Just and Realistic Expectations for Persons with Disabilities Practicing Nursing.

The Americans with Disabilities Act prohibits discrimination on the basis of disability and requires schools to provide reasonable accommodations for persons with disabilities. The profession of nursing is striving for diversity and inclusion, but barriers still exist to realizing accommodations for people with disabilities. Promoting disclosure, a supportive and enabling environment, resilience, and realistic expectations are important considerations if we are to include among our ranks health professionals who can understand, based on similar life experiences of disability, a fuller range of perspectives of the patients we care for.

A legislatively mandated council: a model for palliative care policy integration.

Mechanisms are needed to foster discussion of policy choices about end-of-life care, identify areas of general agreement, and clarify possible areas of disagreement. The Maryland State Advisory Council on Quality Care at the End of Life (MSAC), created by legislation as a permanent part of Maryland government, is one such mechanism. We describe the rationale for creating the MSAC, its operational features, and some of its successes and challenges. Given state-to-state variation in many aspects of health care organization and financing, we do not present the MSAC as a model to be adopted in every state. The MSAC's body of work over 8 years indicates that the model can be an effective catalyst for positive change in end-of-life policy making. Reformers elsewhere should consider this model, with an eye to both the MSAC's accomplishments and areas in which a different approach might be more fruitful.

Building trustworthy relationships with critically ill patients and families.

A difficult case study involving repeated health crises and irreversible organ dysfunction illustrates the challenges critical care professionals face in caring for patients and their families. In such cases, trust is especially fragile, and coexists with its counterpart, betrayal. The Reina Trust & Betrayal Model defines 3 types of Transactional Trust. The first, Competence Trust, or the Trust of Capability, requires that clinicians practice humility, engage in inquiry, honor the patient's choices, and express compassion. The second, Contractual Trust, or the Trust of Character, demands that clinicians keep agreements, manage expectations, establish boundaries, and encourage mutually serving expectations. The third, Communication Trust, or the Trust of Disclosure, must be rooted in respect and based on truth-telling. Particularly in life-and-death situations, communication requires honesty and clarity. Each type of trust involves specific behaviors that build trust and can guide critical care professionals as they interact with patients and their families.