A visit from an angel.
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Attitude of Health Personnel↗
Biomedical subjects
M J Kennard
Publications and source records attributed to M J Kennard.
Preferences for cardiopulmonary resuscitation.
PURPOSE: To examine nurse-patient communication about preferences for cardiopulmonary resuscitation (CPR). DESIGN: Prospective cohort. Sampled were patients and nurses caring for patients enrolled in SUPPORT (1989-91), a multicenter study of seriously-ill hospitalized adults at four U.S. hospitals. METHODS: Information about patient preferences was obtained by interviews with patients and their designated surrogates. For selected patients, nurses were interviewed prospectively about their understanding of patients' preferences and whether they discussed these preferences with their patients. Nurse demographic information was obtained by questionnaire. Additional patient data were obtained by interview and chart review. Logistic regression was used to identify independent correlates of nurse-patient communication and nurses' understanding of patients' preferences. FINDINGS: For 1,763 study patients, 1,427 nurse interviews (response rate 81%) were obtained. The median age of interviewed nurses was 29 years; 96% were women, 68% had a bachelor's or master's degree, and 62% had worked for 5 years or more as a nurse. Nurses reported discussions about CPR with 13% of their patients, and these discussions were more likely if the nurse thought the patient did not want CPR (adjusted odds ratio [AOR] 2.68; 95% CI 1.84 to 3.90), if the nurse had spent more time with the patient (AOR 1.05; 95% CI 1.02 to 1.08) per 5 additional days, if the patient had metastatic cancer (AOR 3.56; 95% CI 1.86 to 6.78), or if the patient was in an intensive care unit at the time of study entry (AOR 2.08; 95% CI 1.26 to 3.42). Diagnosis and study site were also associated with nurses' reports of discussions with patients. Of 551 patients with available data, 58% (n = 317) wanted CPR and 30% (n = 164) did not. Nurses understood patients' CPR preferences correctly for 74% of the patients. Nurses were more likely to understand patients' preferences to forego CPR if the patient was 75 years of age or older (AOR 6.6; 95% CI 2.0 to 22.0) or if the nurse and patient had discussed the patient's preferences (AOR 25.3; 95% CI 6.5 to 98.6) or if the patient had cancer (AOR 10.9; 95% CI 2.3 to 50.1). Nurses' understanding of patients' preferences for CPR was no better than that of physicians or patients' surrogate decision-makers. CONCLUSIONS: In this sample of seriously ill hospitalized adults, discussions between patients and nurses about CPR were infrequent. Nurses' understanding of patients' preferences for care was similar to that of physicians and patients' surrogate decision-makers. Educational interventions should focus on increasing the frequency of nurse-patient discussions about end-of-life care and improving nurses' understanding of patients' preferences for care.
Adult↗
Participation of nurses in decision making for seriously ill adults.
The purpose of this study is to describe the involvement of nurses in the decision-making process of seriously ill hospitalized adults. Nurses (696) completed interviews with 1,427 patients. Patient, surrogate, and physician interviews were also completed. Patients and surrogates perceive the nurse as more influential in decision making than does the nurse or physician. Many nurses reported having no (31%) or little (36%) knowledge of their patients' preferences, and 53% of the nurses did not advocate for their patients' preferences. Only 50% of the nurses reported educating their patients about the treatment plan chosen or discussing treatment options with their patients, and few (17%) discuss prognosis. This study indicates nurses are not actively involved in the decision-making process of their patients, especially older or more experienced nurses and those working in intensive care units.
Adult↗
The nurse's role in end-of-life treatment discussions: preliminary report from the SUPPORT Project.
The methods of the Study to Understand Prognosis and Preferences of Outcomes and Risks of Treatment (SUPPORT), a five year, five-center study of decision making and communication in patients near the end of life, are described. Aspects of the study propose to describe the role of the staff nurse and the specially trained nurse facilitator in decision making in patients near the end of life. The nurse is in a unique position to initiate discussions about patient preferences for end-of-life treatment and quality of life; however, a review of related research describes discordance between clinicians' understanding and patients' preferences for treatment. Ethical issues, practice barriers, and practice innovations in end-of-life treatment are discussed.
Cohort Studies↗
Cocaine use during pregnancy: fetal and neonatal effects.
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Abnormalities, Drug-Induced↗
Neonatal neurobehavior after epidural anesthesia for cesarean section: a comparison of bupivacaine and chloroprocaine.
Reports of whether or not bupivacaine affects neonatal neurobehavior have been contradictory. The purpose of this study was to test the hypothesis that scores on the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) after epidural anesthesia with bupivacaine for cesarean section would not be different than those after chloroprocaine. Furthermore, if there were any effects, it was hypothesized that they would be related to cord blood levels of the drug. Fifty-five healthy mother/infant pairs were studied. Clinical characteristics, pharmacologic data, and BNBAS scores were obtained and analyzed using statistical techniques that included t-tests, repeated measures analysis of variance, and stepwise multiple regression. The results indicate that infants in the bupivacaine group do significantly better than those in the chloroprocaine group in the orientation cluster of the BNBAS (F[1,49] = 22, P less than 0.001); this cluster reflects higher cortical functioning. Furthermore, there was improvement in the bupivacaine group in the regulation of state cluster with age, whereas there was no improvement in the chloroprocaine group (F[1,53] = 4.34, P less than 0.01). This study suggests that performance on the BNBAS after exposure to bupivacaine is better than that after exposure to chloroprocaine.
Anesthesia, Epidural↗
Effects of low doses of meperidine on neonatal behavior.
After meperidine administration during labor, meperidine reaches its highest level in fetal tissues within 2-3 hr. The highest levels of normeperidine, the active metabolite of meperidine, are, on the other hand, determined in fetal tissues by the time between administration of meperidine to the mother and delivery: the greater the drug-to-delivery interval (DDI), the higher the fetal levels of normeperidine. Because of the different times to peak fetal levels of meperidine and normeperidine, it may be possible to partially separate the effects of meperidine and its metabolite on the neonate using the DDI. The purpose of this study was to determine whether low doses of meperidine affected performance on the Brazelton Neonatal Behavioral Assessment Scale (BNBAS), and whether this performance is related to the DDI or to levels of meperidine or to normeperidine. Sixteen control neonates whose mothers received no meperidine and 41 study infants whose mothers received 25-100 mg meperidine intravenously (mean 39 +/- 19 mg) were studied. Comparisons of BNBAS scores of control and study infants measured at less than 12 hr, again at 3 days of age, and the effect of DDI were made using repeated measures analyses of variance (ANOVA). Correlation techniques were used to examine relationships between BNBAS performance and clinical and pharmacological variables related to drug administration. The BNBAS cluster scores representing regulation of state and number of abnormal reflexes were significantly different in study neonates from control neonates. Performance depended upon test day. Further analysis showed that longer DDIs resulted in less optimal BNBAS performance.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Intrauterine exposure to low levels of lead: the status of the neonate.
It has been suggested that lead (Pb) at low exposure levels is a behavioral teratogen. Blood lead (Pb-B) was measured in 185 samples of maternal blood and in 162 samples of cord blood drawn from members of a cohort of mother-infant pairs. Routine newborn assessments, an examination for minor anomalies, the Brazelton Neonatal Behavioral Assessment (NBAS), and part of the Graham/Rosenblith Behavioral Examination (G/R) were administered. Maternal and cord Pb-B correlated 0.80. In regression analyses, Apgar scores, birthweight, length, head circumference, neonatal anomalies, and seven behavioral scales were unrelated to either maternal or cord Pb-B. Three scales--the NBAS Abnormal Reflexes, the G/R Neurological Soft Sign, and the G/R Muscle Tonus Scales--were related minimally to either cord or maternal Pb-B. Because of the contrast in maternal and cord results, despite the high correlation of maternal and cord Pb-B, the data were reanalyzed for 132 cases with paired data. Only the Soft Sign Scale remained significant and that only for cord, but not maternal Pb-B. Regression analysis revealed a suppression with the Soft Sign Scale related to the variance of the cord Pb-B that was not common with maternal Pb-B. The possibility that the fetus under stress tends to accumulate Pb was considered.
Alcohol Drinking↗
Alcohol-related birth defects: syndromal anomalies, intrauterine growth retardation, and neonatal behavioral assessment.
Fetal alcohol effects in 359 infants born to disadvantaged women identified as having a history of alcohol abuse or as controls and who provided reports of alcohol use in pregnancy are being studied in a prospective design. Alcohol abuse was assessed with the Michigan Alcoholism Screening Test (MAST). Alcohol use (AA/day) was based on short-term recall covering 2-week periods prior to each antenatal visit. A tally of anomalies associated with fetal alcohol syndrome was obtained in a blinded examination of each infant. This tally was significantly related to the MAST classification and, for the MAST+ subjects, the tally was related to first trimester AA/day. Birth weight, length, and head circumference were negatively correlated with AA/day (entire pregnancy); however, the effect was attenuated and not statistically significant in models with covariate control. It is possible that these measures were near the threshold of effect. Scale scores of the Brazelton Neonatal Behavioral Assessment Scale and three scale scores of the Graham/Rosenblith Behavioral Examination of the Neonate were unrelated to the MAST classification and to AA/day.
Abnormalities, Drug-Induced↗