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<strong>DNA</strong><br />

REPORTER<br />

CONSTITUENT MEMBER OF ANA<br />

Volume 47 • Issue 1<br />

<strong>December</strong> <strong>2021</strong>, January, February 2022<br />

Inside This Issue<br />

The mission of the Delaware Nurses Association is to improve healthcare in Delaware by the advancement<br />

of nursing. Quarterly publication distributed to approximately 6,700 RNs and LPNs in Delaware.<br />

Guest Editor<br />

End of Life Care Considerations in<br />

Palliative Care and Death with Dignity<br />

Joint Policy Statement Adopted by<br />

the Delaware Nurses Association<br />

PAGE 11<br />

Delaware LPN Leadership<br />

PAGE 13<br />

Suzette M. Flores, DNP, BSW, APRN, NP-C<br />

Dr. Suzette Flores is currently<br />

an inpatient palliative care<br />

consultant at Bayhealth Sussex<br />

Campus Hospital. Dr. Flores<br />

has over 30 years of healthcare<br />

experience in the areas of<br />

social work, geriatric psychiatry,<br />

neurosurgery, cardiology, long<br />

term care, and palliative care.<br />

She is board certified in adult<br />

care by the American Academy<br />

of Nurse Practitioners (AANP).<br />

She earned a Bachelor’s Degree<br />

in Social Work from Michigan Suzette M. Flores<br />

State University (MSU), a Bachelor’s Degree of Nursing from the<br />

University of Delaware (U of D), a Master’s Degree of Science<br />

in Nursing and a Doctorate Degree of Nursing Practice from<br />

Thomas Jefferson University (TJU). Dr. Flores has membership<br />

with the Delaware Medical Reserve Corps, Delta Gamma<br />

Sorority, Alpha Eta Society-Thomas Jefferson University,<br />

Sigma Theta Tau International Society of Nursing-Delta Rho<br />

Chapter, on the Delaware Nurses Association (<strong>DNA</strong>) Advocacy<br />

Committee, on the Delaware Cultural Advisory Committee,<br />

and has been involved ongoing with the Delaware Coalition of<br />

Nurse Practitioners (DCNP). She currently serves as Chair of the<br />

Nominating Committee for the DCNP. Dr. Flores is the recipient<br />

of the 2019 AANP Advocate State Award for Excellence. Dr.<br />

Flores may be reached at suzette_flores@bayhealth.org.<br />

Having worked in palliative care, end of life discussions<br />

and end of life care planning can be difficult and<br />

uncomfortable for patients and their families, as well as for<br />

healthcare providers with preparation, let alone without<br />

preparation. All too often, patients and their families do<br />

not think about death and dying until they are confronted<br />

with that possibility.<br />

Death with Dignity is a topic to be considered in our<br />

fast paced technologically evolving medical environments<br />

in which we may be able to keep ourselves going for<br />

prolonged periods of time. Prolongation of life may not<br />

come with improvement in health, and it may not lead to<br />

improvement in our quality of life, although it may be life<br />

sparing.<br />

Every death experience is unique to a person and their<br />

family. What would constitute a good death experience<br />

for you? What would dignity at the end of your life look<br />

like? What would be most important to you at this time?<br />

According to the Institute of Medicine (1997), a good<br />

death is “one that is free from avoidable distress and<br />

suffering, for patients, family, and caregivers; in general<br />

accord with the patients’ and families’ wishes; and<br />

reasonably consistent with clinical, cultural, and ethical<br />

standards” (p. 24).<br />

Traditionally, it was the patient’s physician who<br />

determined what end of life care should look like. This<br />

trend has since shifted to give patient’s autonomy or selfdetermination<br />

to direct their own medical treatments in<br />

end of life care. The concept of self-determination or Death<br />

with Dignity is that a terminally ill patient should determine<br />

their own end-of-life decisions and determine how much<br />

pain and suffering they should endure based upon their<br />

personal beliefs and values, and what a good death may<br />

mean to them (“Death with Dignity Acts,” n.d.).<br />

In Delaware, Title 16, Health and Safety, Regulatory<br />

Provisions Concerning Public Health, Chapter 25.<br />

Health-Care Decisions, section 2502, the right of selfdetermination<br />

states that “any legal adult, who is mentally<br />

competent has the right to refuse medical or surgical<br />

treatment if such refusal is not contrary to public law”<br />

(“The Delaware Code Online,” n.d.).<br />

The legal rights to self-determination in Delaware, may<br />

be expressed as cognizant decisions to forgo or not initiate<br />

life-saving treatments. In my inpatient hospital practice,<br />

discussions center around the risk versus benefit of<br />

Guest Editor continued on page 4<br />

Index<br />

current resident or<br />

Presort Standard<br />

US Postage<br />

PAID<br />

Permit #14<br />

Princeton, MN<br />

55371<br />

Meet the 2022 <strong>DNA</strong> Board of Directors.................. 2<br />

Executive Director’s Report.............................. 3<br />

COVID-19 Pandemic Through the Lens<br />

of an Inpatient Palliative Medicine Provider............. 6<br />

Community-Based Palliative Care:<br />

High Quality and Cost Effective........................ 7<br />

Palliative Care: Including Nursing in Early Intervention... 8<br />

Non-beneficial Treatment at the End of Life............. 9<br />

Using Respiratory Distress Observation<br />

Scale (RDOS) at End-of-Life..........................10-11<br />

Policy Statement on Dissemination<br />

of Non-Scientific and Misleading<br />

COVID-19 Information by Nurses ...................... 11<br />

Results of Delaware Nursing Dialogue –<br />

Advocacy Prioritization................................ 12<br />

Retirement Readiness Checklist........................ 12<br />

Delaware Licensed Practical Nurse Leadership......... 13<br />

Documenting nursing assessments<br />

in the age of EHRs ...................................14-15<br />

New, Renewing, & Returning Members...............15-16


Page 2 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />

REPORTER<br />

OFFICIAL PUBLICATION<br />

of the<br />

Delaware Nurses Association<br />

4765 Ogletown-Stanton Road, Suite L10<br />

Newark, DE 19713<br />

Phone: 302-733-5880<br />

Web: http://www.denurses.org<br />

The <strong>DNA</strong> <strong>Reporter</strong>, (ISSN-0418-5412) is published quarterly every<br />

March, June, September and <strong>December</strong> by the Arthur L. Davis<br />

Publishing Agency, Inc., for the Delaware Nurses Association,<br />

a constituent member association of the American Nurses<br />

Association.<br />

EXECUTIVE COMMITTEE<br />

President: Leslie Verucci, , MSN, APRN, ANP-BC<br />

President-Elect: Stephanie McClellan, MBA,<br />

MSN, RN, CMSRN, NE-BC<br />

Secretary: Jacqueline C. Armstrong, DNP,<br />

MSN, APRN, FNP-BC, PMHNP-BC<br />

Treasurer: George Zangaro, PhD, RN, FAAN<br />

Director-at-Large, Clinical Nurse: Ramona Negron, BSN, RN<br />

DIRECTORS<br />

Membership Growth Directors<br />

New Castle County: Kathy Neal, PhD, RN<br />

Kent County: Sharon Mills-Wisneski, PhD, RN<br />

Sussex County: Candace Hamner, MA, BA, RN<br />

Professional Development Director<br />

Sandra Nolan, PhD, RN, HN-BC<br />

Advocacy Director<br />

Annamarie Flick, MSN, RN-BC, NE-BC<br />

Editorial Director<br />

Karen Panunto, EdD, MSN, RN<br />

EXECUTIVE DIRECTOR<br />

Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN<br />

executivedirector@denurses.org<br />

ORGANIZATIONAL AFFILIATES<br />

Oncology Nursing Society-Delaware Diamond Chapter<br />

communities.ons.org/delawarediamond<br />

Delaware Organization of Nurse Leaders<br />

www.delawareone.org<br />

Delaware Emergency Nurses Association<br />

www.de-ena.org<br />

Delaware State Affiliate of the American College of Nurse-Midwives<br />

http://delaware.midwife.org/<br />

Delaware Coalition of Nurse Practitioners<br />

https://dcnpweb.enpnetwork.com/<br />

Subscription to the <strong>DNA</strong> <strong>Reporter</strong> may be purchased for $20 per year,<br />

$30 per year for foreign addresses.<br />

For advertising rates and information, please contact Arthur L.<br />

Davis Publishing Agency, Inc., PO Box 216, Cedar Falls, Iowa 50613,<br />

(800) 626-4081, sales@aldpub.com. <strong>DNA</strong> and the Arthur L. Davis<br />

Publishing Agency, Inc. reserve the right to reject any advertisement.<br />

Responsibility for errors in advertising is limited to corrections in the<br />

next issue or refund of price of advertisement.<br />

Visit nursingALD.com today!<br />

Search job listings<br />

in all 50 states, and filter by location<br />

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Browse our online database<br />

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Find events<br />

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Your always-on resource for nursing jobs,<br />

research, and events.<br />

Acceptance of advertising does not imply endorsement or approval<br />

by the Delaware Nurses Association of products advertised, the<br />

advertisers, or the claims made. Rejection of an advertisement does<br />

not imply a product offered for advertising is without merit, or that<br />

the manufacturer lacks integrity, or that this association disapproves<br />

of the product or its use. <strong>DNA</strong> and the Arthur L. Davis Publishing<br />

Agency, Inc. shall not be held liable for any consequences resulting<br />

from purchase or use of an advertiser’s product. Articles appearing<br />

in this publication express the opinions of the authors; they do not<br />

necessarily reflect views of the staff, board, or membership of <strong>DNA</strong> or<br />

those of the national or local associations.<br />

Editorial Director<br />

Karen L. Panunto, Ed.D, MSN, RN<br />

The <strong>DNA</strong> <strong>Reporter</strong> welcomes unsolicited manuscripts by <strong>DNA</strong><br />

members. Articles are submitted for the exclusive use of The <strong>DNA</strong><br />

<strong>Reporter</strong>. All submitted articles must be original, not having been<br />

published before, and not under consideration for publication<br />

elsewhere. Submissions will be acknowledged by e-mail or a selfaddressed<br />

stamped envelope provided by the author. All articles<br />

require a cover letter requesting consideration for publication. Articles<br />

can be submitted by e-mail to Christopher E. Otto, MSN, RN, CHFN,<br />

PCCN, CCRN at executivedirector@denurses.org<br />

Each article should be prefaced with the title, author(s) names,<br />

educational degrees, certification or other licenses, current position,<br />

and how the position or personal experiences relate to the topic of<br />

the article. Include affiliations. Manuscripts should not exceed five (5)<br />

typewritten pages and include APA format. Also include the author’s<br />

mailing address, telephone number where messages may be left,<br />

and fax number. Authors are responsible for obtaining permission to<br />

use any copyrighted material; in the case of an institution, permission<br />

must be obtained from the administrator in writing before publication.<br />

All articles will be peer-reviewed and edited as necessary for content,<br />

style, clarity, grammar and spelling. While student submissions are<br />

greatly sought and appreciated, no articles will be accepted for the sole<br />

purpose of fulfilling any course requirements. It is the policy of <strong>DNA</strong><br />

<strong>Reporter</strong> not to provide monetary compensation for articles.


<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 3<br />

Executive Director’s Report<br />

Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN<br />

Executive Director<br />

executivedirector@denurses.org<br />

or 302-733-5880<br />

The meaningful recognition of<br />

nurses is a heavily researched area<br />

of nursing practice with several<br />

notable outcome improvements<br />

when successfully applied to<br />

professional practice settings.<br />

The American Association of<br />

Critical-care Nurses’ framework<br />

for healthy work environments<br />

includes meaningful recognition<br />

and defines it as, “Nurses<br />

Christopher E. Otto<br />

must be recognized and must<br />

recognize others for the value each brings to the work of<br />

the organization” (American Association of Critical-care<br />

Nurses, <strong>2021</strong>). Meaningful recognition can decrease nurse<br />

burnout and increase compassion satisfaction for nurses<br />

(Kelly & Lefton, 2017). Additionally, meaningful recognition<br />

increases the nurses’ self-perception, pride, and often<br />

reconnects nurses with their “why” (Lefton, 2014).<br />

Recognizing nurses includes all nurses, Licensed<br />

Practical, Registered, and Advanced Practice Registered<br />

Nurses. Research supports the positive impact of<br />

meaningful recognition for Licensed Practical Nurses by<br />

reducing burnout (Kim et al., 2020). The Delaware Nurses<br />

Association has provided recognition for Delaware’s nurses<br />

for decades and continues to evolve existing programs.<br />

We believe in the power of nurse recognition to combat<br />

burnout, increase professional role satisfaction, and<br />

promote a positive image of nursing. Recognizing nurses<br />

at the state level facilitates increased public awareness and<br />

perception of the unique contributions, qualifications, and<br />

service nurses make. By recognizing nurses statewide, the<br />

Delaware Nurses Association can uplift the characteristics<br />

of exceptional nurses and further define the essence of our<br />

profession. On behalf of the Delaware Nurses Association<br />

Board of Directors, I am proud to share the following<br />

evolving advancements for statewide nurse recognition.<br />

Joint Committee on Nursing Recognition<br />

In partnership with our organizational affiliate, the<br />

Delaware Organization for Nursing Leadership, we<br />

established a Joint Committee on Nursing Recognition<br />

to expand, implement, and evolve statewide nursing<br />

recognition programs and partnerships. The newly<br />

forming committee comprises 13 voting, volunteer<br />

members that represent all three nursing licensure levels<br />

and Delaware counties. Additionally, volunteer members<br />

come from numerous practice settings including academia,<br />

private practice, schools, the state, hospitals, and more.<br />

Partnerships and broad nursing representation set this<br />

committee up for success in providing meaningful<br />

statewide recognition. The committee will begin meeting<br />

monthly after the new year.<br />

Delaware Today Top Nurses<br />

The Delaware Nurses Association has partnered with<br />

Delaware Today Media to recognize Delaware’s Top<br />

Nurses for nine years. Starting in 2013, the program has<br />

now grown to recognize all Delaware nurses. Voting is<br />

conducted November-January annually and winners are<br />

selected by a panel of peers, now the Joint Committee<br />

on Nursing Recognition. Every Delaware nurse is eligible<br />

to nominate and be nominated. This is a statewide peer<br />

recognition program, so only nurses may nominate.<br />

Winners and honorees are recognized annually during<br />

May to coincide with nurse’s week. They are provided<br />

recognition in the May edition of Delaware Today and with<br />

a sponsored reception. Nominations for 2022 Delaware<br />

Today Top Nurses are accepted until January 3, 2022.<br />

The DAISY Foundation<br />

The DAISY Foundation is an established and highly<br />

recognized non-profit that exists solely to recognize<br />

nurses for their extraordinary compassion and skill. They<br />

deliver meaningful recognition internationally and across<br />

the nation. Numerous international, national, and state<br />

Celebrating Delaware’s Nurses<br />

associations support The DAISY Foundation and their<br />

incredible work. The Delaware Nurses Association and<br />

Delaware Organization for Nursing Leadership, with the<br />

generous support of Rhoades & Morrow LLC, is proud<br />

to become the first state nursing association to partner<br />

directly and provide DAISY awards to nurses.<br />

There are several existing DAISY-partner organizations<br />

in Delaware: Bayhealth, Beebe Healthcare, ChristianaCare,<br />

Encompass Health, Nemours, Silver Lining Healthcare,<br />

St. Francis Hospital, and University of Delaware. Nurses<br />

working for one of the above employers are already and<br />

remain eligible to be nominated and recognized by their<br />

employers. This new partnership does not change existing<br />

programs; any nominations received at the <strong>DNA</strong> for a<br />

nurse working at an existing partner will be forwarded to<br />

that DAISY coordinator. The Delaware Nurses Association<br />

encourages all eligible nurse employers/organizations to<br />

partner directly with The DAISY Foundation to recognize<br />

as many extraordinary nurses as possible.<br />

Our mission at the Delaware Nurses Association and<br />

Delaware Organization for Nursing Leadership is to provide<br />

extraordinary nurses with this prestigious recognition.<br />

Whether you work in a school, prison, public health, private<br />

practice, medical aid unit, surgery center, etc., you are now<br />

eligible to become a DAISY honoree. We will work with<br />

local media, members, partners, schools, and employers<br />

to raise awareness of this program and exponentially grow<br />

nominations. Patients, families, colleagues, nurses, leaders,<br />

and all are encouraged to submit nominations for their<br />

extraordinary nurses. The nomination form is live and can<br />

be accessed at http://www.daisynomination.org/<strong>DNA</strong>.<br />

Because of the generous support of Rhoades & Morrow<br />

LLC, we will be offering nurse employers free posters and<br />

window clings (in addition to online, self-print materials) to<br />

place in their practice settings to increase awareness and<br />

nominations for this honor.<br />

The nominations will be blinded and reviewed by the<br />

Joint Committee on Nursing Recognition and honorees<br />

selected for various categories (direct care nurse, team,<br />

leader, lifetime achievement, health equity, faculty, and<br />

students). Honorees will be vetted, approved, and presented<br />

with their recognition during a surprise presentation at<br />

their practice setting. Becoming a DAISY honoree provides<br />

nurses with pride, gratitude, and a plethora of benefits<br />

and continued opportunities. Speaking personally, it is<br />

still a career highlight when I and my colleagues in the<br />

Cardiovascular Critical Care Complex were presented with a<br />

DAISY Team Award in June 2018. We were nominated by<br />

the family of a patient we cared for, and it remains one of<br />

my most cherished nursing memories.<br />

We are humbled and excited to bring this<br />

meaningful recognition to all Delaware nurses and<br />

continue building the legacy and history of both<br />

The DAISY Foundation and the profession of<br />

nursing.<br />

Additional Specialized Awards and More<br />

Another focus of the Joint Committee on Nursing<br />

Recognition will be to uplift and celebrate Delaware’s<br />

notable nurses that contributed to the profession here<br />

and nationally. The committee will explore custom awards<br />

named after Delaware’s most influential and noted nurses.<br />

These awards will continue to uplift and celebrate nurse<br />

contributions in specific areas of the profession, such as<br />

advanced practice leadership and government relations/<br />

advocacy. We will also partner with our organizational<br />

affiliates, state specialty nursing associations, to generate<br />

awards for the many nursing practice specialties and elevate<br />

exceptional nurses from all areas of the profession.<br />

Just because the committee has already been selected<br />

doesn’t mean you can’t contribute. Through Delaware<br />

Nursing Dialogue, social media, and other communications<br />

the joint committee will be engaging all nurses in defining,<br />

promoting, and providing meaningful statewide nurse<br />

recognition. Why not start now? Have an idea? Send<br />

it to us using email, contactdna@denurses.org. On this<br />

topic, and all matters affecting Delaware nurses, we are<br />

continuously open to your feedback and suggestions.<br />

We are excited to bring these advancements forward<br />

for Delaware’s nurses. The volunteerism and generosity<br />

of members, organizational affiliates, and partners is<br />

what makes these programs possible. Membership is<br />

not required to be nominated, to nominate, or to be<br />

recognized; however, we hope you will consider sharing<br />

your support in the best way possible – become a <strong>DNA</strong><br />

member. With a large, diverse, and continuously growing<br />

membership, <strong>DNA</strong> can bring Delaware nurses more value,<br />

advocacy, solutions, and more.<br />

References<br />

American Association of Critical-care Nurses. (<strong>2021</strong>). Meaningful<br />

Recognition. Retrieved from https://www.aacn.org/<br />

nursing-excellence/healthy-work-environments/meaningfulrecognition.<br />

Kelly, L. A. & Lefton, C. (2017). Effect of meaningful recognition<br />

on critical care nurses’ compassion fatigue. American Journal<br />

of Critical Care. 26(6), 438-444. doi: 10.4037/ajcc2017471<br />

Kim, L. Y., Rose, D. E., Ganz, D. A., Giannitrapani, K. F., Yano, E.<br />

M., Rubenstein, L. V., & Stockdale, S. E. (2020). Elements of<br />

the healthy work environment associated with lower primary<br />

care nurse burnout. Nursing Outlook. 68(1), 14-25. doi:<br />

10.1016/j.outlook.2019.06.018<br />

Lefton, C. (2014). Beyond thank you: The powerful reach of<br />

meaningful recognition. American Nurse. Retrieved from<br />

https://www.myamericannurse.com/beyond-thank-you-thepowerful-reach-of-meaningful-recognition/.


Page 4 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />

Guest Editor continued from page 1<br />

treatment options and willingness to pursue or not pursue.<br />

How a patient understands their choices influences the<br />

care they receive in end of life care, and options should be<br />

well laid out to our patients for informed decision making.<br />

Treatment decisions in end of life care include<br />

resuscitation in the form of CPR or intubation, palliative<br />

sedation for intractable pain, refusal of artificial nutrition<br />

and hydration via tube, refusal of life saving surgery,<br />

refusal of blood products, refusal of antibiotics, refusal<br />

of chemotherapy or radiation therapy, and refusal for<br />

initiation of or stopping of hemodialysis. These decisions<br />

to stop or not initiate treatments generally result in a<br />

death that would have naturally occurred without the<br />

intervention of medicine.<br />

I have observed that patients nearing the end of<br />

their life may make decisions to continue treatments<br />

inconsistent with their personal preferences based<br />

upon lack of information regarding the impact on their<br />

healthcare outcomes. This unwanted care has led to<br />

increased psychological distress and increased utilization<br />

of health care resources that may offer little therapeutic<br />

benefit or impact on quality of life and may leave their<br />

loved ones without the ability to have closure.<br />

In 1997, Oregon was the first state to legalize aid<br />

in dying. Since that time, Washington, D.C, California,<br />

Colorado, Hawaii, Maine, New Jersey, Vermont,<br />

Washington, and most recently in <strong>2021</strong>, New Mexico<br />

has followed suite. Although Montana does not have a<br />

dedicated law, in 2009, its supreme court supported that<br />

nothing in Montana’s State Law prohibited a physician<br />

from honoring the wishes of a competent terminally ill<br />

adult to be able to hasten their death. Only New Jersey<br />

and Hawaii currently allow nurse practitioners to prescribe<br />

end of life medications (“Death with Dignity Acts,” n.d.).<br />

Death with Dignity is the underlying concept of<br />

Delaware’s House Bill 140 (HB140), with Representative<br />

Paul S. Baumbach as the primary bill sponsor. This <strong>2021</strong>,<br />

the Delaware Death with Dignity Act, HB 140, was<br />

assigned to the House Health & Human Development<br />

Committee on the final day of the session, just before<br />

the Delaware General Assembly adjourned (“Death with<br />

Dignity Delaware,” n.d.).<br />

House Bill 140 would allow another option in end<br />

of life care, and would permit a terminally ill patient<br />

with six months or less life expectancy who is an adult<br />

resident of Delaware (age 18 and above) to request and<br />

self-administer medication to end the individual’s life in<br />

a humane and dignified manner if both the individual’s<br />

attending physician/advanced practice registered nurse<br />

(APRN) and a consulting physician/advanced practice<br />

registered nurse (APRN) agree on the individual’s diagnosis<br />

and prognosis and believe the individual has decision<br />

making capacity, is making an informed decision, and is<br />

acting voluntarily (“Delaware General Assembly,” n.d.,<br />

House Bill 140). House Bill 140 has safeguards built in to<br />

protect the public and providers when considering this as<br />

an option. It would be up to the healthcare institution and<br />

individual practitioner to consider and decide how they<br />

would respond to HB140 based on legal, ethical, moral,<br />

and personal values.<br />

The American Nurses Association (ANA, 2019) as<br />

cited in the ANA Position Statement, stated the hallmarks<br />

of end-of-life care include respect for patient selfdetermination,<br />

nonjudgmental support for patients’<br />

end-of-life preferences and values, and prevention and<br />

alleviation of suffering. Death with Dignity should be<br />

viewed as medical aid to those dying with a terminal illness<br />

(OJIN, 2019). It is not considered suicide, assisted suicide,<br />

homicide, or euthanasia, and would offer another option<br />

in end of life care planning to existing hospice care and<br />

comfort care provided under palliative care. The ANA<br />

2019 position statement recommends that nurses have<br />

knowledge on the current environment for medical aid<br />

in dying and remain objective if patients wish to discuss<br />

medical aid in dying, thus preserving self-autonomy and<br />

dignity in making end of life health care decisions (OJIN,<br />

2019).<br />

States that have Death with Dignity Laws provide<br />

another option suited to meet end of life preferences<br />

in those suffering with a terminal illness. The role of the<br />

nurse is to listen, to be an advocate for their patient’s<br />

needs, and to ensure continuation of care based on the<br />

patient’s personal preferences. Only our patients can state<br />

their wishes for their end of life care planning and tell us if<br />

medical aid in dying would be in their best interest.<br />

This edition of the <strong>DNA</strong> <strong>Reporter</strong> is focused on how<br />

palliative care may improve quality of life and preserve<br />

dignity in end of life care. The first step is to recognize<br />

the need to have end of life care discussions to share<br />

our thoughts on how we want to spend our final days<br />

and to revisit one’s medical wishes as health changes.<br />

Heather Milea, MSN, FNP-BC, AGACNP-BC, PCCN,<br />

CHFN, highlights how the Covid epidemic impacted<br />

patient’s quality of life in end of life care. Ginna Keil,<br />

MSN, FNP-BC demonstrates how community palliative<br />

care is high quality and cost effective when shifting the<br />

focus from active disease treatment to comfort care.<br />

LaTonya Mann, DNP, FNP-BC, OCN discusses that early<br />

intervention of palliative care with the assistance of<br />

nursing leads to a better quality of life for those living<br />

with cancer. Kiernan Quay, DNP, APRN, FNP-C relays<br />

that non beneficial treatment in end of life care may not<br />

equate with quality of life. Karin Cooney-Newton, MSN,<br />

RN, APRN, ACCNS-AG, CCRN presents an effective<br />

objective tool for end of life care that can promote<br />

comfort and alleviate suffering for patients and their<br />

families in end of life care.<br />

References<br />

ANA Position Statement: The nurse’s role when a patient<br />

requests medical aid in dying. (2019). OJIN: The Online<br />

Journal of Issues in Nursing, 24 (3). https://www.doi.<br />

org/10.3912/OJIN.Vol24No03PoSCol02<br />

Death with Dignity. (n.d). https://deathwithdignity.org Retrieved<br />

7/20/<strong>2021</strong>.<br />

Death with Dignity, Delaware. (n.d.). https://deathwithdignity.<br />

org/states/delaware/<br />

Death with Dignity Acts. (n.d.) https://deathwithdignity.org/learn/<br />

death-with-dignity-acts Retrieved 8/11/<strong>2021</strong>.<br />

Delaware General Assembly, House bill 140. https://legis.<br />

delaware.gov/BillDetail?LegislationId=79026 Retrieved<br />

10/7/<strong>2021</strong><br />

Institute of Medicine. (1997). Approaching death: Improving care<br />

at the end of life. Washington,D.C: National Academy Press.<br />

The Delaware Code Online (n.d). Title 16 Health and Safety,<br />

Regulatory Provisions Concerning Public Health Chapter<br />

25. Health-Care Decisions, section 2502. http://delcode.<br />

delaware.gov/title16/c025/ accessed 7/1/<strong>2021</strong>.


<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 5


Page 6 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />

COVID-19 Pandemic Through the Lens of an Inpatient Palliative Medicine Provider<br />

Heather M. Milea, MSN, FNP-BC, AGACNP-BC, PCCN, CHFN<br />

Heather M. Milea is currently a nurse practitioner on the palliative<br />

care team at Christiana Care Hospital where she has worked for<br />

over twenty years with an acumen in family medicine, advanced<br />

heart failure, and cardiology. She is a graduate of the University of<br />

Delaware’s undergraduate baccalaureate nursing program and Master<br />

of Science in Nursing program with a concentration in family nurse<br />

practitioner. She completed a post-master’s graduate degree at the<br />

University of Pennsylvania in adult gerontology acute care. Heather<br />

has been recognized as one of the <strong>2021</strong> top nurse practitioners by<br />

Delaware Today, is a member of the Delaware Coalition for Nurse<br />

Practitioners, and serves on the palliative team wellness committee<br />

and transition team at Christiana Care Hospital. Heather may be<br />

reached at hmilea@christianacare.org.<br />

Heather M. Milea<br />

The COVID-19 pandemic systemically obstructed the delivery of traditional<br />

healthcare, particularly impacting our chronically ill and frail patients. Healthcare<br />

delivery for the hospitalized, critically ill COVID-19 cohort was challenging because<br />

of the complex symptom management, rapid physical decline, high mortality,<br />

and increased intensive care utilization (Rosa et al., 2020). As the virus infiltrated<br />

Delaware, this problem was further aggravated as our healthcare organizations<br />

followed the isolation strategies established by other institutions: significant<br />

restrictions in visitation, limiting the flow of providers in and out of rooms, and<br />

segmenting COVID-19 patients from other patient populations. Despite the obvious<br />

public health need to reduce transmission of the respiratory pathogen, an illconsidered<br />

byproduct was the social isolation, severing our instinct to be present<br />

with loved ones during a serious illness. With the isolation increasing our patients’<br />

suffering and our efforts to provide holistic care frustrated, care delivery models<br />

had to be radically revised as the palliative medicine team innovated and tested our<br />

processes in real time. As the expression goes, we were “building the plane as we<br />

flew.”<br />

Palliative Medicine During a Pandemic<br />

Palliative medicine providers are holistic by virtue of the discipline. Through<br />

disease counseling and goals of care for acute, chronic, or traumatic health<br />

problems, palliative medicine’s foundational ethos is to improve quality of life<br />

both inside and outside the biomedical realm, as well as reduce the burden of<br />

symptoms related to disease states. The diverse team of inpatient palliative care<br />

service providers including physicians, nurse practitioners, physician assistants,<br />

social workers, nurse navigators, and palliative chaplains collaborate to add<br />

robust, holistic care. Communication prowess is one of the revered skillsets among<br />

palliative providers, especially during end-of-life care (Pattison, 2020). The World<br />

Health Organization’s (WHO) 2018 ethical principles in humanitarian contexts<br />

strongly advocate for access to palliative care to minimize suffering and, by the<br />

United Nations International Health Regulations’ own definition of “public health<br />

emergency of international concern,” the COVID-19 pandemic would most certainly<br />

qualify.<br />

As the pandemic disintegrated traditional healthcare delivery, inpatient palliative<br />

care consults for COVID-19 patients surged. Among the significant symptom burden<br />

of a hospitalized COVID-19 patients, anxiety and loneliness may be among the<br />

most hidden and difficult to resolve, even in optimal healthcare scenarios. In an<br />

environment where care teams and resources were burdened, and intensivists and<br />

nurses occupied the limited bedside to provide care, the palliative medicine team<br />

had to reinvent how to expedite care for this vulnerable, often frail, population. That<br />

revitalized care model was discovered in what originally gave our team strength: our<br />

multidisciplinary teamwork.<br />

Multidisciplinary Palliative Medicine Team and Virtual Management<br />

To bridge the gap of visitor restrictions, our team implemented off-the-shelf,<br />

consumer technology (i.e., iPads) equipped with videoconferencing platforms<br />

in COVID-19 rooms and at nursing servers. The care team worked “virtually” for<br />

inpatient visits, allowing for high-touch care in limited-touch environments. Trained,<br />

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medical language translation specialists and cultural consults were brought on to<br />

provide culturally competent care. The palliative medicine team now had an option<br />

to facilitate our exacting, rapport-dependent care for our patients and family,<br />

extending our ability to supply support and connection.<br />

Unfortunately, despite institutional support for the technology program,<br />

family stakeholders did not have universal access to platforms for virtual<br />

visits, forcing many difficult conversations to take place via telephone. In this<br />

context, the absence of important, nonverbal cues diminished the quality<br />

of interaction, especially regarding difficult, end-of-life communications.<br />

Vulnerable stakeholders had to trust a medical team to help with emotionally<br />

overwrought decisions without the comfort of connecting to their loved ones.<br />

Serious Conversations<br />

“Ordinary” critically ill scenarios can limit time to have meaningful<br />

healthcare conversations on the values and wishes of the patient. The often<br />

precipitous decline that can happen with COVID-19 hospitalized patients<br />

further compacted the time to prepare patients and their care circle. Often,<br />

that involved standing outside an ICU room of a COVID-19 patient struggling<br />

with fear, providing through the glass a calm voice of comfort, an ear to<br />

listen, or a provider who could treat symptoms of air hunger, anxiety, or even<br />

claustrophobia.<br />

The palliative medicine team elected to implement best practices from<br />

COVID-19 conversation guides. VITALtalk (n.d.), a nonprofit social impact<br />

organization for clinicians, encouraged early and clear communication, as<br />

well as exploring patient goals and making care recommendations based<br />

on those stated goals. For the team, discussions with the patient and their<br />

support system regarding prior advance care planning documents, anticipatory<br />

guidance of swift clinical deterioration, and code status ensued immediately<br />

into a hospitalized patient’s COVID-19 course. With those that were fortunate<br />

to survive the acute phase of their inflammatory-related respiratory failure,<br />

the palliative medicine team counselled patients on the trajectory of the longterm<br />

sequalae of COVID-19, including fibrotic lung disease, coagulopathies,<br />

cardiomyopathies, debility, and failure to thrive. The work was a delicate<br />

balance of active listening and support to spouses, children, and care circles<br />

physically separated from their sick family members. For patients that passed<br />

without a loved one near, our nurses held their hands.<br />

End-of-life Care for COVID-19 Patients Amidst a Global Pandemic<br />

Suffering, end-of-life COVID-19 patients are most treated for dyspnea,<br />

restlessness, anxiety, and delirium, along with significant spiritual and<br />

psychosocial needs. Dyspnea and delirium are among the most common<br />

symptoms in dying patients with COVID-19 and, despite attempts at managing<br />

underlying cause of dyspnea, refractory dyspnea and hypoxia may persist<br />

(Sun et al., 2020). The Center to Advance Palliative Care (n.d.) developed<br />

crisis protocols for managing common symptoms associated with COVID-19,<br />

which our team follows. Opioids are the treatment choice for refractory<br />

dyspnea and as-needed dosing is safer and more effective compared to an<br />

opioid infusion. Non-pharmacologic interventions include sitting the patient<br />

in either an upright or, in some instances, prone position. The decision in<br />

favor of COVID-19 ventilation focuses on limiting lung damage and mitigating<br />

aerosolization of the virus. In circumstances where continuing aggressive<br />

care was futile or where goals of care dictated de-escalating or withdrawing<br />

ventilation support, the ICU and palliative teams initiate end-of-life discussions<br />

to guide a compassionate withdrawal of care with an emphasis on a dignified<br />

passing. Preparing the family is imperative; expectations, suggestions, and<br />

exploration of their concerns are important to ameliorate prior to withdrawal<br />

of care. Hospice resources for family and their care circle is robust, not only<br />

during their hospice care, but also in bereavement support that extends after<br />

their loved one’s passing.<br />

The palliative team’s principle is to provide physical, spiritual, and<br />

psychosocial comfort for our patients and their extended care circle. During<br />

the COVID-19 pandemic, the collaboration with primary and specialty services<br />

complimented the front-line workers who were brave enough to support our<br />

community. Moreover, just as we do for patients, the palliative medicine team<br />

offers safe haven to support colleagues without prejudice. There have been<br />

far too many tragic losses related to COVID- 19 and, as a society, we share a<br />

collective and complicated grief that we have not yet begun to unpack.<br />

References<br />

Center to Advance Palliative Care (n.d.). COVID-19 rapid response resources hub. https://<br />

www.capc.org/covid-19/<br />

Pattison, N. (2020). End-of-life decisions and care in the midst of a global coronavirus<br />

(COVID-19) pandemic. Intensive and Critical Care Nursing, 58. https://doi.org/10.1016/j.<br />

iccn.2020.102862<br />

Rosa, W.E., Meghani, S.H., Stone, P.W. and Ferrell, B.R. (2020). Opportunities for nursing<br />

science to advance patient care in the time of COVID-19: A palliative care perspective.<br />

Journal of Nursing Scholarship, 52(4), 341-343. https://doi.org/10.1111/jnu.12570<br />

Sun, H., Lee, J., Meyer, B. J., Myers, E. L., Nishikawa, M. S., Tischler, J. L., & Blinderman, C. D.<br />

(2020). Characteristics and palliative care needs of COVID-19 patients receiving comfortdirected<br />

care. Journal of the American Geriatrics Society, 68(6), 1162–1164. https://doi.<br />

org/10.1111/jgs.16507<br />

VITALtalk (n.d.). COVID Ready communication playbook. https://www.vitaltalk.org/wpcontent/uploads/VitalTalk_COVID_English.pdf<br />

World Health Organization (2018). A WHO guide: Integrating palliative care and symptom<br />

relief into the response of humanitarian emergencies and crises. https://apps.who.int/iris/<br />

bitstream/handle/10665/274565/9789241514460-eng.pdf


<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 7<br />

Community-Based Palliative Care: High Quality and Cost Effective<br />

Ginna Keil, MSN, FNP-BC<br />

Ginna Keil earned her Associate of Arts Degree in General<br />

Studies in 2002 followed by her Associates of Science Degree<br />

in Nursing in 2006 from Wor-Wic Community College.<br />

Ginna was a registered nurse in the State of Maryland<br />

and Delaware for 13 years with nursing experience in the<br />

emergency department, women and children’s health,<br />

and neonatal intensive care settings. Ginna furthered her<br />

education by receiving her Bachelor of Science Degree in<br />

Nursing and graduated with her Master of Science Degree<br />

in Nursing from Wilmington University in 2018. Certified<br />

by the American Academy of Nurse Practitioners, Ginna<br />

practices as a Family Nurse Practitioner in the State of<br />

Delaware. Ginna currently is employed with Delaware<br />

Hospice and provides Palliative and Hospice services in the Ginna Keil<br />

community setting. Professional achievements include member of the Phi Theta<br />

Kappa-Honor Society, Daisy Award Recipient, Maternal Child Award, Nursing Service<br />

Excellence Awards, and Delaware Hospice Star Award. Ginna may be reached at<br />

gkeil@delawarehospice.org.<br />

Widely known among healthcare providers are the challenges today’s<br />

Healthcare system face secondary to an expanding aging population who<br />

suffer serious illness compounded by multiple medical comorbidities.<br />

According to data provided by the Center to Advance Palliative Care (CAPC,<br />

2015), there are at least 12 million adults and 400,000 children in the United<br />

States living with a serious illness and by the year 2030, people aged 85<br />

and over are expected to double to 8.5 million. The Delaware Healthcare<br />

Association (DHA, 2019) reported that emphasis on disease specific treatments<br />

have become commonplace rather than holistic treatment that addresses<br />

the needs of patients and their caregivers. In many cases, this focus has<br />

led to fragmented and burdensome care with inadequate management of<br />

symptoms resulting in unnecessary suffering. It is, therefore, a system that<br />

is unsustainable in terms of poor quality and high cost. The question then<br />

becomes, ‘how does the Healthcare system meet the needs of this growing<br />

population while still delivering high quality and financially sustainable care?’<br />

(CAPC, 2015).<br />

A potential solution may lie in the specialty of palliative care medicine which<br />

has been growing in popularity globally over the last two decades. What is<br />

palliative care? With a unique holistic approach that is both patient and<br />

family centered, the Center to Advance Palliative Care (2019) explained that<br />

the design of palliative care is to anticipate, prevent, and manage physical,<br />

spiritual, social, and psychological aspects of health and improve the quality<br />

of life for patients, families, and caregivers throughout their illness trajectory.<br />

Furthermore, based on patient need rather than diagnosis, any individual<br />

regardless of age who are diagnosed with a serious illness may receive<br />

palliative care services alongside curative treatment. Although services may<br />

be initiated at any stage of the illness trajectory, implementation in the early<br />

stages of the disease process have resulted in improved patient care outcomes.<br />

As leaders in healthcare recognize the impact that cost effective and<br />

high-quality palliative care have on patients, caregivers and healthcare<br />

organizations, services are now available in 94% of hospitals with more than<br />

300 beds and available in 72% of hospitals with more than 50 beds (Center<br />

to Advance Palliative Care, n.d.). Inpatient palliative care consultation is<br />

associated with a reduction in healthcare costs with a total savings of more<br />

than $1.3 million for a 300-bed community hospital and more than $2.5<br />

million for the average academic medical center (Cruz-Oliver, 2017).<br />

Expansion of palliative services is a Healthcare necessity and should be<br />

offered on every level and across all settings in efforts to meet the many<br />

needs of Americans living with serious illness compounded by multiple medical<br />

comorbidities (CAPC, <strong>2021</strong>). Hospitals and health systems are now extending<br />

palliative services into community settings including but not limited to<br />

physician offices, ambulatory clinics, cancer centers, skilled nursing facilities,<br />

and patient homes. In addition to hospitals and health systems, service<br />

delivery is provided by primary care physicians, specialty practices, private<br />

companies, home health aid agencies, and hospices (CAPC, n.d.). Palliative<br />

care is multidisciplinary and includes a team of dedicated medical, nursing, and<br />

allied health professionals. The comprehensive role of the palliative care team<br />

throughout the trajectory of the patient’s illness includes but is not limited to<br />

expert pain and complex symptom management, provision of psychological,<br />

spiritual, and emotional support, medication management and monitoring,<br />

and the completion of advance health directives. The palliative care team<br />

works collaboratively with specialists in the community that allows for<br />

coordination of care. As the trajectory of illness progresses, locations as well<br />

as wishes of the patient and their caregivers may change. Community based<br />

palliative care allows for consistency across transitions (CAPC, <strong>2021</strong>).<br />

Community based palliative care allows for a reach to patient populations<br />

that neither fit hospice eligibility nor are hospitalized and are stable enough to<br />

reside in the community setting. Many individuals suffering from serious illness<br />

and chronic medical conditions experience mobility issues with functional<br />

limitations that do not allow travel to office settings or are burdensome.<br />

Often, it is the preference of many individuals suffering from chronic medical<br />

conditions to remain at home while coping with their serious illness.<br />

The National Coalition for Hospice and Palliative Care (NCHPC, 2018)<br />

explained that with disease progression, the emphasis shifts from active<br />

treatment of the disease to treatment that promotes comfort with an improved<br />

quality of life. Anticipatory guidance is provided regarding disease process,<br />

progression, and strategies for management in efforts to optimize quality<br />

of life. They further explained that palliative care providers facilitate patient<br />

autonomy, by providing access to information and choice regarding their care.<br />

Palliative care in the home setting promotes the development of a trusting<br />

rapport and fosters feelings of support and connectivity. This allows for<br />

sensitive conversations of how individual values, preferences, ethnicity, culture,<br />

and spiritual beliefs play a role in their healthcare (NCHPC, 2018).<br />

The Center to Advance Palliative Care, (<strong>2021</strong>) recognizes that there is strong<br />

evidence that implementation of community based palliative care services<br />

results in compassionate, affordable, sustainable high-quality care, and is<br />

associated with reduced nonbeneficial emergency department visits and<br />

hospitalizations. Reduced hospital readmissions may lead to reduced penalties<br />

for hospitalized patients with serious chronic illnesses.<br />

Where do hospitals in the State of Delaware stand regarding equitable<br />

access to palliative care services? Delaware Healthcare Association (DHA, 2019)<br />

President & CEO Wayne A. Smith stated, “Delaware hospitals are proud to<br />

lead the nation in providing access to quality palliative care for our friends and<br />

neighbors” (para. 3). Delaware hospitals were leading the nation in 2019 by<br />

providing individuals living with a serious illness equitable access to palliative<br />

care services according to the 2019 State-by-State Report Card on Access<br />

to Palliative Care in Our Nation’s Hospitals (DHA, 2019). The integration of<br />

palliative care services promotes the high quality and financially sustainable<br />

care needed to meet the physical, spiritual, social, and psychological needs of<br />

patients and their caregivers who suffer serious illness. Leaders in Healthcare<br />

nationwide must strive to integrate palliative care medicine into healthcare<br />

systems and ensure that patients from all populations and across all settings<br />

receive this invaluable service.<br />

References<br />

Center to Advance Palliative Care. (2015). A guide to building a hospital-based<br />

palliative care program. file:///C:/Users/ginna/Downloads/the-capc-guide-tobuilding-a-hospital-palliative-care-program.pdf<br />

Center to Advance Palliative Care. (<strong>2021</strong>). Concepts of community-based palliative care<br />

program design 101: Learner’s Guide. file:///C:/Users/ginna/Downloads/conceptsof-community-based-palliative-care-program-design-101-learners-guide.pdf<br />

Center to Advance Palliative Care. (2019). Key findings on the perceptions of palliative<br />

care. https://media.capc.org/recorded-webinars/slides/1lessAudience_Research_<br />

Webinar_Aug_8-2019_FINAL.pdf<br />

Center to Advance Palliative Care. (n.d.). The case for community-based palliative<br />

care: A new paradigm for improving serious illness care. file:///C:/Users/ginna/<br />

Downloads/the-case-for-community-based-palliative-care.pdf<br />

Cruz-Oliver D. (2017). Palliative Care: An Update. Missouri Medicine, 114(2), 110 –115.<br />

Delaware Healthcare Association. (2019). Delaware receives top “A” grade on access<br />

to palliative care in our nation’s hospitals. https://deha.org/News/Press-Releases/<br />

Delaware-Receives-Top-A%E2%80%9D-Grade-on-Access-to-Pallia<br />

National Coalition for Hospice and Palliative Care. (2018). National Consensus Project<br />

for Quality Palliative Care. https://www.nationalcoalitionhpc.org/ncp<br />

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Page 8 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />

Palliative Care: Including Nursing in Early Intervention<br />

LaTonya E. Mann, DNP, FNP-BC, OCN<br />

Dr. Latonya Mann earned<br />

her Licensed Practical Nurse<br />

degree from Salem Community<br />

College, Associate Degree in<br />

Nursing from Gloucester County<br />

College, Bachelors in Nursing<br />

from Immaculata University,<br />

Master’s Degree from University<br />

of Delaware, and Doctorate in<br />

Nursing Practice from Wilmington<br />

University. She is a board certified<br />

Family Nurse Practitioner. Dr.<br />

Mann is Past President for<br />

Delaware Diamond Chapter LaTonya E. Mann<br />

of Oncology Nursing Society and a member of the Delaware<br />

Nurses Association, Delaware Coalition of Nurse Practitioners,<br />

and Sigma Theta Tau International Honor Society of Nursing.<br />

Dr. Mann brings over 35 years of experience in various<br />

settings of nursing including medical-surgical, intensive care,<br />

home infusion therapy, palliative care, and oncology nursing.<br />

She presently works as a Nurse Practitioner with the Medical<br />

Oncology team at Bayhealth Cancer Center. Dr. Mann may be<br />

reached at LaTonya_Mann@bayhealth.org<br />

The Center of Advanced Palliative Care (CAPC, <strong>2021</strong>)<br />

defines palliative care as:<br />

Specialized medical care for people living with a serious<br />

illness. This type of care is focused on providing relief<br />

from the symptoms and stress of the illness. The goal<br />

is to improve quality of life for both the patient and the<br />

family. Palliative care is provided by a specially-trained<br />

team of doctors, nurses and other specialists who work<br />

together with a patient’s other doctors to provide an<br />

extra layer of support. Palliative care is based on the<br />

needs of the patient, not on the patient’s prognosis. It<br />

is appropriate at any age and at any stage in a serious<br />

illness, and it can be provided along with curative<br />

treatment. (para. 2)<br />

Palliative care teams work alongside a patient’s team<br />

of specialists to provide symptom and communication<br />

expertise, emotional support, assistance with medical<br />

decision making, and assistance with end-of-life care and<br />

bereavement support when appropriate (Finn et al., 2017).<br />

Palliative care can be provided in a variety of settings,<br />

including inpatient hospital consultation, outpatient<br />

clinics, assisted living and long-term care facilities, and<br />

even home-based care. The most familiar mode of<br />

palliative medicine delivery is inpatient-based services<br />

that may involve a single practitioner or a consultant<br />

palliative care medicine team. These medical providers<br />

are available throughout the entire hospital setting, from<br />

Vacancy Announcement<br />

Adjuncts and Part-time Teaching Positions<br />

Department of Nursing<br />

Wesley College of Health & Behavioral Sciences<br />

Part time Adjunct positions-lecture and clinical areas: maternal/<br />

newborn nursing, medical/surgical nursing, mental health nursing, child<br />

and family nursing, community and/or public health nursing.<br />

Full time faculty positions-Clinical Practitioner, Maternal/Newborn<br />

Nursing Faculty, Medical/Surgical Nursing Faculty, Mental Health Nursing<br />

Faculty, Child and Family Nursing Faculty.<br />

Full time Staff positions-Skills Lab Coordinator-<br />

Required:<br />

• Delaware State University Masters of Science in Nursing with a focus<br />

on the area applying for<br />

• Current unencumbered RN license in the state of Delaware<br />

• Current clinical nursing experience<br />

• Teaching experience in higher education preferred<br />

• Simulation experience preferred<br />

Special Instructions: Interested applicants must apply online at DSU<br />

website: www.desu.edu. If invited for an interview, provide resume/<br />

curriculum vitae and three (3) professional references with contact<br />

information.<br />

Apply for this posting only if you are interested AND qualified for the<br />

position in the Department of Nursing. It is important that you specify<br />

your area of clinical expertise and interest in your cover letter in order to<br />

be considered as a viable adjunct/part-time candidate.<br />

DSU is an equal opportunity, Title IX Employer and does not discriminate against persons<br />

on the basis of race, religion, national origin, sexual orientation, gender, marital status,<br />

age or disability.<br />

the emergency department and intensive care unit to a<br />

rehabilitation unit if appropriate (Thomas et al., 2019).<br />

Early Integration<br />

Although there are current guidelines to advocate<br />

early integration of palliative care and research that show<br />

its benefits, there are several barriers to palliative care<br />

referrals. The most common is the misperception that<br />

palliative care is only associated with end of life. However,<br />

most patients accept palliative care intervention without<br />

a loss of hope. The ENABLE and ENABLE II studies<br />

showed decreased depression in patients who received<br />

palliative care, providing evidence that palliative medicine<br />

consultations should not be postponed until failure of<br />

therapy, symptom crisis, or end of life (Thomas et al.,<br />

2019).<br />

As healthcare providers, nurses struggle every<br />

day on what words to choose to deliver bad news to<br />

patients. Many providers wrestle with how to begin the<br />

conversation and knowing the appropriate time to discuss<br />

prognosis. Many have little training on how to deal with<br />

the patient and caregiver emotions. This is due to the<br />

limited training and education in palliative care. According<br />

to Sedhom et al. (2020), oncologists give bad news to<br />

patients an average of 35 times a month, yet few have<br />

training or mentorship in communication skills. Oncologists<br />

are more medicine oriented and fellows report receiving<br />

more coaching on how to perform bone marrow biopsies,<br />

a technical skill, than on how to conduct a family meeting.<br />

Word choice may feel trivial compared with the plethora of<br />

other things that need to be learned. Yet, words influence<br />

medical decision making and have implications for patient<br />

care (Sedhom et al., 2020).<br />

Nursing in Early Intervention<br />

Nursing is a profession within healthcare focused on<br />

the care of individuals, families, and communities so they<br />

may attain, maintain, or recover optimal health and quality<br />

of life. For the fifteenth consecutive year, the Gallup poll<br />

has ranked nursing as the most trusted profession, and<br />

nurses as the professionals who uphold the highest ethical<br />

obligations in establishing community relationships of trust<br />

according to society needs and desires.<br />

Nurses look after patient’s most intimate needs<br />

during their most vulnerable times, and they do so with<br />

compassion. While it is the provider who manages the<br />

overall treatment plan, nurses are the ones who carry it<br />

out. It is the nurse ninety-nine per cent of the time that the<br />

patient and family members interact with in the hospital<br />

setting. Patients know when they call for help, it is their<br />

nurse who will carry out their needs with compassion.<br />

Nurses draw on this trust by advocating for their patient’s<br />

healthcare needs. Patients are more likely to listen to the<br />

advice of their nurse and trust they will advocate for their<br />

overall well-being. When the patient has a poor health<br />

prognosis, patients rely on their nurse who has cared for<br />

them during their hospital stay to tell the truth and help<br />

them to make informed decisions about their healthcare.<br />

For these reasons, it would be to the patient and families’<br />

benefit to have bedside nurses more engaged in family<br />

meetings.<br />

According to Goehring (2017), there are several reasons<br />

a family meeting would be requested by the healthcare<br />

team. Most often there is a decline in the patient’s<br />

medical condition or prognosis and further goals of care<br />

discussions are necessary. There may also be a need for<br />

further discussions about DNR and DNI status as well<br />

as other life sustaining methods such as feeding tube<br />

placement, blood transfusions, and artificial hydration. For<br />

an effective family meeting with an oncology patient, it<br />

would be very beneficial to request the attendance of<br />

the bedside oncology nurse. The oncology nurse can<br />

provide updates on the patient’s medical status, assist<br />

patients with interpreting information, and answer<br />

questions or concerns the patient and loved ones may<br />

have during and post family meeting.<br />

Palliative care for Patients with Advanced Cancer<br />

The role of engaged and involved bedside nurses is<br />

critical to the integration of palliative care for patients<br />

with advanced cancer. A survey was performed<br />

to assess nurses’ perspectives on palliative care<br />

communication. It involved distributing a 46-item<br />

survey via email in 2013 to bedside nurses working<br />

in ICUs across five academic medical centers of the<br />

University of California. The survey was sent to 1791<br />

nurses; 598 (33%) responded. Most participants<br />

reported that their engagement in discussions of<br />

prognosis, goals of care, and palliative care was very<br />

important to the quality of patient care. A minority<br />

reported often discussing palliative care consultations<br />

with physicians (31%) or families (33%); 45% reported<br />

rarely or never participating in family meeting<br />

discussions. Participating nurses most frequently<br />

cited the following barriers to their involvement in<br />

palliative care communications: need for more training<br />

(66%), physicians not asking their perspective (60%),<br />

and the emotional toll of discussions (43%). The<br />

article concluded that ICU bedside nurses see their<br />

involvement in discussions of prognosis, goals of care,<br />

and palliative care as a key element of overall quality<br />

of patient care. Interventions are needed to ensure that<br />

nurses have the education, opportunities, and support<br />

to actively participate in these discussions (Boyle et al.,<br />

2017).<br />

Despite the evidence for a fundamental need for<br />

palliative care services in the practice of oncology,<br />

integration of these medical specialties remains a<br />

clinical challenge. Palliative care has a wide and<br />

significant role in providing palliative care services to<br />

inpatient and outpatient settings. An effective palliative<br />

care and oncology nurse collaboration improves<br />

patient care and QOL. Further research in the role of<br />

integrating the bedside nurse may improve patient and<br />

caregiver outcomes. To stay on top of the profession<br />

and to stay advanced in the field, nurses are expected<br />

to take professional development courses to help<br />

them carry out their duties to the best of their ability.<br />

Taking a course in palliative care would be highly<br />

recommended to assist with goals of care discussions.<br />

References<br />

Boyle, D. A., Barbour, S., Anderson, W., Noort, J., Grywalski,<br />

M., Myer, J., Hermann, H. (2017). Palliative care<br />

communication in the ICU: Implications for an oncologycritical<br />

care nursing partnership. Seminars in oncology<br />

nursing. 33(5) 544-554.<br />

Center to Advanced Palliative Care (CAPC). (<strong>2021</strong>). https://<br />

www.capc.org/about/palliative-care<br />

Ferrell, B., Meyer, J., O’Neil-Page, E., Cain, J., Herman,<br />

H., Mitchell, W., & Pantilat, S. (2016) ICU Bedside<br />

nurses’ involvement in palliative care communication:<br />

A multicenter survey. Journal of Pain Symptom<br />

Manage. Mar; 51(3):589-596.e2. https://doi: 10.1016/j.<br />

painsymman.2015.11.003.<br />

Finn, L., Green, A. R., and Malhotra, S. (2017). Oncology and<br />

palliative medicine: Providing comprehensive care for<br />

patients with cancer. Ochsner Journal, <strong>December</strong>;17 (4)<br />

393-397.<br />

Glajchen, M., Goehring, A. (2017). The family meeting in<br />

palliative care: The role of the oncology nurse. Seminars<br />

in Oncology Nursing; 33 (5): 489-497.<br />

Milton, C. L. (2018). Will nursing continue as the<br />

most trusted profession? Ethical overview.<br />

Nursing Science. Jan; 31 (1): 15-16. https://<br />

DOI: 10.1177/0894318417741099<br />

Sedom, R. Sedhom, R., Gupta, A., Von Roenn, J., & Smith, T.<br />

J. (2020). The case for focused palliative care education<br />

in oncology training. Journal of Clinical Oncology :<br />

official journal of the American Society of Clinical<br />

Oncology, 38(21), 2366–2368. https://doi.org/10.1200/<br />

JCO.20.00236<br />

Thomas, T. H., Jackson, V. A., Carlson, H., Rinaldi, S., Sousa,<br />

A., Hansen, A., Kamdar, M., Jacobsen, J., Park, E. R., Pirl,<br />

W. F., Temel, J. S., Greer, J. A. (2019). Communication<br />

differences between oncologists and palliative care<br />

clinicians: A qualitative analysis of early, integrated<br />

palliative care in patients with advanced cancer. Journal<br />

of Palliative Medicine. 22 (1), 41-49.


<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 9<br />

Non-beneficial Treatment at the End of Life<br />

Kiernan Quay, DNP, APRN, FNP-C<br />

Dr. Kiernan Quay is an inpatient Palliative Care Nurse<br />

Practitioner at Beebe Healthcare located in Lewes, DE.<br />

She obtained her BSN at Johns Hopkins University in<br />

2009, her MSN and DNP at the Medical University of<br />

South Carolina in 2017. She previously worked in the<br />

settings of acute care, medical-surgical, trauma, and<br />

family medicine. Dr. Quay is a board certified Family Nurse<br />

Practitioner. She is a member of the bioethics, readmissions,<br />

advanced practice provider, and bylaws committees<br />

at Beebe Hospital. She is an eight-time DAISY award<br />

nominee and has twice received honorable mention for<br />

Delaware Today Top Nurses. Dr. Quay may be reached at<br />

Kquay@beebehealthcare.org.<br />

Kiernan Quay<br />

Non-beneficial treatment (NBT) affects over a third of patients at end of life (EOL)<br />

(Cardona-Morrell et al., 2016). The shift from beneficence to autonomy coupled with<br />

a dramatic increase in easily accessible medical information can lead patients and<br />

surrogates to expect to be apprised of all options, including those not recommended and<br />

some not even mentioned, regardless as to whether the treatment could lead them to<br />

achieve their overall goals of care (GOC) (Macauley, 2018). This explosion of autonomy<br />

leads to increasingly complex cases where care being asked for at the end of life may be<br />

incredibly aggressive while not improving quality of life. Conflicts can arise when patients<br />

insist on inadvisable care. Some patients may have a nothing-to-lose mindset regarding<br />

interventions such as cardiopulmonary resuscitation (CPR). There is much to lose, even<br />

at the EOL. Non-beneficial treatment at EOL can lead to significant distress whether<br />

that be emotional, spiritual, physical, or financial. States often have vague legislation<br />

that attempts to offer some protection to providers who refuse to offer treatments. It is<br />

difficult to identify care that would be classified as futile with complete accuracy unless<br />

there is no true physiologic benefit (e.g., CPR in patients with substantial, irreparable<br />

head trauma). Every patient is unique, so determining if there is any chance of success<br />

is difficult, and perhaps even harder to determine the exact probability. While there are<br />

avenues for addressing requests for NBT, there may be overall less distress suffered by<br />

patients, families, and staff if NBT requests are prevented at the outset.<br />

Non-beneficial treatment at EOL, and particularly aggressive interventions such as CPR,<br />

may cause substantial distress to those providing and receiving care. One may think there<br />

is no harm in receiving or performing CPR. A nothing-to-lose mentality fails to recognize<br />

the potential for harm and ignores the responsibility to do no harm (Macauley, 2018).<br />

Cardiopulmonary resuscitation often contributes to broken ribs, internal organ damage,<br />

and the likelihood of a compromised quality of life if there is return of spontaneous<br />

circulation. Healthcare staff may experience moral distress while performing CPR at<br />

patients’ EOL. Providers may feel they are stuck in an impossible situation when they are<br />

concerned that the risk of CPR may be greater than the benefit, yet they feel obligated to<br />

fulfill patient requests. Despite significant scientific advancements, the median in-hospital<br />

adult cardiac arrest survival rate remains at 18% (Meaney et al., 2013).<br />

Per Pope (2017), when states have legislation that attempt to address NBT, they are<br />

often vague and tend to use the problematic futility terminology or reference standards<br />

such as medically ineffective or generally accepted healthcare standards. Delaware Title<br />

16, Chapter 25, section 2501 (m) defines medically ineffective treatment as any medical<br />

treatment to a reasonable degree of medical certainty, a medical procedure that will not<br />

prevent or reduce the deterioration of the health of an individual, or a medical procedure<br />

to prevent the impending death of an individual (The Delaware Code Online, n.d.). Vague<br />

legislation coupled with the nearly impossible task of deciding what is futile leads to<br />

providers being appropriately reluctant to refuse to offer treatments.<br />

At the hospital level, a bioethics committee can review cases and provide guidance<br />

on how to resolve ethical dilemmas that arise between patients and providers. Beebe<br />

Healthcare’s committee is comprised of providers, nurses, non-clinical staff, and<br />

community members. The provider who requests the consultation can accept or decline<br />

the committee’s recommendation.<br />

In addition to bioethics committees, some hospitals have a specific policy that outlines<br />

a precise process to address NBT requests. Beebe Healthcare does not currently have a<br />

NBT policy. While policy specifics vary, they must clearly define NBT to avoid treatment<br />

decisions being made based on personal values (Macauley, 2018). The policy should<br />

encourage the involvement of the Palliative Care team, if not already engaged, and the<br />

bioethics committee. Policies outline next steps if the dispute remains unsolved despite<br />

involvement of both groups. If the provider decides to limit, withdraw, or withhold NBT,<br />

the patient should be permitted to request a second opinion. If the second opinion<br />

concurs with the first, the provider must discuss the options for transfer to another<br />

provider, or another facility if appropriate, and the option to seek legal counsel (Macauley,<br />

2018). If after a reasonable period, transfer to another facility is not practical, nor has<br />

any legal action been filed, care may be unilaterally withheld or withdrawn based on the<br />

institution’s policies and procedures (Macauley, 2018).<br />

Ideally, conflicts are resolved before care is unilaterally withheld or withdrawn. With<br />

the assistance of Palliative Care teams, conflicts are avoided by implementation of early<br />

and ongoing GOC discussions prior to involving a bioethics committee and perhaps<br />

working through a NBT policy sequence.<br />

Early involvement of palliative care is advised as complex GOC discussions typically<br />

require a significant degree of rapport to be successful, and a patient-centered approach<br />

requires more than simply listing options and deferring to the patients’ choices (Macauley,<br />

2018). Palliative Care teams need to have ongoing, extensive discussions with patients to<br />

identify the patients’ values, beliefs, and what is of most importance to them in their<br />

lives. A significant portion of time is spent explaining acute and chronic medical issues<br />

and how those interact to create a prognosis. From there, individual treatment options<br />

are evaluated to determine if they may help patients progress towards their goals or<br />

lead them astray. For example, a full code status is inconsistent with the desire to die<br />

peacefully at home.<br />

Palliative Care teams are a key component to avoiding and solving requests for NBT.<br />

Patients and providers may become ensnared in vague laws and futile terminology.<br />

Engaging patients early in GOC conversations assists patients in determining if medical<br />

interventions are truly beneficial. The greatest satisfaction for patients and healthcare<br />

staff alike may come when patients are listened to, patients make decisions based on<br />

reality, and unnecessary distress is avoided.<br />

References<br />

Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016). Nonbeneficial<br />

treatments in hospital at the end of life: A systematic review on extent of the<br />

problem. International Journal for Quality in Health Care, 28(4), 456-469. doi:10.1093/intqhc/<br />

mzw060<br />

Macauley, R. C. (2018). Ethics in Palliative Care: A complete guide. Oxford University Press.<br />

Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenon, J., de Caen, A. R., Bhanji, F., Abella, B.<br />

S., Kleinman, M. E., Edelson, D. P, Berg, R. A., Aufdeheide, T. P., Menon, V., Leary, M., & on<br />

behalf of the CPR Quality Summit Investigators, the American Heart Association Emergency<br />

Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care,<br />

Perioperative and Resuscitation. (2013). Cardiopulmonary resuscitation quality: Improving<br />

cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement<br />

from the American Heart Association. Circulation, 128,417-435. https://doi.org/10.1161/<br />

CIR.0b013e31829d8654<br />

Pope, T. M. (2007). Medical futility statues: No face harbor to unilaterally refuse life-sustaining<br />

treatment. Tennessee Law Review, 1-81. https://ssrn.com/abstract=989662<br />

The Delaware Code Online. (n.d.). https://delcode.delaware.gov/title16/c025/<br />

We are currently hiring:<br />

• RN Triage (Odenton)<br />

• Staff RN (All ages continuing care)<br />

• RN MD PCP Nurse for Population Health<br />

If you have a passion for community health, we invite you to join our team.<br />

When you work for THC, you will be employed by a premier healthcare<br />

organization that continually strives for high quality, professionalism and<br />

service excellence.<br />

For more information about nursing opportunities at THC, please<br />

visit: www.totalhealthcare.org or<br />

email Michelle at: mlane@totalhealthcare.org


Page 10 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />

Using Respiratory Distress Observation Scale (RDOS) at End-of-Life<br />

Karin Cooney-Newton, MSN, RN, APRN,<br />

ACCNS-AG, CCRN<br />

Karin Cooney-Newton is a<br />

Pulmonary Clinical Nurse<br />

Specialist at Bayhealth Medical<br />

Center at both the Kent Campus<br />

in Dover, DE, and the Sussex<br />

Campus in Milford, DE. She<br />

is a BSN graduate of Widener<br />

University, and earned her<br />

Masters at Wesley College.<br />

Karin’s clinical expertise is within<br />

critical care for 33 years where<br />

her passion for end-of-life<br />

improvement is ongoing. She<br />

has presented on compassionate<br />

extubation using an objective<br />

respiratory distress observation<br />

Karin Cooney-<br />

Newton<br />

tool nationally at the National Teaching Institute & Critical<br />

Care Exposition, regionally at TRENDS, and locally at<br />

Nursing Research conferences. She has worked as adjunct<br />

faculty at Wesley College for 10 years; and is co-author<br />

of a chapter in Innovative Strategies in Teaching Nursing<br />

published by Springer April, 2020. Karin may be reached at<br />

karin_cooney-newton@bayhealth.org.<br />

End of life (EOL) patient care can be an extremely<br />

stressful experience for not only the patients, but<br />

also, their families, and the healthcare team. When<br />

training to become a nurse, the focus is largely on<br />

helping patients survive acute episodes and to assist<br />

in restoring their health. Unfortunately, not all patients<br />

are able to fully recover, or return to their desired<br />

quality of life. In 2010, 29% of deaths occurred in the<br />

hospital, and the average terminal admission lasted 7.9<br />

days according to the New England Journal of Medicine<br />

(Blinderman & Billings, 2015). The healthcare team<br />

must transition these patients from restorative care to<br />

palliative care. It is considered one of the most difficult<br />

and important aspects of nursing practice (Truog et al.,<br />

2008).<br />

Optimal pain and symptom management is a priority<br />

for patients and families at EOL. Bender et al. (2017)<br />

stated that surveys of patients and family members, as<br />

well as prospective and retrospective studies revealed<br />

gaps in the quality of care for symptom management<br />

at EOL. These gaps included inadequate pain and<br />

symptom control, and delays in the evaluation and<br />

management of dyspnea (Bender et al., 2017).<br />

Uncontrolled symptoms at EOL adds distress for<br />

patients and their families, as well as compromises the<br />

patient’s quality of life.<br />

When further life-sustaining treatment is deemed<br />

futile, and/or is no longer achieving the patient<br />

and family’s goals of care, the family may choose<br />

to discontinue further treatment. Within the ICU<br />

setting, compassionate extubation (CE) is the<br />

termination of mechanical ventilation and withdrawal<br />

of an artificial airway to avoid prolonged suffering<br />

at EOL. Some patients who are conscious are able to<br />

report dyspnea, but others being withdrawn from<br />

the ventilator are critically ill, cognitively impaired,<br />

or unconscious and unable to self-report dyspnea.<br />

These patients may or may not be able to experience<br />

respiratory distress depending on the severity of<br />

unconsciousness (Campbell et al., 2015). The ability to<br />

experience unrelieved dyspnea continues until death.<br />

These patients near death are vulnerable to be under<br />

recognized and under treated for respiratory distress.<br />

Conversely, a patient runs the risk of being over<br />

treated, which leads to over sedation and unintentional<br />

acceleration of death (Campbell & Templin, 2015).<br />

Unanticipated respiratory distress is a common<br />

complication of CE and one of the most challenging<br />

symptoms for healthcare providers to control for<br />

their patients. This can be an extremely distressing<br />

experience for patients, as well as their families and the<br />

healthcare team.<br />

The use of the Respiratory Distress Observational<br />

Scale (RDOS) at EOL can assist with patient comfort<br />

and decrease stress of the family and healthcare<br />

providers. RDOS is an objective assessment that can<br />

guide the CE process, as well as withdrawal of noninvasive<br />

ventilation device (NIVD), or high-flow nasal<br />

cannula (HFNC). It is an objective tool used to assess<br />

the nonverbal, adult patient for the presence and<br />

intensity of respiratory distress. There are 8 variables<br />

(heart rate, respiratory rate, restlessness, paradoxical<br />

breathing, accessory muscle use, grunting at end<br />

expiration, nasal flaring, look of fear) with numeric<br />

values which are totaled together to obtain the RDOS<br />

score. Scale scores can vary from 0 indicating no<br />

distress to 16 indicating the most severe distress. The<br />

goal is a score


<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 11<br />

of withdrawing life-sustaining measures in the clinical<br />

setting (Campbell et al., 2015).<br />

RDOS not only can be used within the hospital<br />

setting but could be used in the home during hospice/<br />

palliative care. Dr. Campbell initiated the RDOS-<br />

Family as a guide for the family caretaker who has<br />

the around-the-clock responsibility to ensure patient<br />

comfort at EOL (Campbell & Templin, 2014). Educating<br />

family members of patients with dyspnea to use a<br />

standardized patient assessment could increase family<br />

confidence with dyspnea caregiving. Knowledge of<br />

how to assess and manage dyspnea (especially with<br />

the heart and lung disease palliative/hospice patients)<br />

can be initiated using RDOS. This in turn, can improve<br />

patient and family outcomes, with a goal of decreasing<br />

acute hospital admissions where a nonpreferred site of<br />

death could occur (Campbell & Templin, 2014). During<br />

the pilot study, Dr. Campbell found that further testing<br />

would need to be completed including more education<br />

on variables that require more nursing experience that<br />

appeared to be underreported by family members<br />

(Campbell & Templin, 2014).<br />

To summarize, EOL can be a stressful experience for<br />

patients, families, and the healthcare team. Patients<br />

near death are apt to be under recognized and under<br />

treated for respiratory distress. Patients also run the risk<br />

of being over treated, which may lead to over-sedation<br />

and unintentional acceleration of death Using RDOS at<br />

EOL can help alleviate distress and assists to validate<br />

the need for medication titration for comfort during<br />

EOL care.<br />

Although EOL care is challenging and emotionally<br />

exhausting for all those involved, helping patients die<br />

peacefully can be as rewarding as saving a life. Thom<br />

Dick, an EMT paramedic and author, summarizes it<br />

best: “You’re going to be there when a lot of people<br />

are born, and when a lot of people die. In most every<br />

culture, such moments are regarded sacred and<br />

private, made special by a divine presence. No one<br />

on Earth would be welcomed, but you’re personally<br />

invited. What an honor that is” (T. Dick, personal<br />

communication, September, 8, <strong>2021</strong>).<br />

References<br />

Bender, M. A., Hurd, C., Solvang, N., Colagrossi, K., Matsuwaka,<br />

D., & Curtis, J. R. (2017). A new generation of comfort<br />

care order sets: Aligning protocols with current principles.<br />

Journal of Palliative Medicine, 20(9), 922–929. https://doi.<br />

org/10.1089/jpm.2016.0549<br />

Blinderman, C. D., & Billings, J. A. (2015). Comfort care for<br />

patients dying in the hospital. New England Journal of<br />

Medicine, 373(26), 2549–2561. https://doi.org/10.1056/<br />

nejmra1411746<br />

Campbell, M. L. (2016). AACN Webinar: Caring practice:<br />

Evidence-based terminal ventilator withdrawal. AACN.<br />

Campbell, M.L. (2018). Ensuring breathing comfort at the end of<br />

life: the integral role of the<br />

critical care nurse. American Journal of Critical Care, 27(4), 264-<br />

269. doi:https://doi.org/10.4037/ajcc2018420<br />

Campbell, M. L., & Templin, T. N. (2014). RDOS-Family: A guided<br />

learning tool for layperson assessment of respiratory<br />

distress. Journal of Palliative Medicine, 17(9), 982–983.<br />

https://doi.org/10.1089/jpm.2014.0145<br />

Campbell, M. L., & Templin, T. N. (2015). Intensity cut-points for<br />

the respiratory distress observation scale. Palliative Medicine,<br />

29(5), 436–442. https://doi.org/10.1177/0269216314564238<br />

Campbell, M. L., Yarandi, H. N., & Mendez, M. (2015). A twogroup<br />

trial of a terminal ventilator withdrawal algorithm:<br />

Pilot testing. Journal of Palliative Medicine, 18(9), 781–785.<br />

Dick, T. (2018). People care: Perspectives and practices for<br />

professional caregivers. (3rd ed). EMS World.<br />

Downar, J., Delaney, J. W., Hawryluck, L., & Kenny, L. (2016).<br />

Guidelines for the withdrawal of life-sustaining measures.<br />

Intensive Care Medicine, 42(6), 1003–1017. https://doi.<br />

org/10.1007/s00134-016-4330-7<br />

Mularski, R. A., Campbell, M. L., Asch, S. M., Reeve, B. B., Basch,<br />

E., Maxwell, T. L., Hoverman, J. R., Cuny, J., Clauser, S. B.,<br />

Snyder, C., Seow, H., Wu, A. W., & Dy, S. (2010). A review<br />

of quality of care evaluation for the palliation of dyspnea.<br />

American Journal of Respiratory and Critical Care Medicine,<br />

181(6), 534–538. https://doi.org/10.1164/rccm.200903-<br />

0462pp<br />

Truog, R. D., Campbell, M. L., Curtis, J. R., Haas, C. E., Luce,<br />

J. M., Rubenfeld, G. D., Rushton, C. H., & Kaufman,<br />

D. C. (2008). Recommendations for end-of-life care in<br />

the intensive care unit: A consensus statement by the<br />

American College of critical care medicine. Critical Care<br />

Medicine, 36(3), 953–963. https://doi.org/10.1097/<br />

ccm.0b013e3181659096<br />

Zhuang, Q., Yang, G. M., Cheung, Y. B., & Neo, S. H. (2018).<br />

Validity, reliability, and diagnostic accuracy of the respiratory<br />

distress observation scale for assessment of dyspnea in<br />

adult palliative care patients. Journal of Pain and Symptom<br />

Management. https://pubmed.ncbi.nlm.nih.gov/30391404/


Page 12 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />

Advocacy<br />

Results of Delaware Nursing Dialogue – Advocacy Prioritization<br />

Annamarie Flick, MSN, RN-BC, NE-BC,<br />

Advocacy Director<br />

The Delaware Nurses<br />

Association recently launched<br />

Delaware Nursing Dialogue,<br />

an ongoing inquiry series<br />

for all Delaware nurses to<br />

participate in and contribute to<br />

the advancement of nursing in<br />

Delaware. Delaware Nursing<br />

Dialogue will feature a variety of<br />

topics focused on the profession.<br />

The first survey in the series<br />

Annamarie Flick<br />

focused on advocacy and<br />

legislative efforts. These results were recently presented<br />

to the Advocacy Committee and Board of Directors. I am<br />

happy to share them back with you.<br />

Demographics<br />

• There were 194 nurses that participated in the annual<br />

advocacy priorities survey.<br />

o 68% are RNs, 29% are APRNs, and less than 1%<br />

each were LPNs and nursing students.<br />

o 70% of respondents had over 20 years’ experience.<br />

o 66% of respondents are members in the Delaware<br />

Nurses Association.<br />

o 54% of respondents live in New Castle County.<br />

o 37% of respondents work in the hospital setting.<br />

Advocacy Prioritization<br />

• Provided a list of 11 critical topics in nursing<br />

advocacy/policy, respondents ranked them in<br />

highest to lowest priority as below.<br />

o Safe Staffing<br />

o Wellbeing of the Nursing Workforce<br />

o Workplace Violence<br />

o Top of License Practice<br />

o Nursing Education<br />

o Personal Protective Equipment<br />

o Ongoing Emergency Preparedness<br />

o Collaboration/Relationships/Respect within<br />

the Delaware Health Care Professional<br />

Community<br />

o Telehealth Access & Regulation<br />

o Environmental Health<br />

o APRN Clinical Preceptors<br />

• When asked about additional advocacy/<br />

policy opportunities, respondents provided 82<br />

additional responses. The themes that emerged<br />

from these answers include:<br />

o Access, regulation, and payment for home<br />

care services<br />

o Standing order protocols<br />

o Protecting scope of practice for all nurses<br />

o Access to and overall mental health services<br />

o Uplifting and maintaining the scientific,<br />

evidence-backed position of our profession<br />

and combatting mistrust<br />

o Increased, equitable, and consistent nursing<br />

pay/salary<br />

Advocacy Engagement<br />

• 22% of respondents expressed interest in the<br />

Advocacy Ally position to further support<br />

nursing engagement in policy, legislation, and<br />

advocacy.<br />

• 48% of respondents expressed a desire to<br />

be further involved in grassroots advocacy<br />

by connecting with their local legislators and<br />

speaking in support of nursing priorities.<br />

This information, provided by Delaware nurses, is<br />

already reshaping the way the Advocacy Committee<br />

is working and prioritizing our efforts. Several actions<br />

have already come out of the review of this data:<br />

• Marykate McGurk, BSN, RN, CCRN, Susan Conaty-<br />

Buck, DNP, APRN, FNP-C, FAANP, and Suzette<br />

Flores, DNP, BSW, APRN, NP-C have volunteered<br />

to work as grassroots coordinators and connect<br />

with the identified individuals on staying engaged<br />

and elevating the voice of nurses.<br />

• The Advocacy Committee is going to form<br />

three subgroups focused on the top priorities of<br />

Delaware nurses: workforce/staffing, wellbeing,<br />

and workplace violence.<br />

• <strong>DNA</strong>’s Executive Director is connecting with the<br />

identified Advocacy Allies to onboard them to<br />

their role, keep them engaged, and begin our<br />

work for the 2022 Delaware General Assembly.<br />

The Advocacy Committee will continue to analyze<br />

the results and align them with our strategies and<br />

legislation/policy that we support and move forward.<br />

Our 2022 Legislative Platform is also currently being<br />

updated based on these results and changes/trends<br />

in nursing and healthcare policy. This will be shared<br />

with nurses in the next edition of the <strong>DNA</strong> <strong>Reporter</strong>.<br />

The Advocacy Committee and Board of Directors<br />

thanks all nurses that took the time to answer the first<br />

Delaware Nursing Dialogue and provide us with this<br />

rich information. We encourage you to look for the<br />

next in the series to participate and lend your voice.<br />

Additionally, the prioritization of advocacy efforts<br />

will become an annual mainstay in Delaware Nursing<br />

Dialogue, so look for your chance to participate in Fall<br />

2022!<br />

Retirement Readiness Checklist<br />

Every day brings you a little closer to retirement<br />

age. Are you prepared for the financial impact<br />

of leaving the workforce? Here’s a checklist to<br />

help you consider the variables that impact your<br />

retirement readiness:<br />

1. Estimate your retirement living costs. Do<br />

you know how much money you will need to<br />

live comfortably in retirement? The amount you<br />

spend is likely to change over the years. For<br />

many retirees, expenses are highest in the early<br />

active years of retirement, but also may spike<br />

later in life, should you require costly living<br />

assistance.<br />

2. Add up your assets. As you approach<br />

retirement, you’ll want to have a good handle<br />

on the assets available to fund your retirement.<br />

Consider the equity in your home and<br />

other properties, your investment accounts,<br />

retirement accounts, annuities or cash-value<br />

insurance and savings accounts. If you’re a<br />

collector and hope to cash in, now is a good<br />

time to get an appraisal to determine current<br />

market value.<br />

3. Think about liquidity. How will you access<br />

your savings in retirement? Will you need to sell<br />

securities or properties? Do you own an annuity<br />

that can be converted into an income stream? Do<br />

you have a lot of pre-tax dollars in your retirement<br />

accounts? You’ll want to have a plan to withdraw<br />

from your retirement savings in the most financially<br />

advantageous way.<br />

4. Calculate your Social Security earnings. How<br />

much you will receive each month from Social<br />

Security is based on your work history and the<br />

age at which you choose to retire. To receive your<br />

maximum monthly benefit, plan to claim your Social<br />

Security benefits at full retirement age (or later – up<br />

to age 70). Filing at an earlier age will result in a<br />

permanent reduction in monthly benefits.<br />

5. Consider your tax obligations. Taxes continue<br />

even when you stop working. Assuming you meet<br />

the income threshold, some portion of your Social<br />

Security income will be taxed. The good news is that<br />

as a retiree, you will most likely qualify for a lower<br />

marginal income tax rate. State income taxes vary<br />

widely and may influence where you want to retire.<br />

6. Don’t forget about inflation. While your<br />

Social Security benefits are adjusted for inflation,<br />

your other income may not be immune to rising<br />

consumer prices. Keep inflation in mind as you<br />

estimate your living expenses into the future.<br />

7. Sign up for Medicare during the limited<br />

enrollment window. To avoid penalties, you must<br />

elect your Medicare benefits within a limited time<br />

frame on either side of age 65. Special rules apply<br />

for people who continue to work and are covered<br />

by an employer’s health insurance plan. During<br />

Medicare enrollment, you’ll also have the opportunity<br />

to choose an optional Medicare Supplement<br />

insurance plan. Medicare Supplement plans help<br />

pay for out-of-pocket costs such as co-payments,<br />

coinsurance and deductibles under original Medicare.<br />

8. Consult the experts. Don’t wait until the last<br />

minute to figure out how you’ll pay your way in<br />

retirement. Talk to your accountant and financial<br />

advisor and explore your options. Together, you<br />

can devise a retirement strategy to help you make<br />

the most of the savings you’ve accrued from a<br />

lifetime of work.<br />

Christopher Malmstrom, CRPC, APMA, is a Financial Advisor with Point to Point Wealth Planning a private wealth advisory practice of Ameriprise Financial Services, LLC<br />

in Wilmington, DE. He specializes in fee-based financial planning and asset management strategies and has been in practice for 12 years. To contact him, visit his website<br />

www.ameripriseadvisors.com/christopher.malmstrom or call 302-995-7526. His office is located at 5195 W Woodmill Drive, Suite 27, Wilmington, DE 19808-4067.<br />

Ameriprise Financial, Inc. and its affiliates do not offer tax or legal advice. Consumers should consult with their tax advisor or attorney regarding their specific situation.<br />

Investment advisory products and services are made available through Ameriprise Financial Services, LLC, a registered investment adviser.<br />

Ameriprise Financial Services, LLC. Member FINRA and SIPC. | © <strong>2021</strong> Ameriprise Financial, Inc. All rights reserved.


<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 13<br />

Delaware Licensed Practical Nurse Leadership<br />

Journey to State Nursing Leadership<br />

Kenyette Walters, LPN, CDP®<br />

My name is Kenyette, most know me as Keni. I am<br />

a Delaware Licensed Practical Nurse (LPN) and currently,<br />

Vice President, Delaware Board of Nursing. I have been<br />

a nurse since 2012. Originally from Philadelphia, my<br />

background is in investment accounting and corporate<br />

finance. I am also a licensed Cosmetologist, former<br />

phlebotomist, heavy equipment operator, and spent<br />

some time doing academic grading/extern coordinator<br />

and lab administration for a graduate medical school in<br />

Philadelphia.<br />

After relocating to Delaware in 2007, and with long<br />

Kenyette Walters<br />

standing medical issues, I decided to pursue an earlier<br />

dream of entering the nursing profession. I felt that I owed good nursing<br />

care back to the community. I studied and obtained certification as a nursing<br />

assisting, worked in long-term care, and realized that nursing was my passion.<br />

In 2012, I completed nursing school and obtained my LPN license. Never<br />

discouraged by the saying “LPNs will be eliminated,” I endeavored to prove<br />

that LPNs are exceptional and prudent nurses with a wealth of opportunities<br />

to pursue. My career took off quickly. I quickly found that geriatric psychiatric,<br />

dementia, and behavioral nursing were my gift. In my role and practice setting,<br />

I was provided the opportunity to fulfill the charge nurse role and provide<br />

dementia programing for a large long-term care program in Maryland. I am<br />

a member of the National Council of Certified Dementia Practitioners and an<br />

active Certified Dementia Practitioner®.<br />

The road to excellence is not easily traveled. I had to endure many of the<br />

downsides of nursing, including bullying from peers and the “nurses eat their<br />

young” mentality. I persevered and have had the opportunity to practice in<br />

some of the following roles/environments: wound care, corrections, geriatric<br />

psych, orthopedic rehab, assisted living house supervisor, admissions nurse,<br />

and intravenous certification. I am currently an overnight skilled nurse in an<br />

exclusive lifestyle senior community. I also teach clinical instruction in the<br />

medical assistant program at Polytech Adult Education.<br />

Serving as the LPN member on the Delaware Board of Nursing, in addition<br />

to the roles noted below, has been pivotal in my professional practice,<br />

development, and leadership. I was reappointed to the board for a second<br />

term and most recently achieved a landmark milestone, I was elected by<br />

the board to serve as the Vice President. Additionally, I chair the Limited<br />

Lay Administration of Medications (LLAM) Committee. This committee is<br />

responsible for a state regulated program, further defined in the Delaware<br />

Nurse Practice Act, that allows individuals who have successfully completed a<br />

board-approved limited lay administration of medications training program to<br />

administer prescription or nonprescription medications to patients/residents/<br />

clients in select settings.<br />

The Delaware Board of Nursing has been one of the most challenging, often<br />

stressful, yet highly rewarding roles to date. The board’s primary purpose is to<br />

protect the public from negligent/impaired nursing practice. Our other goal is<br />

to support nurses, ensuring that they can practice safely and within the law,<br />

provide assistance programs to help nurses in crises, and exact discipline, when<br />

necessary. This role requires fairness, consistency, and in-depth knowledge of<br />

the Delaware Nurse Practice Act, as well as knowledge of practice limitations<br />

at all levels.<br />

Looking to the future and my continued professional development, my next<br />

major goal is to enroll in a nursing home administrator program and precept<br />

in my current facility with our amazing Executive Director. I hope to one day<br />

be the leader of an entire community/facility. I can be reached via email at<br />

mskeni@prodigy.net.<br />

Nurses, thank you for your continued efforts to serve our community. I<br />

know that, at times, it can be difficult to find the passion needed, but your<br />

efforts are noticed and appreciated. The COVID pandemic has put a strain on<br />

the nursing community, with an end date hard to see at this time. Together,<br />

we will support each other, those we serve, and emerge stronger than ever.<br />

We are tired. We are weary. We will never give up.<br />

We are angels of mercy. We are nurses!


Page 14 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />

Documenting nursing assessments in the age of EHRs<br />

Georgia Reiner, MS, CPHRM, Senior Risk<br />

Specialist, Nurses Service Organization (NSO)<br />

Nurses have grown accustomed to documenting<br />

assessment results in the electronic health record<br />

(EHR), rapidly clicking responses to assessment<br />

checklist questions. However, at times nurses<br />

complete these actions without giving enough<br />

thought to their documentation because they want<br />

to move on to their “real” work: caring for patients.<br />

The danger of this approach is threefold. First,<br />

nurses might base their assessment on the checklist<br />

not the patient, which can lead to an incomplete<br />

assessment, especially if the nurse inadvertently<br />

clicks something as being done when it hasn’t.<br />

Second, nurses might fail to adequately document<br />

a finding if it does not match up with the available<br />

options in the checklist. Third, nurses might fail to<br />

document assessments when a patient’s condition<br />

changes or fail to document practitioner notification<br />

of the change.<br />

All three scenarios can leave nurses open to<br />

legal action. For example, a harried nurse caring<br />

for a patient who had a total hysterectomy clicks<br />

“normal” as the result of abdominal auscultation<br />

even though she hasn’t completed this assessment<br />

and misses the absence of bowel sounds. Soon,<br />

however, the patient develops vomiting and severe<br />

abdominal pain and is diagnosed with a bowel<br />

obstruction. This nurse could be held liable for the<br />

delay in treatment.<br />

Dangers of improper documentation<br />

Documentation is a vital nursing responsibility. It’s<br />

important for planning patient care, communicating<br />

with providers, and demonstrating compliance with<br />

federal, state, third-party, and other regulations.<br />

But documentation issues can result in professional<br />

liability lawsuits or action against a nurse’s license.<br />

NSO and CNA’s Nurse Professional Liability Exposure<br />

Claim Report: 4th Edition found that documentation<br />

deficiencies are contributing factors in many nurse<br />

professional liability claims, and that the average total<br />

incurred for claims involving allegations related to<br />

documentation was $238,761. The same report also<br />

noted that 9.7% of all license protection matters,<br />

which involved defending nurses during State Board<br />

of Nursing inquiries, were related to documentation.<br />

Of these, nearly half (49.6%) involved an allegation of<br />

fraudulent or falsified patient care or billing records.<br />

Failure to document treatment/care as required by<br />

regulatory agencies or facility policy comprised 28.6%<br />

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of matters related to documentation, followed by<br />

documentation that didn’t accurately reflect patient<br />

care and services (12.8%), failure to properly correct<br />

documentation errors according to facility policy<br />

(5.3%), and inadequate or untimely documentation<br />

(3.8%). These matters serve as reminders of how<br />

nurses need take time ensure they are completing<br />

documentation properly.<br />

Benefits of EHRs<br />

Too often nurses view EHRs negatively, feeling<br />

they’re cumbersome and take nurses away from<br />

the patient. But a well-designed EHR has several<br />

benefits, including improved efficiency and quality<br />

patient care. For example:<br />

• EHRs provide an excellent mechanism for<br />

communicating with a variety of healthcare<br />

providers in a timely fashion, thereby improving<br />

care coordination.<br />

• EHRs can incorporate guidelines, reminders,<br />

and decision support tools that can help<br />

providers make better decisions and deliver<br />

better care.<br />

• Electronic documentation eliminates the<br />

problem of misinterpretation of handwritten<br />

orders.<br />

• EHRs facilitate immediate access to data by<br />

multiple people in multiple locations.<br />

EHRs also can protect nurses against lawsuits and<br />

actions taken against their licenses. However, to gain<br />

the most benefit, nurses need to take full advantage<br />

of EHRs. For example, according to NSO and CNA’s<br />

Nurse Professional Liability Exposures: 2015 Claim<br />

Report Update, 45% of nurses who experienced<br />

a liability claim did not use the available EHR,<br />

compared with 19.2% of those without a liability<br />

claim.<br />

Proper EHR documentation<br />

You can take several steps to ensure you’re<br />

documenting assessments and other information<br />

correctly in the EHR.<br />

• Follow basic documentation principles.<br />

Whether you’re documenting on paper or in an<br />

EHR, the same basic principles apply. Document<br />

promptly, accurately, and without bias. Don’t<br />

interject opinions about patients or providers.<br />

When making a correction to previously<br />

recorded information, include the reason for<br />

the change. Remember that the EHR provides a<br />

date and time for each entry, providing a clear<br />

documentation trail.<br />

• Adhere to policies, procedures,<br />

regulations, and guidelines. In the event of<br />

a legal action, one of the first steps an attorney<br />

will take is to determine if you followed your<br />

organization’s policies and procedures related<br />

to nursing assessments and documentation,<br />

as well as any relevant state, federal, or local<br />

guidelines, and guidelines from professional<br />

associations.<br />

• Copy and paste cautiously. The copy and paste<br />

feature in EHRs can be a time saver, but errors,<br />

including errors of omission, can easily occur.<br />

For example, you copy your note for one patient<br />

with a myocardial infarction (MI) into another<br />

MI patient’s record but forget to add that you<br />

notified the provider of the new S4 you heard<br />

on auscultation. If the patient later experiences<br />

severe heart failure, you will have no evidence<br />

that you notified the provider. Another problem<br />

with copy and paste is that errors can rapidly<br />

spread as others pick up the same erroneous<br />

information. For instance, a nurse copies an<br />

assessment for a patient with pneumonia several<br />

times, forgetting to update the temperature,<br />

which has returned the normal. The patient’s<br />

physician reads the note, thinks the patient<br />

isn’t responding to treatment, and changes the<br />

antibiotic. Subsequently, the patient experiences<br />

a significant adverse event from the new<br />

antibiotic, which leads to legal action against the<br />

hospital, the physician, and the nurse.<br />

A report from the Partnership for Health IT<br />

Patient Safety recommends providers “act with<br />

volition,” thinking about what is appropriate for<br />

copying and pasting and reviewing notes carefully.<br />

Ideally, the EHR should have a mechanism for easy<br />

identification of material that has been copied and<br />

pasted (for example, a different color text), so that<br />

providers are reminded to carefully review.<br />

• Beware of autofill and templates. Like<br />

copy and paste, the autofill feature can<br />

save time by avoiding repetitive entries,<br />

but you need to verify that the information<br />

automatically filled in is correct. Similarly,<br />

templates for regularly occurring events such<br />

as the first postoperative visit after a total<br />

knee arthroplasty can help save time and<br />

ensure needed information is collected, but<br />

you still need to be aware of individual patient<br />

needs and assessment findings.<br />

• Use notes appropriately. Sometimes what<br />

you need to document as an assessment<br />

finding isn’t in a checklist or pull-down menu.<br />

Don’t choose the “next best” option; doing<br />

so can lead to miscommunication and clinical<br />

and billing errors. For example, if you select<br />

“pressure injury” because “skin tear” isn’t<br />

available, legal action would be based on the<br />

more serious injury. A better approach is to<br />

add a note to the patient’s record. Be sure your<br />

note provides vital information in a succinct<br />

matter to avoid “note bloat” (also a side effect<br />

of inappropriate copy and paste). If an option<br />

that you would use frequently isn’t available,<br />

talk with your manager or informatics contact<br />

about adding it to the EHR.<br />

• Protect patient privacy. Do not share<br />

your passwords and change them regularly,<br />

according to your facility’s policy. In addition,<br />

don’t enter information in view of other<br />

patients.<br />

• Don’t ignore alerts. Alerts are there to help<br />

you make better decisions when it comes to<br />

patient care. For example, when you enter<br />

your assessment data, you may receive an<br />

alert that a patient could be at risk for sepsis.<br />

Your prompt action could save the patient’s<br />

life. On the other hand, too many alerts may<br />

lessen their efficacy, leading to “alert fatigue”.<br />

Talk with your manager or informatics contact<br />

to discuss settings.<br />

• Complete an effective assessment. You<br />

won’t have the information you need for the<br />

EHR unless you perform a quality assessment.<br />

Don’t simply consider what a computer<br />

checklist tells you to include. Use your critical<br />

thinking skills to match the assessment to the<br />

patient.<br />

• Document changes in the patient’s<br />

condition. Remember to enter changes to the<br />

patient’s status into the computer and include<br />

if you notified the provider of the change.<br />

A partnership<br />

Rather than having an adversarial relationship with<br />

the EHR, nurses should consider the EHR as a care<br />

partner. By serving as a repository of data, providing<br />

alerts as needed, and facilitating communication, the<br />

EHR can help ensure quality patient care—and reduce<br />

nurses’ risk of legal action.<br />

RESOURCES<br />

Balestra ML. Electronic health records: Patient care and<br />

ethical and legal implications for nurse practitioners.<br />

J Nurs Pract. 2017;13(2):105-111.<br />

CNA, NSO. Nurse Professional Liability Exposure Claim<br />

Report: 4th Edition. 2020. www.nso.com/Learning/<br />

Artifacts/Claim-Reports/Nurse-Practitioner-Claim-<br />

Report-4th-Edition-A-Guide-to-Identifying-and-<br />

Addressing-Professional-Liability- Exposures<br />

CNA, NSO. Nurse Professional Liability Exposures:<br />

2015 Claim Report Update. 2015. www.cna.<br />

com/web/wcm/connect/e05b5d91-cf38-<br />

444d-8727- ab65f25f8f6a/RC_Health_Nurses_<br />

Claim_Report_Update_101615.pdf?MOD=AJP<br />

ERES&CACHEID=e05b5d91-cf38-444d-8727-<br />

ab65f25f8f6a


<strong>December</strong> <strong>2021</strong>, January, February 2022 <strong>DNA</strong> <strong>Reporter</strong> • Page 15<br />

Effective use of EHRs<br />

These actions will help you gain the most<br />

benefit from the EHR:<br />

• Document promptly and thoroughly. This<br />

not only helps protect you from liability but,<br />

more importantly, ensures that information is<br />

quickly available to other providers.<br />

• Document accurately. Don’t omit key<br />

information and don’t try to cover up if you<br />

failed to document or take correct action.<br />

• Get involved in EHR selection. Often,<br />

nurses don’t use the EHR correctly or take<br />

full advantage of its capabilities because<br />

the design is poor. Ask to be included on<br />

committees tasked with selecting the EHR<br />

vendor. Consider which systems best reflect<br />

what providers need to document and assess<br />

for user interface by checking items such as<br />

the font size of screen text.<br />

• Identify opportunities for improvements<br />

in EHR function. Instead of engaging in<br />

potentially dangerous workarounds, notify<br />

leadership where improvements are needed.<br />

In some cases, the format of the EHR can be<br />

tweaked to make it easier for the user.<br />

• Don’t assume the EHR is always right. The<br />

EHR isn’t infallible. If, for example, results<br />

of a test don’t seem to match the patient’s<br />

symptoms, follow up with the provider – the<br />

test may need to be redone.<br />

• Provide education. Consider helping<br />

your colleagues learn more about proper<br />

documentation in the EHR by providing an<br />

education program or suggesting such a<br />

program to your professional development<br />

department.<br />

• Be patient centered. The ability to document<br />

at the patient’s bedside can save time and<br />

improve accuracy, but only if you keep<br />

your focus on the patient instead of on the<br />

computer. Maintain eye contact and consider<br />

telling patients what you are entering into<br />

the computer, which can help ensure the<br />

information is accurate.<br />

New, Renewing, & Returning Members<br />

August 28 – November 29, <strong>2021</strong><br />

New & Returning Members<br />

Leila Gaines<br />

Bear<br />

Jessica Seador<br />

Anna Merrick<br />

Elizabeth Phillips<br />

Bridgeville Naomi Higgins<br />

Annamarie Breeden<br />

New Castle Leah Patterson<br />

Jill Erwin<br />

Newark Juliana Rahmer<br />

Denise Jones<br />

Lewes Deborah Streeter<br />

Olusade Banjo<br />

Newark Bonnie Beaston<br />

June Ndibo<br />

Newark Michelle Saienni<br />

Ruth Van Weele<br />

Harrington Marisa Shetzler<br />

Ekor Odaji<br />

Smyrna Eugenia Johnson<br />

Genita Vandell<br />

Wilmington Cynthia Testa<br />

Danette Newby-Mitchell<br />

New Castle Yesenia Sudler<br />

Kim Blanch<br />

Rehoboth Beach Kathleen Carlson<br />

Sheri McAfee-Garner<br />

Millsboro Pete Zingone<br />

Sherri Clark<br />

Dover Anne Kariuki<br />

Patricia Winward<br />

Frankford Kaitlin Steelman<br />

Travis Stevens<br />

Rehoboth Beach Abioseh Pieh<br />

Angie Primus<br />

Bear Thelma Aminu<br />

William Brown<br />

Wilmington Tami Sellers<br />

Julieanne Cloman<br />

Lewes Morgan Webb<br />

Toccara Barber<br />

Dover Kelly Souder<br />

Newark<br />

Ocean View<br />

Claymont<br />

Dover<br />

Wilmington<br />

New Castle<br />

Townsend<br />

Wilmington<br />

Odessa<br />

Dover<br />

Hockessin<br />

Smyrna<br />

Georgetown<br />

Lewes<br />

Bear<br />

Lewes<br />

Newark<br />

New Castle<br />

Ellendale<br />

Milford<br />

Smyrna<br />

Grace Logemann<br />

Hockessin John Reinford<br />

Millsboro<br />

Michael Knorr<br />

Newark Michelle Fisher<br />

Dover<br />

Meghan Elliott<br />

Georgetown<br />

Roselyne Arusei<br />

New Castle<br />

Members continued on page 16<br />

ECRI Institute. Copy/Paste: Prevalence, Problems, and<br />

Best Practices. Special Report. 2015. www.ecri.org/<br />

Resources/HIT/CP_Toolkit/CopyPaste_Literature_final.<br />

pdf. Kelley T. Electronic Health Records for Quality<br />

Nursing and Health Care. Lancaster, PA: DEStech<br />

Publications; 2016.<br />

Pagulayan J, Eltair S, Faber K. Nurse documentation<br />

and the electronic health record. Am Nurs Today.<br />

2018;13(9):48-52, 54.<br />

Partnership for Health IT Patient Safety. Health IT Safe<br />

Practices: Toolkit for the Safe Use of Copy and Paste.<br />

2016. https://d84vr99712pyz.cloudfront.net/p/pdf/<br />

hit-partnership/copy-paste-toolkit.pdf. Tsou AY,<br />

Lehmann CU, Michel J, et al. Safe practices for copy<br />

and paste in the EHR. Appl Clin Inform. 2017;8(1):12-<br />

34.<br />

Disclaimer: The information offered within this<br />

article reflects general principles only and does<br />

not constitute legal advice by Nurses Service<br />

Organization (NSO) or establish appropriate or<br />

acceptable standards of professional conduct.<br />

Readers should consult with an attorney if they<br />

have specific concerns. Neither Affinity Insurance<br />

Services, Inc. nor NSO assumes any liability for how<br />

this information is applied in practice or for the<br />

accuracy of this information.<br />

This risk management information was provided<br />

by Nurses Service Organization (NSO), the nation’s<br />

largest provider of nurses’ professional liability<br />

insurance coverage for over 550,000 nurses since<br />

1976. The individual professional liability insurance<br />

policy administered through NSO is underwritten<br />

by American Casualty Company of Reading,<br />

Pennsylvania, a CNA company. Reproduction<br />

without permission of the publisher is prohibited.<br />

For questions, send an e-mail to service@nso.com<br />

or call 1-800-247-1500. www.nso.com.


Page 16 • <strong>DNA</strong> <strong>Reporter</strong> <strong>December</strong> <strong>2021</strong>, January, February 2022<br />

New, Renewing, & Returning Members<br />

Members continued from page 15<br />

Ann-Marie Spraggs<br />

Wilmington<br />

Jenneh Lashley<br />

New Castle<br />

Kristie Hudson<br />

Selbyville<br />

John Starke<br />

Frederica<br />

Caricia Rickards<br />

Felton<br />

Amy Linzey<br />

Ocean View<br />

Maria Brown<br />

Middletown<br />

Amanda Kulhanek<br />

Smyrna<br />

Caroline Githaiga<br />

Townsend<br />

Kat Kvoka<br />

Wilmington<br />

Cynthia Patterson<br />

Newark<br />

Renewing Members, 1-5 Years<br />

Margaret Mack Wilmington (2)<br />

Patricia Ayers Milton (2)<br />

Felicia Cruz Dover (5)<br />

Sheila Dirocco Marydel, MD (3)<br />

Jennifer Dunford Wilmington (2)<br />

Charles Evans Jr. Wilmington (2)<br />

Katherina Haigh Newark (1)<br />

Susan Hensler Selbyville (3)<br />

Heather Hogan Wilmington (1)<br />

Denise Jones Dover (5)<br />

Denise Larson Lewes (5)<br />

Danielle LeGates Lewes (3)<br />

Laura Mills Milford (2)<br />

Laura Rausch Newark (1)<br />

Pam Rimkis Dagsboro (1)<br />

Anastasia Robinson Ocean View (5)<br />

Tori Sabbatini Newark (2)<br />

Amber Salyers Wilmington (5)<br />

Keiosha Shelton Frankford (3)<br />

Angela Strong Ocean View (1)<br />

Ruth Wamwati Middletown (5)<br />

Sarah Lewis Milton (4)<br />

Ashley Aloba Bear (1)<br />

Rob Dusty Sweetman Clayton (5)<br />

Gayle Jones Milton (5)<br />

Shameka Brown Newark (4)<br />

Catherine Haut Lewes (3)<br />

Betty Alfree Smyrna (2)<br />

Jamie Ayala Middletown (5)<br />

Eric Diehl Middletown (1)<br />

Kristen Doughty Hockessin (3)<br />

Keisi Escalante Georgetown (3)<br />

Janice Evans Lincoln (1)<br />

Suzette Gaydor Newark (1)<br />

Lyrae Graham Middletown (2)<br />

Lindsey Hertsenberg Newark (5)<br />

Melanie Hiester Newark (2)<br />

Nicolette Levere Bear (1)<br />

Robin Maracle Camden (1)<br />

Emily McHugh Milton (5)<br />

Tamyra Mosley Townsend (4)<br />

Mary Pribish Wilmington (3)<br />

Michele Sturgeon Milford (1)<br />

Jessi Wyatt Harrington (4)<br />

Fredeline Pierre Smyrna (2)<br />

Susan Conaty-Buck Newark (1)<br />

Dominique Turner Townsend (1)<br />

Rachel Fields Seaford (5)<br />

Tara Furbush Wilmington (5)<br />

Kathleen Ingram New Castle (1)<br />

Tinagena Pia Inguito Newark (1)<br />

Kayla Shannon Middletown (1)<br />

Mary Matsumoto Newark (5)<br />

Bogonko Achenchi Dover (5)<br />

Heidi Amador Magnolia (5)<br />

Cheryl Andisik Hartly (1)<br />

Noelle Bolingbroke Frederica (5)<br />

Eunice Boyd-Gant Smyrna (3)<br />

Ramona Bradley Laurel (5)<br />

Naomi Cebenka Wilmington (2)<br />

Robin Forester Wilmington (3)<br />

Yvonne Forney Historic New Castle (4)<br />

Heather Gabriel Harrington (2)<br />

Sharon Gibbs Dover (3)<br />

Shawn Grim Seaford (2)<br />

Candace Hamner Lewes (1)<br />

Erica Harrell-Tompkins New Castle (5)<br />

Peter Irungu Smyrna (1)<br />

Sarah Lavelle Wilmington (1)<br />

Pete Lerza Delmar (1)<br />

Shannon Loomis Wilmington (3)<br />

Catherine Mariani Millsboro (2)<br />

Godwin Onuoha New Castle (5)<br />

Kimberly Purcell New Castle (2)<br />

Jennifer Rineer Townsend (1)<br />

Paula Rutledge Townsend (2)<br />

Sylvia Stubbs Lewes (3)<br />

Christina Young Rehoboth Beach (2)<br />

Alexis Morris-Williams Suwanee, GA (5)<br />

Michelle Todd Dover (4)<br />

Renewing Members, 6-10 Years<br />

Michele Gamble Millsboro (6)<br />

Susan Atkison Wilmington (10)<br />

Lyron Deputy Lewes (6)<br />

Margaret Gatti Ocean View (9)<br />

Candice Hubbard Lewes (6)<br />

Derek Lawson Bear (7)<br />

Candice Morris Magnolia (6)<br />

Brittany Oakey Milford (6)<br />

Lizy Thomas Newark (7)<br />

Dorothy Paxson Barker Milton (9)<br />

Jean St. John Newark (6)<br />

Laureen Eick-Benson Hockessin (6)<br />

Karla Sellers Lewes (6)<br />

Christopher Dorsey Wilmington (6)<br />

Carol Minor Milford (7)<br />

Gary Alderson Wilmington (10)<br />

Kimberly Ford Dover (6)<br />

Courtney Johnson Newark (7)<br />

Jill Petrone Lewes (7)<br />

Emily Snyder Dover (8)<br />

Susan Studds Georgetown (8)<br />

Christine Hargrove Newark (8)<br />

Melody Wireman Hartly (9)<br />

Richard Cuming Wilmington (10)<br />

Catherine Barber Felton (7)<br />

Jill Cavalcanti Dover (9)<br />

Nyree Cephas Newark (8)<br />

Devona Fields Frederica (8)<br />

Gwanda Hunter Newark (8)<br />

Danene Lucas Frederica (7)<br />

Melodye Neal Chadds Ford, PA (10)<br />

Debra Lynch Newark (7)<br />

Nicole Phillips Wilmington (6)<br />

Bernadette Thomas Newark (9)<br />

Renewing Members, 11-15 Years<br />

La Donna Allen Smyrna (11)<br />

Sandra Fox Wilmington (14)<br />

Shirley Class Georgetown (11)<br />

Robert McKennett Dover (14)<br />

Veronica Wilbur Lincoln University, PA (11)<br />

Vivian Hendricks Dover (15)<br />

Felisha Alderson Wilmington (13)<br />

Martha Cunningham Wilmington (12)<br />

Moonyeen Klopfenstein Wilmington (12)<br />

Robyn Michaud Viola (13)<br />

Karen Zecher Hockessin (11)<br />

Renewing Members, 16-20 Years<br />

Cindy Jester Smyrna (18)<br />

Susan Sheehy Newark (20)<br />

Joan Blair Newark (19)<br />

Maryellen Sparks Newark (17)<br />

Margery White Milford (20)<br />

Gail Love Wyoming (18)<br />

Teresa Towne Dover (17)<br />

Renewing Members, 21-29 Years<br />

Donna Draper Newark (25)<br />

Eliza Farrow Newark (24)<br />

Cynthia Reid New Castle (21)<br />

Dorothy Baker Delmar (23)<br />

Jane Kurz Milton (24)<br />

Sheila Bryson-Eckroade Hockessin (23)<br />

Donna Mower Wade Middletown (22)<br />

Sandra Nolan New Castle (28)<br />

Kathleen Wood Stuart, FL (24)<br />

Judith Hertz Camden (24)<br />

Donna Merrill Hockessin (26)<br />

Darlene Annas Lewes (22)<br />

Louisa Phillips Dover (24)<br />

Patricia Yancey Middletown (25)<br />

Yvonne Wesley Smyrna (24)<br />

Renewing Members, 30 Years!<br />

Doris Adkins Naples, FL (30)<br />

Margaret Strong Millville (30)<br />

Patricia Gagnon Newark (30)<br />

Bethany Hall-Long Middletown (30)<br />

Marianne Tallman Hockessin (30)

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