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  1. nutella

    Are Nurses Oppressed?

    For years, I rejected the idea that nurses are oppressed. It was based on my own experience (did not feel oppressed) and my understanding. I thought that oppression is something that only applies to the well known marginalized groups that have been experiencing oppression. It was not until I started to work in a community setting and now in a community acute care place that I changed my opinion. I was used to academic centers and never felt powerless. I was mentored by strong clinical nurses who felt as equal partners in care when dealing with providers. A lot has changed in nursing. And what I am seeing now prompted me to re-think. I do think that nurses as a group are oppressed, behave like oppressed groups do, and often oppress fellow oppressed nurses. Ever witnessed report where nurses are afraid of giving report because the next nurse is highly critical and tries to exert passive-aggressive power? This is not an oppression competition where the most oppressed group in the country or world is the only one that can be oppressed or legit oppressed. It is good to understand those dynamics that lead to oppression so we can understand how we are being treated and also how we treat other nurses or people.
  2. nutella

    A Day In The Life Of An OB Charge Nurse

    This is interesting to read - I never worked a single day in GYN - OB other than nursing school clinicals. I have no idea how you guys do it !
  3. nutella

    Death came to visit

    I am sorry to hear that you had a difficult time despite knowing what your mom wanted. You bring up an important issue in end-of-life care. The cornerstone of ethics in the United States is autonomy / independence - patients are encouraged and asked to participate in decision-making regarding their wishes. Thus, we have to respect patient's liberty to make decisions that may be not congruent with our own ideas or clinician's recommendations. But - and like everything in healthcare - this has become much more complicated. To enforce autonomy and liberty, patient-centered care with shared decision-making was introduced more into the medical community. Patients and their families are often lay people when it comes to medical decision-making but need to make decisions that will have impact on their life, quality of life, or even end their life. The idea is that the patient trusts the provider who also provides a recommendations - which should include considerations about what is in the patient's best interest. Nowadays, with our growing arsenal of technology and "advances", we can easily border on futility. When the "highest" goal is to maximize the life-span, aggressive interventions and treatments are often chosen even though the outcome may be negative and leads to "suffering". A patient has the right to "suffer" if that is what they decide to accept and to go through in order to gain more time. They are allowed to sacrifice comfort for the sake of more time but it is important that they understand this implication. Physicians can not be forced to provide futile treatments. After all, many interventions are medical orders and a physician has the right to "not offer" this treatment if the patient is not a candidate because the risk is too high or the outcome negative. Examples are surgeries or heart catheter interventions but could also include dialysis. Patients accept more easily when the surgeon or cardiologist says that the risk is too high and that is not an option because it would most likely result in death. That option is not available and thus patient autonomy does not include to choose a futile options. The same with dialysis - only that patients and families have a hard time with that decision. Nowadays patients who are 90 year old undergo dialysis to extend their life but if a person has other comorbidities, the nephrologist may not offer this treatment and refer to medical management. There is also technology like high flow oxygen, which was thought to be a bridge until a person gets better or dies. But I think nobody really thought about the consequences of this device. When offered to end-stage COPD or similar patients who are so sick that they cannot come off but also do not wish to be trached and live on a ventilator - there is no place for them to go. They "live" in the hospital, which is not the same as home. Lately, I heard more often "if I had known that this is not like regular oxygen and I cannot go home with this - I would have not wanted it". There are a lot of dilemmas all around. As a palliative care nurse, I have no "agenda" - my goal is to provide information and care to help patients to live best with a serious illness. There is a huge grey zone where patients do not want to have pain for example or shortness of breath - but also want to be a full code - and though are limited in what can be realized. But it is not my place to pressure somebody into a decision or coerce them - that would take away the liberty in decision-making. Nurses feel different about suffering than physicians, which is researched. Nurses care and have a hard time when patients suffer "needlessly". Patients and families on the other hand often have their own agenda and are not up front. We see a lot of problems related to not being able to cope with death and not being able to face "loosing somebody" - which ultimately can lead to requests for futile care. As a palliative care nurse I also have a responsibility to realize when the patient asks for palliative care in the sense of "hospice" but this decision is driven by not understanding ones choices. There are cases where nurses or physicians request a palliative care consult because "the patient does not want any treatment and is ready to die" indicating they respect autonomy but the patient is not competent to make this decision due to mental illness or otherwise incapacitated. Or the patient clearly does not understand that for example life with dialysis is possible or that people can live at home with tube feeds. There is a lot of room for conflict and friction at the end of life that can make everything more stressful for everybody. Here is a good article: What's the Role of Autonomy in Patient- and Family-Centered Care When Patients and Family Members Don't Agree?, Jan 16 - AMA Journal of Ethics (formerly Virtual Mentor)
  4. nutella

    Death came to visit

    I think you make a great point when you point out that advanced directives are an important matter to ensure that there is somewhat control over one's care. I also agree that we need to establish a culture within our society that permits the discussion of end-of-life wishes or general thoughts on what constitutes quality of life. However, a living will is not the most important document and there seems to be some ongoing confusion around advanced care planning. I would like to add some information: - the one single document that any competent adult over the age of 18 years should have is the Health Care Power of Attorney, also called Health Care Proxy (HCP). In this form, that differs from state to state, any competent adult over the age of 18 can name a person (or several) who will make healthcare decisions in case that person is unable to do so (as determined by a physician). Anybody above the age of 18 should have one. If something happens to somebody and they are now unable to convey wishes or are not competent due to an illness/accident, and there is no decision maker named, it can place a huge burden on the next of kin. In some cases and states the next of kin has to go to court to ask for guardianship, which takes time but also restricts the guardian in a different way. A person who does not have a health care proxy form filled out, usually also does not get accepted to rehab. In any way - if there is one form that anybody should do - it is that form. Usually no expensive lawyer is needed, the form needs to be witnessed by adults. - Living Will - this is a document where a person conveys what they would like to be done or not done or how in case of certain circumstances.While it is great to have a document that provides guidance, it is also a document that is not statutorily recognized in all states. For example, the state of Massachusetts does not recognize a "living will" as binding. If somebody presents a living will, the health care proxy can still use it for their own guidance in decision making. So - since not all states recognize the living will it is really the most important thing to do the health care proxy form and to talk to that person about the wishes. Otherwise they may struggle with decision making or not make the decision that the person would want. And - a living will depends still on the interpretation by the medical professional and how the HCP understands the circumstances. When people write in their will "if there is no meaningful recovery" - what does that really mean??? And - a living will cost money that a lot of people do not have or want to spend, especially if it is a state that does not recognize the document as binding. And - when there is a situation where the living will says one thing but the HCP says something different - the physicians will usually do what the HCP wants. Nobody wants to get sued. I have seen patients who never wanted to be intubated, who even had a provider order not to intubate. When the HCP panicked or thought that they are not ready to accept death and ask the MD "to do everything" that patient will still get intubated. POLST/MOLST: Provider order for life sustaining treatments - this is a medical order (!) for people with serious illness or high age that is filled out with the MD/NP/PA and details if the patient should get intubated/chest compressions/ dialysis/ artificial nutrition and so on and forth. It is a portable order and goes with the patient. It is always good to have conversations about one's wishes. I could get into a terrible car accident tomorrow and end up in the ICU on a vent - hopefully my spouse knows my wishes and would enforce them. We have talked about those situations so we know what the other one would want. My spouse would want extreme measures unless his head is "cut off" or he "can't think anymore". I asked my oldest child before he left for college and we had discussions, I gave him a health care proxy form to fill out. There is a huge amount of confusion out there about advanced directives ....
  5. There is an intermittent FMLA that would cover absences that happen on single days when you qualify for it. In those cases, once FMLA is in place, you do not get penalized for absences as long as you follow the protocol. I had intermittent FMLA in place for one year when my child was sick because I knew that I might have to call out sick due to her condition once in a while. Although I used it only very occasionally, it gave me peace of mind. Check out if you qualify.
  6. nutella

    A Newly Defined Type of Constipation: Opioid Induced Constipation

    It has been long known that narcotic pain medication also causes constipation. In fact, I have known patients with terrible diarrhea who got prescribed medication containing a narcotic to help with that (opium). Constipation is a side effect that will not get better and it is an issue with chronic but also acute pain relief. Anybody who takes narcotics should be on a bowel regimen. From working in hospice and palliative care, I can tell you that all patients, even if on pain medication only short term, need to take medication to help with bowels.Colace, while a stool softener, will not do much to get the bowels going. But you also do not prescribe all the new EXPENSIVE medications when we have in fact medications (most of the over the counter) that are just fine if given in the right dose. Cheaper and also very effective is Senna - but 1 or even 1 pill twice a day might not be enough. If 1 pill twice a day is not enough, some people have to take 2 in am and 1 in pm or 2 twice a day. There is also Miralax, there is lactulose, bisacodyl p.o. . Heck - even milk of mag or mag citrate. Of course if you wait too long to initiate bowel protocols or people are not taking them - you might find yourself with an order for a bisacodyl sup or enemas. In my personal opinion, there is no reason to give expensive newer medication or subq injections that have much more side effects. It is a huge market for bowel meds but most people who get the low cost bowelmeds upon initiation of narcotics plus teaching do just fine....
  7. nutella

    2/13/16 What I Learned This Week: Discipline is King

    This week I learned that if a patient has cancer and bone mets and needs serious pain management they better stick with their oncology or palliative provider. Asking a PCP who is not well versed in pain management to adjust something can end up in a total disaster with admission to the hospital for uncontrolled pain. Remember : If 300 mg of morphine a day does not make your pain bearable - why do you think a 50 mcg of fentanyl patch would do better??? that the acute hospital is not very equipped in supporting people who are being told that they have cancer and "by the way no treatment options and perhaps months left at best". that my laundry dryer gave up because the vent was blocked and lint accumulated. Now a vent repair specialist will come and try to figure something out. that since my dryer is not working I have to go to the laundromat to dry the laundry and evening hours are best because it is empty. that my son got a great merit scholarship to a good school that I am still not loosing much weight and that is due to me eating too much crap ...