To Continue or to Withhold Opioid Analgesics? An Ethical Dilemma Involving a 63-year-old Cancer Patient Who 'Broke the Pain Contract'.

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

Reevaluation of the critical-care pain observation tool in intubated adults after cardiac surgery.

BACKGROUND: Pain assessment in critically ill patients who are intubated, sedated, and unable to verbalize their needs remains a challenge. No universally accepted pain assessment tool is used in all intensive care units. OBJECTIVES: To examine concurrent validation of scores on the Critical-Care Pain Observation Tool for a painful and a non-painful procedure and to examine interrater reliability of the scores between 2 nurse raters. METHODS: A prospective, repeated-measures within-subject design was used. A convenience sample of 35 patients was recruited to achieve enrollment of 30 patients during a 5-month period. Observational data were collected on patients intubated after cardiac surgery during routine turning and during dressing changes for central catheters. RESULTS: Raters' mean scores did not increase significantly during dressing changes (increase, +0.25; 95% CI, -0.07 to 0.57; P = .12) but did increase significantly during turning (increase, +3.04; 95% CI 2.11-3.98; P < .001). The degree to which mean scores increased was significantly greater during turning than during dressing changes (increase, +2.80; 95% CI, 1.84-3.75; P < .001). The Fleiss-Cohen weighted κ for the inter-rater reliability of the ratings of research nurses was 0.87 (95% CI, 0.79-0.94). CONCLUSION: The results support previous research investigations on validity and reliability of the Critical-Care Pain Observation Tool for evaluating pain in intubated, critically ill adults.

The hospitalized prisoner with a life-threatening illness: criminal first and patient second?

It is generally accepted that the Patient's Bill of Rights applies to all patients including prisoners. Yet, a prisoners' incarcerated status generally prohibits inmates from making any decision that may shorten his/her life, and as such, the de facto medical decision maker becomes the medical director of the state correctional facility. This case study highlights the challenges that arise when the ethically appropriate response to a hospitalized prisoner's terminal medical condition warrants decisions that are in conflict with that advocated by the correctional facility.

Factors that enable or complicate end-of-life transitions in critical care.

BACKGROUND: Nurses in medical intensive care units are routinely involved in negotiations to maintain or withdraw life support. How nurses move from aggressively attempting to extend life to letting life end is not well understood. OBJECTIVE: To explore nurses' experiences of moving from cure- to comfort-oriented care and to describe factors that inhibit or facilitate such transitions. METHOD: A descriptive qualitative research design with brief observation of participants and focus group interviews was used. Participants were 19 female and 5 male nurses in an 18-bed medical intensive care unit in a 719-bed acute care hospital in the northeastern United States. RESULTS: The transition point between cure- and comfort-oriented care was unclear. Nurses reported that the patient's age, misunderstanding of the illness by the patient's family, family discord, and shifting medical care decisions made end-of-life transitions difficult. Conversely, developing a consensus among patients, patients' families, and staff about the direction of medical therapy; exhausting treatment options; and patients' lack of response to aggressive medical interventions helped nurses move toward comfort care. CONCLUSIONS: The most distressing situations for staff were dealing with younger patients with an acute life-threatening illness and performing futile care on elderly patients. End-of-life transitions were difficult when patients' families had conflicts or were indecisive about terminating treatment and when physicians kept offering options that were unlikely to change patients' prognosis. The most important factor enabling nurses to move from cure- to comfort-oriented care was developing a consensus about the treatment.

A descriptive study of coping strategies used by Medical Intensive Care Unit nurses during transitions from cure- to comfort-oriented care.

OBJECTIVE: The aim of this study was to describe Medical Intensive Care Unit (MICU) nurses' coping behaviors while caring for a patient whose medical treatment transitioned from cure- to comfort-oriented care. METHODS: The use of a descriptive qualitative research design with brief selective participant observation and focus group interviews was used to explore the coping experiences of MICU nurses. The study took place in an 18-bed MICU that was part of a 719-bed acute care hospital located in the northeastern United States. Nineteen female and 5 male nurses participated in the study. RESULTS: MICU nurses used a variety of coping strategies including cognitive, affective, and behavioral techniques to cope with end-of-life care transitions. Being a MICU nurse in and of itself provided a sense of pride for staff. Most believed that their clinical opinions were valued and that they were respected as professionals. Providing futile care, the perception of "torturing the patient," and conflict with families caused the greatest distress to staff. CONCLUSIONS: MICU nurses are dynamic and resourceful when responding to challenging end-of-life patient care situations.