Chronicle of a death foretold
Canadian reports show value of listening to nurses
February 7, 2015 – A short piece in today’s Toronto Sun highlighted an admirable initiative by the Registered Nurses Association of Ontario (RNAO) to ensure that nurses play a role in creating new laws related to “physician-assisted” suicide, which the Canadian Supreme Court recently ruled must be permitted. The QMI Agency item features extensive quotes from RNAO CEO Doris Grinspun.
She stresses the critical roles that nurses play in end-of-life care and how much they have to “offer to the development of the new legal framework,” including ensuring that patients’ best interests and wishes are protected. And what happens when nurses’ special expertise is ignored in the creation of important health policies? In a January 7, 2014 Canadian Press piece, Chinta Puxley reported that a Winnipeg hospital nurse had warned that “people will die” as a result of a redesigned emergency department waiting room. Months later, a patient actually was discovered dead there, 34 hours after arriving to be seen for a “treatable bladder infection caused by a blocked catheter.” Nurse Jan Kozubal reportedly told an inquest into the 2008 death of Brian Sinclair that nurses had voiced concerns to senior hospital staff in 2007 “that the redesign made it hard to see patients in the waiting room from the nurses’ station.” However, she said, “nobody was listened to.” It appears that there were other factors in Sinclair’s death, including nurse understaffing. And many hospital staff reportedly saw the man waiting and observed his deteriorating situation. But the sad story shows the harm that can occur when nurses’ input is disregarded, in matters ranging from hospital design to broader health policies. We thank those responsible for both of these helpful pieces.
Designing new laws
The Toronto Sun item, which seems to be based entirely on an RNAO press release, reports that RNAO says Ontario nurses “can play a crucial role in designing new laws around physician-assisted death.” The piece follows the recent Canadian Supreme Court ruling that struck down a national ban on assisted suicide and established specific judicial standards for it to proceed, in anticipation that the nation’s Parliament will create enabling legislation within a year. Most of the item consists of quotes from Grinspun, who says RNAO will help create a regulatory structure that protects the public:
Nurses play a critical role in end-of-life care and have much to offer to the development of the new legal framework. End-of-life care is top-of-mind for nurses who work across the health system and in all sectors, from providing palliative care including appropriate pain management, to working with families on a do-not-resuscitate order, to helping patients with advanced-care planning to make sure loved ones are prepared. … We all have a right to our own views, but it’s dangerous to disregard those who don’t share the same perspectives. We need to work together to ensure this process is respectful, and keeps the patient’s best interest and wishes at the forefront.
This is very short and fairly general, but there are several good elements. First, the very fact that the press is reporting that someone thinks nurses can and should help create major health policy is helpful. In addition, Grinspun stresses that nurses play a key role in end-of-life care, giving specific examples: palliative care including pain control, advanced-care planning, and the “do-not-resuscitate order” (perhaps better termed an “allow-a-natural-death” directive). And Grinspun includes a fairly pointed note that the key consideration, whatever views people may have about assisted suicide, is “the patient’s best interests and wishes”—and presumably not other people’s religious, professional, or personal interests, any of which might cause someone’s final days or hours to proceed in ways that person does not want. Ideally the piece might have made sure readers know that “Dr.” Grinspun is a nurse rather than a physician, since some may not be aware that nurses get doctorates. Also, while we realize that the media and legal discussion of the issue has been mainly about whether “physicians” and “doctors” may assist in suicides, it would appear that advanced practice nurses would be at least as qualified to do so, especially in view of the points Grinspun makes about nurses’ focus on issues surrounding end-of-life care.
On the other hand, what happens when nurses’ perspectives on key health issues are ignored?
People will die
According to Puxley’s Canadian Press piece, hospital nurse Jan Kozubal “says she sounded a warning that ‘people will die’ in a newly designed emergency room months before a man died during a 34-hour wait for care” at Winnipeg Health Sciences Centre. Kozubal told a 2014 inquest into the death of Brian Sinclair that she had “voiced concerns” when the new emergency department (ED) opened in 2007, well before Sinclair’s death in 2008, that “the redesign made it hard to see patients in the waiting room from the nurses’ station.” She had reportedly told an emergency physician soon after the redesign that “people will die in here.” Kozubal had said that “‘we voiced our concerns from Day 1 about the TV facing backwards’ making it impossible to see the faces of many patients from the nurses’ station.” Testimony at the inquest showed that other nurses had “expressed similar concerns” that the new layout “made it hard to monitor the waiting room.” However, Kozubal said, “nobody was listened to.” It is not clear from this piece who heard these concerns beyond that physician. Of course, it might not be enough to simply tell a colleague who had no management authority. Physicians do not necessarily have that, and they do not have authority over hospital nurses; nurses manage other nurses, and a nursing manager would presumably be the best person for a concerned nurse to start with. In any case, Kozubal reportedly also told the inquest that the ED was “busy and short-staffed” the day Sinclair arrived:
There were only two of us at triage when there should have been three of us. It was very difficult to keep up with the workload. Reassessment was not getting done as it should have been.
The Canadian Press report says Sinclair was a double-amputee who went to the ED in September 2008 because he had not urinated in 24 hours. According to the administrative review, 17 staff observed Sinclair—one even gave him a bowl when he started vomiting—but all made different assumptions that apparently did not involve them doing anything to help him, including that he had already been triaged and was awaiting a bed, that he had been treated and discharged, and that he was drunk and awaiting a ride elsewhere. After 34 hours, he was discovered dead, having “died of a treatable bladder infection caused by a blocked catheter.”
Obviously there is more going on here than the hospital redesign about which the nurses expressed concern. But even the apparent nurse understaffing is, to a great extent, the result of a failure to listen to nurses’ concerns about that critical aspect of the health care environment. Nurses worldwide have persistently raised those concerns in the face of the cost-cutting measures of recent years, citing research showing that when nurses are understaffed, patients die. In general, nurses are the health professionals who are most focused on the care environment, who spend the most time there, who think broadly about all factors that may affect patient wellbeing, and whose profession is built on the notion of patient advocacy and protection. It seems that Sinclair may have been the victim of a number of failures in the hospital system, but that at least some of them might have been avoided—and the patient might have survived—had nurses’ concerns been heeded. Of course, the piece does not come out and say all of that. And it might have been helpful to learn who heard the nurses’ earlier concerns about the redesign. Did the nurses not inform anyone with real authority because they assumed, perhaps with reason, that their views would be ignored? That kind of dynamic is a real barrier to nursing advocacy as well as a threat to patients. But the piece does have enough information for readers to draw the conclusions that the views of triage nurses matter, that nurse staffing levels matter, and that those in authority should pay more attention to nurses and their concerns.
See the article “Nurses should have a say in new assisted suicide legislation, group says,” posted on the Toronto Sun website on February 7, 2015.
See Chinta Puxley’s “Nurse had concerns that ‘people will die’ in new ER months before man died,” posted on The Canadian Press website on January 7, 2014.