Therapeutic relations decision making: the Rainbow Framework.

The giving and receiving of gifts, funeral attendance, post-discharge babysitting, usurping of parental roles, indiscriminate sharing of personal information, and other issues prompted a pediatric tertiary care facility in the Midwest to examine intricacies involved in the promotion and maintenance of therapeutic relationships. A multidisciplinary group developed a therapeutic relations decision-making framework to (a) foster a proactive process of conscious deliberation regarding nurse/patient interactions, and (b) afford a nonthreatening mechanism for retrospective review of apparently non-therapeutic relationships. The framework, based upon an "act utilitarian" approach to moral reasoning, promotes the clarification of personal philosophy and values. The framework provides a basis for deliberate, consistent, and confident nursing care delivery and the impetus for developing of new patient and family care initiatives.

Hantavirus pulmonary syndrome: recognition and emergency department management.

Hantavirus infection with respiratory involvement is a new clinical entity. The respiratory and cardiovascular abnormalities associated with hantavirus infection define the hantavirus pulmonary syndrome (HPS). We present two cases of HPS and discuss the presentation, epidemiology, emergency department management, and differential diagnosis. Treatment of HPS involves intensive care monitoring, airway management, and cardiovascular support. Because human hantavirus infection with respiratory involvement has been recognized recently in all geographic regions of the United States, it is important for emergency physicians to recognize this syndrome's characteristic symptoms and laboratory abnormalities. The fulminant clinical course of HPS and its 65% mortality rate underscore the importance of early recognition if potentially life-saving interventions are to be initiated.

Expected death and unwanted resuscitation in the prehospital setting.

STUDY OBJECTIVE: To determine the outcome, location, preexisting conditions, and resuscitation wishes of prehospital cardiac arrest patients. DESIGN: Retrospective review of paramedic and emergency medical technician run reports. SETTING: Urban area with a two-tiered emergency medical services response system covering an area of 2,128 square miles and serving a population of 1,413,900 (in 1988). PARTICIPANTS: All prehospital cardiac arrest patients to which the King County, Washington, Emergency Medical Services (KCEMS) system responded to during a 12-month period. Unless decapitation, decomposition, or dependent lividity existed, all cardiac arrest patients in the KCEMS system received full resuscitative efforts. MEASUREMENTS: We analyzed run reports from 694 cardiac arrest patients, excluding all cardiac arrests from trauma, overdose, or drowning, or obvious signs of extended downtime such as decomposition or dependent lividity. We defined an unwanted resuscitation as a resuscitation attempt despite written or verbal requests by the patient, family, or private physician. We defined a patient as having severe, chronic disease if the run report listed one or more conditions associated with poor survival rates after inpatient CPR. These included cancer, cerebral vascular accident, dementia, renal failure, dialysis, AIDS, thoracic or abdominal aneurysms, cirrhosis, or if the patient was bedridden or was receiving chronic home nursing care. MAIN RESULTS: Overall 16% (103 of 633) of all cardiac arrest patients survived to hospital discharge. Seven percent (47 of 633) of all cardiac arrest patients fit the unwanted resuscitation definition; 2% (one of 47) survived to hospital discharge. Twenty-five percent (158 of 633) of cardiac arrest patients fit the definition of severe chronic disease; 8% (12 of 158) survived to hospital discharge. CONCLUSION: Severe chronic disease and unwanted resuscitation patients comprised one-third of all resuscitation attempts by KCEMS during a 12-month period. Both groups had lower survival rates compared to cardiac arrest patients who did not have severe chronic disease or indications of unwanted resuscitation.

Professional development framework. Pathway to the future.

Staff development educators in a large midwestern university hospital developed a framework for professional development. The framework, applicable to all nurses, has four levels of professional development, from professional awareness to professional mastery. Within each developmental level five dimensions of nursing practice are identified: nursing process and practice skills, communication/collaboration, leadership, professional integration, and research/evaluation. This framework for professional development is reported and its potential use in the areas of planning, development and evaluation of staff development programs; restructure of a clinical ladder for nurses; and individual career development is discussed.