br />
o Top of License Practice<br />
o Nursing Education<br />
o Personal Protective Equipment<br />
o Ongoing Emergency Preparedness<br />
o Collaboration/Relationships/Respect within<br />
the Delaware Health Care Professional<br />
Community<br />
o Telehealth Access & Regulation<br />
o Environmental Health<br />
o APRN Clinical Preceptors<br />
• When asked about additional advocacy/<br />
policy opportunities, respondents provided 82<br />
additional responses. The themes that emerged<br />
from these answers include:<br />
o Access, regulation, and payment for home<br />
care services<br />
o Standing order protocols<br />
o Protecting scope of practice for all nurses<br />
o Access to and overall mental health services<br />
o Uplifting and maintaining the scientific,<br />
evidence-backed position of our profession<br />
and combatting mistrust<br />
o Increased, equitable, and consistent nursing<br />
pay/salary<br />
Advocacy Engagement<br />
• 22% of respondents expressed interest in the<br />
Advocacy Ally position to further support<br />
nursing engagement in policy, legislation, and<br />
advocacy.<br />
• 48% of respondents expressed a desire to<br />
be further involved in grassroots advocacy<br />
by connecting with their local legislators and<br />
speaking in support of nursing priorities.<br />
This information, provided by Delaware nurses, is<br />
already reshaping the way the Advocacy Committee<br />
is working and prioritizing our efforts. Several actions<br />
have already come out of the review of this data:<br />
• Marykate McGurk, BSN, RN, CCRN, Susan Conaty-<br />
Buck, DNP, APRN, FNP-C, FAANP, and Suzette<br />
Flores, DNP, BSW, APRN, NP-C have volunteered<br />
to work as grassroots coordinators and connect<br />
with the identified individuals on staying engaged<br />
and elevating the voice of nurses.<br />
• The Advocacy Committee is going to form<br />
three subgroups focused on the top priorities of<br />
Delaware nurses: workforce/staffing, wellbeing,<br />
and workplace violence.<br />
• <strong>DNA</strong>’s Executive Director is connecting with the<br />
identified Advocacy Allies to onboard them to<br />
their role, keep them engaged, and begin our<br />
work for the 2022 Delaware General Assembly.<br />
The Advocacy Committee will continue to analyze<br />
the results and align them with our strategies and<br />
legislation/policy that we support and move forward.<br />
Our 2022 Legislative Platform is also currently being<br />
updated based on these results and changes/trends<br />
in nursing and healthcare policy. This will be shared<br />
with nurses in the next edition of the <strong>DNA</strong> <strong>Reporter</strong>.<br />
The Advocacy Committee and Board of Directors<br />
thanks all nurses that took the time to answer the first<br />
Delaware Nursing Dialogue and provide us with this<br />
rich information. We encourage you to look for the<br />
next in the series to participate and lend your voice.<br />
Additionally, the prioritization of advocacy efforts<br />
will become an annual mainstay in Delaware Nursing<br />
Dialogue, so look for your chance to participate in Fall<br />
2022!<br />
Retirement Readiness Checklist<br />
Every day brings you a little closer to retirement<br />
age. Are you prepared for the financial impact<br />
of leaving the workforce? Here’s a checklist to<br />
help you consider the variables that impact your<br />
retirement readiness:<br />
1. Estimate your retirement living costs. Do<br />
you know how much money you will need to<br />
live comfortably in retirement? The amount you<br />
spend is likely to change over the years. For<br />
many retirees, expenses are highest in the early<br />
active years of retirement, but also may spike<br />
later in life, should you require costly living<br />
assistance.<br />
2. Add up your assets. As you approach<br />
retirement, you’ll want to have a good handle<br />
on the assets available to fund your retirement.<br />
Consider the equity in your home and<br />
other properties, your investment accounts,<br />
retirement accounts, annuities or cash-value<br />
insurance and savings accounts. If you’re a<br />
collector and hope to cash in, now is a good<br />
time to get an appraisal to determine current<br />
market value.<br />
3. Think about liquidity. How will you access<br />
your savings in retirement? Will you need to sell<br />
securities or properties? Do you own an annuity<br />
that can be converted into an income stream? Do<br />
you have a lot of pre-tax dollars in your retirement<br />
accounts? You’ll want to have a plan to withdraw<br />
from your retirement savings in the most financially<br />
advantageous way.<br />
4. Calculate your Social Security earnings. How<br />
much you will receive each month from Social<br />
Security is based on your work history and the<br />
age at which you choose to retire. To receive your<br />
maximum monthly benefit, plan to claim your Social<br />
Security benefits at full retirement age (or later – up<br />
to age 70). Filing at an earlier age will result in a<br />
permanent reduction in monthly benefits.<br />
5. Consider your tax obligations. Taxes continue<br />
even when you stop working. Assuming you meet<br />
the income threshold, some portion of your Social<br />
Security income will be taxed. The good news is that<br />
as a retiree, you will most likely qualify for a lower<br />
marginal income tax rate. State income taxes vary<br />
widely and may influence where you want to retire.<br />
6. Don’t forget about inflation. While your<br />
Social Security benefits are adjusted for inflation,<br />
your other income may not be immune to rising<br />
consumer prices. Keep inflation in mind as you<br />
estimate your living expenses into the future.<br />
7. Sign up for Medicare during the limited<br />
enrollment window. To avoid penalties, you must<br />
elect your Medicare benefits within a limited time<br />
frame on either side of age 65. Special rules apply<br />
for people who continue to work and are covered<br />
by an employer’s health insurance plan. During<br />
Medicare enrollment, you’ll also have the opportunity<br />
to choose an optional Medicare Supplement<br />
insurance plan. Medicare Supplement plans help<br />
pay for out-of-pocket costs such as co-payments,<br />
coinsurance and deductibles under original Medicare.<br />
8. Consult the experts. Don’t wait until the last<br />
minute to figure out how you’ll pay your way in<br />
retirement. Talk to your accountant and financial<br />
advisor and explore your options. Together, you<br />
can devise a retirement strategy to help you make<br />
the most of the savings you’ve accrued from a<br />
lifetime of work.<br />
Christopher Malmstrom, CRPC, APMA, is a Financial Advisor with Point to Point Wealth Planning a private wealth advisory practice of Ameriprise Financial Services, LLC<br />
in Wilmington, DE. He specializes in fee-based financial planning and asset management strategies and has been in practice for 12 years. To contact him, visit his website<br />
www.ameripriseadvisors.com/christopher.malmstrom or call 302-995-7526. His office is located at 5195 W Woodmill Drive, Suite 27, Wilmington, DE 19808-4067.<br />
Ameriprise Financial, Inc. and its affiliates do not offer tax or legal advice. Consumers should consult with their tax advisor or attorney regarding their specific situation.<br />
Investment advisory products and services are made available through Ameriprise Financial Services, LLC, a registered investment adviser.<br />
Ameriprise Financial Services, LLC. Member FINRA and SIPC. | © <strong>2021</strong> Ameriprise Financial, Inc. All rights reserved.
<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 13<br />
Delaware Licensed Practical Nurse Leadership<br />
Journey to State Nursing Leadership<br />
Kenyette Walters, LPN, CDP®<br />
My name is Kenyette, most know me as Keni. I am<br />
a Delaware Licensed Practical Nurse (LPN) and currently,<br />
Vice President, Delaware Board of Nursing. I have been<br />
a nurse since 2012. Originally from Philadelphia, my<br />
background is in investment accounting and corporate<br />
finance. I am also a licensed Cosmetologist, former<br />
phlebotomist, heavy equipment operator, and spent<br />
some time doing academic grading/extern coordinator<br />
and lab administration for a graduate medical school in<br />
Philadelphia.<br />
After relocating to Delaware in 2007, and with long<br />
Kenyette Walters<br />
standing medical issues, I decided to pursue an earlier<br />
dream of entering the nursing profession. I felt that I owed good nursing<br />
care back to the community. I studied and obtained certification as a nursing<br />
assisting, worked in long-term care, and realized that nursing was my passion.<br />
In 2012, I completed nursing school and obtained my LPN license. Never<br />
discouraged by the saying “LPNs will be eliminated,” I endeavored to prove<br />
that LPNs are exceptional and prudent nurses with a wealth of opportunities<br />
to pursue. My career took off quickly. I quickly found that geriatric psychiatric,<br />
dementia, and behavioral nursing were my gift. In my role and practice setting,<br />
I was provided the opportunity to fulfill the charge nurse role and provide<br />
dementia programing for a large long-term care program in Maryland. I am<br />
a member of the National Council of Certified Dementia Practitioners and an<br />
active Certified Dementia Practitioner®.<br />
The road to excellence is not easily traveled. I had to endure many of the<br />
downsides of nursing, including bullying from peers and the “nurses eat their<br />
young” mentality. I persevered and have had the opportunity to practice in<br />
some of the following roles/environments: wound care, corrections, geriatric<br />
psych, orthopedic rehab, assisted living house supervisor, admissions nurse,<br />
and intravenous certification. I am currently an overnight skilled nurse in an<br />
exclusive lifestyle senior community. I also teach clinical instruction in the<br />
medical assistant program at Polytech Adult Education.<br />
Serving as the LPN member on the Delaware Board of Nursing, in addition<br />
to the roles noted below, has been pivotal in my professional practice,<br />
development, and leadership. I was reappointed to the board for a second<br />
term and most recently achieved a landmark milestone, I was elected by<br />
the board to serve as the Vice President. Additionally, I chair the Limited<br />
Lay Administration of Medications (LLAM) Committee. This committee is<br />
responsible for a state regulated program, further defined in the Delaware<br />
Nurse Practice Act, that allows individuals who have successfully completed a<br />
board-approved limited lay administration of medications training program to<br />
administer prescription or nonprescription medications to patients/residents/<br />
clients in select settings.<br />
The Delaware Board of Nursing has been one of the most challenging, often<br />
stressful, yet highly rewarding roles to date. The board’s primary purpose is to<br />
protect the public from negligent/impaired nursing practice. Our other goal is<br />
to support nurses, ensuring that they can practice safely and within the law,<br />
provide assistance programs to help nurses in crises, and exact discipline, when<br />
necessary. This role requires fairness, consistency, and in-depth knowledge of<br />
the Delaware Nurse Practice Act, as well as knowledge of practice limitations<br />
at all levels.<br />
Looking to the future and my continued professional development, my next<br />
major goal is to enroll in a nursing home administrator program and precept<br />
in my current facility with our amazing Executive Director. I hope to one day<br />
be the leader of an entire community/facility. I can be reached via email at<br />
mskeni@prodigy.net.<br />
Nurses, thank you for your continued efforts to serve our community. I<br />
know that, at times, it can be difficult to find the passion needed, but your<br />
efforts are noticed and appreciated. The COVID pandemic has put a strain on<br />
the nursing community, with an end date hard to see at this time. Together,<br />
we will support each other, those we serve, and emerge stronger than ever.<br />
We are tired. We are weary. We will never give up.<br />
We are angels of mercy. We are nurses!
Page 14 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />
Documenting nursing assessments in the age of EHRs<br />
Georgia Reiner, MS, CPHRM, Senior Risk<br />
Specialist, Nurses Service Organization (NSO)<br />
Nurses have grown accustomed to documenting<br />
assessment results in the electronic health record<br />
(EHR), rapidly clicking responses to assessment<br />
checklist questions. However, at times nurses<br />
complete these actions without giving enough<br />
thought to their documentation because they want<br />
to move on to their “real” work: caring for patients.<br />
The danger of this approach is threefold. First,<br />
nurses might base their assessment on the checklist<br />
not the patient, which can lead to an incomplete<br />
assessment, especially if the nurse inadvertently<br />
clicks something as being done when it hasn’t.<br />
Second, nurses might fail to adequately document<br />
a finding if it does not match up with the available<br />
options in the checklist. Third, nurses might fail to<br />
document assessments when a patient’s condition<br />
changes or fail to document practitioner notification<br />
of the change.<br />
All three scenarios can leave nurses open to<br />
legal action. For example, a harried nurse caring<br />
for a patient who had a total hysterectomy clicks<br />
“normal” as the result of abdominal auscultation<br />
even though she hasn’t completed this assessment<br />
and misses the absence of bowel sounds. Soon,<br />
however, the patient develops vomiting and severe<br />
abdominal pain and is diagnosed with a bowel<br />
obstruction. This nurse could be held liable for the<br />
delay in treatment.<br />
Dangers of improper documentation<br />
Documentation is a vital nursing responsibility. It’s<br />
important for planning patient care, communicating<br />
with providers, and demonstrating compliance with<br />
federal, state, third-party, and other regulations.<br />
But documentation issues can result in professional<br />
liability lawsuits or action against a nurse’s license.<br />
NSO and CNA’s Nurse Professional Liability Exposure<br />
Claim Report: 4th Edition found that documentation<br />
deficiencies are contributing factors in many nurse<br />
professional liability claims, and that the average total<br />
incurred for claims involving allegations related to<br />
documentation was $238,761. The same report also<br />
noted that 9.7% of all license protection matters,<br />
which involved defending nurses during State Board<br />
of Nursing inquiries, were related to documentation.<br />
Of these, nearly half (49.6%) involved an allegation of<br />
fraudulent or falsified patient care or billing records.<br />
Failure to document treatment/care as required by<br />
regulatory agencies or facility policy comprised 28.6%<br />
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of matters related to documentation, followed by<br />
documentation that didn’t accurately reflect patient<br />
care and services (12.8%), failure to properly correct<br />
documentation errors according to facility policy<br />
(5.3%), and inadequate or untimely documentation<br />
(3.8%). These matters serve as reminders of how<br />
nurses need take time ensure they are completing<br />
documentation properly.<br />
Benefits of EHRs<br />
Too often nurses view EHRs negatively, feeling<br />
they’re cumbersome and take nurses away from<br />
the patient. But a well-designed EHR has several<br />
benefits, including improved efficiency and quality<br />
patient care. For example:<br />
• EHRs provide an excellent mechanism for<br />
communicating with a variety of healthcare<br />
providers in a timely fashion, thereby improving<br />
care coordination.<br />
• EHRs can incorporate guidelines, reminders,<br />
and decision support tools that can help<br />
providers make better decisions and deliver<br />
better care.<br />
• Electronic documentation eliminates the<br />
problem of misinterpretation of handwritten<br />
orders.<br />
• EHRs facilitate immediate access to data by<br />
multiple people in multiple locations.<br />
EHRs also can protect nurses against lawsuits and<br />
actions taken against their licenses. However, to gain<br />
the most benefit, nurses need to take full advantage<br />
of EHRs. For example, according to NSO and CNA’s<br />
Nurse Professional Liability Exposures: 2015 Claim<br />
Report Update, 45% of nurses who experienced<br />
a liability claim did not use the available EHR,<br />
compared with 19.2% of those without a liability<br />
claim.<br />
Proper EHR documentation<br />
You can take several steps to ensure you’re<br />
documenting assessments and other information<br />
correctly in the EHR.<br />
• Follow basic documentation principles.<br />
Whether you’re documenting on paper or in an<br />
EHR, the same basic principles apply. Document<br />
promptly, accurately, and without bias. Don’t<br />
interject opinions about patients or providers.<br />
When making a correction to previously<br />
recorded information, include the reason for<br />
the change. Remember that the EHR provides a<br />
date and time for each entry, providing a clear<br />
documentation trail.<br />
• Adhere to policies, procedures,<br />
regulations, and guidelines. In the event of<br />
a legal action, one of the first steps an attorney<br />
will take is to determine if you followed your<br />
organization’s policies and procedures related<br />
to nursing assessments and documentation,<br />
as well as any relevant state, federal, or local<br />
guidelines, and guidelines from professional<br />
associations.<br />
• Copy and paste cautiously. The copy and paste<br />
feature in EHRs can be a time saver, but errors,<br />
including errors of omission, can easily occur.<br />
For example, you copy your note for one patient<br />
with a myocardial infarction (MI) into another<br />
MI patient’s record but forget to add that you<br />
notified the provider of the new S4 you heard<br />
on auscultation. If the patient later experiences<br />
severe heart failure, you will have no evidence<br />
that you notified the provider. Another problem<br />
with copy and paste is that errors can rapidly<br />
spread as others pick up the same erroneous<br />
information. For instance, a nurse copies an<br />
assessment for a patient with pneumonia several<br />
times, forgetting to update the temperature,<br />
which has returned the normal. The patient’s<br />
physician reads the note, thinks the patient<br />
isn’t responding to treatment, and changes the<br />
antibiotic. Subsequently, the patient experiences<br />
a significant adverse event from the new<br />
antibiotic, which leads to legal action against the<br />
hospital, the physician, and the nurse.<br />
A report from the Partnership for Health IT<br />
Patient Safety recommends providers “act with<br />
volition,” thinking about what is appropriate for<br />
copying and pasting and reviewing notes carefully.<br />
Ideally, the EHR should have a mechanism for easy<br />
identification of material that has been copied and<br />
pasted (for example, a different color text), so that<br />
providers are reminded to carefully review.<br />
• Beware of autofill and templates. Like<br />
copy and paste, the autofill feature can<br />
save time by avoiding repetitive entries,<br />
but you need to verify that the information<br />
automatically filled in is correct. Similarly,<br />
templates for regularly occurring events such<br />
as the first postoperative visit after a total<br />
knee arthroplasty can help save time and<br />
ensure needed information is collected, but<br />
you still need to be aware of individual patient<br />
needs and assessment findings.<br />
• Use notes appropriately. Sometimes what<br />
you need to document as an assessment<br />
finding isn’t in a checklist or pull-down menu.<br />
Don’t choose the “next best” option; doing<br />
so can lead to miscommunication and clinical<br />
and billing errors. For example, if you select<br />
“pressure injury” because “skin tear” isn’t<br />
available, legal action would be based on the<br />
more serious injury. A better approach is to<br />
add a note to the patient’s record. Be sure your<br />
note provides vital information in a succinct<br />
matter to avoid “note bloat” (also a side effect<br />
of inappropriate copy and paste). If an option<br />
that you would use frequently isn’t available,<br />
talk with your manager or informatics contact<br />
about adding it to the EHR.<br />
• Protect patient privacy. Do not share<br />
your passwords and change them regularly,<br />
according to your facility’s policy. In addition,<br />
don’t enter information in view of other<br />
patients.<br />
• Don’t ignore alerts. Alerts are there to help<br />
you make better decisions when it comes to<br />
patient care. For example, when you enter<br />
your assessment data, you may receive an<br />
alert that a patient could be at risk for sepsis.<br />
Your prompt action could save the patient’s<br />
life. On the other hand, too many alerts may<br />
lessen their efficacy, leading to “alert fatigue”.<br />
Talk with your manager or informatics contact<br />
to discuss settings.<br />
• Complete an effective assessment. You<br />
won’t have the information you need for the<br />
EHR unless you perform a quality assessment.<br />
Don’t simply consider what a computer<br />
checklist tells you to include. Use your critical<br />
thinking skills to match the assessment to the<br />
patient.<br />
• Document changes in the patient’s<br />
condition. Remember to enter changes to the<br />
patient’s status into the computer and include<br />
if you notified the provider of the change.<br />
A partnership<br />
Rather than having an adversarial relationship with<br />
the EHR, nurses should consider the EHR as a care<br />
partner. By serving as a repository of data, providing<br />
alerts as needed, and facilitating communication, the<br />
EHR can help ensure quality patient care—and reduce<br />
nurses’ risk of legal action.<br />
RESOURCES<br />
Balestra ML. Electronic health records: Patient care and<br />
ethical and legal implications for nurse practitioners.<br />
J Nurs Pract. 2017;13(2):105-111.<br />
CNA, NSO. Nurse Professional Liability Exposure Claim<br />
Report: 4th Edition. 2020. www.nso.com/Learning/<br />
Artifacts/Claim-Reports/Nurse-Practitioner-Claim-<br />
Report-4th-Edition-A-Guide-to-Identifying-and-<br />
Addressing-Professional-Liability- Exposures<br />
CNA, NSO. Nurse Professional Liability Exposures:<br />
2015 Claim Report Update. 2015. www.cna.<br />
com/web/wcm/connect/e05b5d91-cf38-<br />
444d-8727- ab65f25f8f6a/RC_Health_Nurses_<br />
Claim_Report_Update_101615.pdf?MOD=AJP<br />
ERES&CACHEID=e05b5d91-cf38-444d-8727-<br />
ab65f25f8f6a
<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 15<br />
Effective use of EHRs<br />
These actions will help you gain the most<br />
benefit from the EHR:<br />
• Document promptly and thoroughly. This<br />
not only helps protect you from liability but,<br />
more importantly, ensures that information is<br />
quickly available to other providers.<br />
• Document accurately. Don’t omit key<br />
information and don’t try to cover up if you<br />
failed to document or take correct action.<br />
• Get involved in EHR selection. Often,<br />
nurses don’t use the EHR correctly or take<br />
full advantage of its capabilities because<br />
the design is poor. Ask to be included on<br />
committees tasked with selecting the EHR<br />
vendor. Consider which systems best reflect<br />
what providers need to document and assess<br />
for user interface by checking items such as<br />
the font size of screen text.<br />
• Identify opportunities for improvements<br />
in EHR function. Instead of engaging in<br />
potentially dangerous workarounds, notify<br />
leadership where improvements are needed.<br />
In some cases, the format of the EHR can be<br />
tweaked to make it easier for the user.<br />
• Don’t assume the EHR is always right. The<br />
EHR isn’t infallible. If, for example, results<br />
of a test don’t seem to match the patient’s<br />
symptoms, follow up with the provider – the<br />
test may need to be redone.<br />
• Provide education. Consider helping<br />
your colleagues learn more about proper<br />
documentation in the EHR by providing an<br />
education program or suggesting such a<br />
program to your professional development<br />
department.<br />
• Be patient centered. The ability to document<br />
at the patient’s bedside can save time and<br />
improve accuracy, but only if you keep<br />
your focus on the patient instead of on the<br />
computer. Maintain eye contact and consider<br />
telling patients what you are entering into<br />
the computer, which can help ensure the<br />
information is accurate.<br />
New, Renewing, & Returning Members<br />
August 28 – November 29, <strong>2021</strong><br />
New & Returning Members<br />
Leila Gaines<br />
Bear<br />
Jessica Seador<br />
Anna Merrick<br />
Elizabeth Phillips<br />
Bridgeville Naomi Higgins<br />
Annamarie Breeden<br />
New Castle Leah Patterson<br />
Jill Erwin<br />
Newark Juliana Rahmer<br />
Denise Jones<br />
Lewes Deborah Streeter<br />
Olusade Banjo<br />
Newark Bonnie Beaston<br />
June Ndibo<br />
Newark Michelle Saienni<br />
Ruth Van Weele<br />
Harrington Marisa Shetzler<br />
Ekor Odaji<br />
Smyrna Eugenia Johnson<br />
Genita Vandell<br />
Wilmington Cynthia Testa<br />
Danette Newby-Mitchell<br />
New Castle Yesenia Sudler<br />
Kim Blanch<br />
Rehoboth Beach Kathleen Carlson<br />
Sheri McAfee-Garner<br />
Millsboro Pete Zingone<br />
Sherri Clark<br />
Dover Anne Kariuki<br />
Patricia Winward<br />
Frankford Kaitlin Steelman<br />
Travis Stevens<br />
Rehoboth Beach Abioseh Pieh<br />
Angie Primus<br />
Bear Thelma Aminu<br />
William Brown<br />
Wilmington Tami Sellers<br />
Julieanne Cloman<br />
Lewes Morgan Webb<br />
Toccara Barber<br />
Dover Kelly Souder<br />
Newark<br />
Ocean View<br />
Claymont<br />
Dover<br />
Wilmington<br />
New Castle<br />
Townsend<br />
Wilmington<br />
Odessa<br />
Dover<br />
Hockessin<br />
Smyrna<br />
Georgetown<br />
Lewes<br />
Bear<br />
Lewes<br />
Newark<br />
New Castle<br />
Ellendale<br />
Milford<br />
Smyrna<br />
Grace Logemann<br />
Hockessin John Reinford<br />
Millsboro<br />
Michael Knorr<br />
Newark Michelle Fisher<br />
Dover<br />
Meghan Elliott<br />
Georgetown<br />
Roselyne Arusei<br />
New Castle<br />
Members continued on page 16<br />
ECRI Institute. Copy/Paste: Prevalence, Problems, and<br />
Best Practices. Special Report. 2015. www.ecri.org/<br />
Resources/HIT/CP_Toolkit/CopyPaste_Literature_final.<br />
pdf. Kelley T. Electronic Health Records for Quality<br />
Nursing and Health Care. Lancaster, PA: DEStech<br />
Publications; 2016.<br />
Pagulayan J, Eltair S, Faber K. Nurse documentation<br />
and the electronic health record. Am Nurs Today.<br />
2018;13(9):48-52, 54.<br />
Partnership for Health IT Patient Safety. Health IT Safe<br />
Practices: Toolkit for the Safe Use of Copy and Paste.<br />
2016. https://d84vr99712pyz.cloudfront.net/p/pdf/<br />
hit-partnership/copy-paste-toolkit.pdf. Tsou AY,<br />
Lehmann CU, Michel J, et al. Safe practices for copy<br />
and paste in the EHR. Appl Clin Inform. 2017;8(1):12-<br />
34.<br />
Disclaimer: The information offered within this<br />
article reflects general principles only and does<br />
not constitute legal advice by Nurses Service<br />
Organization (NSO) or establish appropriate or<br />
acceptable standards of professional conduct.<br />
Readers should consult with an attorney if they<br />
have specific concerns. Neither Affinity Insurance<br />
Services, Inc. nor NSO assumes any liability for how<br />
this information is applied in practice or for the<br />
accuracy of this information.<br />
This risk management information was provided<br />
by Nurses Service Organization (NSO), the nation’s<br />
largest provider of nurses’ professional liability<br />
insurance coverage for over 550,000 nurses since<br />
1976. The individual professional liability insurance<br />
policy administered through NSO is underwritten<br />
by American Casualty Company of Reading,<br />
Pennsylvania, a CNA company. Reproduction<br />
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For questions, send an e-mail to service@nso.com<br />
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Page 16 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />
New, Renewing, & Returning Members<br />
Members continued from page 15<br />
Ann-Marie Spraggs<br />
Wilmington<br />
Jenneh Lashley<br />
New Castle<br />
Kristie Hudson<br />
Selbyville<br />
John Starke<br />
Frederica<br />
Caricia Rickards<br />
Felton<br />
Amy Linzey<br />
Ocean View<br />
Maria Brown<br />
Middletown<br />
Amanda Kulhanek<br />
Smyrna<br />
Caroline Githaiga<br />
Townsend<br />
Kat Kvoka<br />
Wilmington<br />
Cynthia Patterson<br />
Newark<br />
Renewing Members, 1-5 Years<br />
Margaret Mack Wilmington (2)<br />
Patricia Ayers Milton (2)<br />
Felicia Cruz Dover (5)<br />
Sheila Dirocco Marydel, MD (3)<br />
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Charles Evans Jr. Wilmington (2)<br />
Katherina Haigh Newark (1)<br />
Susan Hensler Selbyville (3)<br />
Heather Hogan Wilmington (1)<br />
Denise Jones Dover (5)<br />
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Laura Mills Milford (2)<br />
Laura Rausch Newark (1)<br />
Pam Rimkis Dagsboro (1)<br />
Anastasia Robinson Ocean View (5)<br />
Tori Sabbatini Newark (2)<br />
Amber Salyers Wilmington (5)<br />
Keiosha Shelton Frankford (3)<br />
Angela Strong Ocean View (1)<br />
Ruth Wamwati Middletown (5)<br />
Sarah Lewis Milton (4)<br />
Ashley Aloba Bear (1)<br />
Rob Dusty Sweetman Clayton (5)<br />
Gayle Jones Milton (5)<br />
Shameka Brown Newark (4)<br />
Catherine Haut Lewes (3)<br />
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Robin Forester Wilmington (3)<br />
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Michelle Todd Dover (4)<br />
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Susan Atkison Wilmington (10)<br />
Lyron Deputy Lewes (6)<br />
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Derek Lawson Bear (7)<br />
Candice Morris Magnolia (6)<br />
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Lizy Thomas Newark (7)<br />
Dorothy Paxson Barker Milton (9)<br />
Jean St. John Newark (6)<br />
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Karla Sellers Lewes (6)<br />
Christopher Dorsey Wilmington (6)<br />
Carol Minor Milford (7)<br />
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Kimberly Ford Dover (6)<br />
Courtney Johnson Newark (7)<br />
Jill Petrone Lewes (7)<br />
Emily Snyder Dover (8)<br />
Susan Studds Georgetown (8)<br />
Christine Hargrove Newark (8)<br />
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Catherine Barber Felton (7)<br />
Jill Cavalcanti Dover (9)<br />
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Devona Fields Frederica (8)<br />
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Debra Lynch Newark (7)<br />
Nicole Phillips Wilmington (6)<br />
Bernadette Thomas Newark (9)<br />
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Renewing Members, 16-20 Years<br />
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Margery White Milford (20)<br />
Gail Love Wyoming (18)<br />
Teresa Towne Dover (17)<br />
Renewing Members, 21-29 Years<br />
Donna Draper Newark (25)<br />
Eliza Farrow Newark (24)<br />
Cynthia Reid New Castle (21)<br />
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Judith Hertz Camden (24)<br />
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