DNA Reporter - December 2021





Volume 47 • Issue 1

December 2021, January, February 2022

Inside This Issue

The mission of the Delaware Nurses Association is to improve healthcare in Delaware by the advancement

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

Guest Editor

End of Life Care Considerations in

Palliative Care and Death with Dignity

Joint Policy Statement Adopted by

the Delaware Nurses Association


Delaware LPN Leadership


Suzette M. Flores, DNP, BSW, APRN, NP-C

Dr. Suzette Flores is currently

an inpatient palliative care

consultant at Bayhealth Sussex

Campus Hospital. Dr. Flores

has over 30 years of healthcare

experience in the areas of

social work, geriatric psychiatry,

neurosurgery, cardiology, long

term care, and palliative care.

She is board certified in adult

care by the American Academy

of Nurse Practitioners (AANP).

She earned a Bachelor’s Degree

in Social Work from Michigan Suzette M. Flores

State University (MSU), a Bachelor’s Degree of Nursing from the

University of Delaware (U of D), a Master’s Degree of Science

in Nursing and a Doctorate Degree of Nursing Practice from

Thomas Jefferson University (TJU). Dr. Flores has membership

with the Delaware Medical Reserve Corps, Delta Gamma

Sorority, Alpha Eta Society-Thomas Jefferson University,

Sigma Theta Tau International Society of Nursing-Delta Rho

Chapter, on the Delaware Nurses Association (DNA) Advocacy

Committee, on the Delaware Cultural Advisory Committee,

and has been involved ongoing with the Delaware Coalition of

Nurse Practitioners (DCNP). She currently serves as Chair of the

Nominating Committee for the DCNP. Dr. Flores is the recipient

of the 2019 AANP Advocate State Award for Excellence. Dr.

Flores may be reached at suzette_flores@bayhealth.org.

Having worked in palliative care, end of life discussions

and end of life care planning can be difficult and

uncomfortable for patients and their families, as well as for

healthcare providers with preparation, let alone without

preparation. All too often, patients and their families do

not think about death and dying until they are confronted

with that possibility.

Death with Dignity is a topic to be considered in our

fast paced technologically evolving medical environments

in which we may be able to keep ourselves going for

prolonged periods of time. Prolongation of life may not

come with improvement in health, and it may not lead to

improvement in our quality of life, although it may be life


Every death experience is unique to a person and their

family. What would constitute a good death experience

for you? What would dignity at the end of your life look

like? What would be most important to you at this time?

According to the Institute of Medicine (1997), a good

death is “one that is free from avoidable distress and

suffering, for patients, family, and caregivers; in general

accord with the patients’ and families’ wishes; and

reasonably consistent with clinical, cultural, and ethical

standards” (p. 24).

Traditionally, it was the patient’s physician who

determined what end of life care should look like. This

trend has since shifted to give patient’s autonomy or selfdetermination

to direct their own medical treatments in

end of life care. The concept of self-determination or Death

with Dignity is that a terminally ill patient should determine

their own end-of-life decisions and determine how much

pain and suffering they should endure based upon their

personal beliefs and values, and what a good death may

mean to them (“Death with Dignity Acts,” n.d.).

In Delaware, Title 16, Health and Safety, Regulatory

Provisions Concerning Public Health, Chapter 25.

Health-Care Decisions, section 2502, the right of selfdetermination

states that “any legal adult, who is mentally

competent has the right to refuse medical or surgical

treatment if such refusal is not contrary to public law”

(“The Delaware Code Online,” n.d.).

The legal rights to self-determination in Delaware, may

be expressed as cognizant decisions to forgo or not initiate

life-saving treatments. In my inpatient hospital practice,

discussions center around the risk versus benefit of

Guest Editor continued on page 4


current resident or

Presort Standard

US Postage


Permit #14

Princeton, MN


Meet the 2022 DNA Board of Directors.................. 2

Executive Director’s Report.............................. 3

COVID-19 Pandemic Through the Lens

of an Inpatient Palliative Medicine Provider............. 6

Community-Based Palliative Care:

High Quality and Cost Effective........................ 7

Palliative Care: Including Nursing in Early Intervention... 8

Non-beneficial Treatment at the End of Life............. 9

Using Respiratory Distress Observation

Scale (RDOS) at End-of-Life..........................10-11

Policy Statement on Dissemination

of Non-Scientific and Misleading

COVID-19 Information by Nurses ...................... 11

Results of Delaware Nursing Dialogue –

Advocacy Prioritization................................ 12

Retirement Readiness Checklist........................ 12

Delaware Licensed Practical Nurse Leadership......... 13

Documenting nursing assessments

in the age of EHRs ...................................14-15

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

Page 2 • DNA Reporter December 2021, January, February 2022



of the

Delaware Nurses Association

4765 Ogletown-Stanton Road, Suite L10

Newark, DE 19713

Phone: 302-733-5880

Web: http://www.denurses.org

The DNA Reporter, (ISSN-0418-5412) is published quarterly every

March, June, September and December by the Arthur L. Davis

Publishing Agency, Inc., for the Delaware Nurses Association,

a constituent member association of the American Nurses



President: Leslie Verucci, , MSN, APRN, ANP-BC

President-Elect: Stephanie McClellan, MBA,


Secretary: Jacqueline C. Armstrong, DNP,


Treasurer: George Zangaro, PhD, RN, FAAN

Director-at-Large, Clinical Nurse: Ramona Negron, BSN, RN


Membership Growth Directors

New Castle County: Kathy Neal, PhD, RN

Kent County: Sharon Mills-Wisneski, PhD, RN

Sussex County: Candace Hamner, MA, BA, RN

Professional Development Director

Sandra Nolan, PhD, RN, HN-BC

Advocacy Director

Annamarie Flick, MSN, RN-BC, NE-BC

Editorial Director

Karen Panunto, EdD, MSN, RN


Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN



Oncology Nursing Society-Delaware Diamond Chapter


Delaware Organization of Nurse Leaders


Delaware Emergency Nurses Association


Delaware State Affiliate of the American College of Nurse-Midwives


Delaware Coalition of Nurse Practitioners


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from purchase or use of an advertiser’s product. Articles appearing

in this publication express the opinions of the authors; they do not

necessarily reflect views of the staff, board, or membership of DNA or

those of the national or local associations.

Editorial Director

Karen L. Panunto, Ed.D, MSN, RN

The DNA Reporter welcomes unsolicited manuscripts by DNA

members. Articles are submitted for the exclusive use of The DNA

Reporter. All submitted articles must be original, not having been

published before, and not under consideration for publication

elsewhere. Submissions will be acknowledged by e-mail or a selfaddressed

stamped envelope provided by the author. All articles

require a cover letter requesting consideration for publication. Articles

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

PCCN, CCRN at executivedirector@denurses.org

Each article should be prefaced with the title, author(s) names,

educational degrees, certification or other licenses, current position,

and how the position or personal experiences relate to the topic of

the article. Include affiliations. Manuscripts should not exceed five (5)

typewritten pages and include APA format. Also include the author’s

mailing address, telephone number where messages may be left,

and fax number. Authors are responsible for obtaining permission to

use any copyrighted material; in the case of an institution, permission

must be obtained from the administrator in writing before publication.

All articles will be peer-reviewed and edited as necessary for content,

style, clarity, grammar and spelling. While student submissions are

greatly sought and appreciated, no articles will be accepted for the sole

purpose of fulfilling any course requirements. It is the policy of DNA

Reporter not to provide monetary compensation for articles.

December 2021, January, February 2022 DNA Reporter • Page 3

Executive Director’s Report

Christopher E. Otto, MSN, RN, CHFN, PCCN, CCRN

Executive Director


or 302-733-5880

The meaningful recognition of

nurses is a heavily researched area

of nursing practice with several

notable outcome improvements

when successfully applied to

professional practice settings.

The American Association of

Critical-care Nurses’ framework

for healthy work environments

includes meaningful recognition

and defines it as, “Nurses

Christopher E. Otto

must be recognized and must

recognize others for the value each brings to the work of

the organization” (American Association of Critical-care

Nurses, 2021). Meaningful recognition can decrease nurse

burnout and increase compassion satisfaction for nurses

(Kelly & Lefton, 2017). Additionally, meaningful recognition

increases the nurses’ self-perception, pride, and often

reconnects nurses with their “why” (Lefton, 2014).

Recognizing nurses includes all nurses, Licensed

Practical, Registered, and Advanced Practice Registered

Nurses. Research supports the positive impact of

meaningful recognition for Licensed Practical Nurses by

reducing burnout (Kim et al., 2020). The Delaware Nurses

Association has provided recognition for Delaware’s nurses

for decades and continues to evolve existing programs.

We believe in the power of nurse recognition to combat

burnout, increase professional role satisfaction, and

promote a positive image of nursing. Recognizing nurses

at the state level facilitates increased public awareness and

perception of the unique contributions, qualifications, and

service nurses make. By recognizing nurses statewide, the

Delaware Nurses Association can uplift the characteristics

of exceptional nurses and further define the essence of our

profession. On behalf of the Delaware Nurses Association

Board of Directors, I am proud to share the following

evolving advancements for statewide nurse recognition.

Joint Committee on Nursing Recognition

In partnership with our organizational affiliate, the

Delaware Organization for Nursing Leadership, we

established a Joint Committee on Nursing Recognition

to expand, implement, and evolve statewide nursing

recognition programs and partnerships. The newly

forming committee comprises 13 voting, volunteer

members that represent all three nursing licensure levels

and Delaware counties. Additionally, volunteer members

come from numerous practice settings including academia,

private practice, schools, the state, hospitals, and more.

Partnerships and broad nursing representation set this

committee up for success in providing meaningful

statewide recognition. The committee will begin meeting

monthly after the new year.

Delaware Today Top Nurses

The Delaware Nurses Association has partnered with

Delaware Today Media to recognize Delaware’s Top

Nurses for nine years. Starting in 2013, the program has

now grown to recognize all Delaware nurses. Voting is

conducted November-January annually and winners are

selected by a panel of peers, now the Joint Committee

on Nursing Recognition. Every Delaware nurse is eligible

to nominate and be nominated. This is a statewide peer

recognition program, so only nurses may nominate.

Winners and honorees are recognized annually during

May to coincide with nurse’s week. They are provided

recognition in the May edition of Delaware Today and with

a sponsored reception. Nominations for 2022 Delaware

Today Top Nurses are accepted until January 3, 2022.

The DAISY Foundation

The DAISY Foundation is an established and highly

recognized non-profit that exists solely to recognize

nurses for their extraordinary compassion and skill. They

deliver meaningful recognition internationally and across

the nation. Numerous international, national, and state

Celebrating Delaware’s Nurses

associations support The DAISY Foundation and their

incredible work. The Delaware Nurses Association and

Delaware Organization for Nursing Leadership, with the

generous support of Rhoades & Morrow LLC, is proud

to become the first state nursing association to partner

directly and provide DAISY awards to nurses.

There are several existing DAISY-partner organizations

in Delaware: Bayhealth, Beebe Healthcare, ChristianaCare,

Encompass Health, Nemours, Silver Lining Healthcare,

St. Francis Hospital, and University of Delaware. Nurses

working for one of the above employers are already and

remain eligible to be nominated and recognized by their

employers. This new partnership does not change existing

programs; any nominations received at the DNA for a

nurse working at an existing partner will be forwarded to

that DAISY coordinator. The Delaware Nurses Association

encourages all eligible nurse employers/organizations to

partner directly with The DAISY Foundation to recognize

as many extraordinary nurses as possible.

Our mission at the Delaware Nurses Association and

Delaware Organization for Nursing Leadership is to provide

extraordinary nurses with this prestigious recognition.

Whether you work in a school, prison, public health, private

practice, medical aid unit, surgery center, etc., you are now

eligible to become a DAISY honoree. We will work with

local media, members, partners, schools, and employers

to raise awareness of this program and exponentially grow

nominations. Patients, families, colleagues, nurses, leaders,

and all are encouraged to submit nominations for their

extraordinary nurses. The nomination form is live and can

be accessed at http://www.daisynomination.org/DNA.

Because of the generous support of Rhoades & Morrow

LLC, we will be offering nurse employers free posters and

window clings (in addition to online, self-print materials) to

place in their practice settings to increase awareness and

nominations for this honor.

The nominations will be blinded and reviewed by the

Joint Committee on Nursing Recognition and honorees

selected for various categories (direct care nurse, team,

leader, lifetime achievement, health equity, faculty, and

students). Honorees will be vetted, approved, and presented

with their recognition during a surprise presentation at

their practice setting. Becoming a DAISY honoree provides

nurses with pride, gratitude, and a plethora of benefits

and continued opportunities. Speaking personally, it is

still a career highlight when I and my colleagues in the

Cardiovascular Critical Care Complex were presented with a

DAISY Team Award in June 2018. We were nominated by

the family of a patient we cared for, and it remains one of

my most cherished nursing memories.

We are humbled and excited to bring this

meaningful recognition to all Delaware nurses and

continue building the legacy and history of both

The DAISY Foundation and the profession of


Additional Specialized Awards and More

Another focus of the Joint Committee on Nursing

Recognition will be to uplift and celebrate Delaware’s

notable nurses that contributed to the profession here

and nationally. The committee will explore custom awards

named after Delaware’s most influential and noted nurses.

These awards will continue to uplift and celebrate nurse

contributions in specific areas of the profession, such as

advanced practice leadership and government relations/

advocacy. We will also partner with our organizational

affiliates, state specialty nursing associations, to generate

awards for the many nursing practice specialties and elevate

exceptional nurses from all areas of the profession.

Just because the committee has already been selected

doesn’t mean you can’t contribute. Through Delaware

Nursing Dialogue, social media, and other communications

the joint committee will be engaging all nurses in defining,

promoting, and providing meaningful statewide nurse

recognition. Why not start now? Have an idea? Send

it to us using email, contactdna@denurses.org. On this

topic, and all matters affecting Delaware nurses, we are

continuously open to your feedback and suggestions.

We are excited to bring these advancements forward

for Delaware’s nurses. The volunteerism and generosity

of members, organizational affiliates, and partners is

what makes these programs possible. Membership is

not required to be nominated, to nominate, or to be

recognized; however, we hope you will consider sharing

your support in the best way possible – become a DNA

member. With a large, diverse, and continuously growing

membership, DNA can bring Delaware nurses more value,

advocacy, solutions, and more.


American Association of Critical-care Nurses. (2021). Meaningful

Recognition. Retrieved from https://www.aacn.org/


Kelly, L. A. & Lefton, C. (2017). Effect of meaningful recognition

on critical care nurses’ compassion fatigue. American Journal

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

Kim, L. Y., Rose, D. E., Ganz, D. A., Giannitrapani, K. F., Yano, E.

M., Rubenstein, L. V., & Stockdale, S. E. (2020). Elements of

the healthy work environment associated with lower primary

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


Lefton, C. (2014). Beyond thank you: The powerful reach of

meaningful recognition. American Nurse. Retrieved from


Page 4 • DNA Reporter December 2021, January, February 2022

Guest Editor continued from page 1

treatment options and willingness to pursue or not pursue.

How a patient understands their choices influences the

care they receive in end of life care, and options should be

well laid out to our patients for informed decision making.

Treatment decisions in end of life care include

resuscitation in the form of CPR or intubation, palliative

sedation for intractable pain, refusal of artificial nutrition

and hydration via tube, refusal of life saving surgery,

refusal of blood products, refusal of antibiotics, refusal

of chemotherapy or radiation therapy, and refusal for

initiation of or stopping of hemodialysis. These decisions

to stop or not initiate treatments generally result in a

death that would have naturally occurred without the

intervention of medicine.

I have observed that patients nearing the end of

their life may make decisions to continue treatments

inconsistent with their personal preferences based

upon lack of information regarding the impact on their

healthcare outcomes. This unwanted care has led to

increased psychological distress and increased utilization

of health care resources that may offer little therapeutic

benefit or impact on quality of life and may leave their

loved ones without the ability to have closure.

In 1997, Oregon was the first state to legalize aid

in dying. Since that time, Washington, D.C, California,

Colorado, Hawaii, Maine, New Jersey, Vermont,

Washington, and most recently in 2021, New Mexico

has followed suite. Although Montana does not have a

dedicated law, in 2009, its supreme court supported that

nothing in Montana’s State Law prohibited a physician

from honoring the wishes of a competent terminally ill

adult to be able to hasten their death. Only New Jersey

and Hawaii currently allow nurse practitioners to prescribe

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

Death with Dignity is the underlying concept of

Delaware’s House Bill 140 (HB140), with Representative

Paul S. Baumbach as the primary bill sponsor. This 2021,

the Delaware Death with Dignity Act, HB 140, was

assigned to the House Health & Human Development

Committee on the final day of the session, just before

the Delaware General Assembly adjourned (“Death with

Dignity Delaware,” n.d.).

House Bill 140 would allow another option in end

of life care, and would permit a terminally ill patient

with six months or less life expectancy who is an adult

resident of Delaware (age 18 and above) to request and

self-administer medication to end the individual’s life in

a humane and dignified manner if both the individual’s

attending physician/advanced practice registered nurse

(APRN) and a consulting physician/advanced practice

registered nurse (APRN) agree on the individual’s diagnosis

and prognosis and believe the individual has decision

making capacity, is making an informed decision, and is

acting voluntarily (“Delaware General Assembly,” n.d.,

House Bill 140). House Bill 140 has safeguards built in to

protect the public and providers when considering this as

an option. It would be up to the healthcare institution and

individual practitioner to consider and decide how they

would respond to HB140 based on legal, ethical, moral,

and personal values.

The American Nurses Association (ANA, 2019) as

cited in the ANA Position Statement, stated the hallmarks

of end-of-life care include respect for patient selfdetermination,

nonjudgmental support for patients’

end-of-life preferences and values, and prevention and

alleviation of suffering. Death with Dignity should be

viewed as medical aid to those dying with a terminal illness

(OJIN, 2019). It is not considered suicide, assisted suicide,

homicide, or euthanasia, and would offer another option

in end of life care planning to existing hospice care and

comfort care provided under palliative care. The ANA

2019 position statement recommends that nurses have

knowledge on the current environment for medical aid

in dying and remain objective if patients wish to discuss

medical aid in dying, thus preserving self-autonomy and

dignity in making end of life health care decisions (OJIN,


States that have Death with Dignity Laws provide

another option suited to meet end of life preferences

in those suffering with a terminal illness. The role of the

nurse is to listen, to be an advocate for their patient’s

needs, and to ensure continuation of care based on the

patient’s personal preferences. Only our patients can state

their wishes for their end of life care planning and tell us if

medical aid in dying would be in their best interest.

This edition of the DNA Reporter is focused on how

palliative care may improve quality of life and preserve

dignity in end of life care. The first step is to recognize

the need to have end of life care discussions to share

our thoughts on how we want to spend our final days

and to revisit one’s medical wishes as health changes.

Heather Milea, MSN, FNP-BC, AGACNP-BC, PCCN,

CHFN, highlights how the Covid epidemic impacted

patient’s quality of life in end of life care. Ginna Keil,

MSN, FNP-BC demonstrates how community palliative

care is high quality and cost effective when shifting the

focus from active disease treatment to comfort care.

LaTonya Mann, DNP, FNP-BC, OCN discusses that early

intervention of palliative care with the assistance of

nursing leads to a better quality of life for those living

with cancer. Kiernan Quay, DNP, APRN, FNP-C relays

that non beneficial treatment in end of life care may not

equate with quality of life. Karin Cooney-Newton, MSN,

RN, APRN, ACCNS-AG, CCRN presents an effective

objective tool for end of life care that can promote

comfort and alleviate suffering for patients and their

families in end of life care.


ANA Position Statement: The nurse’s role when a patient

requests medical aid in dying. (2019). OJIN: The Online

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


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


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


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

death-with-dignity-acts Retrieved 8/11/2021.

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

delaware.gov/BillDetail?LegislationId=79026 Retrieved


Institute of Medicine. (1997). Approaching death: Improving care

at the end of life. Washington,D.C: National Academy Press.

The Delaware Code Online (n.d). Title 16 Health and Safety,

Regulatory Provisions Concerning Public Health Chapter

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

delaware.gov/title16/c025/ accessed 7/1/2021.

December 2021, January, February 2022 DNA Reporter • Page 5

Page 6 • DNA Reporter December 2021, January, February 2022

COVID-19 Pandemic Through the Lens of an Inpatient Palliative Medicine Provider


Heather M. Milea is currently a nurse practitioner on the palliative

care team at Christiana Care Hospital where she has worked for

over twenty years with an acumen in family medicine, advanced

heart failure, and cardiology. She is a graduate of the University of

Delaware’s undergraduate baccalaureate nursing program and Master

of Science in Nursing program with a concentration in family nurse

practitioner. She completed a post-master’s graduate degree at the

University of Pennsylvania in adult gerontology acute care. Heather

has been recognized as one of the 2021 top nurse practitioners by

Delaware Today, is a member of the Delaware Coalition for Nurse

Practitioners, and serves on the palliative team wellness committee

and transition team at Christiana Care Hospital. Heather may be

reached at hmilea@christianacare.org.

Heather M. Milea

The COVID-19 pandemic systemically obstructed the delivery of traditional

healthcare, particularly impacting our chronically ill and frail patients. Healthcare

delivery for the hospitalized, critically ill COVID-19 cohort was challenging because

of the complex symptom management, rapid physical decline, high mortality,

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

Delaware, this problem was further aggravated as our healthcare organizations

followed the isolation strategies established by other institutions: significant

restrictions in visitation, limiting the flow of providers in and out of rooms, and

segmenting COVID-19 patients from other patient populations. Despite the obvious

public health need to reduce transmission of the respiratory pathogen, an illconsidered

byproduct was the social isolation, severing our instinct to be present

with loved ones during a serious illness. With the isolation increasing our patients’

suffering and our efforts to provide holistic care frustrated, care delivery models

had to be radically revised as the palliative medicine team innovated and tested our

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


Palliative Medicine During a Pandemic

Palliative medicine providers are holistic by virtue of the discipline. Through

disease counseling and goals of care for acute, chronic, or traumatic health

problems, palliative medicine’s foundational ethos is to improve quality of life

both inside and outside the biomedical realm, as well as reduce the burden of

symptoms related to disease states. The diverse team of inpatient palliative care

service providers including physicians, nurse practitioners, physician assistants,

social workers, nurse navigators, and palliative chaplains collaborate to add

robust, holistic care. Communication prowess is one of the revered skillsets among

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

Health Organization’s (WHO) 2018 ethical principles in humanitarian contexts

strongly advocate for access to palliative care to minimize suffering and, by the

United Nations International Health Regulations’ own definition of “public health

emergency of international concern,” the COVID-19 pandemic would most certainly


As the pandemic disintegrated traditional healthcare delivery, inpatient palliative

care consults for COVID-19 patients surged. Among the significant symptom burden

of a hospitalized COVID-19 patients, anxiety and loneliness may be among the

most hidden and difficult to resolve, even in optimal healthcare scenarios. In an

environment where care teams and resources were burdened, and intensivists and

nurses occupied the limited bedside to provide care, the palliative medicine team

had to reinvent how to expedite care for this vulnerable, often frail, population. That

revitalized care model was discovered in what originally gave our team strength: our

multidisciplinary teamwork.

Multidisciplinary Palliative Medicine Team and Virtual Management

To bridge the gap of visitor restrictions, our team implemented off-the-shelf,

consumer technology (i.e., iPads) equipped with videoconferencing platforms

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

inpatient visits, allowing for high-touch care in limited-touch environments. Trained,

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medical language translation specialists and cultural consults were brought on to

provide culturally competent care. The palliative medicine team now had an option

to facilitate our exacting, rapport-dependent care for our patients and family,

extending our ability to supply support and connection.

Unfortunately, despite institutional support for the technology program,

family stakeholders did not have universal access to platforms for virtual

visits, forcing many difficult conversations to take place via telephone. In this

context, the absence of important, nonverbal cues diminished the quality

of interaction, especially regarding difficult, end-of-life communications.

Vulnerable stakeholders had to trust a medical team to help with emotionally

overwrought decisions without the comfort of connecting to their loved ones.

Serious Conversations

“Ordinary” critically ill scenarios can limit time to have meaningful

healthcare conversations on the values and wishes of the patient. The often

precipitous decline that can happen with COVID-19 hospitalized patients

further compacted the time to prepare patients and their care circle. Often,

that involved standing outside an ICU room of a COVID-19 patient struggling

with fear, providing through the glass a calm voice of comfort, an ear to

listen, or a provider who could treat symptoms of air hunger, anxiety, or even


The palliative medicine team elected to implement best practices from

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

organization for clinicians, encouraged early and clear communication, as

well as exploring patient goals and making care recommendations based

on those stated goals. For the team, discussions with the patient and their

support system regarding prior advance care planning documents, anticipatory

guidance of swift clinical deterioration, and code status ensued immediately

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

to survive the acute phase of their inflammatory-related respiratory failure,

the palliative medicine team counselled patients on the trajectory of the longterm

sequalae of COVID-19, including fibrotic lung disease, coagulopathies,

cardiomyopathies, debility, and failure to thrive. The work was a delicate

balance of active listening and support to spouses, children, and care circles

physically separated from their sick family members. For patients that passed

without a loved one near, our nurses held their hands.

End-of-life Care for COVID-19 Patients Amidst a Global Pandemic

Suffering, end-of-life COVID-19 patients are most treated for dyspnea,

restlessness, anxiety, and delirium, along with significant spiritual and

psychosocial needs. Dyspnea and delirium are among the most common

symptoms in dying patients with COVID-19 and, despite attempts at managing

underlying cause of dyspnea, refractory dyspnea and hypoxia may persist

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

crisis protocols for managing common symptoms associated with COVID-19,

which our team follows. Opioids are the treatment choice for refractory

dyspnea and as-needed dosing is safer and more effective compared to an

opioid infusion. Non-pharmacologic interventions include sitting the patient

in either an upright or, in some instances, prone position. The decision in

favor of COVID-19 ventilation focuses on limiting lung damage and mitigating

aerosolization of the virus. In circumstances where continuing aggressive

care was futile or where goals of care dictated de-escalating or withdrawing

ventilation support, the ICU and palliative teams initiate end-of-life discussions

to guide a compassionate withdrawal of care with an emphasis on a dignified

passing. Preparing the family is imperative; expectations, suggestions, and

exploration of their concerns are important to ameliorate prior to withdrawal

of care. Hospice resources for family and their care circle is robust, not only

during their hospice care, but also in bereavement support that extends after

their loved one’s passing.

The palliative team’s principle is to provide physical, spiritual, and

psychosocial comfort for our patients and their extended care circle. During

the COVID-19 pandemic, the collaboration with primary and specialty services

complimented the front-line workers who were brave enough to support our

community. Moreover, just as we do for patients, the palliative medicine team

offers safe haven to support colleagues without prejudice. There have been

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

collective and complicated grief that we have not yet begun to unpack.


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


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

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


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

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

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

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

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

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


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

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

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


December 2021, January, February 2022 DNA Reporter • Page 7

Community-Based Palliative Care: High Quality and Cost Effective

Ginna Keil, MSN, FNP-BC

Ginna Keil earned her Associate of Arts Degree in General

Studies in 2002 followed by her Associates of Science Degree

in Nursing in 2006 from Wor-Wic Community College.

Ginna was a registered nurse in the State of Maryland

and Delaware for 13 years with nursing experience in the

emergency department, women and children’s health,

and neonatal intensive care settings. Ginna furthered her

education by receiving her Bachelor of Science Degree in

Nursing and graduated with her Master of Science Degree

in Nursing from Wilmington University in 2018. Certified

by the American Academy of Nurse Practitioners, Ginna

practices as a Family Nurse Practitioner in the State of

Delaware. Ginna currently is employed with Delaware

Hospice and provides Palliative and Hospice services in the Ginna Keil

community setting. Professional achievements include member of the Phi Theta

Kappa-Honor Society, Daisy Award Recipient, Maternal Child Award, Nursing Service

Excellence Awards, and Delaware Hospice Star Award. Ginna may be reached at


Widely known among healthcare providers are the challenges today’s

Healthcare system face secondary to an expanding aging population who

suffer serious illness compounded by multiple medical comorbidities.

According to data provided by the Center to Advance Palliative Care (CAPC,

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

States living with a serious illness and by the year 2030, people aged 85

and over are expected to double to 8.5 million. The Delaware Healthcare

Association (DHA, 2019) reported that emphasis on disease specific treatments

have become commonplace rather than holistic treatment that addresses

the needs of patients and their caregivers. In many cases, this focus has

led to fragmented and burdensome care with inadequate management of

symptoms resulting in unnecessary suffering. It is, therefore, a system that

is unsustainable in terms of poor quality and high cost. The question then

becomes, ‘how does the Healthcare system meet the needs of this growing

population while still delivering high quality and financially sustainable care?’

(CAPC, 2015).

A potential solution may lie in the specialty of palliative care medicine which

has been growing in popularity globally over the last two decades. What is

palliative care? With a unique holistic approach that is both patient and

family centered, the Center to Advance Palliative Care (2019) explained that

the design of palliative care is to anticipate, prevent, and manage physical,

spiritual, social, and psychological aspects of health and improve the quality

of life for patients, families, and caregivers throughout their illness trajectory.

Furthermore, based on patient need rather than diagnosis, any individual

regardless of age who are diagnosed with a serious illness may receive

palliative care services alongside curative treatment. Although services may

be initiated at any stage of the illness trajectory, implementation in the early

stages of the disease process have resulted in improved patient care outcomes.

As leaders in healthcare recognize the impact that cost effective and

high-quality palliative care have on patients, caregivers and healthcare

organizations, services are now available in 94% of hospitals with more than

300 beds and available in 72% of hospitals with more than 50 beds (Center

to Advance Palliative Care, n.d.). Inpatient palliative care consultation is

associated with a reduction in healthcare costs with a total savings of more

than $1.3 million for a 300-bed community hospital and more than $2.5

million for the average academic medical center (Cruz-Oliver, 2017).

Expansion of palliative services is a Healthcare necessity and should be

offered on every level and across all settings in efforts to meet the many

needs of Americans living with serious illness compounded by multiple medical

comorbidities (CAPC, 2021). Hospitals and health systems are now extending

palliative services into community settings including but not limited to

physician offices, ambulatory clinics, cancer centers, skilled nursing facilities,

and patient homes. In addition to hospitals and health systems, service

delivery is provided by primary care physicians, specialty practices, private

companies, home health aid agencies, and hospices (CAPC, n.d.). Palliative

care is multidisciplinary and includes a team of dedicated medical, nursing, and

allied health professionals. The comprehensive role of the palliative care team

throughout the trajectory of the patient’s illness includes but is not limited to

expert pain and complex symptom management, provision of psychological,

spiritual, and emotional support, medication management and monitoring,

and the completion of advance health directives. The palliative care team

works collaboratively with specialists in the community that allows for

coordination of care. As the trajectory of illness progresses, locations as well

as wishes of the patient and their caregivers may change. Community based

palliative care allows for consistency across transitions (CAPC, 2021).

Community based palliative care allows for a reach to patient populations

that neither fit hospice eligibility nor are hospitalized and are stable enough to

reside in the community setting. Many individuals suffering from serious illness

and chronic medical conditions experience mobility issues with functional

limitations that do not allow travel to office settings or are burdensome.

Often, it is the preference of many individuals suffering from chronic medical

conditions to remain at home while coping with their serious illness.

The National Coalition for Hospice and Palliative Care (NCHPC, 2018)

explained that with disease progression, the emphasis shifts from active

treatment of the disease to treatment that promotes comfort with an improved

quality of life. Anticipatory guidance is provided regarding disease process,

progression, and strategies for management in efforts to optimize quality

of life. They further explained that palliative care providers facilitate patient

autonomy, by providing access to information and choice regarding their care.

Palliative care in the home setting promotes the development of a trusting

rapport and fosters feelings of support and connectivity. This allows for

sensitive conversations of how individual values, preferences, ethnicity, culture,

and spiritual beliefs play a role in their healthcare (NCHPC, 2018).

The Center to Advance Palliative Care, (2021) recognizes that there is strong

evidence that implementation of community based palliative care services

results in compassionate, affordable, sustainable high-quality care, and is

associated with reduced nonbeneficial emergency department visits and

hospitalizations. Reduced hospital readmissions may lead to reduced penalties

for hospitalized patients with serious chronic illnesses.

Where do hospitals in the State of Delaware stand regarding equitable

access to palliative care services? Delaware Healthcare Association (DHA, 2019)

President & CEO Wayne A. Smith stated, “Delaware hospitals are proud to

lead the nation in providing access to quality palliative care for our friends and

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

providing individuals living with a serious illness equitable access to palliative

care services according to the 2019 State-by-State Report Card on Access

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

palliative care services promotes the high quality and financially sustainable

care needed to meet the physical, spiritual, social, and psychological needs of

patients and their caregivers who suffer serious illness. Leaders in Healthcare

nationwide must strive to integrate palliative care medicine into healthcare

systems and ensure that patients from all populations and across all settings

receive this invaluable service.


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

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

Center to Advance Palliative Care. (2021). Concepts of community-based palliative care

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

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

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


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

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


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

Delaware Healthcare Association. (2019). Delaware receives top “A” grade on access

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


National Coalition for Hospice and Palliative Care. (2018). National Consensus Project

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

Injury Attorneys

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Page 8 • DNA Reporter December 2021, January, February 2022

Palliative Care: Including Nursing in Early Intervention

LaTonya E. Mann, DNP, FNP-BC, OCN

Dr. Latonya Mann earned

her Licensed Practical Nurse

degree from Salem Community

College, Associate Degree in

Nursing from Gloucester County

College, Bachelors in Nursing

from Immaculata University,

Master’s Degree from University

of Delaware, and Doctorate in

Nursing Practice from Wilmington

University. She is a board certified

Family Nurse Practitioner. Dr.

Mann is Past President for

Delaware Diamond Chapter LaTonya E. Mann

of Oncology Nursing Society and a member of the Delaware

Nurses Association, Delaware Coalition of Nurse Practitioners,

and Sigma Theta Tau International Honor Society of Nursing.

Dr. Mann brings over 35 years of experience in various

settings of nursing including medical-surgical, intensive care,

home infusion therapy, palliative care, and oncology nursing.

She presently works as a Nurse Practitioner with the Medical

Oncology team at Bayhealth Cancer Center. Dr. Mann may be

reached at LaTonya_Mann@bayhealth.org

The Center of Advanced Palliative Care (CAPC, 2021)

defines palliative care as:

Specialized medical care for people living with a serious

illness. This type of care is focused on providing relief

from the symptoms and stress of the illness. The goal

is to improve quality of life for both the patient and the

family. Palliative care is provided by a specially-trained

team of doctors, nurses and other specialists who work

together with a patient’s other doctors to provide an

extra layer of support. Palliative care is based on the

needs of the patient, not on the patient’s prognosis. It

is appropriate at any age and at any stage in a serious

illness, and it can be provided along with curative

treatment. (para. 2)

Palliative care teams work alongside a patient’s team

of specialists to provide symptom and communication

expertise, emotional support, assistance with medical

decision making, and assistance with end-of-life care and

bereavement support when appropriate (Finn et al., 2017).

Palliative care can be provided in a variety of settings,

including inpatient hospital consultation, outpatient

clinics, assisted living and long-term care facilities, and

even home-based care. The most familiar mode of

palliative medicine delivery is inpatient-based services

that may involve a single practitioner or a consultant

palliative care medicine team. These medical providers

are available throughout the entire hospital setting, from

Vacancy Announcement

Adjuncts and Part-time Teaching Positions

Department of Nursing

Wesley College of Health & Behavioral Sciences

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

newborn nursing, medical/surgical nursing, mental health nursing, child

and family nursing, community and/or public health nursing.

Full time faculty positions-Clinical Practitioner, Maternal/Newborn

Nursing Faculty, Medical/Surgical Nursing Faculty, Mental Health Nursing

Faculty, Child and Family Nursing Faculty.

Full time Staff positions-Skills Lab Coordinator-


• Delaware State University Masters of Science in Nursing with a focus

on the area applying for

• Current unencumbered RN license in the state of Delaware

• Current clinical nursing experience

• Teaching experience in higher education preferred

• Simulation experience preferred

Special Instructions: Interested applicants must apply online at DSU

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

curriculum vitae and three (3) professional references with contact


Apply for this posting only if you are interested AND qualified for the

position in the Department of Nursing. It is important that you specify

your area of clinical expertise and interest in your cover letter in order to

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

DSU is an equal opportunity, Title IX Employer and does not discriminate against persons

on the basis of race, religion, national origin, sexual orientation, gender, marital status,

age or disability.

the emergency department and intensive care unit to a

rehabilitation unit if appropriate (Thomas et al., 2019).

Early Integration

Although there are current guidelines to advocate

early integration of palliative care and research that show

its benefits, there are several barriers to palliative care

referrals. The most common is the misperception that

palliative care is only associated with end of life. However,

most patients accept palliative care intervention without

a loss of hope. The ENABLE and ENABLE II studies

showed decreased depression in patients who received

palliative care, providing evidence that palliative medicine

consultations should not be postponed until failure of

therapy, symptom crisis, or end of life (Thomas et al.,


As healthcare providers, nurses struggle every

day on what words to choose to deliver bad news to

patients. Many providers wrestle with how to begin the

conversation and knowing the appropriate time to discuss

prognosis. Many have little training on how to deal with

the patient and caregiver emotions. This is due to the

limited training and education in palliative care. According

to Sedhom et al. (2020), oncologists give bad news to

patients an average of 35 times a month, yet few have

training or mentorship in communication skills. Oncologists

are more medicine oriented and fellows report receiving

more coaching on how to perform bone marrow biopsies,

a technical skill, than on how to conduct a family meeting.

Word choice may feel trivial compared with the plethora of

other things that need to be learned. Yet, words influence

medical decision making and have implications for patient

care (Sedhom et al., 2020).

Nursing in Early Intervention

Nursing is a profession within healthcare focused on

the care of individuals, families, and communities so they

may attain, maintain, or recover optimal health and quality

of life. For the fifteenth consecutive year, the Gallup poll

has ranked nursing as the most trusted profession, and

nurses as the professionals who uphold the highest ethical

obligations in establishing community relationships of trust

according to society needs and desires.

Nurses look after patient’s most intimate needs

during their most vulnerable times, and they do so with

compassion. While it is the provider who manages the

overall treatment plan, nurses are the ones who carry it

out. It is the nurse ninety-nine per cent of the time that the

patient and family members interact with in the hospital

setting. Patients know when they call for help, it is their

nurse who will carry out their needs with compassion.

Nurses draw on this trust by advocating for their patient’s

healthcare needs. Patients are more likely to listen to the

advice of their nurse and trust they will advocate for their

overall well-being. When the patient has a poor health

prognosis, patients rely on their nurse who has cared for

them during their hospital stay to tell the truth and help

them to make informed decisions about their healthcare.

For these reasons, it would be to the patient and families’

benefit to have bedside nurses more engaged in family


According to Goehring (2017), there are several reasons

a family meeting would be requested by the healthcare

team. Most often there is a decline in the patient’s

medical condition or prognosis and further goals of care

discussions are necessary. There may also be a need for

further discussions about DNR and DNI status as well

as other life sustaining methods such as feeding tube

placement, blood transfusions, and artificial hydration. For

an effective family meeting with an oncology patient, it

would be very beneficial to request the attendance of

the bedside oncology nurse. The oncology nurse can

provide updates on the patient’s medical status, assist

patients with interpreting information, and answer

questions or concerns the patient and loved ones may

have during and post family meeting.

Palliative care for Patients with Advanced Cancer

The role of engaged and involved bedside nurses is

critical to the integration of palliative care for patients

with advanced cancer. A survey was performed

to assess nurses’ perspectives on palliative care

communication. It involved distributing a 46-item

survey via email in 2013 to bedside nurses working

in ICUs across five academic medical centers of the

University of California. The survey was sent to 1791

nurses; 598 (33%) responded. Most participants

reported that their engagement in discussions of

prognosis, goals of care, and palliative care was very

important to the quality of patient care. A minority

reported often discussing palliative care consultations

with physicians (31%) or families (33%); 45% reported

rarely or never participating in family meeting

discussions. Participating nurses most frequently

cited the following barriers to their involvement in

palliative care communications: need for more training

(66%), physicians not asking their perspective (60%),

and the emotional toll of discussions (43%). The

article concluded that ICU bedside nurses see their

involvement in discussions of prognosis, goals of care,

and palliative care as a key element of overall quality

of patient care. Interventions are needed to ensure that

nurses have the education, opportunities, and support

to actively participate in these discussions (Boyle et al.,


Despite the evidence for a fundamental need for

palliative care services in the practice of oncology,

integration of these medical specialties remains a

clinical challenge. Palliative care has a wide and

significant role in providing palliative care services to

inpatient and outpatient settings. An effective palliative

care and oncology nurse collaboration improves

patient care and QOL. Further research in the role of

integrating the bedside nurse may improve patient and

caregiver outcomes. To stay on top of the profession

and to stay advanced in the field, nurses are expected

to take professional development courses to help

them carry out their duties to the best of their ability.

Taking a course in palliative care would be highly

recommended to assist with goals of care discussions.


Boyle, D. A., Barbour, S., Anderson, W., Noort, J., Grywalski,

M., Myer, J., Hermann, H. (2017). Palliative care

communication in the ICU: Implications for an oncologycritical

care nursing partnership. Seminars in oncology

nursing. 33(5) 544-554.

Center to Advanced Palliative Care (CAPC). (2021). https://


Ferrell, B., Meyer, J., O’Neil-Page, E., Cain, J., Herman,

H., Mitchell, W., & Pantilat, S. (2016) ICU Bedside

nurses’ involvement in palliative care communication:

A multicenter survey. Journal of Pain Symptom

Manage. Mar; 51(3):589-596.e2. https://doi: 10.1016/j.


Finn, L., Green, A. R., and Malhotra, S. (2017). Oncology and

palliative medicine: Providing comprehensive care for

patients with cancer. Ochsner Journal, December;17 (4)


Glajchen, M., Goehring, A. (2017). The family meeting in

palliative care: The role of the oncology nurse. Seminars

in Oncology Nursing; 33 (5): 489-497.

Milton, C. L. (2018). Will nursing continue as the

most trusted profession? Ethical overview.

Nursing Science. Jan; 31 (1): 15-16. https://

DOI: 10.1177/0894318417741099

Sedom, R. Sedhom, R., Gupta, A., Von Roenn, J., & Smith, T.

J. (2020). The case for focused palliative care education

in oncology training. Journal of Clinical Oncology :

official journal of the American Society of Clinical

Oncology, 38(21), 2366–2368. https://doi.org/10.1200/


Thomas, T. H., Jackson, V. A., Carlson, H., Rinaldi, S., Sousa,

A., Hansen, A., Kamdar, M., Jacobsen, J., Park, E. R., Pirl,

W. F., Temel, J. S., Greer, J. A. (2019). Communication

differences between oncologists and palliative care

clinicians: A qualitative analysis of early, integrated

palliative care in patients with advanced cancer. Journal

of Palliative Medicine. 22 (1), 41-49.

December 2021, January, February 2022 DNA Reporter • Page 9

Non-beneficial Treatment at the End of Life

Kiernan Quay, DNP, APRN, FNP-C

Dr. Kiernan Quay is an inpatient Palliative Care Nurse

Practitioner at Beebe Healthcare located in Lewes, DE.

She obtained her BSN at Johns Hopkins University in

2009, her MSN and DNP at the Medical University of

South Carolina in 2017. She previously worked in the

settings of acute care, medical-surgical, trauma, and

family medicine. Dr. Quay is a board certified Family Nurse

Practitioner. She is a member of the bioethics, readmissions,

advanced practice provider, and bylaws committees

at Beebe Hospital. She is an eight-time DAISY award

nominee and has twice received honorable mention for

Delaware Today Top Nurses. Dr. Quay may be reached at


Kiernan Quay

Non-beneficial treatment (NBT) affects over a third of patients at end of life (EOL)

(Cardona-Morrell et al., 2016). The shift from beneficence to autonomy coupled with

a dramatic increase in easily accessible medical information can lead patients and

surrogates to expect to be apprised of all options, including those not recommended and

some not even mentioned, regardless as to whether the treatment could lead them to

achieve their overall goals of care (GOC) (Macauley, 2018). This explosion of autonomy

leads to increasingly complex cases where care being asked for at the end of life may be

incredibly aggressive while not improving quality of life. Conflicts can arise when patients

insist on inadvisable care. Some patients may have a nothing-to-lose mindset regarding

interventions such as cardiopulmonary resuscitation (CPR). There is much to lose, even

at the EOL. Non-beneficial treatment at EOL can lead to significant distress whether

that be emotional, spiritual, physical, or financial. States often have vague legislation

that attempts to offer some protection to providers who refuse to offer treatments. It is

difficult to identify care that would be classified as futile with complete accuracy unless

there is no true physiologic benefit (e.g., CPR in patients with substantial, irreparable

head trauma). Every patient is unique, so determining if there is any chance of success

is difficult, and perhaps even harder to determine the exact probability. While there are

avenues for addressing requests for NBT, there may be overall less distress suffered by

patients, families, and staff if NBT requests are prevented at the outset.

Non-beneficial treatment at EOL, and particularly aggressive interventions such as CPR,

may cause substantial distress to those providing and receiving care. One may think there

is no harm in receiving or performing CPR. A nothing-to-lose mentality fails to recognize

the potential for harm and ignores the responsibility to do no harm (Macauley, 2018).

Cardiopulmonary resuscitation often contributes to broken ribs, internal organ damage,

and the likelihood of a compromised quality of life if there is return of spontaneous

circulation. Healthcare staff may experience moral distress while performing CPR at

patients’ EOL. Providers may feel they are stuck in an impossible situation when they are

concerned that the risk of CPR may be greater than the benefit, yet they feel obligated to

fulfill patient requests. Despite significant scientific advancements, the median in-hospital

adult cardiac arrest survival rate remains at 18% (Meaney et al., 2013).

Per Pope (2017), when states have legislation that attempt to address NBT, they are

often vague and tend to use the problematic futility terminology or reference standards

such as medically ineffective or generally accepted healthcare standards. Delaware Title

16, Chapter 25, section 2501 (m) defines medically ineffective treatment as any medical

treatment to a reasonable degree of medical certainty, a medical procedure that will not

prevent or reduce the deterioration of the health of an individual, or a medical procedure

to prevent the impending death of an individual (The Delaware Code Online, n.d.). Vague

legislation coupled with the nearly impossible task of deciding what is futile leads to

providers being appropriately reluctant to refuse to offer treatments.

At the hospital level, a bioethics committee can review cases and provide guidance

on how to resolve ethical dilemmas that arise between patients and providers. Beebe

Healthcare’s committee is comprised of providers, nurses, non-clinical staff, and

community members. The provider who requests the consultation can accept or decline

the committee’s recommendation.

In addition to bioethics committees, some hospitals have a specific policy that outlines

a precise process to address NBT requests. Beebe Healthcare does not currently have a

NBT policy. While policy specifics vary, they must clearly define NBT to avoid treatment

decisions being made based on personal values (Macauley, 2018). The policy should

encourage the involvement of the Palliative Care team, if not already engaged, and the

bioethics committee. Policies outline next steps if the dispute remains unsolved despite

involvement of both groups. If the provider decides to limit, withdraw, or withhold NBT,

the patient should be permitted to request a second opinion. If the second opinion

concurs with the first, the provider must discuss the options for transfer to another

provider, or another facility if appropriate, and the option to seek legal counsel (Macauley,

2018). If after a reasonable period, transfer to another facility is not practical, nor has

any legal action been filed, care may be unilaterally withheld or withdrawn based on the

institution’s policies and procedures (Macauley, 2018).

Ideally, conflicts are resolved before care is unilaterally withheld or withdrawn. With

the assistance of Palliative Care teams, conflicts are avoided by implementation of early

and ongoing GOC discussions prior to involving a bioethics committee and perhaps

working through a NBT policy sequence.

Early involvement of palliative care is advised as complex GOC discussions typically

require a significant degree of rapport to be successful, and a patient-centered approach

requires more than simply listing options and deferring to the patients’ choices (Macauley,

2018). Palliative Care teams need to have ongoing, extensive discussions with patients to

identify the patients’ values, beliefs, and what is of most importance to them in their

lives. A significant portion of time is spent explaining acute and chronic medical issues

and how those interact to create a prognosis. From there, individual treatment options

are evaluated to determine if they may help patients progress towards their goals or

lead them astray. For example, a full code status is inconsistent with the desire to die

peacefully at home.

Palliative Care teams are a key component to avoiding and solving requests for NBT.

Patients and providers may become ensnared in vague laws and futile terminology.

Engaging patients early in GOC conversations assists patients in determining if medical

interventions are truly beneficial. The greatest satisfaction for patients and healthcare

staff alike may come when patients are listened to, patients make decisions based on

reality, and unnecessary distress is avoided.


Cardona-Morrell, M., Kim, J., Turner, R. M., Anstey, M., Mitchell, I. A., & Hillman, K. (2016). Nonbeneficial

treatments in hospital at the end of life: A systematic review on extent of the

problem. International Journal for Quality in Health Care, 28(4), 456-469. doi:10.1093/intqhc/


Macauley, R. C. (2018). Ethics in Palliative Care: A complete guide. Oxford University Press.

Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenon, J., de Caen, A. R., Bhanji, F., Abella, B.

S., Kleinman, M. E., Edelson, D. P, Berg, R. A., Aufdeheide, T. P., Menon, V., Leary, M., & on

behalf of the CPR Quality Summit Investigators, the American Heart Association Emergency

Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care,

Perioperative and Resuscitation. (2013). Cardiopulmonary resuscitation quality: Improving

cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement

from the American Heart Association. Circulation, 128,417-435. https://doi.org/10.1161/


Pope, T. M. (2007). Medical futility statues: No face harbor to unilaterally refuse life-sustaining

treatment. Tennessee Law Review, 1-81. https://ssrn.com/abstract=989662

The Delaware Code Online. (n.d.). https://delcode.delaware.gov/title16/c025/

We are currently hiring:

• RN Triage (Odenton)

• Staff RN (All ages continuing care)

• RN MD PCP Nurse for Population Health

If you have a passion for community health, we invite you to join our team.

When you work for THC, you will be employed by a premier healthcare

organization that continually strives for high quality, professionalism and

service excellence.

For more information about nursing opportunities at THC, please

visit: www.totalhealthcare.org or

email Michelle at: mlane@totalhealthcare.org

Page 10 • DNA Reporter December 2021, January, February 2022

Using Respiratory Distress Observation Scale (RDOS) at End-of-Life

Karin Cooney-Newton, MSN, RN, APRN,


Karin Cooney-Newton is a

Pulmonary Clinical Nurse

Specialist at Bayhealth Medical

Center at both the Kent Campus

in Dover, DE, and the Sussex

Campus in Milford, DE. She

is a BSN graduate of Widener

University, and earned her

Masters at Wesley College.

Karin’s clinical expertise is within

critical care for 33 years where

her passion for end-of-life

improvement is ongoing. She

has presented on compassionate

extubation using an objective

respiratory distress observation

Karin Cooney-


tool nationally at the National Teaching Institute & Critical

Care Exposition, regionally at TRENDS, and locally at

Nursing Research conferences. She has worked as adjunct

faculty at Wesley College for 10 years; and is co-author

of a chapter in Innovative Strategies in Teaching Nursing

published by Springer April, 2020. Karin may be reached at


End of life (EOL) patient care can be an extremely

stressful experience for not only the patients, but

also, their families, and the healthcare team. When

training to become a nurse, the focus is largely on

helping patients survive acute episodes and to assist

in restoring their health. Unfortunately, not all patients

are able to fully recover, or return to their desired

quality of life. In 2010, 29% of deaths occurred in the

hospital, and the average terminal admission lasted 7.9

days according to the New England Journal of Medicine

(Blinderman & Billings, 2015). The healthcare team

must transition these patients from restorative care to

palliative care. It is considered one of the most difficult

and important aspects of nursing practice (Truog et al.,


Optimal pain and symptom management is a priority

for patients and families at EOL. Bender et al. (2017)

stated that surveys of patients and family members, as

well as prospective and retrospective studies revealed

gaps in the quality of care for symptom management

at EOL. These gaps included inadequate pain and

symptom control, and delays in the evaluation and

management of dyspnea (Bender et al., 2017).

Uncontrolled symptoms at EOL adds distress for

patients and their families, as well as compromises the

patient’s quality of life.

When further life-sustaining treatment is deemed

futile, and/or is no longer achieving the patient

and family’s goals of care, the family may choose

to discontinue further treatment. Within the ICU

setting, compassionate extubation (CE) is the

termination of mechanical ventilation and withdrawal

of an artificial airway to avoid prolonged suffering

at EOL. Some patients who are conscious are able to

report dyspnea, but others being withdrawn from

the ventilator are critically ill, cognitively impaired,

or unconscious and unable to self-report dyspnea.

These patients may or may not be able to experience

respiratory distress depending on the severity of

unconsciousness (Campbell et al., 2015). The ability to

experience unrelieved dyspnea continues until death.

These patients near death are vulnerable to be under

recognized and under treated for respiratory distress.

Conversely, a patient runs the risk of being over

treated, which leads to over sedation and unintentional

acceleration of death (Campbell & Templin, 2015).

Unanticipated respiratory distress is a common

complication of CE and one of the most challenging

symptoms for healthcare providers to control for

their patients. This can be an extremely distressing

experience for patients, as well as their families and the

healthcare team.

The use of the Respiratory Distress Observational

Scale (RDOS) at EOL can assist with patient comfort

and decrease stress of the family and healthcare

providers. RDOS is an objective assessment that can

guide the CE process, as well as withdrawal of noninvasive

ventilation device (NIVD), or high-flow nasal

cannula (HFNC). It is an objective tool used to assess

the nonverbal, adult patient for the presence and

intensity of respiratory distress. There are 8 variables

(heart rate, respiratory rate, restlessness, paradoxical

breathing, accessory muscle use, grunting at end

expiration, nasal flaring, look of fear) with numeric

values which are totaled together to obtain the RDOS

score. Scale scores can vary from 0 indicating no

distress to 16 indicating the most severe distress. The

goal is a score

December 2021, January, February 2022 DNA Reporter • Page 11

of withdrawing life-sustaining measures in the clinical

setting (Campbell et al., 2015).

RDOS not only can be used within the hospital

setting but could be used in the home during hospice/

palliative care. Dr. Campbell initiated the RDOS-

Family as a guide for the family caretaker who has

the around-the-clock responsibility to ensure patient

comfort at EOL (Campbell & Templin, 2014). Educating

family members of patients with dyspnea to use a

standardized patient assessment could increase family

confidence with dyspnea caregiving. Knowledge of

how to assess and manage dyspnea (especially with

the heart and lung disease palliative/hospice patients)

can be initiated using RDOS. This in turn, can improve

patient and family outcomes, with a goal of decreasing

acute hospital admissions where a nonpreferred site of

death could occur (Campbell & Templin, 2014). During

the pilot study, Dr. Campbell found that further testing

would need to be completed including more education

on variables that require more nursing experience that

appeared to be underreported by family members

(Campbell & Templin, 2014).

To summarize, EOL can be a stressful experience for

patients, families, and the healthcare team. Patients

near death are apt to be under recognized and under

treated for respiratory distress. Patients also run the risk

of being over treated, which may lead to over-sedation

and unintentional acceleration of death Using RDOS at

EOL can help alleviate distress and assists to validate

the need for medication titration for comfort during

EOL care.

Although EOL care is challenging and emotionally

exhausting for all those involved, helping patients die

peacefully can be as rewarding as saving a life. Thom

Dick, an EMT paramedic and author, summarizes it

best: “You’re going to be there when a lot of people

are born, and when a lot of people die. In most every

culture, such moments are regarded sacred and

private, made special by a divine presence. No one

on Earth would be welcomed, but you’re personally

invited. What an honor that is” (T. Dick, personal

communication, September, 8, 2021).


Bender, M. A., Hurd, C., Solvang, N., Colagrossi, K., Matsuwaka,

D., & Curtis, J. R. (2017). A new generation of comfort

care order sets: Aligning protocols with current principles.

Journal of Palliative Medicine, 20(9), 922–929. https://doi.


Blinderman, C. D., & Billings, J. A. (2015). Comfort care for

patients dying in the hospital. New England Journal of

Medicine, 373(26), 2549–2561. https://doi.org/10.1056/


Campbell, M. L. (2016). AACN Webinar: Caring practice:

Evidence-based terminal ventilator withdrawal. AACN.

Campbell, M.L. (2018). Ensuring breathing comfort at the end of

life: the integral role of the

critical care nurse. American Journal of Critical Care, 27(4), 264-

269. doi:https://doi.org/10.4037/ajcc2018420

Campbell, M. L., & Templin, T. N. (2014). RDOS-Family: A guided

learning tool for layperson assessment of respiratory

distress. Journal of Palliative Medicine, 17(9), 982–983.


Campbell, M. L., & Templin, T. N. (2015). Intensity cut-points for

the respiratory distress observation scale. Palliative Medicine,

29(5), 436–442. https://doi.org/10.1177/0269216314564238

Campbell, M. L., Yarandi, H. N., & Mendez, M. (2015). A twogroup

trial of a terminal ventilator withdrawal algorithm:

Pilot testing. Journal of Palliative Medicine, 18(9), 781–785.

Dick, T. (2018). People care: Perspectives and practices for

professional caregivers. (3rd ed). EMS World.

Downar, J., Delaney, J. W., Hawryluck, L., & Kenny, L. (2016).

Guidelines for the withdrawal of life-sustaining measures.

Intensive Care Medicine, 42(6), 1003–1017. https://doi.


Mularski, R. A., Campbell, M. L., Asch, S. M., Reeve, B. B., Basch,

E., Maxwell, T. L., Hoverman, J. R., Cuny, J., Clauser, S. B.,

Snyder, C., Seow, H., Wu, A. W., & Dy, S. (2010). A review

of quality of care evaluation for the palliation of dyspnea.

American Journal of Respiratory and Critical Care Medicine,

181(6), 534–538. https://doi.org/10.1164/rccm.200903-


Truog, R. D., Campbell, M. L., Curtis, J. R., Haas, C. E., Luce,

J. M., Rubenfeld, G. D., Rushton, C. H., & Kaufman,

D. C. (2008). Recommendations for end-of-life care in

the intensive care unit: A consensus statement by the

American College of critical care medicine. Critical Care

Medicine, 36(3), 953–963. https://doi.org/10.1097/


Zhuang, Q., Yang, G. M., Cheung, Y. B., & Neo, S. H. (2018).

Validity, reliability, and diagnostic accuracy of the respiratory

distress observation scale for assessment of dyspnea in

adult palliative care patients. Journal of Pain and Symptom

Management. https://pubmed.ncbi.nlm.nih.gov/30391404/

Page 12 • DNA Reporter December 2021, January, February 2022


Results of Delaware Nursing Dialogue – Advocacy Prioritization

Annamarie Flick, MSN, RN-BC, NE-BC,

Advocacy Director

The Delaware Nurses

Association recently launched

Delaware Nursing Dialogue,

an ongoing inquiry series

for all Delaware nurses to

participate in and contribute to

the advancement of nursing in

Delaware. Delaware Nursing

Dialogue will feature a variety of

topics focused on the profession.

The first survey in the series

Annamarie Flick

focused on advocacy and

legislative efforts. These results were recently presented

to the Advocacy Committee and Board of Directors. I am

happy to share them back with you.


• There were 194 nurses that participated in the annual

advocacy priorities survey.

o 68% are RNs, 29% are APRNs, and less than 1%

each were LPNs and nursing students.

o 70% of respondents had over 20 years’ experience.

o 66% of respondents are members in the Delaware

Nurses Association.

o 54% of respondents live in New Castle County.

o 37% of respondents work in the hospital setting.

Advocacy Prioritization

• Provided a list of 11 critical topics in nursing

advocacy/policy, respondents ranked them in

highest to lowest priority as below.

o Safe Staffing

o Wellbeing of the Nursing Workforce

o Workplace Violence

o Top of License Practice

o Nursing Education

o Personal Protective Equipment

o Ongoing Emergency Preparedness

o Collaboration/Relationships/Respect within

the Delaware Health Care Professional


o Telehealth Access & Regulation

o Environmental Health

o APRN Clinical Preceptors

• When asked about additional advocacy/

policy opportunities, respondents provided 82

additional responses. The themes that emerged

from these answers include:

o Access, regulation, and payment for home

care services

o Standing order protocols

o Protecting scope of practice for all nurses

o Access to and overall mental health services

o Uplifting and maintaining the scientific,

evidence-backed position of our profession

and combatting mistrust

o Increased, equitable, and consistent nursing


Advocacy Engagement

• 22% of respondents expressed interest in the

Advocacy Ally position to further support

nursing engagement in policy, legislation, and


• 48% of respondents expressed a desire to

be further involved in grassroots advocacy

by connecting with their local legislators and

speaking in support of nursing priorities.

This information, provided by Delaware nurses, is

already reshaping the way the Advocacy Committee

is working and prioritizing our efforts. Several actions

have already come out of the review of this data:

• Marykate McGurk, BSN, RN, CCRN, Susan Conaty-

Buck, DNP, APRN, FNP-C, FAANP, and Suzette

Flores, DNP, BSW, APRN, NP-C have volunteered

to work as grassroots coordinators and connect

with the identified individuals on staying engaged

and elevating the voice of nurses.

• The Advocacy Committee is going to form

three subgroups focused on the top priorities of

Delaware nurses: workforce/staffing, wellbeing,

and workplace violence.

DNA’s Executive Director is connecting with the

identified Advocacy Allies to onboard them to

their role, keep them engaged, and begin our

work for the 2022 Delaware General Assembly.

The Advocacy Committee will continue to analyze

the results and align them with our strategies and

legislation/policy that we support and move forward.

Our 2022 Legislative Platform is also currently being

updated based on these results and changes/trends

in nursing and healthcare policy. This will be shared

with nurses in the next edition of the DNA Reporter.

The Advocacy Committee and Board of Directors

thanks all nurses that took the time to answer the first

Delaware Nursing Dialogue and provide us with this

rich information. We encourage you to look for the

next in the series to participate and lend your voice.

Additionally, the prioritization of advocacy efforts

will become an annual mainstay in Delaware Nursing

Dialogue, so look for your chance to participate in Fall


Retirement Readiness Checklist

Every day brings you a little closer to retirement

age. Are you prepared for the financial impact

of leaving the workforce? Here’s a checklist to

help you consider the variables that impact your

retirement readiness:

1. Estimate your retirement living costs. Do

you know how much money you will need to

live comfortably in retirement? The amount you

spend is likely to change over the years. For

many retirees, expenses are highest in the early

active years of retirement, but also may spike

later in life, should you require costly living


2. Add up your assets. As you approach

retirement, you’ll want to have a good handle

on the assets available to fund your retirement.

Consider the equity in your home and

other properties, your investment accounts,

retirement accounts, annuities or cash-value

insurance and savings accounts. If you’re a

collector and hope to cash in, now is a good

time to get an appraisal to determine current

market value.

3. Think about liquidity. How will you access

your savings in retirement? Will you need to sell

securities or properties? Do you own an annuity

that can be converted into an income stream? Do

you have a lot of pre-tax dollars in your retirement

accounts? You’ll want to have a plan to withdraw

from your retirement savings in the most financially

advantageous way.

4. Calculate your Social Security earnings. How

much you will receive each month from Social

Security is based on your work history and the

age at which you choose to retire. To receive your

maximum monthly benefit, plan to claim your Social

Security benefits at full retirement age (or later – up

to age 70). Filing at an earlier age will result in a

permanent reduction in monthly benefits.

5. Consider your tax obligations. Taxes continue

even when you stop working. Assuming you meet

the income threshold, some portion of your Social

Security income will be taxed. The good news is that

as a retiree, you will most likely qualify for a lower

marginal income tax rate. State income taxes vary

widely and may influence where you want to retire.

6. Don’t forget about inflation. While your

Social Security benefits are adjusted for inflation,

your other income may not be immune to rising

consumer prices. Keep inflation in mind as you

estimate your living expenses into the future.

7. Sign up for Medicare during the limited

enrollment window. To avoid penalties, you must

elect your Medicare benefits within a limited time

frame on either side of age 65. Special rules apply

for people who continue to work and are covered

by an employer’s health insurance plan. During

Medicare enrollment, you’ll also have the opportunity

to choose an optional Medicare Supplement

insurance plan. Medicare Supplement plans help

pay for out-of-pocket costs such as co-payments,

coinsurance and deductibles under original Medicare.

8. Consult the experts. Don’t wait until the last

minute to figure out how you’ll pay your way in

retirement. Talk to your accountant and financial

advisor and explore your options. Together, you

can devise a retirement strategy to help you make

the most of the savings you’ve accrued from a

lifetime of work.

Christopher Malmstrom, CRPC, APMA, is a Financial Advisor with Point to Point Wealth Planning a private wealth advisory practice of Ameriprise Financial Services, LLC

in Wilmington, DE. He specializes in fee-based financial planning and asset management strategies and has been in practice for 12 years. To contact him, visit his website

www.ameripriseadvisors.com/christopher.malmstrom or call 302-995-7526. His office is located at 5195 W Woodmill Drive, Suite 27, Wilmington, DE 19808-4067.

Ameriprise Financial, Inc. and its affiliates do not offer tax or legal advice. Consumers should consult with their tax advisor or attorney regarding their specific situation.

Investment advisory products and services are made available through Ameriprise Financial Services, LLC, a registered investment adviser.

Ameriprise Financial Services, LLC. Member FINRA and SIPC. | © 2021 Ameriprise Financial, Inc. All rights reserved.

December 2021, January, February 2022 DNA Reporter • Page 13

Delaware Licensed Practical Nurse Leadership

Journey to State Nursing Leadership

Kenyette Walters, LPN, CDP®

My name is Kenyette, most know me as Keni. I am

a Delaware Licensed Practical Nurse (LPN) and currently,

Vice President, Delaware Board of Nursing. I have been

a nurse since 2012. Originally from Philadelphia, my

background is in investment accounting and corporate

finance. I am also a licensed Cosmetologist, former

phlebotomist, heavy equipment operator, and spent

some time doing academic grading/extern coordinator

and lab administration for a graduate medical school in


After relocating to Delaware in 2007, and with long

Kenyette Walters

standing medical issues, I decided to pursue an earlier

dream of entering the nursing profession. I felt that I owed good nursing

care back to the community. I studied and obtained certification as a nursing

assisting, worked in long-term care, and realized that nursing was my passion.

In 2012, I completed nursing school and obtained my LPN license. Never

discouraged by the saying “LPNs will be eliminated,” I endeavored to prove

that LPNs are exceptional and prudent nurses with a wealth of opportunities

to pursue. My career took off quickly. I quickly found that geriatric psychiatric,

dementia, and behavioral nursing were my gift. In my role and practice setting,

I was provided the opportunity to fulfill the charge nurse role and provide

dementia programing for a large long-term care program in Maryland. I am

a member of the National Council of Certified Dementia Practitioners and an

active Certified Dementia Practitioner®.

The road to excellence is not easily traveled. I had to endure many of the

downsides of nursing, including bullying from peers and the “nurses eat their

young” mentality. I persevered and have had the opportunity to practice in

some of the following roles/environments: wound care, corrections, geriatric

psych, orthopedic rehab, assisted living house supervisor, admissions nurse,

and intravenous certification. I am currently an overnight skilled nurse in an

exclusive lifestyle senior community. I also teach clinical instruction in the

medical assistant program at Polytech Adult Education.

Serving as the LPN member on the Delaware Board of Nursing, in addition

to the roles noted below, has been pivotal in my professional practice,

development, and leadership. I was reappointed to the board for a second

term and most recently achieved a landmark milestone, I was elected by

the board to serve as the Vice President. Additionally, I chair the Limited

Lay Administration of Medications (LLAM) Committee. This committee is

responsible for a state regulated program, further defined in the Delaware

Nurse Practice Act, that allows individuals who have successfully completed a

board-approved limited lay administration of medications training program to

administer prescription or nonprescription medications to patients/residents/

clients in select settings.

The Delaware Board of Nursing has been one of the most challenging, often

stressful, yet highly rewarding roles to date. The board’s primary purpose is to

protect the public from negligent/impaired nursing practice. Our other goal is

to support nurses, ensuring that they can practice safely and within the law,

provide assistance programs to help nurses in crises, and exact discipline, when

necessary. This role requires fairness, consistency, and in-depth knowledge of

the Delaware Nurse Practice Act, as well as knowledge of practice limitations

at all levels.

Looking to the future and my continued professional development, my next

major goal is to enroll in a nursing home administrator program and precept

in my current facility with our amazing Executive Director. I hope to one day

be the leader of an entire community/facility. I can be reached via email at


Nurses, thank you for your continued efforts to serve our community. I

know that, at times, it can be difficult to find the passion needed, but your

efforts are noticed and appreciated. The COVID pandemic has put a strain on

the nursing community, with an end date hard to see at this time. Together,

we will support each other, those we serve, and emerge stronger than ever.

We are tired. We are weary. We will never give up.

We are angels of mercy. We are nurses!

Page 14 • DNA Reporter December 2021, January, February 2022

Documenting nursing assessments in the age of EHRs

Georgia Reiner, MS, CPHRM, Senior Risk

Specialist, Nurses Service Organization (NSO)

Nurses have grown accustomed to documenting

assessment results in the electronic health record

(EHR), rapidly clicking responses to assessment

checklist questions. However, at times nurses

complete these actions without giving enough

thought to their documentation because they want

to move on to their “real” work: caring for patients.

The danger of this approach is threefold. First,

nurses might base their assessment on the checklist

not the patient, which can lead to an incomplete

assessment, especially if the nurse inadvertently

clicks something as being done when it hasn’t.

Second, nurses might fail to adequately document

a finding if it does not match up with the available

options in the checklist. Third, nurses might fail to

document assessments when a patient’s condition

changes or fail to document practitioner notification

of the change.

All three scenarios can leave nurses open to

legal action. For example, a harried nurse caring

for a patient who had a total hysterectomy clicks

“normal” as the result of abdominal auscultation

even though she hasn’t completed this assessment

and misses the absence of bowel sounds. Soon,

however, the patient develops vomiting and severe

abdominal pain and is diagnosed with a bowel

obstruction. This nurse could be held liable for the

delay in treatment.

Dangers of improper documentation

Documentation is a vital nursing responsibility. It’s

important for planning patient care, communicating

with providers, and demonstrating compliance with

federal, state, third-party, and other regulations.

But documentation issues can result in professional

liability lawsuits or action against a nurse’s license.

NSO and CNA’s Nurse Professional Liability Exposure

Claim Report: 4th Edition found that documentation

deficiencies are contributing factors in many nurse

professional liability claims, and that the average total

incurred for claims involving allegations related to

documentation was $238,761. The same report also

noted that 9.7% of all license protection matters,

which involved defending nurses during State Board

of Nursing inquiries, were related to documentation.

Of these, nearly half (49.6%) involved an allegation of

fraudulent or falsified patient care or billing records.

Failure to document treatment/care as required by

regulatory agencies or facility policy comprised 28.6%

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of matters related to documentation, followed by

documentation that didn’t accurately reflect patient

care and services (12.8%), failure to properly correct

documentation errors according to facility policy

(5.3%), and inadequate or untimely documentation

(3.8%). These matters serve as reminders of how

nurses need take time ensure they are completing

documentation properly.

Benefits of EHRs

Too often nurses view EHRs negatively, feeling

they’re cumbersome and take nurses away from

the patient. But a well-designed EHR has several

benefits, including improved efficiency and quality

patient care. For example:

• EHRs provide an excellent mechanism for

communicating with a variety of healthcare

providers in a timely fashion, thereby improving

care coordination.

• EHRs can incorporate guidelines, reminders,

and decision support tools that can help

providers make better decisions and deliver

better care.

• Electronic documentation eliminates the

problem of misinterpretation of handwritten


• EHRs facilitate immediate access to data by

multiple people in multiple locations.

EHRs also can protect nurses against lawsuits and

actions taken against their licenses. However, to gain

the most benefit, nurses need to take full advantage

of EHRs. For example, according to NSO and CNA’s

Nurse Professional Liability Exposures: 2015 Claim

Report Update, 45% of nurses who experienced

a liability claim did not use the available EHR,

compared with 19.2% of those without a liability


Proper EHR documentation

You can take several steps to ensure you’re

documenting assessments and other information

correctly in the EHR.

• Follow basic documentation principles.

Whether you’re documenting on paper or in an

EHR, the same basic principles apply. Document

promptly, accurately, and without bias. Don’t

interject opinions about patients or providers.

When making a correction to previously

recorded information, include the reason for

the change. Remember that the EHR provides a

date and time for each entry, providing a clear

documentation trail.

• Adhere to policies, procedures,

regulations, and guidelines. In the event of

a legal action, one of the first steps an attorney

will take is to determine if you followed your

organization’s policies and procedures related

to nursing assessments and documentation,

as well as any relevant state, federal, or local

guidelines, and guidelines from professional


• Copy and paste cautiously. The copy and paste

feature in EHRs can be a time saver, but errors,

including errors of omission, can easily occur.

For example, you copy your note for one patient

with a myocardial infarction (MI) into another

MI patient’s record but forget to add that you

notified the provider of the new S4 you heard

on auscultation. If the patient later experiences

severe heart failure, you will have no evidence

that you notified the provider. Another problem

with copy and paste is that errors can rapidly

spread as others pick up the same erroneous

information. For instance, a nurse copies an

assessment for a patient with pneumonia several

times, forgetting to update the temperature,

which has returned the normal. The patient’s

physician reads the note, thinks the patient

isn’t responding to treatment, and changes the

antibiotic. Subsequently, the patient experiences

a significant adverse event from the new

antibiotic, which leads to legal action against the

hospital, the physician, and the nurse.

A report from the Partnership for Health IT

Patient Safety recommends providers “act with

volition,” thinking about what is appropriate for

copying and pasting and reviewing notes carefully.

Ideally, the EHR should have a mechanism for easy

identification of material that has been copied and

pasted (for example, a different color text), so that

providers are reminded to carefully review.

• Beware of autofill and templates. Like

copy and paste, the autofill feature can

save time by avoiding repetitive entries,

but you need to verify that the information

automatically filled in is correct. Similarly,

templates for regularly occurring events such

as the first postoperative visit after a total

knee arthroplasty can help save time and

ensure needed information is collected, but

you still need to be aware of individual patient

needs and assessment findings.

• Use notes appropriately. Sometimes what

you need to document as an assessment

finding isn’t in a checklist or pull-down menu.

Don’t choose the “next best” option; doing

so can lead to miscommunication and clinical

and billing errors. For example, if you select

“pressure injury” because “skin tear” isn’t

available, legal action would be based on the

more serious injury. A better approach is to

add a note to the patient’s record. Be sure your

note provides vital information in a succinct

matter to avoid “note bloat” (also a side effect

of inappropriate copy and paste). If an option

that you would use frequently isn’t available,

talk with your manager or informatics contact

about adding it to the EHR.

• Protect patient privacy. Do not share

your passwords and change them regularly,

according to your facility’s policy. In addition,

don’t enter information in view of other


• Don’t ignore alerts. Alerts are there to help

you make better decisions when it comes to

patient care. For example, when you enter

your assessment data, you may receive an

alert that a patient could be at risk for sepsis.

Your prompt action could save the patient’s

life. On the other hand, too many alerts may

lessen their efficacy, leading to “alert fatigue”.

Talk with your manager or informatics contact

to discuss settings.

• Complete an effective assessment. You

won’t have the information you need for the

EHR unless you perform a quality assessment.

Don’t simply consider what a computer

checklist tells you to include. Use your critical

thinking skills to match the assessment to the


• Document changes in the patient’s

condition. Remember to enter changes to the

patient’s status into the computer and include

if you notified the provider of the change.

A partnership

Rather than having an adversarial relationship with

the EHR, nurses should consider the EHR as a care

partner. By serving as a repository of data, providing

alerts as needed, and facilitating communication, the

EHR can help ensure quality patient care—and reduce

nurses’ risk of legal action.


Balestra ML. Electronic health records: Patient care and

ethical and legal implications for nurse practitioners.

J Nurs Pract. 2017;13(2):105-111.

CNA, NSO. Nurse Professional Liability Exposure Claim

Report: 4th Edition. 2020. www.nso.com/Learning/



Addressing-Professional-Liability- Exposures

CNA, NSO. Nurse Professional Liability Exposures:

2015 Claim Report Update. 2015. www.cna.


444d-8727- ab65f25f8f6a/RC_Health_Nurses_




December 2021, January, February 2022 DNA Reporter • Page 15

Effective use of EHRs

These actions will help you gain the most

benefit from the EHR:

• Document promptly and thoroughly. This

not only helps protect you from liability but,

more importantly, ensures that information is

quickly available to other providers.

• Document accurately. Don’t omit key

information and don’t try to cover up if you

failed to document or take correct action.

• Get involved in EHR selection. Often,

nurses don’t use the EHR correctly or take

full advantage of its capabilities because

the design is poor. Ask to be included on

committees tasked with selecting the EHR

vendor. Consider which systems best reflect

what providers need to document and assess

for user interface by checking items such as

the font size of screen text.

• Identify opportunities for improvements

in EHR function. Instead of engaging in

potentially dangerous workarounds, notify

leadership where improvements are needed.

In some cases, the format of the EHR can be

tweaked to make it easier for the user.

• Don’t assume the EHR is always right. The

EHR isn’t infallible. If, for example, results

of a test don’t seem to match the patient’s

symptoms, follow up with the provider – the

test may need to be redone.

• Provide education. Consider helping

your colleagues learn more about proper

documentation in the EHR by providing an

education program or suggesting such a

program to your professional development


• Be patient centered. The ability to document

at the patient’s bedside can save time and

improve accuracy, but only if you keep

your focus on the patient instead of on the

computer. Maintain eye contact and consider

telling patients what you are entering into

the computer, which can help ensure the

information is accurate.

New, Renewing, & Returning Members

August 28 – November 29, 2021

New & Returning Members

Leila Gaines


Jessica Seador

Anna Merrick

Elizabeth Phillips

Bridgeville Naomi Higgins

Annamarie Breeden

New Castle Leah Patterson

Jill Erwin

Newark Juliana Rahmer

Denise Jones

Lewes Deborah Streeter

Olusade Banjo

Newark Bonnie Beaston

June Ndibo

Newark Michelle Saienni

Ruth Van Weele

Harrington Marisa Shetzler

Ekor Odaji

Smyrna Eugenia Johnson

Genita Vandell

Wilmington Cynthia Testa

Danette Newby-Mitchell

New Castle Yesenia Sudler

Kim Blanch

Rehoboth Beach Kathleen Carlson

Sheri McAfee-Garner

Millsboro Pete Zingone

Sherri Clark

Dover Anne Kariuki

Patricia Winward

Frankford Kaitlin Steelman

Travis Stevens

Rehoboth Beach Abioseh Pieh

Angie Primus

Bear Thelma Aminu

William Brown

Wilmington Tami Sellers

Julieanne Cloman

Lewes Morgan Webb

Toccara Barber

Dover Kelly Souder


Ocean View




New Castle












New Castle




Grace Logemann

Hockessin John Reinford


Michael Knorr

Newark Michelle Fisher


Meghan Elliott


Roselyne Arusei

New Castle

Members continued on page 16

ECRI Institute. Copy/Paste: Prevalence, Problems, and

Best Practices. Special Report. 2015. www.ecri.org/


pdf. Kelley T. Electronic Health Records for Quality

Nursing and Health Care. Lancaster, PA: DEStech

Publications; 2016.

Pagulayan J, Eltair S, Faber K. Nurse documentation

and the electronic health record. Am Nurs Today.

2018;13(9):48-52, 54.

Partnership for Health IT Patient Safety. Health IT Safe

Practices: Toolkit for the Safe Use of Copy and Paste.

2016. https://d84vr99712pyz.cloudfront.net/p/pdf/

hit-partnership/copy-paste-toolkit.pdf. Tsou AY,

Lehmann CU, Michel J, et al. Safe practices for copy

and paste in the EHR. Appl Clin Inform. 2017;8(1):12-


Disclaimer: The information offered within this

article reflects general principles only and does

not constitute legal advice by Nurses Service

Organization (NSO) or establish appropriate or

acceptable standards of professional conduct.

Readers should consult with an attorney if they

have specific concerns. Neither Affinity Insurance

Services, Inc. nor NSO assumes any liability for how

this information is applied in practice or for the

accuracy of this information.

This risk management information was provided

by Nurses Service Organization (NSO), the nation’s

largest provider of nurses’ professional liability

insurance coverage for over 550,000 nurses since

1976. The individual professional liability insurance

policy administered through NSO is underwritten

by American Casualty Company of Reading,

Pennsylvania, a CNA company. Reproduction

without permission of the publisher is prohibited.

For questions, send an e-mail to service@nso.com

or call 1-800-247-1500. www.nso.com.

Page 16 • DNA Reporter December 2021, January, February 2022

New, Renewing, & Returning Members

Members continued from page 15

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Kristie Hudson


John Starke


Caricia Rickards


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Maria Brown


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Caroline Githaiga


Kat Kvoka


Cynthia Patterson


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Renewing Members, 16-20 Years

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Renewing Members, 21-29 Years

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Donna Mower Wade Middletown (22)

Sandra Nolan New Castle (28)

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Judith Hertz Camden (24)

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