DNA
REPORTER
CONSTITUENT MEMBER OF ANA
Volume 47 • Issue 1
December 2021, January, February 2022
Inside This Issue
The mission of the Delaware Nurses Association is to improve healthcare in Delaware by the advancement
of nursing. Quarterly publication distributed to approximately 6,700 RNs and LPNs in Delaware.
Guest Editor
End of Life Care Considerations in
Palliative Care and Death with Dignity
Joint Policy Statement Adopted by
the Delaware Nurses Association
PAGE 11
Delaware LPN Leadership
PAGE 13
Suzette M. Flores, DNP, BSW, APRN, NP-C
Dr. Suzette Flores is currently
an inpatient palliative care
consultant at Bayhealth Sussex
Campus Hospital. Dr. Flores
has over 30 years of healthcare
experience in the areas of
social work, geriatric psychiatry,
neurosurgery, cardiology, long
term care, and palliative care.
She is board certified in adult
care by the American Academy
of Nurse Practitioners (AANP).
She earned a Bachelor’s Degree
in Social Work from Michigan Suzette M. Flores
State University (MSU), a Bachelor’s Degree of Nursing from the
University of Delaware (U of D), a Master’s Degree of Science
in Nursing and a Doctorate Degree of Nursing Practice from
Thomas Jefferson University (TJU). Dr. Flores has membership
with the Delaware Medical Reserve Corps, Delta Gamma
Sorority, Alpha Eta Society-Thomas Jefferson University,
Sigma Theta Tau International Society of Nursing-Delta Rho
Chapter, on the Delaware Nurses Association (DNA) Advocacy
Committee, on the Delaware Cultural Advisory Committee,
and has been involved ongoing with the Delaware Coalition of
Nurse Practitioners (DCNP). She currently serves as Chair of the
Nominating Committee for the DCNP. Dr. Flores is the recipient
of the 2019 AANP Advocate State Award for Excellence. Dr.
Flores may be reached at suzette_flores@bayhealth.org.
Having worked in palliative care, end of life discussions
and end of life care planning can be difficult and
uncomfortable for patients and their families, as well as for
healthcare providers with preparation, let alone without
preparation. All too often, patients and their families do
not think about death and dying until they are confronted
with that possibility.
Death with Dignity is a topic to be considered in our
fast paced technologically evolving medical environments
in which we may be able to keep ourselves going for
prolonged periods of time. Prolongation of life may not
come with improvement in health, and it may not lead to
improvement in our quality of life, although it may be life
sparing.
Every death experience is unique to a person and their
family. What would constitute a good death experience
for you? What would dignity at the end of your life look
like? What would be most important to you at this time?
According to the Institute of Medicine (1997), a good
death is “one that is free from avoidable distress and
suffering, for patients, family, and caregivers; in general
accord with the patients’ and families’ wishes; and
reasonably consistent with clinical, cultural, and ethical
standards” (p. 24).
Traditionally, it was the patient’s physician who
determined what end of life care should look like. This
trend has since shifted to give patient’s autonomy or selfdetermination
to direct their own medical treatments in
end of life care. The concept of self-determination or Death
with Dignity is that a terminally ill patient should determine
their own end-of-life decisions and determine how much
pain and suffering they should endure based upon their
personal beliefs and values, and what a good death may
mean to them (“Death with Dignity Acts,” n.d.).
In Delaware, Title 16, Health and Safety, Regulatory
Provisions Concerning Public Health, Chapter 25.
Health-Care Decisions, section 2502, the right of selfdetermination
states that “any legal adult, who is mentally
competent has the right to refuse medical or surgical
treatment if such refusal is not contrary to public law”
(“The Delaware Code Online,” n.d.).
The legal rights to self-determination in Delaware, may
be expressed as cognizant decisions to forgo or not initiate
life-saving treatments. In my inpatient hospital practice,
discussions center around the risk versus benefit of
Guest Editor continued on page 4
Index
current resident or
Presort Standard
US Postage
PAID
Permit #14
Princeton, MN
55371
Meet the 2022 DNA Board of Directors.................. 2
Executive Director’s Report.............................. 3
COVID-19 Pandemic Through the Lens
of an Inpatient Palliative Medicine Provider............. 6
Community-Based Palliative Care:
High Quality and Cost Effective........................ 7
Palliative Care: Including Nursing in Early Intervention... 8
Non-beneficial Treatment at the End of Life............. 9
Using Respiratory Distress Observation
Scale (RDOS) at End-of-Life..........................10-11
Policy Statement on Dissemination
of Non-Scientific and Misleading
COVID-19 Information by Nurses ...................... 11
Results of Delaware Nursing Dialogue –
Advocacy Prioritization................................ 12
Retirement Readiness Checklist........................ 12
Delaware Licensed Practical Nurse Leadership......... 13
Documenting nursing assessments
in the age of EHRs ...................................14-15
New, Renewing, & Returning Members...............15-16
Page 2 • DNA Reporter December 2021, January, February 2022
REPORTER
OFFICIAL PUBLICATION
of the
Delaware Nurses Association
4765 Ogletown-Stanton Road, Suite L10
Newark, DE 19713
Phone: 302-733-5880
Web: http://www.denurses.org
The DNA Reporter, (ISSN-0418-5412) is published quarterly every
March, June, September and December by the Arthur L. Davis
Publishing Agency, Inc., for the Delaware Nurses Association,
a constituent member association of the American Nurses
Association.
EXECUTIVE COMMITTEE
President: Leslie Verucci, , MSN, APRN, ANP-BC
President-Elect: Stephanie McClellan, MBA,
MSN, RN, CMSRN, NE-BC
Secretary: Jacqueline C. Armstrong, DNP,
MSN, APRN, FNP-BC, PMHNP-BC
Treasurer: George Zangaro, PhD, RN, FAAN
Director-at-Large, Clinical Nurse: Ramona Negron, BSN, RN
DIRECTORS
Membership Growth Directors
New Castle County: Kathy Neal, PhD, RN
Kent County: Sharon Mills-Wisneski, PhD, RN
Sussex County: Candace Hamner, MA, BA, RN
Professional Development Director
Sandra Nolan, PhD, RN, HN-BC
Advocacy Director
Annamarie Flick, MSN, RN-BC, NE-BC
Editorial Director
Karen Panunto, EdD, MSN, RN
EXECUTIVE DIRECTOR
Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN
executivedirector@denurses.org
ORGANIZATIONAL AFFILIATES
Oncology Nursing Society-Delaware Diamond Chapter
communities.ons.org/delawarediamond
Delaware Organization of Nurse Leaders
www.delawareone.org
Delaware Emergency Nurses Association
www.de-ena.org
Delaware State Affiliate of the American College of Nurse-Midwives
http://delaware.midwife.org/
Delaware Coalition of Nurse Practitioners
https://dcnpweb.enpnetwork.com/
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in this publication express the opinions of the authors; they do not
necessarily reflect views of the staff, board, or membership of DNA or
those of the national or local associations.
Editorial Director
Karen L. Panunto, Ed.D, MSN, RN
The DNA Reporter welcomes unsolicited manuscripts by DNA
members. Articles are submitted for the exclusive use of The DNA
Reporter. All submitted articles must be original, not having been
published before, and not under consideration for publication
elsewhere. Submissions will be acknowledged by e-mail or a selfaddressed
stamped envelope provided by the author. All articles
require a cover letter requesting consideration for publication. Articles
can be submitted by e-mail to Christopher E. Otto, MSN, RN, CHFN,
PCCN, CCRN at executivedirector@denurses.org
Each article should be prefaced with the title, author(s) names,
educational degrees, certification or other licenses, current position,
and how the position or personal experiences relate to the topic of
the article. Include affiliations. Manuscripts should not exceed five (5)
typewritten pages and include APA format. Also include the author’s
mailing address, telephone number where messages may be left,
and fax number. Authors are responsible for obtaining permission to
use any copyrighted material; in the case of an institution, permission
must be obtained from the administrator in writing before publication.
All articles will be peer-reviewed and edited as necessary for content,
style, clarity, grammar and spelling. While student submissions are
greatly sought and appreciated, no articles will be accepted for the sole
purpose of fulfilling any course requirements. It is the policy of DNA
Reporter not to provide monetary compensation for articles.
December 2021, January, February 2022 DNA Reporter • Page 3
Executive Director’s Report
Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN
Executive Director
executivedirector@denurses.org
or 302-733-5880
The meaningful recognition of
nurses is a heavily researched area
of nursing practice with several
notable outcome improvements
when successfully applied to
professional practice settings.
The American Association of
Critical-care Nurses’ framework
for healthy work environments
includes meaningful recognition
and defines it as, “Nurses
Christopher E. Otto
must be recognized and must
recognize others for the value each brings to the work of
the organization” (American Association of Critical-care
Nurses, 2021). Meaningful recognition can decrease nurse
burnout and increase compassion satisfaction for nurses
(Kelly & Lefton, 2017). Additionally, meaningful recognition
increases the nurses’ self-perception, pride, and often
reconnects nurses with their “why” (Lefton, 2014).
Recognizing nurses includes all nurses, Licensed
Practical, Registered, and Advanced Practice Registered
Nurses. Research supports the positive impact of
meaningful recognition for Licensed Practical Nurses by
reducing burnout (Kim et al., 2020). The Delaware Nurses
Association has provided recognition for Delaware’s nurses
for decades and continues to evolve existing programs.
We believe in the power of nurse recognition to combat
burnout, increase professional role satisfaction, and
promote a positive image of nursing. Recognizing nurses
at the state level facilitates increased public awareness and
perception of the unique contributions, qualifications, and
service nurses make. By recognizing nurses statewide, the
Delaware Nurses Association can uplift the characteristics
of exceptional nurses and further define the essence of our
profession. On behalf of the Delaware Nurses Association
Board of Directors, I am proud to share the following
evolving advancements for statewide nurse recognition.
Joint Committee on Nursing Recognition
In partnership with our organizational affiliate, the
Delaware Organization for Nursing Leadership, we
established a Joint Committee on Nursing Recognition
to expand, implement, and evolve statewide nursing
recognition programs and partnerships. The newly
forming committee comprises 13 voting, volunteer
members that represent all three nursing licensure levels
and Delaware counties. Additionally, volunteer members
come from numerous practice settings including academia,
private practice, schools, the state, hospitals, and more.
Partnerships and broad nursing representation set this
committee up for success in providing meaningful
statewide recognition. The committee will begin meeting
monthly after the new year.
Delaware Today Top Nurses
The Delaware Nurses Association has partnered with
Delaware Today Media to recognize Delaware’s Top
Nurses for nine years. Starting in 2013, the program has
now grown to recognize all Delaware nurses. Voting is
conducted November-January annually and winners are
selected by a panel of peers, now the Joint Committee
on Nursing Recognition. Every Delaware nurse is eligible
to nominate and be nominated. This is a statewide peer
recognition program, so only nurses may nominate.
Winners and honorees are recognized annually during
May to coincide with nurse’s week. They are provided
recognition in the May edition of Delaware Today and with
a sponsored reception. Nominations for 2022 Delaware
Today Top Nurses are accepted until January 3, 2022.
The DAISY Foundation
The DAISY Foundation is an established and highly
recognized non-profit that exists solely to recognize
nurses for their extraordinary compassion and skill. They
deliver meaningful recognition internationally and across
the nation. Numerous international, national, and state
Celebrating Delaware’s Nurses
associations support The DAISY Foundation and their
incredible work. The Delaware Nurses Association and
Delaware Organization for Nursing Leadership, with the
generous support of Rhoades & Morrow LLC, is proud
to become the first state nursing association to partner
directly and provide DAISY awards to nurses.
There are several existing DAISY-partner organizations
in Delaware: Bayhealth, Beebe Healthcare, ChristianaCare,
Encompass Health, Nemours, Silver Lining Healthcare,
St. Francis Hospital, and University of Delaware. Nurses
working for one of the above employers are already and
remain eligible to be nominated and recognized by their
employers. This new partnership does not change existing
programs; any nominations received at the DNA for a
nurse working at an existing partner will be forwarded to
that DAISY coordinator. The Delaware Nurses Association
encourages all eligible nurse employers/organizations to
partner directly with The DAISY Foundation to recognize
as many extraordinary nurses as possible.
Our mission at the Delaware Nurses Association and
Delaware Organization for Nursing Leadership is to provide
extraordinary nurses with this prestigious recognition.
Whether you work in a school, prison, public health, private
practice, medical aid unit, surgery center, etc., you are now
eligible to become a DAISY honoree. We will work with
local media, members, partners, schools, and employers
to raise awareness of this program and exponentially grow
nominations. Patients, families, colleagues, nurses, leaders,
and all are encouraged to submit nominations for their
extraordinary nurses. The nomination form is live and can
be accessed at http://www.daisynomination.org/DNA.
Because of the generous support of Rhoades & Morrow
LLC, we will be offering nurse employers free posters and
window clings (in addition to online, self-print materials) to
place in their practice settings to increase awareness and
nominations for this honor.
The nominations will be blinded and reviewed by the
Joint Committee on Nursing Recognition and honorees
selected for various categories (direct care nurse, team,
leader, lifetime achievement, health equity, faculty, and
students). Honorees will be vetted, approved, and presented
with their recognition during a surprise presentation at
their practice setting. Becoming a DAISY honoree provides
nurses with pride, gratitude, and a plethora of benefits
and continued opportunities. Speaking personally, it is
still a career highlight when I and my colleagues in the
Cardiovascular Critical Care Complex were presented with a
DAISY Team Award in June 2018. We were nominated by
the family of a patient we cared for, and it remains one of
my most cherished nursing memories.
We are humbled and excited to bring this
meaningful recognition to all Delaware nurses and
continue building the legacy and history of both
The DAISY Foundation and the profession of
nursing.
Additional Specialized Awards and More
Another focus of the Joint Committee on Nursing
Recognition will be to uplift and celebrate Delaware’s
notable nurses that contributed to the profession here
and nationally. The committee will explore custom awards
named after Delaware’s most influential and noted nurses.
These awards will continue to uplift and celebrate nurse
contributions in specific areas of the profession, such as
advanced practice leadership and government relations/
advocacy. We will also partner with our organizational
affiliates, state specialty nursing associations, to generate
awards for the many nursing practice specialties and elevate
exceptional nurses from all areas of the profession.
Just because the committee has already been selected
doesn’t mean you can’t contribute. Through Delaware
Nursing Dialogue, social media, and other communications
the joint committee will be engaging all nurses in defining,
promoting, and providing meaningful statewide nurse
recognition. Why not start now? Have an idea? Send
it to us using email, contactdna@denurses.org. On this
topic, and all matters affecting Delaware nurses, we are
continuously open to your feedback and suggestions.
We are excited to bring these advancements forward
for Delaware’s nurses. The volunteerism and generosity
of members, organizational affiliates, and partners is
what makes these programs possible. Membership is
not required to be nominated, to nominate, or to be
recognized; however, we hope you will consider sharing
your support in the best way possible – become a DNA
member. With a large, diverse, and continuously growing
membership, DNA can bring Delaware nurses more value,
advocacy, solutions, and more.
References
American Association of Critical-care Nurses. (2021). Meaningful
Recognition. Retrieved from https://www.aacn.org/
nursing-excellence/healthy-work-environments/meaningfulrecognition.
Kelly, L. A. & Lefton, C. (2017). Effect of meaningful recognition
on critical care nurses’ compassion fatigue. American Journal
of Critical Care. 26(6), 438-444. doi: 10.4037/ajcc2017471
Kim, L. Y., Rose, D. E., Ganz, D. A., Giannitrapani, K. F., Yano, E.
M., Rubenstein, L. V., & Stockdale, S. E. (2020). Elements of
the healthy work environment associated with lower primary
care nurse burnout. Nursing Outlook. 68(1), 14-25. doi:
10.1016/j.outlook.2019.06.018
Lefton, C. (2014). Beyond thank you: The powerful reach of
meaningful recognition. American Nurse. Retrieved from
https://www.myamericannurse.com/beyond-thank-you-thepowerful-reach-of-meaningful-recognition/.
Page 4 • DNA Reporter December 2021, January, February 2022
Guest Editor continued from page 1
treatment options and willingness to pursue or not pursue.
How a patient understands their choices influences the
care they receive in end of life care, and options should be
well laid out to our patients for informed decision making.
Treatment decisions in end of life care include
resuscitation in the form of CPR or intubation, palliative
sedation for intractable pain, refusal of artificial nutrition
and hydration via tube, refusal of life saving surgery,
refusal of blood products, refusal of antibiotics, refusal
of chemotherapy or radiation therapy, and refusal for
initiation of or stopping of hemodialysis. These decisions
to stop or not initiate treatments generally result in a
death that would have naturally occurred without the
intervention of medicine.
I have observed that patients nearing the end of
their life may make decisions to continue treatments
inconsistent with their personal preferences based
upon lack of information regarding the impact on their
healthcare outcomes. This unwanted care has led to
increased psychological distress and increased utilization
of health care resources that may offer little therapeutic
benefit or impact on quality of life and may leave their
loved ones without the ability to have closure.
In 1997, Oregon was the first state to legalize aid
in dying. Since that time, Washington, D.C, California,
Colorado, Hawaii, Maine, New Jersey, Vermont,
Washington, and most recently in 2021, New Mexico
has followed suite. Although Montana does not have a
dedicated law, in 2009, its supreme court supported that
nothing in Montana’s State Law prohibited a physician
from honoring the wishes of a competent terminally ill
adult to be able to hasten their death. Only New Jersey
and Hawaii currently allow nurse practitioners to prescribe
end of life medications (“Death with Dignity Acts,” n.d.).
Death with Dignity is the underlying concept of
Delaware’s House Bill 140 (HB140), with Representative
Paul S. Baumbach as the primary bill sponsor. This 2021,
the Delaware Death with Dignity Act, HB 140, was
assigned to the House Health & Human Development
Committee on the final day of the session, just before
the Delaware General Assembly adjourned (“Death with
Dignity Delaware,” n.d.).
House Bill 140 would allow another option in end
of life care, and would permit a terminally ill patient
with six months or less life expectancy who is an adult
resident of Delaware (age 18 and above) to request and
self-administer medication to end the individual’s life in
a humane and dignified manner if both the individual’s
attending physician/advanced practice registered nurse
(APRN) and a consulting physician/advanced practice
registered nurse (APRN) agree on the individual’s diagnosis
and prognosis and believe the individual has decision
making capacity, is making an informed decision, and is
acting voluntarily (“Delaware General Assembly,” n.d.,
House Bill 140). House Bill 140 has safeguards built in to
protect the public and providers when considering this as
an option. It would be up to the healthcare institution and
individual practitioner to consider and decide how they
would respond to HB140 based on legal, ethical, moral,
and personal values.
The American Nurses Association (ANA, 2019) as
cited in the ANA Position Statement, stated the hallmarks
of end-of-life care include respect for patient selfdetermination,
nonjudgmental support for patients’
end-of-life preferences and values, and prevention and
alleviation of suffering. Death with Dignity should be
viewed as medical aid to those dying with a terminal illness
(OJIN, 2019). It is not considered suicide, assisted suicide,
homicide, or euthanasia, and would offer another option
in end of life care planning to existing hospice care and
comfort care provided under palliative care. The ANA
2019 position statement recommends that nurses have
knowledge on the current environment for medical aid
in dying and remain objective if patients wish to discuss
medical aid in dying, thus preserving self-autonomy and
dignity in making end of life health care decisions (OJIN,
2019).
States that have Death with Dignity Laws provide
another option suited to meet end of life preferences
in those suffering with a terminal illness. The role of the
nurse is to listen, to be an advocate for their patient’s
needs, and to ensure continuation of care based on the
patient’s personal preferences. Only our patients can state
their wishes for their end of life care planning and tell us if
medical aid in dying would be in their best interest.
This edition of the DNA Reporter is focused on how
palliative care may improve quality of life and preserve
dignity in end of life care. The first step is to recognize
the need to have end of life care discussions to share
our thoughts on how we want to spend our final days
and to revisit one’s medical wishes as health changes.
Heather Milea, MSN, FNP-BC, AGACNP-BC, PCCN,
CHFN, highlights how the Covid epidemic impacted
patient’s quality of life in end of life care. Ginna Keil,
MSN, FNP-BC demonstrates how community palliative
care is high quality and cost effective when shifting the
focus from active disease treatment to comfort care.
LaTonya Mann, DNP, FNP-BC, OCN discusses that early
intervention of palliative care with the assistance of
nursing leads to a better quality of life for those living
with cancer. Kiernan Quay, DNP, APRN, FNP-C relays
that non beneficial treatment in end of life care may not
equate with quality of life. Karin Cooney-Newton, MSN,
RN, APRN, ACCNS-AG, CCRN presents an effective
objective tool for end of life care that can promote
comfort and alleviate suffering for patients and their
families in end of life care.
References
ANA Position Statement: The nurse’s role when a patient
requests medical aid in dying. (2019). OJIN: The Online
Journal of Issues in Nursing, 24 (3). https://www.doi.
org/10.3912/OJIN.Vol24No03PoSCol02
Death with Dignity. (n.d). https://deathwithdignity.org Retrieved
7/20/2021.
Death with Dignity, Delaware. (n.d.). https://deathwithdignity.
org/states/delaware/
Death with Dignity Acts. (n.d.) https://deathwithdignity.org/learn/
death-with-dignity-acts Retrieved 8/11/2021.
Delaware General Assembly, House bill 140. https://legis.
delaware.gov/BillDetail?LegislationId=79026 Retrieved
10/7/2021
Institute of Medicine. (1997). Approaching death: Improving care
at the end of life. Washington,D.C: National Academy Press.
The Delaware Code Online (n.d). Title 16 Health and Safety,
Regulatory Provisions Concerning Public Health Chapter
25. Health-Care Decisions, section 2502. http://delcode.
delaware.gov/title16/c025/ accessed 7/1/2021.
December 2021, January, February 2022 DNA Reporter • Page 5
Page 6 • DNA Reporter December 2021, January, February 2022
COVID-19 Pandemic Through the Lens of an Inpatient Palliative Medicine Provider
Heather M. Milea, MSN, FNP-BC, AGACNP-BC, PCCN, CHFN
Heather M. Milea is currently a nurse practitioner on the palliative
care team at Christiana Care Hospital where she has worked for
over twenty years with an acumen in family medicine, advanced
heart failure, and cardiology. She is a graduate of the University of
Delaware’s undergraduate baccalaureate nursing program and Master
of Science in Nursing program with a concentration in family nurse
practitioner. She completed a post-master’s graduate degree at the
University of Pennsylvania in adult gerontology acute care. Heather
has been recognized as one of the 2021 top nurse practitioners by
Delaware Today, is a member of the Delaware Coalition for Nurse
Practitioners, and serves on the palliative team wellness committee
and transition team at Christiana Care Hospital. Heather may be
reached at hmilea@christianacare.org.
Heather M. Milea
The COVID-19 pandemic systemically obstructed the delivery of traditional
healthcare, particularly impacting our chronically ill and frail patients. Healthcare
delivery for the hospitalized, critically ill COVID-19 cohort was challenging because
of the complex symptom management, rapid physical decline, high mortality,
and increased intensive care utilization (Rosa et al., 2020). As the virus infiltrated
Delaware, this problem was further aggravated as our healthcare organizations
followed the isolation strategies established by other institutions: significant
restrictions in visitation, limiting the flow of providers in and out of rooms, and
segmenting COVID-19 patients from other patient populations. Despite the obvious
public health need to reduce transmission of the respiratory pathogen, an illconsidered
byproduct was the social isolation, severing our instinct to be present
with loved ones during a serious illness. With the isolation increasing our patients’
suffering and our efforts to provide holistic care frustrated, care delivery models
had to be radically revised as the palliative medicine team innovated and tested our
processes in real time. As the expression goes, we were “building the plane as we
flew.”
Palliative Medicine During a Pandemic
Palliative medicine providers are holistic by virtue of the discipline. Through
disease counseling and goals of care for acute, chronic, or traumatic health
problems, palliative medicine’s foundational ethos is to improve quality of life
both inside and outside the biomedical realm, as well as reduce the burden of
symptoms related to disease states. The diverse team of inpatient palliative care
service providers including physicians, nurse practitioners, physician assistants,
social workers, nurse navigators, and palliative chaplains collaborate to add
robust, holistic care. Communication prowess is one of the revered skillsets among
palliative providers, especially during end-of-life care (Pattison, 2020). The World
Health Organization’s (WHO) 2018 ethical principles in humanitarian contexts
strongly advocate for access to palliative care to minimize suffering and, by the
United Nations International Health Regulations’ own definition of “public health
emergency of international concern,” the COVID-19 pandemic would most certainly
qualify.
As the pandemic disintegrated traditional healthcare delivery, inpatient palliative
care consults for COVID-19 patients surged. Among the significant symptom burden
of a hospitalized COVID-19 patients, anxiety and loneliness may be among the
most hidden and difficult to resolve, even in optimal healthcare scenarios. In an
environment where care teams and resources were burdened, and intensivists and
nurses occupied the limited bedside to provide care, the palliative medicine team
had to reinvent how to expedite care for this vulnerable, often frail, population. That
revitalized care model was discovered in what originally gave our team strength: our
multidisciplinary teamwork.
Multidisciplinary Palliative Medicine Team and Virtual Management
To bridge the gap of visitor restrictions, our team implemented off-the-shelf,
consumer technology (i.e., iPads) equipped with videoconferencing platforms
in COVID-19 rooms and at nursing servers. The care team worked “virtually” for
inpatient visits, allowing for high-touch care in limited-touch environments. Trained,
Horizon House is a nationally
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services to adults with support
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Nursing Career Opportunities
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Certified Nursing Assistant
Wilmington, DE and Newark, DE
Qualified candidates should forward their
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Horizon House offers competitive compensation and a comprehensive benefit package.
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medical language translation specialists and cultural consults were brought on to
provide culturally competent care. The palliative medicine team now had an option
to facilitate our exacting, rapport-dependent care for our patients and family,
extending our ability to supply support and connection.
Unfortunately, despite institutional support for the technology program,
family stakeholders did not have universal access to platforms for virtual
visits, forcing many difficult conversations to take place via telephone. In this
context, the absence of important, nonverbal cues diminished the quality
of interaction, especially regarding difficult, end-of-life communications.
Vulnerable stakeholders had to trust a medical team to help with emotionally
overwrought decisions without the comfort of connecting to their loved ones.
Serious Conversations
“Ordinary” critically ill scenarios can limit time to have meaningful
healthcare conversations on the values and wishes of the patient. The often
precipitous decline that can happen with COVID-19 hospitalized patients
further compacted the time to prepare patients and their care circle. Often,
that involved standing outside an ICU room of a COVID-19 patient struggling
with fear, providing through the glass a calm voice of comfort, an ear to
listen, or a provider who could treat symptoms of air hunger, anxiety, or even
claustrophobia.
The palliative medicine team elected to implement best practices from
COVID-19 conversation guides. VITALtalk (n.d.), a nonprofit social impact
organization for clinicians, encouraged early and clear communication, as
well as exploring patient goals and making care recommendations based
on those stated goals. For the team, discussions with the patient and their
support system regarding prior advance care planning documents, anticipatory
guidance of swift clinical deterioration, and code status ensued immediately
into a hospitalized patient’s COVID-19 course. With those that were fortunate
to survive the acute phase of their inflammatory-related respiratory failure,
the palliative medicine team counselled patients on the trajectory of the longterm
sequalae of COVID-19, including fibrotic lung disease, coagulopathies,
cardiomyopathies, debility, and failure to thrive. The work was a delicate
balance of active listening and support to spouses, children, and care circles
physically separated from their sick family members. For patients that passed
without a loved one near, our nurses held their hands.
End-of-life Care for COVID-19 Patients Amidst a Global Pandemic
Suffering, end-of-life COVID-19 patients are most treated for dyspnea,
restlessness, anxiety, and delirium, along with significant spiritual and
psychosocial needs. Dyspnea and delirium are among the most common
symptoms in dying patients with COVID-19 and, despite attempts at managing
underlying cause of dyspnea, refractory dyspnea and hypoxia may persist
(Sun et al., 2020). The Center to Advance Palliative Care (n.d.) developed
crisis protocols for managing common symptoms associated with COVID-19,
which our team follows. Opioids are the treatment choice for refractory
dyspnea and as-needed dosing is safer and more effective compared to an
opioid infusion. Non-pharmacologic interventions include sitting the patient
in either an upright or, in some instances, prone position. The decision in
favor of COVID-19 ventilation focuses on limiting lung damage and mitigating
aerosolization of the virus. In circumstances where continuing aggressive
care was futile or where goals of care dictated de-escalating or withdrawing
ventilation support, the ICU and palliative teams initiate end-of-life discussions
to guide a compassionate withdrawal of care with an emphasis on a dignified
passing. Preparing the family is imperative; expectations, suggestions, and
exploration of their concerns are important to ameliorate prior to withdrawal
of care. Hospice resources for family and their care circle is robust, not only
during their hospice care, but also in bereavement support that extends after
their loved one’s passing.
The palliative team’s principle is to provide physical, spiritual, and
psychosocial comfort for our patients and their extended care circle. During
the COVID-19 pandemic, the collaboration with primary and specialty services
complimented the front-line workers who were brave enough to support our
community. Moreover, just as we do for patients, the palliative medicine team
offers safe haven to support colleagues without prejudice. There have been
far too many tragic losses related to COVID- 19 and, as a society, we share a
collective and complicated grief that we have not yet begun to unpack.
References
Center to Advance Palliative Care (n.d.). COVID-19 rapid response resources hub. https://
www.capc.org/covid-19/
Pattison, N. (2020). End-of-life decisions and care in the midst of a global coronavirus
(COVID-19) pandemic. Intensive and Critical Care Nursing, 58. https://doi.org/10.1016/j.
iccn.2020.102862
Rosa, W.E., Meghani, S.H., Stone, P.W. and Ferrell, B.R. (2020). Opportunities for nursing
science to advance patient care in the time of COVID-19: A palliative care perspective.
Journal of Nursing Scholarship, 52(4), 341-343. https://doi.org/10.1111/jnu.12570
Sun, H., Lee, J., Meyer, B. J., Myers, E. L., Nishikawa, M. S., Tischler, J. L., & Blinderman, C. D.
(2020). Characteristics and palliative care needs of COVID-19 patients receiving comfortdirected
care. Journal of the American Geriatrics Society, 68(6), 1162–1164. https://doi.
org/10.1111/jgs.16507
VITALtalk (n.d.). COVID Ready communication playbook. https://www.vitaltalk.org/wpcontent/uploads/VitalTalk_COVID_English.pdf
World Health Organization (2018). A WHO guide: Integrating palliative care and symptom
relief into the response of humanitarian emergencies and crises. https://apps.who.int/iris/
bitstream/handle/10665/274565/9789241514460-eng.pdf
December 2021, January, February 2022 DNA Reporter • Page 7
Community-Based Palliative Care: High Quality and Cost Effective
Ginna Keil, MSN, FNP-BC
Ginna Keil earned her Associate of Arts Degree in General
Studies in 2002 followed by her Associates of Science Degree
in Nursing in 2006 from Wor-Wic Community College.
Ginna was a registered nurse in the State of Maryland
and Delaware for 13 years with nursing experience in the
emergency department, women and children’s health,
and neonatal intensive care settings. Ginna furthered her
education by receiving her Bachelor of Science Degree in
Nursing and graduated with her Master of Science Degree
in Nursing from Wilmington University in 2018. Certified
by the American Academy of Nurse Practitioners, Ginna
practices as a Family Nurse Practitioner in the State of
Delaware. Ginna currently is employed with Delaware
Hospice and provides Palliative and Hospice services in the Ginna Keil
community setting. Professional achievements include member of the Phi Theta
Kappa-Honor Society, Daisy Award Recipient, Maternal Child Award, Nursing Service
Excellence Awards, and Delaware Hospice Star Award. Ginna may be reached at
gkeil@delawarehospice.org.
Widely known among healthcare providers are the challenges today’s
Healthcare system face secondary to an expanding aging population who
suffer serious illness compounded by multiple medical comorbidities.
According to data provided by the Center to Advance Palliative Care (CAPC,
2015), there are at least 12 million adults and 400,000 children in the United
States living with a serious illness and by the year 2030, people aged 85
and over are expected to double to 8.5 million. The Delaware Healthcare
Association (DHA, 2019) reported that emphasis on disease specific treatments
have become commonplace rather than holistic treatment that addresses
the needs of patients and their caregivers. In many cases, this focus has
led to fragmented and burdensome care with inadequate management of
symptoms resulting in unnecessary suffering. It is, therefore, a system that
is unsustainable in terms of poor quality and high cost. The question then
becomes, ‘how does the Healthcare system meet the needs of this growing
population while still delivering high quality and financially sustainable care?’
(CAPC, 2015).
A potential solution may lie in the specialty of palliative care medicine which
has been growing in popularity globally over the last two decades. What is
palliative care? With a unique holistic approach that is both patient and
family centered, the Center to Advance Palliative Care (2019) explained that
the design of palliative care is to anticipate, prevent, and manage physical,
spiritual, social, and psychological aspects of health and improve the quality
of life for patients, families, and caregivers throughout their illness trajectory.
Furthermore, based on patient need rather than diagnosis, any individual
regardless of age who are diagnosed with a serious illness may receive
palliative care services alongside curative treatment. Although services may
be initiated at any stage of the illness trajectory, implementation in the early
stages of the disease process have resulted in improved patient care outcomes.
As leaders in healthcare recognize the impact that cost effective and
high-quality palliative care have on patients, caregivers and healthcare
organizations, services are now available in 94% of hospitals with more than
300 beds and available in 72% of hospitals with more than 50 beds (Center
to Advance Palliative Care, n.d.). Inpatient palliative care consultation is
associated with a reduction in healthcare costs with a total savings of more
than $1.3 million for a 300-bed community hospital and more than $2.5
million for the average academic medical center (Cruz-Oliver, 2017).
Expansion of palliative services is a Healthcare necessity and should be
offered on every level and across all settings in efforts to meet the many
needs of Americans living with serious illness compounded by multiple medical
comorbidities (CAPC, 2021). Hospitals and health systems are now extending
palliative services into community settings including but not limited to
physician offices, ambulatory clinics, cancer centers, skilled nursing facilities,
and patient homes. In addition to hospitals and health systems, service
delivery is provided by primary care physicians, specialty practices, private
companies, home health aid agencies, and hospices (CAPC, n.d.). Palliative
care is multidisciplinary and includes a team of dedicated medical, nursing, and
allied health professionals. The comprehensive role of the palliative care team
throughout the trajectory of the patient’s illness includes but is not limited to
expert pain and complex symptom management, provision of psychological,
spiritual, and emotional support, medication management and monitoring,
and the completion of advance health directives. The palliative care team
works collaboratively with specialists in the community that allows for
coordination of care. As the trajectory of illness progresses, locations as well
as wishes of the patient and their caregivers may change. Community based
palliative care allows for consistency across transitions (CAPC, 2021).
Community based palliative care allows for a reach to patient populations
that neither fit hospice eligibility nor are hospitalized and are stable enough to
reside in the community setting. Many individuals suffering from serious illness
and chronic medical conditions experience mobility issues with functional
limitations that do not allow travel to office settings or are burdensome.
Often, it is the preference of many individuals suffering from chronic medical
conditions to remain at home while coping with their serious illness.
The National Coalition for Hospice and Palliative Care (NCHPC, 2018)
explained that with disease progression, the emphasis shifts from active
treatment of the disease to treatment that promotes comfort with an improved
quality of life. Anticipatory guidance is provided regarding disease process,
progression, and strategies for management in efforts to optimize quality
of life. They further explained that palliative care providers facilitate patient
autonomy, by providing access to information and choice regarding their care.
Palliative care in the home setting promotes the development of a trusting
rapport and fosters feelings of support and connectivity. This allows for
sensitive conversations of how individual values, preferences, ethnicity, culture,
and spiritual beliefs play a role in their healthcare (NCHPC, 2018).
The Center to Advance Palliative Care, (2021) recognizes that there is strong
evidence that implementation of community based palliative care services
results in compassionate, affordable, sustainable high-quality care, and is
associated with reduced nonbeneficial emergency department visits and
hospitalizations. Reduced hospital readmissions may lead to reduced penalties
for hospitalized patients with serious chronic illnesses.
Where do hospitals in the State of Delaware stand regarding equitable
access to palliative care services? Delaware Healthcare Association (DHA, 2019)
President & CEO Wayne A. Smith stated, “Delaware hospitals are proud to
lead the nation in providing access to quality palliative care for our friends and
neighbors” (para. 3). Delaware hospitals were leading the nation in 2019 by
providing individuals living with a serious illness equitable access to palliative
care services according to the 2019 State-by-State Report Card on Access
to Palliative Care in Our Nation’s Hospitals (DHA, 2019). The integration of
palliative care services promotes the high quality and financially sustainable
care needed to meet the physical, spiritual, social, and psychological needs of
patients and their caregivers who suffer serious illness. Leaders in Healthcare
nationwide must strive to integrate palliative care medicine into healthcare
systems and ensure that patients from all populations and across all settings
receive this invaluable service.
References
Center to Advance Palliative Care. (2015). A guide to building a hospital-based
palliative care program. file:///C:/Users/ginna/Downloads/the-capc-guide-tobuilding-a-hospital-palliative-care-program.pdf
Center to Advance Palliative Care. (2021). Concepts of community-based palliative care
program design 101: Learner’s Guide. file:///C:/Users/ginna/Downloads/conceptsof-community-based-palliative-care-program-design-101-learners-guide.pdf
Center to Advance Palliative Care. (2019). Key findings on the perceptions of palliative
care. https://media.capc.org/recorded-webinars/slides/1lessAudience_Research_
Webinar_Aug_8-2019_FINAL.pdf
Center to Advance Palliative Care. (n.d.). The case for community-based palliative
care: A new paradigm for improving serious illness care. file:///C:/Users/ginna/
Downloads/the-case-for-community-based-palliative-care.pdf
Cruz-Oliver D. (2017). Palliative Care: An Update. Missouri Medicine, 114(2), 110 –115.
Delaware Healthcare Association. (2019). Delaware receives top “A” grade on access
to palliative care in our nation’s hospitals. https://deha.org/News/Press-Releases/
Delaware-Receives-Top-A%E2%80%9D-Grade-on-Access-to-Pallia
National Coalition for Hospice and Palliative Care. (2018). National Consensus Project
for Quality Palliative Care. https://www.nationalcoalitionhpc.org/ncp
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Page 8 • DNA Reporter December 2021, January, February 2022
Palliative Care: Including Nursing in Early Intervention
LaTonya E. Mann, DNP, FNP-BC, OCN
Dr. Latonya Mann earned
her Licensed Practical Nurse
degree from Salem Community
College, Associate Degree in
Nursing from Gloucester County
College, Bachelors in Nursing
from Immaculata University,
Master’s Degree from University
of Delaware, and Doctorate in
Nursing Practice from Wilmington
University. She is a board certified
Family Nurse Practitioner. Dr.
Mann is Past President for
Delaware Diamond Chapter LaTonya E. Mann
of Oncology Nursing Society and a member of the Delaware
Nurses Association, Delaware Coalition of Nurse Practitioners,
and Sigma Theta Tau International Honor Society of Nursing.
Dr. Mann brings over 35 years of experience in various
settings of nursing including medical-surgical, intensive care,
home infusion therapy, palliative care, and oncology nursing.
She presently works as a Nurse Practitioner with the Medical
Oncology team at Bayhealth Cancer Center. Dr. Mann may be
reached at LaTonya_Mann@bayhealth.org
The Center of Advanced Palliative Care (CAPC, 2021)
defines palliative care as:
Specialized medical care for people living with a serious
illness. This type of care is focused on providing relief
from the symptoms and stress of the illness. The goal
is to improve quality of life for both the patient and the
family. Palliative care is provided by a specially-trained
team of doctors, nurses and other specialists who work
together with a patient’s other doctors to provide an
extra layer of support. Palliative care is based on the
needs of the patient, not on the patient’s prognosis. It
is appropriate at any age and at any stage in a serious
illness, and it can be provided along with curative
treatment. (para. 2)
Palliative care teams work alongside a patient’s team
of specialists to provide symptom and communication
expertise, emotional support, assistance with medical
decision making, and assistance with end-of-life care and
bereavement support when appropriate (Finn et al., 2017).
Palliative care can be provided in a variety of settings,
including inpatient hospital consultation, outpatient
clinics, assisted living and long-term care facilities, and
even home-based care. The most familiar mode of
palliative medicine delivery is inpatient-based services
that may involve a single practitioner or a consultant
palliative care medicine team. These medical providers
are available throughout the entire hospital setting, from
Vacancy Announcement
Adjuncts and Part-time Teaching Positions
Department of Nursing
Wesley College of Health & Behavioral Sciences
Part time Adjunct positions-lecture and clinical areas: maternal/
newborn nursing, medical/surgical nursing, mental health nursing, child
and family nursing, community and/or public health nursing.
Full time faculty positions-Clinical Practitioner, Maternal/Newborn
Nursing Faculty, Medical/Surgical Nursing Faculty, Mental Health Nursing
Faculty, Child and Family Nursing Faculty.
Full time Staff positions-Skills Lab Coordinator-
Required:
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on the area applying for
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Special Instructions: Interested applicants must apply online at DSU
website: www.desu.edu. If invited for an interview, provide resume/
curriculum vitae and three (3) professional references with contact
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Apply for this posting only if you are interested AND qualified for the
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DSU is an equal opportunity, Title IX Employer and does not discriminate against persons
on the basis of race, religion, national origin, sexual orientation, gender, marital status,
age or disability.
the emergency department and intensive care unit to a
rehabilitation unit if appropriate (Thomas et al., 2019).
Early Integration
Although there are current guidelines to advocate
early integration of palliative care and research that show
its benefits, there are several barriers to palliative care
referrals. The most common is the misperception that
palliative care is only associated with end of life. However,
most patients accept palliative care intervention without
a loss of hope. The ENABLE and ENABLE II studies
showed decreased depression in patients who received
palliative care, providing evidence that palliative medicine
consultations should not be postponed until failure of
therapy, symptom crisis, or end of life (Thomas et al.,
2019).
As healthcare providers, nurses struggle every
day on what words to choose to deliver bad news to
patients. Many providers wrestle with how to begin the
conversation and knowing the appropriate time to discuss
prognosis. Many have little training on how to deal with
the patient and caregiver emotions. This is due to the
limited training and education in palliative care. According
to Sedhom et al. (2020), oncologists give bad news to
patients an average of 35 times a month, yet few have
training or mentorship in communication skills. Oncologists
are more medicine oriented and fellows report receiving
more coaching on how to perform bone marrow biopsies,
a technical skill, than on how to conduct a family meeting.
Word choice may feel trivial compared with the plethora of
other things that need to be learned. Yet, words influence
medical decision making and have implications for patient
care (Sedhom et al., 2020).
Nursing in Early Intervention
Nursing is a profession within healthcare focused on
the care of individuals, families, and communities so they
may attain, maintain, or recover optimal health and quality
of life. For the fifteenth consecutive year, the Gallup poll
has ranked nursing as the most trusted profession, and
nurses as the professionals who uphold the highest ethical
obligations in establishing community relationships of trust
according to society needs and desires.
Nurses look after patient’s most intimate needs
during their most vulnerable times, and they do so with
compassion. While it is the provider who manages the
overall treatment plan, nurses are the ones who carry it
out. It is the nurse ninety-nine per cent of the time that the
patient and family members interact with in the hospital
setting. Patients know when they call for help, it is their
nurse who will carry out their needs with compassion.
Nurses draw on this trust by advocating for their patient’s
healthcare needs. Patients are more likely to listen to the
advice of their nurse and trust they will advocate for their
overall well-being. When the patient has a poor health
prognosis, patients rely on their nurse who has cared for
them during their hospital stay to tell the truth and help
them to make informed decisions about their healthcare.
For these reasons, it would be to the patient and families’
benefit to have bedside nurses more engaged in family
meetings.
According to Goehring (2017), there are several reasons
a family meeting would be requested by the healthcare
team. Most often there is a decline in the patient’s
medical condition or prognosis and further goals of care
discussions are necessary. There may also be a need for
further discussions about DNR and DNI status as well
as other life sustaining methods such as feeding tube
placement, blood transfusions, and artificial hydration. For
an effective family meeting with an oncology patient, it
would be very beneficial to request the attendance of
the bedside oncology nurse. The oncology nurse can
provide updates on the patient’s medical status, assist
patients with interpreting information, and answer
questions or concerns the patient and loved ones may
have during and post family meeting.
Palliative care for Patients with Advanced Cancer
The role of engaged and involved bedside nurses is
critical to the integration of palliative care for patients
with advanced cancer. A survey was performed
to assess nurses’ perspectives on palliative care
communication. It involved distributing a 46-item
survey via email in 2013 to bedside nurses working
in ICUs across five academic medical centers of the
University of California. The survey was sent to 1791
nurses; 598 (33%) responded. Most participants
reported that their engagement in discussions of
prognosis, goals of care, and palliative care was very
important to the quality of patient care. A minority
reported often discussing palliative care consultations
with physicians (31%) or families (33%); 45% reported
rarely or never participating in family meeting
discussions. Participating nurses most frequently
cited the following barriers to their involvement in
palliative care communications: need for more training
(66%), physicians not asking their perspective (60%),
and the emotional toll of discussions (43%). The
article concluded that ICU bedside nurses see their
involvement in discussions of prognosis, goals of care,
and palliative care as a key element of overall quality
of patient care. Interventions are needed to ensure that
nurses have the education, opportunities, and support
to actively participate in these discussions (Boyle et al.,
2017).
Despite the evidence for a fundamental need for
palliative care services in the practice of oncology,
integration of these medical specialties remains a
clinical challenge. Palliative care has a wide and
significant role in providing palliative care services to
inpatient and outpatient settings. An effective palliative
care and oncology nurse collaboration improves
patient care and QOL. Further research in the role of
integrating the bedside nurse may improve patient and
caregiver outcomes. To stay on top of the profession
and to stay advanced in the field, nurses are expected
to take professional development courses to help
them carry out their duties to the best of their ability.
Taking a course in palliative care would be highly
recommended to assist with goals of care discussions.
References
Boyle, D. A., Barbour, S., Anderson, W., Noort, J., Grywalski,
M., Myer, J., Hermann, H. (2017). Palliative care
communication in the ICU: Implications for an oncologycritical
care nursing partnership. Seminars in oncology
nursing. 33(5) 544-554.
Center to Advanced Palliative Care (CAPC). (2021). https://
www.capc.org/about/palliative-care
Ferrell, B., Meyer, J., O’Neil-Page, E., Cain, J., Herman,
H., Mitchell, W., & Pantilat, S. (2016) ICU Bedside
nurses’ involvement in palliative care communication:
A multicenter survey. Journal of Pain Symptom
Manage. Mar; 51(3):589-596.e2. https://doi: 10.1016/j.
painsymman.2015.11.003.
Finn, L., Green, A. R., and Malhotra, S. (2017). Oncology and
palliative medicine: Providing comprehensive care for
patients with cancer. Ochsner Journal, December;17 (4)
393-397.
Glajchen, M., Goehring, A. (2017). The family meeting in
palliative care: The role of the oncology nurse. Seminars
in Oncology Nursing; 33 (5): 489-497.
Milton, C. L. (2018). Will nursing continue as the
most trusted profession? Ethical overview.
Nursing Science. Jan; 31 (1): 15-16. https://
DOI: 10.1177/0894318417741099
Sedom, R. Sedhom, R., Gupta, A., Von Roenn, J., & Smith, T.
J. (2020). The case for focused palliative care education
in oncology training. Journal of Clinical Oncology :
official journal of the American Society of Clinical
Oncology, 38(21), 2366–2368. https://doi.org/10.1200/
JCO.20.00236
Thomas, T. H., Jackson, V. A., Carlson, H., Rinaldi, S., Sousa,
A., Hansen, A., Kamdar, M., Jacobsen, J., Park, E. R., Pirl,
W. F., Temel, J. S., Greer, J. A. (2019). Communication
differences between oncologists and palliative care
clinicians: A qualitative analysis of early, integrated
palliative care in patients with advanced cancer. Journal
of Palliative Medicine. 22 (1), 41-49.
December 2021, January, February 2022 DNA Reporter • Page 9
Non-beneficial Treatment at the End of Life
Kiernan Quay, DNP, APRN, FNP-C
Dr. Kiernan Quay is an inpatient Palliative Care Nurse
Practitioner at Beebe Healthcare located in Lewes, DE.
She obtained her BSN at Johns Hopkins University in
2009, her MSN and DNP at the Medical University of
South Carolina in 2017. She previously worked in the
settings of acute care, medical-surgical, trauma, and
family medicine. Dr. Quay is a board certified Family Nurse
Practitioner. She is a member of the bioethics, readmissions,
advanced practice provider, and bylaws committees
at Beebe Hospital. She is an eight-time DAISY award
nominee and has twice received honorable mention for
Delaware Today Top Nurses. Dr. Quay may be reached at
Kquay@beebehealthcare.org.
Kiernan Quay
Non-beneficial treatment (NBT) affects over a third of patients at end of life (EOL)
(Cardona-Morrell et al., 2016). The shift from beneficence to autonomy coupled with
a dramatic increase in easily accessible medical information can lead patients and
surrogates to expect to be apprised of all options, including those not recommended and
some not even mentioned, regardless as to whether the treatment could lead them to
achieve their overall goals of care (GOC) (Macauley, 2018). This explosion of autonomy
leads to increasingly complex cases where care being asked for at the end of life may be
incredibly aggressive while not improving quality of life. Conflicts can arise when patients
insist on inadvisable care. Some patients may have a nothing-to-lose mindset regarding
interventions such as cardiopulmonary resuscitation (CPR). There is much to lose, even
at the EOL. Non-beneficial treatment at EOL can lead to significant distress whether
that be emotional, spiritual, physical, or financial. States often have vague legislation
that attempts to offer some protection to providers who refuse to offer treatments. It is
difficult to identify care that would be classified as futile with complete accuracy unless
there is no true physiologic benefit (e.g., CPR in patients with substantial, irreparable
head trauma). Every patient is unique, so determining if there is any chance of success
is difficult, and perhaps even harder to determine the exact probability. While there are
avenues for addressing requests for NBT, there may be overall less distress suffered by
patients, families, and staff if NBT requests are prevented at the outset.
Non-beneficial treatment at EOL, and particularly aggressive interventions such as CPR,
may cause substantial distress to those providing and receiving care. One may think there
is no harm in receiving or performing CPR. A nothing-to-lose mentality fails to recognize
the potential for harm and ignores the responsibility to do no harm (Macauley, 2018).
Cardiopulmonary resuscitation often contributes to broken ribs, internal organ damage,
and the likelihood of a compromised quality of life if there is return of spontaneous
circulation. Healthcare staff may experience moral distress while performing CPR at
patients’ EOL. Providers may feel they are stuck in an impossible situation when they are
concerned that the risk of CPR may be greater than the benefit, yet they feel obligated to
fulfill patient requests. Despite significant scientific advancements, the median in-hospital
adult cardiac arrest survival rate remains at 18% (Meaney et al., 2013).
Per Pope (2017), when states have legislation that attempt to address NBT, they are
often vague and tend to use the problematic futility terminology or reference standards
such as medically ineffective or generally accepted healthcare standards. Delaware Title
16, Chapter 25, section 2501 (m) defines medically ineffective treatment as any medical
treatment to a reasonable degree of medical certainty, a medical procedure that will not
prevent or reduce the deterioration of the health of an individual, or a medical procedure
to prevent the impending death of an individual (The Delaware Code Online, n.d.). Vague
legislation coupled with the nearly impossible task of deciding what is futile leads to
providers being appropriately reluctant to refuse to offer treatments.
At the hospital level, a bioethics committee can review cases and provide guidance
on how to resolve ethical dilemmas that arise between patients and providers. Beebe
Healthcare’s committee is comprised of providers, nurses, non-clinical staff, and
community members. The provider who requests the consultation can accept or decline
the committee’s recommendation.
In addition to bioethics committees, some hospitals have a specific policy that outlines
a precise process to address NBT requests. Beebe Healthcare does not currently have a
NBT policy. While policy specifics vary, they must clearly define NBT to avoid treatment
decisions being made based on personal values (Macauley, 2018). The policy should
encourage the involvement of the Palliative Care team, if not already engaged, and the
bioethics committee. Policies outline next steps if the dispute remains unsolved despite
involvement of both groups. If the provider decides to limit, withdraw, or withhold NBT,
the patient should be permitted to request a second opinion. If the second opinion
concurs with the first, the provider must discuss the options for transfer to another
provider, or another facility if appropriate, and the option to seek legal counsel (Macauley,
2018). If after a reasonable period, transfer to another facility is not practical, nor has
any legal action been filed, care may be unilaterally withheld or withdrawn based on the
institution’s policies and procedures (Macauley, 2018).
Ideally, conflicts are resolved before care is unilaterally withheld or withdrawn. With
the assistance of Palliative Care teams, conflicts are avoided by implementation of early
and ongoing GOC discussions prior to involving a bioethics committee and perhaps
working through a NBT policy sequence.
Early involvement of palliative care is advised as complex GOC discussions typically
require a significant degree of rapport to be successful, and a patient-centered approach
requires more than simply listing options and deferring to the patients’ choices (Macauley,
2018). Palliative Care teams need to have ongoing, extensive discussions with patients to
identify the patients’ values, beliefs, and what is of most importance to them in their
lives. A significant portion of time is spent explaining acute and chronic medical issues
and how those interact to create a prognosis. From there, individual treatment options
are evaluated to determine if they may help patients progress towards their goals or
lead them astray. For example, a full code status is inconsistent with the desire to die
peacefully at home.
Palliative Care teams are a key component to avoiding and solving requests for NBT.
Patients and providers may become ensnared in vague laws and futile terminology.
Engaging patients early in GOC conversations assists patients in determining if medical
interventions are truly beneficial. The greatest satisfaction for patients and healthcare
staff alike may come when patients are listened to, patients make decisions based on
reality, and unnecessary distress is avoided.
References
Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016). Nonbeneficial
treatments in hospital at the end of life: A systematic review on extent of the
problem. International Journal for Quality in Health Care, 28(4), 456-469. doi:10.1093/intqhc/
mzw060
Macauley, R. C. (2018). Ethics in Palliative Care: A complete guide. Oxford University Press.
Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenon, J., de Caen, A. R., Bhanji, F., Abella, B.
S., Kleinman, M. E., Edelson, D. P, Berg, R. A., Aufdeheide, T. P., Menon, V., Leary, M., & on
behalf of the CPR Quality Summit Investigators, the American Heart Association Emergency
Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care,
Perioperative and Resuscitation. (2013). Cardiopulmonary resuscitation quality: Improving
cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement
from the American Heart Association. Circulation, 128,417-435. https://doi.org/10.1161/
CIR.0b013e31829d8654
Pope, T. M. (2007). Medical futility statues: No face harbor to unilaterally refuse life-sustaining
treatment. Tennessee Law Review, 1-81. https://ssrn.com/abstract=989662
The Delaware Code Online. (n.d.). https://delcode.delaware.gov/title16/c025/
We are currently hiring:
• RN Triage (Odenton)
• Staff RN (All ages continuing care)
• RN MD PCP Nurse for Population Health
If you have a passion for community health, we invite you to join our team.
When you work for THC, you will be employed by a premier healthcare
organization that continually strives for high quality, professionalism and
service excellence.
For more information about nursing opportunities at THC, please
visit: www.totalhealthcare.org or
email Michelle at: mlane@totalhealthcare.org
Page 10 • DNA Reporter December 2021, January, February 2022
Using Respiratory Distress Observation Scale (RDOS) at End-of-Life
Karin Cooney-Newton, MSN, RN, APRN,
ACCNS-AG, CCRN
Karin Cooney-Newton is a
Pulmonary Clinical Nurse
Specialist at Bayhealth Medical
Center at both the Kent Campus
in Dover, DE, and the Sussex
Campus in Milford, DE. She
is a BSN graduate of Widener
University, and earned her
Masters at Wesley College.
Karin’s clinical expertise is within
critical care for 33 years where
her passion for end-of-life
improvement is ongoing. She
has presented on compassionate
extubation using an objective
respiratory distress observation
Karin Cooney-
Newton
tool nationally at the National Teaching Institute & Critical
Care Exposition, regionally at TRENDS, and locally at
Nursing Research conferences. She has worked as adjunct
faculty at Wesley College for 10 years; and is co-author
of a chapter in Innovative Strategies in Teaching Nursing
published by Springer April, 2020. Karin may be reached at
karin_cooney-newton@bayhealth.org.
End of life (EOL) patient care can be an extremely
stressful experience for not only the patients, but
also, their families, and the healthcare team. When
training to become a nurse, the focus is largely on
helping patients survive acute episodes and to assist
in restoring their health. Unfortunately, not all patients
are able to fully recover, or return to their desired
quality of life. In 2010, 29% of deaths occurred in the
hospital, and the average terminal admission lasted 7.9
days according to the New England Journal of Medicine
(Blinderman & Billings, 2015). The healthcare team
must transition these patients from restorative care to
palliative care. It is considered one of the most difficult
and important aspects of nursing practice (Truog et al.,
2008).
Optimal pain and symptom management is a priority
for patients and families at EOL. Bender et al. (2017)
stated that surveys of patients and family members, as
well as prospective and retrospective studies revealed
gaps in the quality of care for symptom management
at EOL. These gaps included inadequate pain and
symptom control, and delays in the evaluation and
management of dyspnea (Bender et al., 2017).
Uncontrolled symptoms at EOL adds distress for
patients and their families, as well as compromises the
patient’s quality of life.
When further life-sustaining treatment is deemed
futile, and/or is no longer achieving the patient
and family’s goals of care, the family may choose
to discontinue further treatment. Within the ICU
setting, compassionate extubation (CE) is the
termination of mechanical ventilation and withdrawal
of an artificial airway to avoid prolonged suffering
at EOL. Some patients who are conscious are able to
report dyspnea, but others being withdrawn from
the ventilator are critically ill, cognitively impaired,
or unconscious and unable to self-report dyspnea.
These patients may or may not be able to experience
respiratory distress depending on the severity of
unconsciousness (Campbell et al., 2015). The ability to
experience unrelieved dyspnea continues until death.
These patients near death are vulnerable to be under
recognized and under treated for respiratory distress.
Conversely, a patient runs the risk of being over
treated, which leads to over sedation and unintentional
acceleration of death (Campbell & Templin, 2015).
Unanticipated respiratory distress is a common
complication of CE and one of the most challenging
symptoms for healthcare providers to control for
their patients. This can be an extremely distressing
experience for patients, as well as their families and the
healthcare team.
The use of the Respiratory Distress Observational
Scale (RDOS) at EOL can assist with patient comfort
and decrease stress of the family and healthcare
providers. RDOS is an objective assessment that can
guide the CE process, as well as withdrawal of noninvasive
ventilation device (NIVD), or high-flow nasal
cannula (HFNC). It is an objective tool used to assess
the nonverbal, adult patient for the presence and
intensity of respiratory distress. There are 8 variables
(heart rate, respiratory rate, restlessness, paradoxical
breathing, accessory muscle use, grunting at end
expiration, nasal flaring, look of fear) with numeric
values which are totaled together to obtain the RDOS
score. Scale scores can vary from 0 indicating no
distress to 16 indicating the most severe distress. The
goal is a score
December 2021, January, February 2022 DNA Reporter • Page 11
of withdrawing life-sustaining measures in the clinical
setting (Campbell et al., 2015).
RDOS not only can be used within the hospital
setting but could be used in the home during hospice/
palliative care. Dr. Campbell initiated the RDOS-
Family as a guide for the family caretaker who has
the around-the-clock responsibility to ensure patient
comfort at EOL (Campbell & Templin, 2014). Educating
family members of patients with dyspnea to use a
standardized patient assessment could increase family
confidence with dyspnea caregiving. Knowledge of
how to assess and manage dyspnea (especially with
the heart and lung disease palliative/hospice patients)
can be initiated using RDOS. This in turn, can improve
patient and family outcomes, with a goal of decreasing
acute hospital admissions where a nonpreferred site of
death could occur (Campbell & Templin, 2014). During
the pilot study, Dr. Campbell found that further testing
would need to be completed including more education
on variables that require more nursing experience that
appeared to be underreported by family members
(Campbell & Templin, 2014).
To summarize, EOL can be a stressful experience for
patients, families, and the healthcare team. Patients
near death are apt to be under recognized and under
treated for respiratory distress. Patients also run the risk
of being over treated, which may lead to over-sedation
and unintentional acceleration of death Using RDOS at
EOL can help alleviate distress and assists to validate
the need for medication titration for comfort during
EOL care.
Although EOL care is challenging and emotionally
exhausting for all those involved, helping patients die
peacefully can be as rewarding as saving a life. Thom
Dick, an EMT paramedic and author, summarizes it
best: “You’re going to be there when a lot of people
are born, and when a lot of people die. In most every
culture, such moments are regarded sacred and
private, made special by a divine presence. No one
on Earth would be welcomed, but you’re personally
invited. What an honor that is” (T. Dick, personal
communication, September, 8, 2021).
References
Bender, M. A., Hurd, C., Solvang, N., Colagrossi, K., Matsuwaka,
D., & Curtis, J. R. (2017). A new generation of comfort
care order sets: Aligning protocols with current principles.
Journal of Palliative Medicine, 20(9), 922–929. https://doi.
org/10.1089/jpm.2016.0549
Blinderman, C. D., & Billings, J. A. (2015). Comfort care for
patients dying in the hospital. New England Journal of
Medicine, 373(26), 2549–2561. https://doi.org/10.1056/
nejmra1411746
Campbell, M. L. (2016). AACN Webinar: Caring practice:
Evidence-based terminal ventilator withdrawal. AACN.
Campbell, M.L. (2018). Ensuring breathing comfort at the end of
life: the integral role of the
critical care nurse. American Journal of Critical Care, 27(4), 264-
269. doi:https://doi.org/10.4037/ajcc2018420
Campbell, M. L., & Templin, T. N. (2014). RDOS-Family: A guided
learning tool for layperson assessment of respiratory
distress. Journal of Palliative Medicine, 17(9), 982–983.
https://doi.org/10.1089/jpm.2014.0145
Campbell, M. L., & Templin, T. N. (2015). Intensity cut-points for
the respiratory distress observation scale. Palliative Medicine,
29(5), 436–442. https://doi.org/10.1177/0269216314564238
Campbell, M. L., Yarandi, H. N., & Mendez, M. (2015). A twogroup
trial of a terminal ventilator withdrawal algorithm:
Pilot testing. Journal of Palliative Medicine, 18(9), 781–785.
Dick, T. (2018). People care: Perspectives and practices for
professional caregivers. (3rd ed). EMS World.
Downar, J., Delaney, J. W., Hawryluck, L., & Kenny, L. (2016).
Guidelines for the withdrawal of life-sustaining measures.
Intensive Care Medicine, 42(6), 1003–1017. https://doi.
org/10.1007/s00134-016-4330-7
Mularski, R. A., Campbell, M. L., Asch, S. M., Reeve, B. B., Basch,
E., Maxwell, T. L., Hoverman, J. R., Cuny, J., Clauser, S. B.,
Snyder, C., Seow, H., Wu, A. W., & Dy, S. (2010). A review
of quality of care evaluation for the palliation of dyspnea.
American Journal of Respiratory and Critical Care Medicine,
181(6), 534–538. https://doi.org/10.1164/rccm.200903-
0462pp
Truog, R. D., Campbell, M. L., Curtis, J. R., Haas, C. E., Luce,
J. M., Rubenfeld, G. D., Rushton, C. H., & Kaufman,
D. C. (2008). Recommendations for end-of-life care in
the intensive care unit: A consensus statement by the
American College of critical care medicine. Critical Care
Medicine, 36(3), 953–963. https://doi.org/10.1097/
ccm.0b013e3181659096
Zhuang, Q., Yang, G. M., Cheung, Y. B., & Neo, S. H. (2018).
Validity, reliability, and diagnostic accuracy of the respiratory
distress observation scale for assessment of dyspnea in
adult palliative care patients. Journal of Pain and Symptom
Management. https://pubmed.ncbi.nlm.nih.gov/30391404/
Page 12 • DNA Reporter December 2021, January, February 2022
Advocacy
Results of Delaware Nursing Dialogue – Advocacy Prioritization
Annamarie Flick, MSN, RN-BC, NE-BC,
Advocacy Director
The Delaware Nurses
Association recently launched
Delaware Nursing Dialogue,
an ongoing inquiry series
for all Delaware nurses to
participate in and contribute to
the advancement of nursing in
Delaware. Delaware Nursing
Dialogue will feature a variety of
topics focused on the profession.
The first survey in the series
Annamarie Flick
focused on advocacy and
legislative efforts. These results were recently presented
to the Advocacy Committee and Board of Directors. I am
happy to share them back with you.
Demographics
• There were 194 nurses that participated in the annual
advocacy priorities survey.
o 68% are RNs, 29% are APRNs, and less than 1%
each were LPNs and nursing students.
o 70% of respondents had over 20 years’ experience.
o 66% of respondents are members in the Delaware
Nurses Association.
o 54% of respondents live in New Castle County.
o 37% of respondents work in the hospital setting.
Advocacy Prioritization
• Provided a list of 11 critical topics in nursing
advocacy/policy, respondents ranked them in
highest to lowest priority as below.
o Safe Staffing
o Wellbeing of the Nursing Workforce
o Workplace Violence
o Top of License Practice
o Nursing Education
o Personal Protective Equipment
o Ongoing Emergency Preparedness
o Collaboration/Relationships/Respect within
the Delaware Health Care Professional
Community
o Telehealth Access & Regulation
o Environmental Health
o APRN Clinical Preceptors
• When asked about additional advocacy/
policy opportunities, respondents provided 82
additional responses. The themes that emerged
from these answers include:
o Access, regulation, and payment for home
care services
o Standing order protocols
o Protecting scope of practice for all nurses
o Access to and overall mental health services
o Uplifting and maintaining the scientific,
evidence-backed position of our profession
and combatting mistrust
o Increased, equitable, and consistent nursing
pay/salary
Advocacy Engagement
• 22% of respondents expressed interest in the
Advocacy Ally position to further support
nursing engagement in policy, legislation, and
advocacy.
• 48% of respondents expressed a desire to
be further involved in grassroots advocacy
by connecting with their local legislators and
speaking in support of nursing priorities.
This information, provided by Delaware nurses, is
already reshaping the way the Advocacy Committee
is working and prioritizing our efforts. Several actions
have already come out of the review of this data:
• Marykate McGurk, BSN, RN, CCRN, Susan Conaty-
Buck, DNP, APRN, FNP-C, FAANP, and Suzette
Flores, DNP, BSW, APRN, NP-C have volunteered
to work as grassroots coordinators and connect
with the identified individuals on staying engaged
and elevating the voice of nurses.
• The Advocacy Committee is going to form
three subgroups focused on the top priorities of
Delaware nurses: workforce/staffing, wellbeing,
and workplace violence.
• DNA’s Executive Director is connecting with the
identified Advocacy Allies to onboard them to
their role, keep them engaged, and begin our
work for the 2022 Delaware General Assembly.
The Advocacy Committee will continue to analyze
the results and align them with our strategies and
legislation/policy that we support and move forward.
Our 2022 Legislative Platform is also currently being
updated based on these results and changes/trends
in nursing and healthcare policy. This will be shared
with nurses in the next edition of the DNA Reporter.
The Advocacy Committee and Board of Directors
thanks all nurses that took the time to answer the first
Delaware Nursing Dialogue and provide us with this
rich information. We encourage you to look for the
next in the series to participate and lend your voice.
Additionally, the prioritization of advocacy efforts
will become an annual mainstay in Delaware Nursing
Dialogue, so look for your chance to participate in Fall
2022!
Retirement Readiness Checklist
Every day brings you a little closer to retirement
age. Are you prepared for the financial impact
of leaving the workforce? Here’s a checklist to
help you consider the variables that impact your
retirement readiness:
1. Estimate your retirement living costs. Do
you know how much money you will need to
live comfortably in retirement? The amount you
spend is likely to change over the years. For
many retirees, expenses are highest in the early
active years of retirement, but also may spike
later in life, should you require costly living
assistance.
2. Add up your assets. As you approach
retirement, you’ll want to have a good handle
on the assets available to fund your retirement.
Consider the equity in your home and
other properties, your investment accounts,
retirement accounts, annuities or cash-value
insurance and savings accounts. If you’re a
collector and hope to cash in, now is a good
time to get an appraisal to determine current
market value.
3. Think about liquidity. How will you access
your savings in retirement? Will you need to sell
securities or properties? Do you own an annuity
that can be converted into an income stream? Do
you have a lot of pre-tax dollars in your retirement
accounts? You’ll want to have a plan to withdraw
from your retirement savings in the most financially
advantageous way.
4. Calculate your Social Security earnings. How
much you will receive each month from Social
Security is based on your work history and the
age at which you choose to retire. To receive your
maximum monthly benefit, plan to claim your Social
Security benefits at full retirement age (or later – up
to age 70). Filing at an earlier age will result in a
permanent reduction in monthly benefits.
5. Consider your tax obligations. Taxes continue
even when you stop working. Assuming you meet
the income threshold, some portion of your Social
Security income will be taxed. The good news is that
as a retiree, you will most likely qualify for a lower
marginal income tax rate. State income taxes vary
widely and may influence where you want to retire.
6. Don’t forget about inflation. While your
Social Security benefits are adjusted for inflation,
your other income may not be immune to rising
consumer prices. Keep inflation in mind as you
estimate your living expenses into the future.
7. Sign up for Medicare during the limited
enrollment window. To avoid penalties, you must
elect your Medicare benefits within a limited time
frame on either side of age 65. Special rules apply
for people who continue to work and are covered
by an employer’s health insurance plan. During
Medicare enrollment, you’ll also have the opportunity
to choose an optional Medicare Supplement
insurance plan. Medicare Supplement plans help
pay for out-of-pocket costs such as co-payments,
coinsurance and deductibles under original Medicare.
8. Consult the experts. Don’t wait until the last
minute to figure out how you’ll pay your way in
retirement. Talk to your accountant and financial
advisor and explore your options. Together, you
can devise a retirement strategy to help you make
the most of the savings you’ve accrued from a
lifetime of work.
Christopher Malmstrom, CRPC, APMA, is a Financial Advisor with Point to Point Wealth Planning a private wealth advisory practice of Ameriprise Financial Services, LLC
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
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.
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.
Investment advisory products and services are made available through Ameriprise Financial Services, LLC, a registered investment adviser.
Ameriprise Financial Services, LLC. Member FINRA and SIPC. | © 2021 Ameriprise Financial, Inc. All rights reserved.
December 2021, January, February 2022 DNA Reporter • Page 13
Delaware Licensed Practical Nurse Leadership
Journey to State Nursing Leadership
Kenyette Walters, LPN, CDP®
My name is Kenyette, most know me as Keni. I am
a Delaware Licensed Practical Nurse (LPN) and currently,
Vice President, Delaware Board of Nursing. I have been
a nurse since 2012. Originally from Philadelphia, my
background is in investment accounting and corporate
finance. I am also a licensed Cosmetologist, former
phlebotomist, heavy equipment operator, and spent
some time doing academic grading/extern coordinator
and lab administration for a graduate medical school in
Philadelphia.
After relocating to Delaware in 2007, and with long
Kenyette Walters
standing medical issues, I decided to pursue an earlier
dream of entering the nursing profession. I felt that I owed good nursing
care back to the community. I studied and obtained certification as a nursing
assisting, worked in long-term care, and realized that nursing was my passion.
In 2012, I completed nursing school and obtained my LPN license. Never
discouraged by the saying “LPNs will be eliminated,” I endeavored to prove
that LPNs are exceptional and prudent nurses with a wealth of opportunities
to pursue. My career took off quickly. I quickly found that geriatric psychiatric,
dementia, and behavioral nursing were my gift. In my role and practice setting,
I was provided the opportunity to fulfill the charge nurse role and provide
dementia programing for a large long-term care program in Maryland. I am
a member of the National Council of Certified Dementia Practitioners and an
active Certified Dementia Practitioner®.
The road to excellence is not easily traveled. I had to endure many of the
downsides of nursing, including bullying from peers and the “nurses eat their
young” mentality. I persevered and have had the opportunity to practice in
some of the following roles/environments: wound care, corrections, geriatric
psych, orthopedic rehab, assisted living house supervisor, admissions nurse,
and intravenous certification. I am currently an overnight skilled nurse in an
exclusive lifestyle senior community. I also teach clinical instruction in the
medical assistant program at Polytech Adult Education.
Serving as the LPN member on the Delaware Board of Nursing, in addition
to the roles noted below, has been pivotal in my professional practice,
development, and leadership. I was reappointed to the board for a second
term and most recently achieved a landmark milestone, I was elected by
the board to serve as the Vice President. Additionally, I chair the Limited
Lay Administration of Medications (LLAM) Committee. This committee is
responsible for a state regulated program, further defined in the Delaware
Nurse Practice Act, that allows individuals who have successfully completed a
board-approved limited lay administration of medications training program to
administer prescription or nonprescription medications to patients/residents/
clients in select settings.
The Delaware Board of Nursing has been one of the most challenging, often
stressful, yet highly rewarding roles to date. The board’s primary purpose is to
protect the public from negligent/impaired nursing practice. Our other goal is
to support nurses, ensuring that they can practice safely and within the law,
provide assistance programs to help nurses in crises, and exact discipline, when
necessary. This role requires fairness, consistency, and in-depth knowledge of
the Delaware Nurse Practice Act, as well as knowledge of practice limitations
at all levels.
Looking to the future and my continued professional development, my next
major goal is to enroll in a nursing home administrator program and precept
in my current facility with our amazing Executive Director. I hope to one day
be the leader of an entire community/facility. I can be reached via email at
mskeni@prodigy.net.
Nurses, thank you for your continued efforts to serve our community. I
know that, at times, it can be difficult to find the passion needed, but your
efforts are noticed and appreciated. The COVID pandemic has put a strain on
the nursing community, with an end date hard to see at this time. Together,
we will support each other, those we serve, and emerge stronger than ever.
We are tired. We are weary. We will never give up.
We are angels of mercy. We are nurses!
Page 14 • DNA Reporter December 2021, January, February 2022
Documenting nursing assessments in the age of EHRs
Georgia Reiner, MS, CPHRM, Senior Risk
Specialist, Nurses Service Organization (NSO)
Nurses have grown accustomed to documenting
assessment results in the electronic health record
(EHR), rapidly clicking responses to assessment
checklist questions. However, at times nurses
complete these actions without giving enough
thought to their documentation because they want
to move on to their “real” work: caring for patients.
The danger of this approach is threefold. First,
nurses might base their assessment on the checklist
not the patient, which can lead to an incomplete
assessment, especially if the nurse inadvertently
clicks something as being done when it hasn’t.
Second, nurses might fail to adequately document
a finding if it does not match up with the available
options in the checklist. Third, nurses might fail to
document assessments when a patient’s condition
changes or fail to document practitioner notification
of the change.
All three scenarios can leave nurses open to
legal action. For example, a harried nurse caring
for a patient who had a total hysterectomy clicks
“normal” as the result of abdominal auscultation
even though she hasn’t completed this assessment
and misses the absence of bowel sounds. Soon,
however, the patient develops vomiting and severe
abdominal pain and is diagnosed with a bowel
obstruction. This nurse could be held liable for the
delay in treatment.
Dangers of improper documentation
Documentation is a vital nursing responsibility. It’s
important for planning patient care, communicating
with providers, and demonstrating compliance with
federal, state, third-party, and other regulations.
But documentation issues can result in professional
liability lawsuits or action against a nurse’s license.
NSO and CNA’s Nurse Professional Liability Exposure
Claim Report: 4th Edition found that documentation
deficiencies are contributing factors in many nurse
professional liability claims, and that the average total
incurred for claims involving allegations related to
documentation was $238,761. The same report also
noted that 9.7% of all license protection matters,
which involved defending nurses during State Board
of Nursing inquiries, were related to documentation.
Of these, nearly half (49.6%) involved an allegation of
fraudulent or falsified patient care or billing records.
Failure to document treatment/care as required by
regulatory agencies or facility policy comprised 28.6%
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of matters related to documentation, followed by
documentation that didn’t accurately reflect patient
care and services (12.8%), failure to properly correct
documentation errors according to facility policy
(5.3%), and inadequate or untimely documentation
(3.8%). These matters serve as reminders of how
nurses need take time ensure they are completing
documentation properly.
Benefits of EHRs
Too often nurses view EHRs negatively, feeling
they’re cumbersome and take nurses away from
the patient. But a well-designed EHR has several
benefits, including improved efficiency and quality
patient care. For example:
• EHRs provide an excellent mechanism for
communicating with a variety of healthcare
providers in a timely fashion, thereby improving
care coordination.
• EHRs can incorporate guidelines, reminders,
and decision support tools that can help
providers make better decisions and deliver
better care.
• Electronic documentation eliminates the
problem of misinterpretation of handwritten
orders.
• EHRs facilitate immediate access to data by
multiple people in multiple locations.
EHRs also can protect nurses against lawsuits and
actions taken against their licenses. However, to gain
the most benefit, nurses need to take full advantage
of EHRs. For example, according to NSO and CNA’s
Nurse Professional Liability Exposures: 2015 Claim
Report Update, 45% of nurses who experienced
a liability claim did not use the available EHR,
compared with 19.2% of those without a liability
claim.
Proper EHR documentation
You can take several steps to ensure you’re
documenting assessments and other information
correctly in the EHR.
• Follow basic documentation principles.
Whether you’re documenting on paper or in an
EHR, the same basic principles apply. Document
promptly, accurately, and without bias. Don’t
interject opinions about patients or providers.
When making a correction to previously
recorded information, include the reason for
the change. Remember that the EHR provides a
date and time for each entry, providing a clear
documentation trail.
• Adhere to policies, procedures,
regulations, and guidelines. In the event of
a legal action, one of the first steps an attorney
will take is to determine if you followed your
organization’s policies and procedures related
to nursing assessments and documentation,
as well as any relevant state, federal, or local
guidelines, and guidelines from professional
associations.
• Copy and paste cautiously. The copy and paste
feature in EHRs can be a time saver, but errors,
including errors of omission, can easily occur.
For example, you copy your note for one patient
with a myocardial infarction (MI) into another
MI patient’s record but forget to add that you
notified the provider of the new S4 you heard
on auscultation. If the patient later experiences
severe heart failure, you will have no evidence
that you notified the provider. Another problem
with copy and paste is that errors can rapidly
spread as others pick up the same erroneous
information. For instance, a nurse copies an
assessment for a patient with pneumonia several
times, forgetting to update the temperature,
which has returned the normal. The patient’s
physician reads the note, thinks the patient
isn’t responding to treatment, and changes the
antibiotic. Subsequently, the patient experiences
a significant adverse event from the new
antibiotic, which leads to legal action against the
hospital, the physician, and the nurse.
A report from the Partnership for Health IT
Patient Safety recommends providers “act with
volition,” thinking about what is appropriate for
copying and pasting and reviewing notes carefully.
Ideally, the EHR should have a mechanism for easy
identification of material that has been copied and
pasted (for example, a different color text), so that
providers are reminded to carefully review.
• Beware of autofill and templates. Like
copy and paste, the autofill feature can
save time by avoiding repetitive entries,
but you need to verify that the information
automatically filled in is correct. Similarly,
templates for regularly occurring events such
as the first postoperative visit after a total
knee arthroplasty can help save time and
ensure needed information is collected, but
you still need to be aware of individual patient
needs and assessment findings.
• Use notes appropriately. Sometimes what
you need to document as an assessment
finding isn’t in a checklist or pull-down menu.
Don’t choose the “next best” option; doing
so can lead to miscommunication and clinical
and billing errors. For example, if you select
“pressure injury” because “skin tear” isn’t
available, legal action would be based on the
more serious injury. A better approach is to
add a note to the patient’s record. Be sure your
note provides vital information in a succinct
matter to avoid “note bloat” (also a side effect
of inappropriate copy and paste). If an option
that you would use frequently isn’t available,
talk with your manager or informatics contact
about adding it to the EHR.
• Protect patient privacy. Do not share
your passwords and change them regularly,
according to your facility’s policy. In addition,
don’t enter information in view of other
patients.
• Don’t ignore alerts. Alerts are there to help
you make better decisions when it comes to
patient care. For example, when you enter
your assessment data, you may receive an
alert that a patient could be at risk for sepsis.
Your prompt action could save the patient’s
life. On the other hand, too many alerts may
lessen their efficacy, leading to “alert fatigue”.
Talk with your manager or informatics contact
to discuss settings.
• Complete an effective assessment. You
won’t have the information you need for the
EHR unless you perform a quality assessment.
Don’t simply consider what a computer
checklist tells you to include. Use your critical
thinking skills to match the assessment to the
patient.
• Document changes in the patient’s
condition. Remember to enter changes to the
patient’s status into the computer and include
if you notified the provider of the change.
A partnership
Rather than having an adversarial relationship with
the EHR, nurses should consider the EHR as a care
partner. By serving as a repository of data, providing
alerts as needed, and facilitating communication, the
EHR can help ensure quality patient care—and reduce
nurses’ risk of legal action.
RESOURCES
Balestra ML. Electronic health records: Patient care and
ethical and legal implications for nurse practitioners.
J Nurs Pract. 2017;13(2):105-111.
CNA, NSO. Nurse Professional Liability Exposure Claim
Report: 4th Edition. 2020. www.nso.com/Learning/
Artifacts/Claim-Reports/Nurse-Practitioner-Claim-
Report-4th-Edition-A-Guide-to-Identifying-and-
Addressing-Professional-Liability- Exposures
CNA, NSO. Nurse Professional Liability Exposures:
2015 Claim Report Update. 2015. www.cna.
com/web/wcm/connect/e05b5d91-cf38-
444d-8727- ab65f25f8f6a/RC_Health_Nurses_
Claim_Report_Update_101615.pdf?MOD=AJP
ERES&CACHEID=e05b5d91-cf38-444d-8727-
ab65f25f8f6a
December 2021, January, February 2022 DNA Reporter • Page 15
Effective use of EHRs
These actions will help you gain the most
benefit from the EHR:
• Document promptly and thoroughly. This
not only helps protect you from liability but,
more importantly, ensures that information is
quickly available to other providers.
• Document accurately. Don’t omit key
information and don’t try to cover up if you
failed to document or take correct action.
• Get involved in EHR selection. Often,
nurses don’t use the EHR correctly or take
full advantage of its capabilities because
the design is poor. Ask to be included on
committees tasked with selecting the EHR
vendor. Consider which systems best reflect
what providers need to document and assess
for user interface by checking items such as
the font size of screen text.
• Identify opportunities for improvements
in EHR function. Instead of engaging in
potentially dangerous workarounds, notify
leadership where improvements are needed.
In some cases, the format of the EHR can be
tweaked to make it easier for the user.
• Don’t assume the EHR is always right. The
EHR isn’t infallible. If, for example, results
of a test don’t seem to match the patient’s
symptoms, follow up with the provider – the
test may need to be redone.
• Provide education. Consider helping
your colleagues learn more about proper
documentation in the EHR by providing an
education program or suggesting such a
program to your professional development
department.
• Be patient centered. The ability to document
at the patient’s bedside can save time and
improve accuracy, but only if you keep
your focus on the patient instead of on the
computer. Maintain eye contact and consider
telling patients what you are entering into
the computer, which can help ensure the
information is accurate.
New, Renewing, & Returning Members
August 28 – November 29, 2021
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Members continued on page 16
ECRI Institute. Copy/Paste: Prevalence, Problems, and
Best Practices. Special Report. 2015. www.ecri.org/
Resources/HIT/CP_Toolkit/CopyPaste_Literature_final.
pdf. Kelley T. Electronic Health Records for Quality
Nursing and Health Care. Lancaster, PA: DEStech
Publications; 2016.
Pagulayan J, Eltair S, Faber K. Nurse documentation
and the electronic health record. Am Nurs Today.
2018;13(9):48-52, 54.
Partnership for Health IT Patient Safety. Health IT Safe
Practices: Toolkit for the Safe Use of Copy and Paste.
2016. https://d84vr99712pyz.cloudfront.net/p/pdf/
hit-partnership/copy-paste-toolkit.pdf. Tsou AY,
Lehmann CU, Michel J, et al. Safe practices for copy
and paste in the EHR. Appl Clin Inform. 2017;8(1):12-
34.
Disclaimer: The information offered within this
article reflects general principles only and does
not constitute legal advice by Nurses Service
Organization (NSO) or establish appropriate or
acceptable standards of professional conduct.
Readers should consult with an attorney if they
have specific concerns. Neither Affinity Insurance
Services, Inc. nor NSO assumes any liability for how
this information is applied in practice or for the
accuracy of this information.
This risk management information was provided
by Nurses Service Organization (NSO), the nation’s
largest provider of nurses’ professional liability
insurance coverage for over 550,000 nurses since
1976. The individual professional liability insurance
policy administered through NSO is underwritten
by American Casualty Company of Reading,
Pennsylvania, a CNA company. Reproduction
without permission of the publisher is prohibited.
For questions, send an e-mail to service@nso.com
or call 1-800-247-1500. www.nso.com.
Page 16 • DNA Reporter December 2021, January, February 2022
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