Death and Dying in a Pandemic: Preparing Nurses for End-of-Life Care

Death and Dying in a Pandemic: Preparing Nurses for End-of-Life Care

Nurses in every clinical practice specialty will encounter a patient who is dying and will provide care to that patient as well as give support to the patient’s family. This is not a new phenomenon and the experiences of nurses providing end-of-life care have been extensively documented (Coffey, et al., 2016; Holms, Milligan, and Kidd, 2014; Hussin, et al., 2018; Lusignani, et al., 2017; Puente-Fernandez, et al., 2020; Zheng, Lee and Bloomer, 2018). Over the last several decades, nurses continue to report a lack of education and preparation to manage the complex care associated with dying and decision making at the end of life (Holms, et. al, 2014; McCourt, et. al, 2013; Suryani, et. al, 2018). Nurses’ experiences with death and dying under “normal” circumstances can be challenging and emotional as they advocate for patients’ wishes and promote a comfortable, dignified death (Griffiths, 2019; Peterson, et al., 2010).

Enter COVID-19 – a coronavirus that affected the globe and caused healthcare workers, including nurses, to change their routine practice of caring for patients, particularly dying patients. There is no current literature on the effects of this global pandemic on nurses caring for this special population of dying patients.  Pattison (2020) reviewed some literature on disaster management and end-of-life care with outbreaks such as the H1N1 virus; palliative and end-of-life care planning is not fully developed and still needed. In this current pandemic, COVID-19 has caused a high number of unexpected deaths, there has been greater demand for beds and other resources, and provision of end-of-life care has been hampered due to respiratory transmission of the virus and maintaining safety for nurses at the bedside.

Nursing students, often employed in hospitals as patient care technicians, are witnessing death and dying at an alarming rate. As a professor at a local university, I have spoken with third and fourth-year nursing students who were working in hospital units designated for COVID-19 patients. The students shared that they were performing multiple post-mortem cares on patients that had died from the virus. Students also discussed the difficulty of trying to manage communication between the dying patient and their family, since visitors were restricted. Technology such as smart phones or tablets were used to have video conversations between patients and families as the patient was nearing the end of life.

It is imperative that nurse educators in both academia and healthcare systems provide additional and continuing education and support to nursing students as well as nurses practicing at the bedsides of the dying. The high stress environment of a COVID-19 unit paired with critically ill patients who may die unexpectedly may cause burnout in nurses. Resources such as the End of Life Nursing Education Consortium (ELNEC) are available online for educators to share with students and nurses.  ELNEC has provided educational resources for palliative care and end-of-life care to nurses for the last two decades. Information in the modules includes physical symptom management, pain, spiritual care, ethical/legal issues and communication. ELNEC has created free online resources in response to COVID-19 and may be useful for pre-licensure education as well as continuing education and support for nurses (ELNEC, 2020).

Further support which can be provided to students and nurses includes virtual support groups, arranged by nursing faculty, hospital nurse educators or referral to social media support groups. When nurses are ready to talk about their experiences with dying patients, they need an outlet to express their emotions regarding their participation in end-of-life care during a pandemic. This may assist in validating their feelings and sharing their grief. Additional strategies to enhance positive coping mechanisms include self-care such as exercise, sleep, healthy diet, leisure activities, and spiritual or religious support (Zheng, Lee and Bloomer, 2017).

COVID-19 has changed the way nurses interact with patients and families at the end of life. Technology has been a useful tool; however, we must not forget the human side of care. The need for pre-licensure and continuing education on end-of-life care is essential. Nurses have been reporting high anxiety and lack of preparedness about caring for a dying patient over the last several decades. We must provide education as well as emotional support to our front line during this pandemic as well as prepare for future pandemics and other unusual circumstances surrounding the end of life.

References

Coffey, A., McCarthy, G., Weathers, E., Friedman, M., Gallo, K., Ehrenfeld, M., Chan, S., Li, W., Poletti, P., Anotti, R., Molloy, D., McGlade, C., Fitzpatrick, J. & Itzhaki, M. (2016). Nurses’ knowledge of advance directives and perceived confidence in end-of-life care: A cross-sectional study in five counties. International Journal of Nursing Practice, 22, 247-257. DOI: 10.1111/ijn.12417

ELNEC (2020).  End of life nursing education consortium.  https://www.aacnnursing.org/elnec

Griffiths, I. (2019).  What are the challenges for nurses when providing end-of-life care in  intensive care units?  British Journal of Nursing, 28, (16), 1047-1052.

Holms, N., Milligan, S. &  Kydd, A. (2014). A study of the lived experiences of registered nurses who have provided end-of-life care within an intensive care unit. International Journal of Palliative Nursing, 20, (11), 549-556.

Hussin, E., Wong, L., Chong, M. & Subramanian, P. (2018).  Nurses’ perceptions of barriers and facilitators and their associations with the quality of end-of-life care. Journal of Clinical Nursing, 27, (3-4), e688-e702.

Lusignani, M., Gianni, M., Re, L. & Buffon (2017). Moral distress among nurses in medical, surgical and intensive-care units. Journal of Nursing Management, 25, 477-485. DOI: 10.1111/jonm.12431

McCourt, R., Power, J. & Glackin, M. (2013).  General nurses’ experiences of end-of-life care in the acute hospital setting: A literature review.  International Journal of Palliative Nursing, 19, (10), 510-516.

Pattison, N. (2020). End-of-life decisions and care in the midst of a global coronavirus (COVID19) pandemic.  Intensive & Critical Care Nursing, 58. DOI:10.1016/j.jccn.2020.102862

Peterson, J., Johnson, M., Halvorsen, B., Apmann, L., Chang, P-C, Kershek, S., Scherr, C., Ogi, M. & Pincon, D. (2010).  What is so stressful about caring for a dying patient? A qualitative study of nurses’ experiences.  International Journal of Palliative Nursing, 16, (4), 181-187.

Puente-Fernandez, D., Lozano-Romero, M., Montoya-Juarez, R., Marti-Garcia, C., Campos Calderon, C., & Hueso-Montoro, C. (2020). Nursing professionals’ attitudes, strategies, and care practices towards death:  A systematic review of qualitative studies. Journal of Nursing Scholarship, 52, (3), 301-310.

Suryani, R., Allenidekania, A. &  Rachmawati, I. (2018). Phenomenology on nurses’ experiences in understanding the comfort of children at the end-of-life. Indian Journal of Palliative Care, 24, (2), 162-166.

Zheng, R., Lee, S. & Bloomer, M. (2018).  How nurses cope with patient death: A systematic review and qualitative meta-synthesis. Journal of Clinical Nursing, 27, e39-e49.  DOI:  10.1111/jocn.13975

Social Distancing Brings Telemedicine Into the Mainstream

Social Distancing Brings Telemedicine Into the Mainstream

Among the many changes ushered in by the pandemic, one of the most notable is the acceleration of telemedicine into the mainstream. Advances in technology have made it available for years, but before the advent of COVID-19, telemedicine was usually mentioned as a resource for patients in remote rural areas—and regardless of location, virtual visits were retarded by federal and state regulations, seemingly impenetrable insurance restrictions, and resistance to change on the part of many healthcare providers. With the need for social distancing, though, regulations have been relaxed, insurers are recognizing virtual visits, and practitioners are discovering that telemedicine has a valuable place regardless of the region you live in.

The benefits of telemedicine extend well beyond its ability to protect front-line providers and preserve scarce PPE supplies. Telehealth video interaction, it turns out, can be a boon for COVID-19 patients. Far from being an estranging experience, video meetings allow patients to see health providers’ faces without the dehumanizing barrier created by masks and PPE. Isolation has always posed a psychological risk to hospital patients, but being treated during a pandemic—with personal contact limited to healthcare workers clad in masks and goggles—can be an alienating, deeply stressful experience. Under current conditions, video visits allow cloistered patients their only opportunity to see a healthcare provider’s face. As one doctor told the Annenberg Center for Health Journalism, “In some ways, the virtual visits bring the human — and empathy — back to the bedside. They can see me smile or laugh and they really appreciate it.”

Life under lockdown and the altered regulatory landscape are helping telemedicine enter the lives of patients with other ailments as well. As a result of changes implemented by the Office for Civil Rights (OCR) at the Department of Health and Human Services, TechnologyNetworks notes, “healthcare providers… are now allowed to use any non-public facing remote device that is available to speak to patients. The relaxation of the OCR’s rule enforcement applies to telehealth services offered for any medical issue, even those unrelated to COVID-19.” A few long months ago, videoconferences were mainly the province of mental health practitioners, but since the advent of social distancing, virtual visits are making inroads in pediatric and maternal care, and have been adopted by a growing number of NPs.

Some of the NPs who have made the move to telemedicine have been pleasantly surprised. “I found, through experience, that my virtual visits were of much shorter duration and ran on time. Nearly every patient has been positive regarding the virtual visits and appreciate it as an option,” reported one St Louis NP in a Clinical Advisor survey. In the same survey, an NP in Three Rivers, Minnesota enthused, “In transitioning almost completely to virtual office visits we’ve really streamlined the way we provide healthcare…. we are providing the type of patient-centered, innovative, accessible medicine that we wish could always be our sole focus. Out of this horrific tragedy, we are making enormous strides in just a few days that would have taken years to change in any other reality.”

However, just as remote work is an option only for a privileged minority (only 20% of Americans are able to work from home), not everyone is able to visit their practitioner on Zoom or Skype. In a recent survey of healthcare providers, FierceHealthcare found that many patients—especially seniors—simply do not have the technological resources for telemedicine: “Two-thirds of clinicians (65%) report they have patients who can’t use virtual health as they have no computer or Internet.” Most of those surveyed added that they were “using video for less than 20% of their visits (43%) or not at all (14%). Instead, 44% of respondents are using the telephone for the majority of their visits.”

To take a long term view, though, telemedicine was already (finally) on the move even before the pandemic struck. In the time since, as in the case of remote working, the pandemic has normalized the concept of telehealth and accelerated its incorporation into the mainstream. While plenty of changes lie ahead, such as the reimposition of HIPAA privacy requirements as lockdowns end and social distancing recedes, the virtual visit is set to become a standard option in healthcare practice.

How Do You Deal with A Patient’s Death?

How Do You Deal with A Patient’s Death?

Death is a natural part of life but that doesn’t make it any easier. Intensive care nurse Rhianna Ferial says that, “as healthcare professionals, we are there for people and their families during the final moments. This can be hard emotionally, so it’s important to recognize and find ways to deal with your feelings.”

Watch the video or read the transcript below [edited for length] — and use the comment tool to let us know how you deal with patient death in your own work.

Rhianna Ferial: Hi, everyone. Today, I wanted to have a little nurse talk, a sit-down talk, and I wanted to talk about dealing with patient death. I want to tell you about my first experiences with patient death, my experiences since then in some ways that I think help coping with patient death and dealing with your grief or your emotions over the situation.

I honestly think the most stressful and emotionally taxing part of dealing with patient death is being there for their families, and this is something that’s very important. I feel like we don’t get enough education or practice with this part because we’re there for treatment and I know how to take care of patients. I know how to do ACLS. I know what to do to save them. But when we can’t save them, what comes after that is dealing with the family while they say goodbye to their loved one. We’re there with them afterwards while they’re grieving.

That’s the hardest thing for me in my career. It was the hardest thing for me to get used to from the beginning, and I always thought the actual scenario of trying to save somebody or them passing away would be the hardest. For me, it’s actually the emotional part of dealing with the remaining family members who are just grieving and so upset.

My #1 piece of advice in dealing with the families is it’s okay to be silent. I always used to feel like I need to say something when a tragic situation was going on. I was in the room with a family who’s saying goodbye to their dead loved one and I felt like I should be saying something or talking to them, trying to console them, but there’s nothing you can really say to help them. There’s nothing you can say to take their pain away. Sometimes just being there, handing out tissues, trying to hand out waters or anything you can to just make them a little more comfortable is all you can do.

Sometimes people just need a hug. Not everybody is a hugger, but sometimes family members just want you to be there with them. Sometimes they need a hug, a shoulder to cry on, and you can be that person. You don’t always need to be saying something. Don’t be scared of saying the wrong thing. Don’t be worried that you’re not saying enough. Honestly, there is no right answer here, and all you can do is what feels right. Oftentimes, for me, I found that that’s silence and waiting for them to start talking. If they talk and initiate and want to have a conversation more about what’s happening, I’m there and I’ll talk to them as well.

The second piece of advice I have… and these are in no particular order. I’m not saying one of these is more important than the other. But the second thing I would say is please try not to blame yourself and try and find things wrong with what you did when somebody dies in your care. We’ve tried everything we can to save somebody. We’ve given blood and ACLS, done CPR, done everything we can think of, tried to save this person, and they just couldn’t make it. Their body couldn’t handle it, and it was just time for them to go, even though it doesn’t feel like it’s time and doesn’t feel like it’s right. There’s nothing that you could have done, not one thing specifically that you could have done or changed what you did, or change the timing is something usually that would have saved that person.

There’s too much, too many factors going on, so try not to blame yourself, try not to replay scenarios over and over again in your head blaming yourself. I know a lot of newer nurses or younger nurses that are dealing with death for the first time tend to do that. I’ve had people tell me they do that. I’ve done that in the past before, too. Just realize that that’s not a productive way to deal with your feelings, and it’s just going to make you feel worse.

This kind of leads me into the third thing that I wanted to talk about and that is don’t compare your feelings to how other people are feeling during this situation. Everybody processes situations and feelings and emotions differently. Just because one nurse is extremely upset and one doesn’t seem to be upset at all does not mean that either one of them is dealing with the situation in the wrong way. We all just handle things in our own unique ways. Obviously, you need to be able to keep it together during the situation. You can’t really be functioning during the code or like a mass transfusion protocol or any kind of dire situation if you’re completely overwhelmed and upset. If that’s happening during the situation, obviously that’s another issue that needs to be addressed, but I’m talking about afterwards.

Take things at your own pace, deal with things how you feel like you need to deal with them. If you’re upset and you need to go in the bathroom or the break room and cry for a second, do that and don’t think there’s anything wrong with that. If you’re not upset and you feel like you can go right into your next patient’s room and provide them with care, and you feel like you need to keep going, keep yourself busy, do that as well. There’s no right answer here. Everybody deals with it differently. I just wanted to say that because often in healthcare there’s this kind of vibe that you shouldn’t get upset about things. You should keep a wall up. You shouldn’t get upset about patients or situations. You should kind of just move on to your next task. That’s not always the case.

The fourth thing I wanted to say is something that has really helped me in the past and continues to help me is find an outlet for yourself, whether that be working out, whether that be crafting, whether that be continuing education, something that you can focus on and spend your time on that’s for you. This isn’t just with patient death, but with stress in general. Having something for you is very helpful, something productive that makes you feel good, which makes you feel like you’re getting stuff done and you can put your mind and soul into and really focus on that.

Now, the last piece of advice I have, I think it would be tip #5, is to talk with others, whether this be your co-workers who are there with you during the incident or whether this be a therapist or a counselor, or somebody who can help you deal with your feelings. Obviously, don’t violate HIPAA if you’re not talking to your co-workers who were there in the situation, but you can talk about situations without giving details. If you need to see a therapist or a counselor, do not feel bad about that. Sometimes you need somebody objective to talk to who’s very neutral and can just give you advice and just be there for you to listen and you don’t feel like is judging you.

Talking to your co-workers can be great, too, if you have good co-workers and just depending on the situation. If you come home and you just had a really bad day, you lost a patient, something horrible happened, don’t be afraid to tell your family that you’re just really not feeling good and you had a bad day at work. You don’t need to go into detail or make it gruesome for them or tell them anything specific. Maybe you just need to go take a bath or listen to some music or read a book or go sit in your room by yourself for a little while, but oftentimes they’ll be very understanding of this. I’m sure they know your job is stressful. Just don’t be afraid to vocalize when you need a little you time.

That’s it for my tips for dealing with death. Obviously, there’s many more things you can do. That’s just kind of some things that I found that are helpful. I hope they were helpful to you guys as well. If you have any tips or things that you do to help you cope with loss, please leave them in the comments below because people who have dealt with stuff before can help new nurses, new health care workers who are just now dealing with it for the first time. By sharing your feelings and experiences, you can really help lift them up and help them realize that they’re not going through this alone.

Health Equity: What Does it Mean for Nursing?

Health Equity: What Does it Mean for Nursing?

According to the Robert Wood Johnson Foundation, “Health equity means increasing opportunities for everyone to live the healthiest life possible, no matter who we are, where we live, or how much money we make.”

Health equity is of vital concern to nurses, whose daily work as patient educators and healthcare practitioners is influenced by interrelated factors such as:

  • Health Disparities
  • Social Determinants of Health
  • Cultural Competence
  • Social Justice

With the help of Drs. Janice Phillips (PhD, RN, FAAN) and Margaret Moss (PhD, RN, JN, FAAN), editors of the upcoming book Health Equity and Nursing, DailyNurse is looking at these basic concepts and exploring the role of health equity considerations in the day-to-day work of nursing.

Health Disparities

“Health disparities” refers to the inequalities in health and health care between different population groups. There are widespread inequalities that impinge upon public and individual health and well-being. Among the patients most directly affected are members of ethnic minorities, immigrant and low-income families, and people living in areas far from accessible care. According to a 2018 study, the US spends an estimated $93 billion in excess medical costs per year due to racial disparities alone.

DailyNurse: Can nurses help to overcome health disparities that affect their patients?

Janice Phillips: “It’s been over a decade since nurse leader Dr. Gloria Smith wrote a commentary “Health Disparities: What Can Nursing Do?’ In her commentary, Dr. Smith encouraged nurses to promote nurse managed primary care and focus on changing local, state and national policies to help address health disparities.

In recent years however, we have expanded our efforts to reduce health disparities to include an emphasis on achieving health equity. Healthy People 2020 defines health disparities as a type of particular difference in health status that is closely linked with economic, social, or environmental disadvantages. Populations that experience greater social and economic hardships are more likely to experience health disparities.

In contrast, health equity is a principle that underscores a commitment to reducing and ultimately eliminating health disparities. Health equity occurs when all populations (especially vulnerable, less advantaged socioeconomic populations) experience their highest level of health. Efforts to achieve health equity are intertwined with our ability to effectively eradicate health disparities. In our daily practice, nurses can be mindful to assess for these and other conditions that may adversely impact health outcomes and make appropriate referrals to members of the health care team such as social workers and case managers who are skillful in addressing identified social needs and can make appropriate referrals for additional services.

On a higher level of intervention, nurses must become skillful in advocating for social policies that can positively impact the myriad of social and economic conditions (inadequate housing, lack of employment and education opportunities) that adversely impact the health and well-being of those we serve.”

Health Equity and Social Determinants of Health (SDOH)

Social determinants of health (SDOHs) are factors apart from medical care and genetics that account for roughly 80 percent of overall individual health outcomes, according to the National Academy of Medicine. SDOHs are factors such as socio-economic status, availability of nutritious food, air and water quality, housing, education, transportation, racial segregation, and exposure to racism and violence. SDOHs can include a patient’s neighborhood and environment, access to health care (including insurance); social, cultural, and community context; level of education; and economic stability—all of which play a role in a nurse’s assessment of a patient’s wellbeing and risks to the same.

DN: In what ways can a nurse incorporate SDOH considerations into treatment?

Janice Phillips: “As they are working on the frontlines providing direct care to patients, it is important for nurses to be mindful of the many social and economic factors that may impact the health and well-being of patients and communities at large. In recent years hospitals have started screening patients for social needs that may have some bearing on a patient’s health and health outcomes. Factors such as access to stable housing, primary care, nutritious foods and transportation have emerged as significant factors impacting health status and health outcomes. Thus nurses are pivotal to integrating these factors when conducting patient assessments and making referrals that can help address the identified social needs. Other factors such as structural racism, income, education, poverty also impact health status and outcomes.

As patient advocates, nurses are well positioned to relay important information to social workers, case managers and other members of the interprofessional health care team who have the expertise to refer patients to needed resources. Nurses are valued collaborators in this regard and are encouraged to familiarize themselves with how their respective hospitals and health care systems are assessing and addressing the identified needs of patients. According to the American Hospital Association, by 2023, 48% of health care organizations will have a standardized means for collecting data on the social determinants of health, making this an important opportunity for nursing practice. Knowing where one’s organization stands with these efforts is an important first step.

Public policies that address the root causes of poor health status and longevity are central to any effort devoted to addressing the social determinants of health. Nurses are encouraged to get involved with their professional organizations, home institutions or other stakeholders who can work together to advance a policy agenda aimed at addressing the myriad of social and economic factors that impact health.”

Cultural Competence

According to Dr Jasmin Whitfield (RN, MSN, MPH, DNP), “culturally competent care is not just acquiring information on a particular group of people but rather developing a respect for and understanding that the beliefs, attitudes, behaviors, language, and rituals of that group all play a role.” The epidemiology, manifestation of disease, and effects of medications vary among different ethnic and cultural minorities, so nurses need to make themselves aware of matters such as ethnicity and culture, sexual preferences, and other points of identity as part of their patient dialogue, as all of these matters have specific health connotations.

DN: How can a nurse deal with topics such as patients’ ethnicity, language, culture, sexual orientation, and gender identity in a sensitive, yet direct manner?

Margaret Moss: “It may be of help for the practicing nurse to know of other care modalities recognizing a cultural component. There is Cultural Safety, defined by Williams (1999), “as an environment that is spiritually, socially and emotionally safe, as well as physically safe for people”. This includes being safe to tell your nurse how you identify, relay your spiritual and other needs without fear of retribution etc. Especially when there is patient-provider racial, gender or ethnic discordance, there can be a tentativeness on either side to communicate effectively and fully.

There is Cultural Humility and Cultural Respect as well. So, a big tip is just ask…very simple. With humility, state you are unaware of any special needs or care they may have and ask. Ask, how do you identify? Instead of guessing and then go from there. Whereas Cultural Competency can be seen as useful for the dominant culture caring for the ‘other’. As an Indigenous nurse, no one offered me a Cultural Competency course or workshop as I cared for dominant culture patients. However, safety, humility and respect always serve to increase a patient’s comfort and optimize results.”

Health Equity and Social Justice in Nursing

Social justice is a key aspect of health equity and is a core concept of nursing ethics. The American Nurses Association (ANA) states that nursing has a “professional responsibility to address unjust systems and structures.” Adhering to this ethic can lead to involvement in some divisive issues, but nurses have been advocates for social justice and human rights since the days of Florence Nightingale.

DN: In your view, what role do today’s nurses have in working towards social justice?

Margaret Moss: “Social Justice (from the Oxford Dictionary at Lexico) is justice in terms of the distribution of wealth, opportunities, and privileges within a society. It is well known, published, proved, that minorities in the US suffer, daily and out of proportion to non-minority peoples, at the lower end of these distributions.  Other groups such as the poor, working poor, chronically ill and disabled, and LGBTQQ2+ suffer as well. To help even out these disparities in the health realm, nurses must advocate. At times, they are the only thing standing between a patient and health or death. 

Similarly, nurses are and must be advocates beyond the individual. Nursing programs at the bachelor’s level and above incorporate Community Health, Population Health, Leadership and often Health Policy into the curriculum. I sought a law degree after my PhD in nursing, as both have at their base-advocacy. I have worked my career in advocating for more just American Indian Health. Social Justice Issues face every nurse every day and they are deep and wide. They hit ethics; policy and procedures that may be seen as detrimental but are, “always done that way”; unpotable water such as in Flint, MI; or Uranium on American Indian reservations; lack of available medicines; unfunded programing, and the massive leading edge of aging care; autism; and a host of other issues.”

DN: Finally, what actions can nurses take to further social justice and health equity in healthcare?

Margaret Moss: “Nurses at 3 million strong have the collective and individual power to help change these imbalances, by showing up (legislatures); speaking up (comment on proposed rules); and participating (in practice and advocacy associations).”

Influenza Vaccinations: Do Jails and Prisons Vaccinate Inmates?

Influenza Vaccinations: Do Jails and Prisons Vaccinate Inmates?

By Jeffrey E. Keller, MD, FAACP

Border detention facilities that house immigrants have been in the news recently because of their policy of not providing influenza vaccinations to their detainees, sparking high-profile protests. Why would an immigration detention facility, tasked among other things with providing comprehensive medical care to its detainees, refuse to provide them with flu vaccines?

To answer this question, it might be instructive to ask how influenza vaccinations are handled at other prisons and jails in the U.S. It depends on what type of facility you are in and how long you will be there. All prison systems I know of offer influenza vaccinations to their inmates. On the other hand, most jails (short-term detention facilities) do not have a routine flu vaccination program, though there are exceptions.

Vaccinations in Prisons

Inmates are sentenced to prison for a minimum of one year and usually longer. As a result, prison populations are stable. Almost all of the inmates in a particular prison now will still be there next year. Also, prisons are tasked with providing comprehensive medical care to their inmates. This includes influenza vaccinations, but also other recommended vaccinations and boosters. Of course, just like in the community at large, not all inmates want to be vaccinated. The percentage of prison inmates who get vaccinated depends on how vigorously the prison pushes the program.

If a prison advertises the availability of the flu vaccine and actively encourages its inmates to be vaccinated, the acceptance rate can be greater than 50% (compared to about 33% of adults in the community who get vaccinated). Most prisons have a “big push” campaign to encourage flu vaccines once a year in the fall. However, if a prison does not advertise the availability of the flu vaccine, the percentage of inmates vaccinated can be very low. It makes economic sense for prisons to actively encourage their inmates to be vaccinated. Every dollar spent on influenza vaccinations will save more than a dollar down the road trying to deal with influenza outbreaks.

Vaccinations in Jail

Influenza programs in jails are different for several reasons. The first issue is that the inmate population in a jail is not stable. The average length of stay in the average jail in the U.S. is around 2-3 weeks and many are released within days. If a jail offers influenza vaccinations in October, most of the inmates vaccinated will be gone by November. The jail will now be filled with new, unvaccinated inmates. If you vaccinate the November inmates, most (again) will be gone by December. So, to be effective, influenza programs in a jail must last the length of the influenza season — making jail influenza programs more difficult and expensive to administer than a prison program.

As an example, remember that one must order influenza vaccines well in advance. In order to have influenza vaccines ready in the fall, a prison or a jail has to order them at least six months earlier. A prison will know how many influenza doses it will need based on its population and previous acceptance rate. But how many doses will a jail need with inmates coming and going over the course of an entire flu season? That can be hard to get right in a jail! It is expensive and maddening to order too many vaccines only to throw the unused doses away at the end of the flu season.

Also, jails vary greatly by size and sophistication of the medical services they provide. There are many small jails in the U.S. (think 10 beds) where no medical personnel ever come to the jail for routine medical care. If their inmates need medical attention, the deputies have to load them into a van and take them to a clinic or ER in the community. Such a jail is unlikely to offer influenza vaccinations to their inmates. On the other hand, bigger jails (say, more than 1,000 beds) with a full-time medical staff may indeed have an influenza vaccination program.

“Kicking the Can Down the Road”

The most successful jail influenza programs that I have seen are done in cooperation with the local health department. The health department is tasked with providing vaccinations to the community at large, which includes jail inmates. When asked, health departments often will come to the local jail once a month to provide influenza vaccinations to any inmate who requests one. (This is also a good way to provide screening for sexually transmitted diseases in asymptomatic inmates.) Even small jails can approach their local health department about providing immunizations to inmates, though few do.

Customs and Border Patrol reportedly defended its policy of not providing influenza vaccinations during border detention by saying that immigrants are only there for a few days and are expected to get the flu vaccine later, when they are moved to a long-term facility. Where I grew up, this was called “kicking the can down the road.” To my mind, deferring vaccinations until later makes little medical or financial sense. Since none of these detainees is going to be released, and since you are going to vaccinate them later anyway (as reported), why not do it as part of their initial medical screening?

Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his “true calling” of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at JailMedicine.com.

This post was originally published in MedPage Today.

The Problem of Pain: Prescribing Opioids to Addicted Populations

The Problem of Pain: Prescribing Opioids to Addicted Populations

Between 2006 and 2012, more than 32 million prescription pain pills circulated through Berkshire County, Massachusetts, a rural area of about 130,000 people.

Patients recovering from opioid addiction are seen at the local emergency department every day, according to Martha Roberts, a critical care Nurse Practitioner (NP) and Georgetown University School of Nursing & Health Studies alumna. Roberts works in Berkshire’s emergency department, which sees 50,000 patients per year — more than a third of the county’s population.

“It’s challenging,” she said. “It’s also an opportunity to help those patients in a way that may improve their outcomes.”

Patients in addiction recovery aren’t exempt from the need for pain relief in the case of acute injuries, surgical operations, or chronic pain. Providers like Roberts are tasked with finding and offering alternatives to opioids.

How can clinicians balance the weight of ethical responsibility with a patient’s need for immediate relief?

Opioid Dependence and Addiction in the United States

About 21% to 29% of individuals who are prescribed opioids misuse them, and 8% to 12% of them develop an addiction, according to the National Institutes of Health. Though only a small percentage of patients are likely to develop an addiction, there is still a chance of dependence, which is characterized by a physical reliance on the medication that, if unaddressed, can lead to addiction.

Even if the patient is not demonstrating symptoms of addiction, providers look for specific signs of dependence, according to Dr. Jill Ogg-Gress, assistant Family Nurse Practitioner (FNP) program director at Georgetown University.

“Opiate medications have side effects of dependence,” said Ogg-Gress, who works as a board-certified emergency NP in several Iowa and Nebraska emergency rooms. “If a provider recognizes that a patient is experiencing dependence, or if a patient demonstrates behaviors of dependence, it should be recommended to the patient they should talk to their primary care provider or the prescriber of the opioids.”

Signs of opioid dependence
  • Taking painkillers more frequently than prescribed
  • Taking higher doses than prescribed
  • Seeking a euphoric effect to counter physical pain
  • Experiencing excessive sleepiness or irritability

Taking these signs into account, providers can evaluate patients’ needs on an individual level to assess the magnitude of pain. If the patient is likely to develop a dependence, the providers may need to help them find an alternative treatment plan that is effective and sustainable.

Ruling out opioids altogether isn’t a realistic approach, Roberts said.

“There are still some painful injuries that will benefit from short-term opioid use,” she said.

Her key to implementing an effective treatment plan is working with the patient to assess their needs and openness to non-opioid pain medication.

Commonly Used Alternatives to Opioids

Opioids are a class of drugs that can be prescribed for pain relief but are highly addictive and illegal for consumption when not prescribed by a health care provider.

Individuals recovering from drug addiction might encounter injuries or surgical operations that require management of immediate acute pain or chronic pain in the long term. Providers can evaluate a patient’s needs when creating a treatment plan to manage that pain.

Pharmacological alternatives to opioids

Analgesics: Some of the most common painkillers can be obtained over the counter in small doses or prescribed in high doses by a health care provider. Roberts and Ogg-Gress agreed that these are the most common alternatives to opioid prescriptions.

Acetaminophen can be used for pain relief and fever reduction, but it does not reduce inflammation. It’s one of the most common pain relievers among Americans, used by roughly 23% of adults each week.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can treat acute pain and inflammation. A 2018 report found that NSAIDs make up 5% to 10% of all medications prescribed each year.

Gabapentinoids: This class of drugs includes gabapentin and pregabalin and has been historically used for seizure prevention. It is available by prescription to address pain but only in circumstances set by the Food and Drug Administration. While these painkillers can be an alternative to opioids, Roberts said they are not her intervention of choice because studies show there are other, more effective alternatives.

When medication isn’t appropriate or preferable, many non-pharmacological options exist to relieve pain and suffering.

“There are a lot of other nonpharmacological therapies that are available, if people are willing to try it,” Ogg-Gress said. “Providers need to educate patients regarding these pain therapies instead of the common thought of, ‘Here, take a pill, swallow it, and you’ll feel better.'”

Non-pharmacological alternatives to opioids
  • Localized numbing
  • Ice
  • Massage
  • Exercise
  • Physical therapy
  • Acupuncture
  • Relaxation

Supporting Patients in Recovery

Every patient deserves time and attention to explain their case and their needs to a provider who is listening thoughtfully. Providers treating addicted populations must keep a constant eye out for identifying drug seeking behaviors, without stereotyping or wrongly assuming a patient’s motives. A 2016 report published by the National Institutes of Health described several types of drug-seeking behaviors:

Common Drug-Seeking Behaviors
Requests and complaints
  • Describing a need for a controlled substance
  • Asking for specific opioids by brand name
  • Requesting to have a dose increased
  • Citing multiple allergies to alternative pain therapies
Inappropriate self-medicating
  • Taking more doses than recommended by the provider
  • Hoarding a controlled substance
  • Using a medication despite not being in pain
  • Injecting an oral formula instead of consuming orally
Inappropriate use of general practice
  • Visiting multiple providers for controlled substances
  • Calling clinics when providers who prescribe controlled substances are on call
  • Frequent unscheduled visits, especially for early refills
  • Consistently disruptive behavior
Patterns of resistance
  • Hesitancy to consider alternative pain treatments
  • Declining to sign controlled substances agreement
  • Resisting diagnostic workup or consultation
  • Being more interested in the medication than solving the medical problem
Illegal activity
  • Obtaining controlled drugs from family members or illicit sources
  • Using aliases or forging prescriptions
  • Pattern of lost or stolen prescriptions

Clinicians who have identified these behaviors can use electronic medical records and crossover notes from other providers to see how many times a patient has sought medication for the same problem.

“People are here for assistance, but they’re not taking personal responsibility,” Roberts said. Engaging with patients to help them understand treatment plans can build a sense of agency over their own care.

Roberts said providers can help patients identify ways to care for themselves before writing a prescription for opioids. She recommended a gradual approach to trying different types of treatment:

A Step-Wise Approach for Pain Management

  1. Get to know the patient
  2. Use analgesics to address pain symptoms
  3. Use non-pharmacological treatments as intervention for side effects
  4. Encourage patient to stop smoking and drinking alcohol
  5. Eliminate foods that irritate the stomach or digestive system
  6. Reflect on previous steps: Did you really exhaust everything?
  7. Consider opioids as a last resort, and only enough to support immediate pain relief

Nurse Practitioners who work with a multidisciplinary team are uniquely positioned to provide holistic care. Clinicians serving communities with large addicted populations have to be familiar with law enforcement, social work organizations and, in the case of making a referral outside the clinic or emergency department, recovery programs and child protective services.

Roberts also acknowledged that providers working in communities fraught with addiction are at a high risk for fatigue. “If you have three back pain patients in a row, you’re going to be pretty burned out within two hours of working your shift, so you really, truly have to look at each case individually,” she said.

Taking time to self-reflect on personal motivations for treating patients can help remind providers of why caring for others is important to them.

“It’s hard to walk in and do a good job if you’re upset about the work you’re doing,” Roberts said. “Make sure you can do this without letting your own bias get in the way.”

Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.

Citation for this content: [email protected], the online DNP program from the School of Nursing & Health Studies

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