advanced directives: do they really mean what they mean?

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  • Letters Letters to the Editor are encouraged and welcomed. All letters must be typed double-spaced, and should be sent on disk or via E-mail to:

    Care plans sought for ED patients with chronic pain Dear Editor:

    Holy Rosary Medical Center has been working toward improved pain management for the past 2 years through our Interdisciplinary Pain Management Committee

    One of the areas we would like to address is our ap-proach to patients who have chronic pam (eg, back pain and headaches) and who seek pain relief through our emergency department. We assess and treat all pa-tIents who come to our emergency department but be-lieve a better way eXlsts to help our patients with their pain management. Addressing the patient's needs with a more holistic approach to mclude then mind, body, and spirit will serve our patients far better than the almost exclusive method of administering narcotIcs or other medications that we are using at this time. We believe that pain management is most effective when pain medication is combined Wlth holistic care.

    Given our need to approach pain management in the emergency department with a more holistic ap-proach, I am requesting any care plans that would per-tain to this patient population. Does anyone either have care plans for ED chronic pain management pa-tients that they would be willing to share, or do you know of anyone else I can contact. with this request? -Eilene Sweeney, RN, Clinical Education, Holy Ro-sary Medical Center, 351 SW9th St, Ontario, OR 97914

    Advanced directives: Do they really mean what they mean? Dear Editor:

    John Doe, a 67-year-old white man, arrived in our department by ambulance, with a presenting com-plamt of shortness of breath The patient was not known in our department, and the paramedics report-ed a hIStOry of chronic obstructlVe pulmonary disease. John was struggling to breathe at this pomt and he was exhausted, yet his eyes seemed to wildly search the room for help He became more anxious, diaphoretic,

    J Emerg Nurs 1998.24.382-3 CopyrIght 1998 by the Emergency Nurses ASSOCIatIOn 0099-1767/98 $5.00 + 0 18/64/92994

    382 Volume 24, Number 5

    and ashy colored. The nursing staff was in the hurried process of comfortmg and assessing John, when it hap-pened ... he arrested ... just hke that ... without allowing us the time to ask if he had advanced directives

    What do we do? No response, no respirations, no pulse, no directives ... simple ... airway, breath, circu-late, code call, intubate, protocol, response, admit to unit ... then the chart arrives with his advanced direc-tives. The family arrives .. John goes to the ICU ... the unit staff enquires, why did we resuscitate John? I apologize to the famIly, explaining that we were un-aware of John's directive and had to act on his behalf. They were kind, and said they understood. I follow John's condition through his stay, checking m on him and his family daily, feeling guilty that I somehow have contributed to their trial and tribulation. John im-proves .. .is extubated ... 1S observed ... and then is dis-charged and goes home. He lives at home for another year and a half before hIS disease overcomes him.

    Now I realize that John was a fighter; he did not want to die. He was not ready to die. His eyes told me that the first day ... not so much that he was afrmd, but more that he was not finished. He knew his disease would eventually win; he just was not ready to let it win that day. Suddenly it hits me: John could have been my dad. My dad has advanced directives. If my dad went through the same events as John, but the staff knew of his directives, they would have given him comfort and privacy and let him die, like many others have done.

    What would we miss? What would John have missed? What would John's family and friends have missed? Birthdays, holidays, new great grandbabies, afternoon naps, weddings, graduations, sunset views, and shared memories and laughs, to name just a few. When we go over advanced directives with our pa-tients, we talk about quality of life on a machine and the impact it may have on the patient and family. We make It easy to decide to sign advanced directives; not many want to be a burden-but do they really mean "let me die now"?

    I have clanfied my dad's dnectives with him; now we both clearly understand what he means, what he wants, what he has decided.

  • Whenever I assist with advanced directives now, I am very specific about what they mean. I believe there is an ethical need and place for advanced dliectives in health care, and for some persons, death today in my emergency department is a kInder death than a termi-nal process may provide. I am willIng to honor their di-rectives, but I will ensure they understand them. It is not just something we do--the impact is too great, too final. The next time you assist with advanced direc-tives, make sure that your patient understands them. If your patient can respond, ensure that his or her direc-tives are what he or she really wants, before you decide to just hold your patient's hand.-Bud Parks, RN, BSN, Manager of Clinical Service, Emergency Department, Dallas Veterans Affairs Medical Center, Veterans Af-fairs North Texas Health Care System, Department of Veterans Affairs, Dallas, Tex

    Responding to an injured patient just outside the emergency department One nurse's experience Dear Editor:

    With recent headlines condemning the staff of an emergency department for not swiftly responding to an injured person lying on the ground outside the hos-pital, I would like to share my own experience with re-sponding too quickly and not rationalizing the poten-tial dangers of such a "knee jerk" response. These comments in no way condone or condemn the actions of others in similar situations. This is just a reminder of what can (and did) happen if we act before we think.

    I was in charge of the 3 PM to 11 PM shift at an inner-city level I trauma center and was giving a tour of the emergency department to a small group of students one evening. It had been a very calm shift, and one of the students looked around the emergency depart-ment and said matter-of-factly, "Boy, it sure is quiet here." No sooner had I condemned the student for ut-tering the "Q" word than a stat page rang out from the triage desk: "Charge nurse to triage, NOW'" On enter-ing the triage area I noticed that the triage nurse was in the process of cutting the clothes off a bloody person who was lying on the floor. We summoned a stretcher and counted at least 4 gunshot wounds to the chest and abdomen as we transported the patient to the trauma room. All the way to the room the patient kept shouting, "Where's my brother? Somebody go get my brother'" As we pulled the triage patient into the trau-ma room, EMS was coming in the ambulance entrance with another shooting victim who ran up to them in the ED parking lot as they were getting ready to pull out of the hospital. Thinking that we had found the other guy's brother, I went to the trauma room to tell that patient that his brother was okay. I asked the sec-ond victim his name and ran to tell the first patient that


    "Michael"* was alive and kicking. The first patient looked at me and said, "Michael? Who's that? My brother's name is Enrico,* and he's still in the car." "What color car and where is it?" I asked. "A blue Nova, in the parking lot outside the door," replied the patient. I instructed the now wide-eyed students to stay in the trauma room and headed for the ambulance door. On my way out I motioned to several paramedics and they followed me out. The ED parkIng lot was full of cars, most of them blue. I noticed that off to the rear of the lot, in an area reserved for on-call staff parking, a blue car was sitting at an odd angle. It looked as if it had a flat tire. I got a little closer and saw that it was Indeed a Nova and that it had a flat rear tire as well as bullet-rid-den trunk. On the passenger side a person was sitting, motionless. I picked up my pace, and when I got within 15 feet of the rear of the car I felt a hand grab the collar of my lab coat. I jerked to a stop and realized it was one of the paramedics. He motioned for me to stay back and radioed for the dispatcher to call the police and have hospital security respond. Two police officers were in the triage area talking with security, and they responded to the parking lot in just a few seconds. One of the officers, gun in hand, crouched along the side of the Nova and peered through the shattered window. He immediately sprang back from the car and shouted to his partner, "Gun'" The other police officer and our hospital security officer drew thelI weapons and slow-ly converged on the car. The passenger remaIned mo-tionless. One of the offlCers opened the car door and re-moved a nickel-plated, semiautomatic pistol from the lifeless hand of the passenger. The paramedics and I now rushed to assess this person. He was pulseless and apneic. I noted gunshot wounds to his neck and chest. We extricated the patient from the car and transported him into the emergency department, where he was immediately pronounced dead.

    Later that evening when the activity slowed down, I reflected on my actions. I shuddered as I real-ized that I had placed myself in horrific danger. Thoughts raced through my head. What if he had been semiconscious and I had opened the door and he took a shot at me? What would have happened? I have a wife and a newborn baby daughter at home'

    ED personnel place themselves in harm's way every day (including me, up until that day). This sce-nario is a vivid reminder to all of us that we need to follow the same rules as our prehospital colleagues and assure that the "scene is safe" before charging outside the walls of our "controlled" environment. -Steve Weinman, RN, CEN, ED I


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