Psychiatric diagnoses in children with alopecia areata.

OBJECTIVE: To identify psychiatric diagnoses in a sample of 12 children with alopecia areata (AA), to assess the possible relationship between life stressors and AA and to correlate any consistent physical findings to psychiatric data. METHOD: Twelve children with AA completed systematic psychiatric evaluations. The assessments included structured and semistructured interviews, rating scales, and parent checklists. Children had previously undergone immunological and endocrinological blood testing. RESULTS: Seven of the 12 subjects met criteria for anxiety disorders (including simple phobia) on structured interviews. An additional subject met criteria for dysthymia. Self-esteem measures indicated a high positive self-concept, and rating scales measuring anxiety and depression were within normal limits. No significant difference was found between mean number of positive or negative life events of children with AA compared with a normative sample. CONCLUSIONS: Although structured interviews revealed a higher than expected rate of anxiety or depressive disorders in this small clinical sample, self-report rating scales and semistructured interviews did not support the conclusion that significant psychopathology was present.

Initiating and maintaining an ethics committee.

Ethics committees are an evolving approach to conflict resolution. They provide education and set Institutional policy. They are an exciting and sometimes frightening reflection of changing health care, as issues involving allocation of scarce resources, withholding or withdrawing treatment, autonomy and the patient's right to refuse treatment, and access to care arise in clinical care. This article has described how to initiate and maintain an ethics committee, as well as the nurse's pivotal role in identifying conflict and assisting in conflict resolution. Cranford and Roberts offer a few timeless tips for the beginning committee. They advise forming the committee with three or four people who have expressed interest, rather than recruiting those who may lose interest. More than three or four people may be needed to conduct committee business, so if recruiting is necessary, select compassionate people who are not likely to monopolize the meetings. Likewise, the chair should be affable yet assertive. Recognize that ethics committees will function differently from institution to institution, so comparisons may not be helpful. Proceed toward goals, but pay attention to the process of committee function and modify the process as needed. Finally, proceed at a pace most comfortable to members of the committee and to the institution. The pace may seem slow, but attitudes toward the committee, which may be negative at first, are slow to change. The end result is a viable body of caring people to address the needs of its institution, its staff, and most importantly, its patients and families. That is the goal we all seek.

Children with severe and profound disabilities and the issue of social justice.

Children with severe and profound disabilities are often seen as less worthy of health care resources. In times of managed care and utilitarian allocation decisions, the return on investment of resources is not easily appreciated for children with severe disabilities. This article discusses the quality-of-life considerations, societal attitudes toward people with disabilities, and the tension of the technological imperative. Advanced practice nurses are in a position to advocate for the needs of children with severe disabilities. There is a chance that an ugly history could be repeated if the lives of children with disabilities are not valued.

The nurse's role on ethics committees and as an ethics consultant.

Nurses share in the moral responsibility of their institution to ensure that the best ethical decision-making process is in place to meet patient needs, uphold the philosophy of the institution, and preserve the integrity of the profession. With health care reform under way, clinical ethical decision making will be even more difficult and complex than it is now. As members of ethics committees, nurses have a role to share their unique perspective. Nursing's prolonged contact with the patient, therapeutic communication skills, and goal-oriented approach facilitate the ethical decision-making process and make nurses well-suited to participate on ethics committees. This article discusses the role of the nurse on an ethics committee and, briefly, the advanced practice nurse as an ethics consultant.

Early intervention: the unique role of nursing.

The nursing profession is experiencing an expansion of nursing roles into many and varied areas of health care. This article seeks to identify the role and unique contributions of the nurse in the early intervention setting. Employing Levine's conservation principles as a framework for assessment and intervention, a case study is provided and a nursing care plan is developed for a 16-month-old, multiply-handicapped child. Suggestions for nursing practice, nursing education, and nursing research in the early intervention area are offered.

The patient who could not be discharged. How far should patient autonomy extend?

A male patient was admitted to the acquired immune deficiency syndrome (AIDS) unit for hemodialysis. His history revealed that he was homeless and that he had tested positive for human immunodeficiency virus (HIV+). He also had a history of alcohol and intravenous drug abuse and tuberculosis. Based on the results of a chest X-ray, he was placed in respiratory isolation. During the next few days of his hospitalization, he exhibited nonadherent behavior toward the treatment regime. Because of previous verbal and physical abuse to staff and patients, all local hemodialysis centers refused to accept him as a patient. Thus, he became a patient who seemingly could never be discharged. A discussion related to the theoretical and practical scope of patient autonomy, institutional altruism vs. institutional self-interest, and the need for social policy to facilitate a just and humane resolution to this ethical situation is presented here.

When surrogate decision-making is not straightforward. Guidelines for nurse administrators.

When ethical or pragmatic questions arise concerning surrogate decision-making, nurse administrators often are consulted, so they must be knowledgeable about current legislation as well as the surrogate decision-maker's role and ethical obligations. Case exemplars are presented in this article to facilitate the reader's awareness on how value conflicts and communication failures can complicate surrogate decision-making. Recommendations for clinical practice and research are presented.

Nurses' responses to do-not-resuscitate orders in the neonatal intensive care unit.

A statewide survey of nurses in perinatal centers was conducted to assess the prevalence of do-not-resuscitate (DNR) policies in neonatal intensive care units (NICUs) and to examine factors influencing nurses in those centers in their compliance with DNR orders. Three nurses in each of 10 perinatal centers were asked to complete a questionnaire on DNR policies and nurses' compliance and to respond to four hypothetical clinical situations. Eighteen of the 27 responding nurses reported the existence of a DNR policy. Factors affecting compliance with DNR orders were agreement that the infant should not be resuscitated (n = 24) or respect for the parents' wishes (n = 19). Nurses' intention to resuscitate despite a DNR order varied, depending on the description of the infant. Multiple regression analyses showed that subjective norms (beta = .41 to .82) rather than attitudes (beta = .17 to .39) exerted a more powerful influence on nurses' decisions not to resuscitate.