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Biomedical subjects

B J Daly

Publications and source records attributed to B J Daly.

At least 19 recordsLinked to original sources
PubMed1997

Acute-care nurse practitioners: 'strangers in a strange land'.

In 1961, Heinlein described a "stranger" from another planet struggling to comprehend and integrate the cultural idiosyncracies of earthlings in his adopted land. One could compare that situation with what confronts acute-care nurse practitioners (ACNPs) as they embark into the practitioner's world of acute care. Rather than embrace the expensive and fragmented patient-care world through collaboration with its "strangers," ACNPs would benefit from clinging to elements of their own native nursing culture and become "nesters" rather than "perchers" in the quest for improved health care.

Acute Disease↗
PubMed1996

Procedures used in withdrawal of mechanical ventilation.

OBJECTIVE: The purpose of this study was to describe ways in which withdrawal of mechanical ventilation is carried out in one institution, patient responses to the various methods of withdrawal, and nurses' perceptions of the methods and morality of ventilator withdrawal. METHOD: A retrospective descriptive study was used with a convenience sample of adult patients who underwent terminal weaning at University Hospitals of Cleveland. Demographic and clinical data, and descriptions of the exact method of ventilator withdrawal were collected from the medical records of these patients. The nurse caring for the patient was interviewed about his or her perceptions, within 7 days of the withdrawal. RESULTS: Data were obtained on 42 subjects. There were no differences in mental status, ventilatory status, age, or duration of survival between the patients who had support removed gradually and those from whom it was abruptly removed. Morphine was administered to 88% of the sample during withdrawal. Survival duration was unrelated to morphine dosage, but did correlate with ventilatory status at the time of withdrawal. Every nurse interviewed reported that he or she believed the act of withdrawal for that patient was morally correct, although only 85% were completely comfortable with carrying out the procedure. CONCLUSIONS: These results provide a foundation for preliminary recommendations about the most humane form of ventilator withdrawal and the appropriate use of narcotics and sedatives during withdrawal.

Adult↗
PubMed1995

Withholding nutrition and hydration revisited.

The concerns Hall raises in her article, "Caring for Corpses or Killing Patients" (October 1994) are reasonable points to consider but careful examination suggests that this form of treatment limitation is not prohibited by moral, legal or professional principles. In fact, in situations in which we have reliable information about what the patient's preferences were, we may have a very strong obligation to cease this unwanted intervention. In situations of uncertainty because of lack of data, lack of confidence in the information or sincere philosophical differences, we must hesitate before acting, calling upon whatever ethical, legal and professional resources can shed light on the issues at hand and lead us to consensus.

Coma↗
PubMed1995

Weaning chronically critically ill adults from mechanical ventilatory support: a descriptive study.

BACKGROUND: Ventilator-dependent patients average 11,419 daily in US acute care hospitals. OBJECTIVE: To describe the process of ventilatory weaning among chronically critically ill adults. METHODS A retrospective survey was used to study ventilator-dependent adults enrolled in a larger randomized study. Patients records were used to obtain duration of mechanical ventilatory support, success of weaning, serum albumin level, left ventricular function, number of drugs used to treat heart failure, and 24-hour fluid balance. Data were collected on admission to the intensive care unit; 24 hours after initiation of mechanical ventilation; and 7 days before, and on the day of, weaning status determination. RESULTS: Of 174 subjects, 120 were weaned from mechanical ventilation. There were no differences in maximum inspiratory pressure, minute ventilation, or ventilatory capacity between successful and unsuccessful candidates. There were differences in serum albumin level, rapid shallow breathing index, fraction of inspired oxygen, and 24-hour fluid balance. Among subjects who were weaned, the duration of mechanical ventilation was significantly longer in those with left ventricular dysfunction (n = 53; 29.1 +/- 25.2 days) than in those with normal left ventricular function (n = 67; 21.1 +/- 18.1 days). Subjects who were weaned received a greater number of drugs to treat heart failure (1.46 +/- 1.24) than did those who were not (0.77 +/- 1.04). CONCLUSIONS Many weaning parameters do not differentiate patients able to be weaned from those who are unable. The presence of left ventricular dysfunction, number of drugs used to treat heart failure, serum albumin level, and 24-hour fluid balance were associated with weaning success and/or duration of mechanical ventilation in adults requiring prolonged mechanical ventilation.

Adolescent↗
PubMed1994

Futility.

Futility is a complex concept with several possible meanings. It has become an important concept in acute care as situations arise in which patients or their families request interventions that caregivers believe serve no purpose. Resolving these dilemmas requires an understanding of the concept of futility, knowledge of empirical data relevant to the particular situation, and unambiguous communication. The definitions, criteria, and application of the concept of futility are presented, followed by a discussion of the implications of decisions about futile care for nurses and others.

Aged↗
PubMed1994

Preparing advanced practice nurses for acute care.

BACKGROUND: As a result of changes occurring in healthcare, providers have become increasingly specialized, resulting in fragmented care of patients and their families. With these changes, the need has developed for professionals who possess both advanced clinical decision-making ability and expanded psychomotor skills to serve as case managers in collaboration with physicians. As a result, evolving and innovative roles for advanced practice nurses have developed in American hospitals. The development of such roles, within the acute care hospital environment, has led directly to the creation of graduate programs to prepare acute care nurse practitioners. OBJECTIVE: This article describes the efforts to develop a specific graduate program to prepare nurses as acute care nurse practitioners. These efforts include the needs assessment, curriculum and role development, implementation, and evaluation of the program. RESULTS: Phase 1 evaluation showed significant support for acute care nurse practitioners. External support for the training and use of nurse practitioners in acute care was evidenced by significant financial support for this program provided by an acute care hospital and a private foundation. The first graduates are now practicing as acute care nurse practitioners; Phase 2 evaluation of patient outcomes is under way. CONCLUSION: The emergence of acute care nurse practitioners has been stimulated by changes in American healthcare. Support for the use of acute care nurse practitioners is significant, but barriers to implementing the role and patient and fiscal outcomes must be studied.

Acute Disease↗
PubMed1993

Withdrawal of mechanical ventilation: ethical principles and guidelines for terminal weaning.

BACKGROUND: Discontinuation of mechanical ventilation because of the recognition of futility of continued treatment or because of patient or family request is an increasingly frequent occurrence in critical care. Although there is broad consensus about the patient's right to refuse life support, little has been written about the actual procedure of withdrawing mechanical ventilation. OBJECTIVE: The purposes of this article are: (1) to review ethical arguments supporting the view that it may be morally permissible to withdraw mechanical ventilation from patients who are neither terminally ill nor imminently dying and (2) to provide guidelines for the procedure of ventilator withdrawal. METHOD: Ethical principles supporting the position that ventilator withdrawal under these conditions can be morally justified and principles suggesting that ventilator withdrawal is morally objectionable are evaluated. Factors contributing to clinicians' ambivalence about this issue and guidelines for planning and implementing treatment withdrawal are discussed.

Attitude of Health Personnel↗
PubMed1991

Development of a special care unit for chronically critically ill patients.

Intensive care units (ICUs) are recognized as one of the most expensive services provided by hospitals. Within these ICUs are a growing population of patients whose stays are extensively prolonged because of complications or underlying chronic health conditions that are exacerbated by a critical illness. These patients can be described as "chronically critically ill" and are costly to hospitals both in terms of actual dollars and in terms of the burden of care to nurses and physicians. This article describes the creation of a special care unit (SCU) designed specifically to meet the needs of chronically critically ill patients. The SCU environment is composed of a physical design that accommodates limited technology and care aimed at family involvement and rehabilitation, a case management practice model, and a shared governance management model. This structure is in contrast to traditional ICU environments, which include physical layouts that allow for high technology and close monitoring of patients, a primary nursing delivery system, and a bureaucratic management model. A research project to compare the effects of the SCU with the effects of the traditional ICUs on nurse and patient outcomes is described.

Adult↗
PubMed1990

Withdrawal of food and fluid.

John S. is a 72-year-old patriarch of a large, extended family. He underwent a mitral and aortic valve replacement, followed by a complicated postoperative course. His recovery was complicated by hemodynamic instability, several cardiac arrests, acute renal failure, and sepsis. He has been in the ICU for 14 weeks and has been unable to wean from mechanical ventilation. After many conferences between the patient's family and the ICU staff, a decision was made to remove ventilator support. This was done 3 days ago. John's condition seems stable now, but it is clear that he will not regain his former state of health. He is very debilitated, may require chronic dialysis, and has suffered some anoxic brain damage during his arrests. The nursing and medical staff are now faced with the question of further withdrawal of treatment and are considering whether or not to discontinue his parenteral nutrition and all IV fluids.

Aged↗
PubMedDate not supplied

Do-not-resuscitate practices in the chronically critically ill.

OBJECTIVES: To determine the frequency of do-not-resuscitate (DNR) orders in the chronically critically ill; to identify the differences in clinical and demographic characteristics of chronically critically ill patients who have DNR orders and those who do not; to identify the differences in the cost of care between patients with and without DNR orders; and to identify the differences in DNR practices between an experimental special care unit and the traditional intensive care unit (ICU). DESIGN: Randomized, prospective design with a block randomization scheme. SUBJECTS: Two hundred twenty patients who met the following eligibility criteria for enrollment in a parent study of the special care unit: an ICU stay of at least 5 days, an absence of pulmonary artery monitoring, an absence of frequent titration of intravenous vasopressors, an Acute Physiology and Chronic Health Evaluation II score of less than 18, and a Therapeutic Intervention Scoring System score of less than 39. SETTING: A large, urban academic medical center. MEASURES: Clinical and demographic variables describing the study populations, mental status, and timing of DNR orders, mortality rates, and cost of hospitalization. RESULTS: There was no difference in the frequency of DNR orders between the special care unit versus the intensive care unit--although patients in the special care unit had a longer interval between hospital admission and initiation of the DNR order. DNR patients differed from non-DNR in that they were older, less likely to be married, and had a higher Acute Physiology and Chronic Health Evaluation II score on admission to the study. The mortality rate in the DNR group was 71% versus 6% in the non-DNR group. There was no difference in total costs. DNR patients were also more likely to have an impaired mental status on admission, and more likely to have deterioration in mental status by the time of discharge than the non-DNR patients.

Aged↗
PubMedDate not supplied

Survival experience of chronically critically ill patients.

Intensive care unit (ICU) patients were randomly assigned to either a traditional ICU or a special care unit (SCU) for chronically critically ill patients. The SCU used a low-technology, family-oriented environment, nursing case management, no physician house staff, and a shared governance model. In comparison, the ICU used high technology, limited family visiting, primary care nursing, and a bureaucratic management model. The survival experience of chronically critically ill patients in the two environments during hospitalization, as well as after hospital discharge, was examined. Using survival analytic techniques, the 1-year cumulative mortality for all patients in the study was found to be 59.9%. Risk of death was significantly lower after discharge than during hospitalization. Similar mortality experiences were found for SCU and ICU patients. Thus, the high-technology ICU environment did not produce better outcomes than the SCU environment.

Aged↗
PubMedDate not supplied

A nurse-managed special care unit.

The authors describe the first year of operation of a nurse-managed intensive care unit (ICU). Concerned with the problems, costs, and inadequacies of caring for long-term patients in traditional ICUs, nurse administrators designed a special care unit that incorporates a physical design facilitating family involvement and rehabilitative care, registered nurse case management, and a shared governance management philosophy. Compared with traditional ICUs, the effectiveness of the special care unit is tested in terms of patient and nurse outcomes. Implications of this innovation for health-care delivery systems and the nursing profession are discussed.

Aged↗