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A D V A N C E D P R A C T I C E

I n the acute care hospital setting, the interdisciplinary care team is faced with challenges on a daily basis and must respond to any abrupt changes in a patient’s con- dition. Often, the course of a hospitalization for one patient is unpredictable and involves frequent commu-

nication between the patient, the family, and members of the care team to achieve positive outcomes. Trauma sur- gery is a multifaceted specialty that requires collaboration between nursing staff, physicians, and therapists. With the diverse needs in trauma surgery, from specialized procedures, to critical care management, to evaluation of

ABSTRACT The trauma acute care nurse practitioner (ACNP)

participates in the care of critically-ill patients by utilizing his

or her advanced clinical skills at the bedside and through

communication with the interdisciplinary team, the patient,

and the patient's family. Although the incidence of morbidity

is decreasing in trauma, death can occur shortly after

arrival to hospital, or in the days after initial injury, leading

to the need for the unexpected conversation of end-of-life

wishes with a patient or the patient's family. It is within the

scope of the ACNP to facilitate these conversations, and

it is recommended that ACNPs engage patients and their

families in these conversations for overall improved patient

outcomes. Many techniques exist to aid in this difficult

decision-making process and may be useful to the trauma

ACNP when having end-of-life discussions.

Key Words Acute care nurse practitioner , Communication , Decision-

making strategies , End-of-life , Trauma

Author Affiliation: Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, and Paoli Hospital, Paoli, Pennsylvania.

Supplemental digital content is available for this article. Direct URL citations

appear in the printed text and are provided in the HTML and PDF versions

of this article on the journal's Web site ( www.journaloftraumanursing.com ).

The author declares no conflict of interest .

Correspondence: Stephanie N. Barndt, MSN, CRNP, AGACNP-BC, CEN, Department of Medicine, Penn Presbyterian Medical Center, 51 N. 39th

Street, Wright-Saunders W128, Philadelphia, PA 19104 ( stephanie.fuga@

gmail.com ).

Death in Trauma: The Role of the ACNP in Patient Advocacy and Familial Support in End-of-Life Care Decision-Making

Stephanie N. Barndt , MSN, CRNP, AGACNP-BC, CEN

DOI: 10.1097/JTN.0000000000000363

discharge planning needs, acute care nurse practitioners (ACNPs) are being utilized in the care of these patients as a resource for their expanded nursing scope and exper- tise in understanding holistic patient care. Although the inherent goal of trauma surgery is to “fix the problem” and save the life of a patient, traumatic injuries are often devastating and life altering, affecting all age groups and both relatively “healthy” patients as well as patients with numerous comorbidities. Neither patients nor their loved ones are able to anticipate a traumatic injury, thus mak- ing traumatic events complex situations to handle and only further demonstrating the need for ACNPs as team members in this field.

PROBLEM In the occasional unpredicted patient care trajectory that occurs in trauma, the provider must discuss a patient’s wishes for medical intervention with the patient and the patient’s family, so long as the patient approves of this, or in the instance of the unresponsive patient. The stress surrounding critical care management weighs heavily on patients and their families, making for an even more dif- ficult experience in the decision-making process. ACNPs are uniquely beneficial to the high-stress and sensitive situations that arise, because they are required to have a background in bedside critical care nursing. As a member of the trauma team, the trauma ACNP should be utilized in the decision-making process for medical intervention and end-of-life decision-making in this critically-ill patient population, because he or she has both the advanced knowledge of the traumatic disease process in addition to finessed communication and education techniques that can potentially guide the patient and the family to an informed decision regarding this delicate subject. This article discusses the value of utilizing the ACNP in end- of-life care planning for the trauma patient, as well as decision-making techniques that may benefit the ACNP when facilitating these discussions.

BACKGROUND AND SIGNIFICANCE The trauma ACNP participates in multiple settings, from the emergency department and critical care units, to the operating room, to medical–surgical units and outpatient

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offices. This designation is determined per a specific hos- pital or facility, and as a result, the ACNP’s clinical skills vary based on the needs of that setting ( Lafferty, 2011 ; Sherwood, Price, White, Stevens, & Van Boerum, 2009 ). Examples of common competencies of the trauma ACNP include completing history and physicals, prescribing medications, laboratory and diagnostic testing interpreta- tion, central line and chest tube insertion, and suturing wounds. In addition to varied clinical responsibilities and an expansive practice scope, the trauma ACNP also par- ticipates in rounding on patients and discharge planning, as well as collaborates with physicians and other interdis- ciplinary team members ( Lafferty, 2011 ; Sherwood et al., 2009 ). The utilization of specialized trauma ACNPs has shown to improve patient outcomes overall by decreas- ing lengths of stay, decreasing rates of complications, and improving patient satisfaction through clear discussion of plan of care and overall open communication ( Lome, Stalnaker, Carlson, Kline, & Sise, 2010 ; Morris et al., 2012 ; Noffsinger, 2014 ; Sherwood et al., 2009 ).

Relevance As of 2014, approximately 2.3 million people were ad- mitted to hospital for traumatic injury, with 192,000 dy- ing from trauma ( National Trauma Institute, 2016 ). Lead- ing mechanisms of unintentional injury included motor vehicle crashes, falls, and poisonings. According to the Centers for Disease Control and Prevention, trauma is the leading cause of death for adults aged 18–46 years, and ranks in the top three leading causes of death in the United States for all age groups ( Centers for Disease Control and Prevention, 2014 ). Timing of death can be categorized according to its relationship to the initial in- jury: death immediately following the injury, death within 24 hr after admission to hospital, and death days to weeks following the initial injury. The incidence of “late death,” or that occurring greater than 24 hr after the initial insult, has decreased over time from 20% to approximately 9% ( Sobrino & Shafi, 2013 ). Although the end goal is always to save a life in trauma, death is not entirely preventable and remains rather prevalent, only further demonstrating the need for ACNPs to undertake the role of assisting in medical intervention and end-of-life decision-making with the seriously injured trauma patient.

Review of Literature Numerous studies have demonstrated the benefits of in- cluding ACNPs as members of the trauma team, not only because of their broad skill set but also for their success- ful patient care statistics. According to reviews by Fry (2011) , Lome et al. (2010), and Sherwood et al. (2009), ACNPs have achieved a reduction in hospital length of stay, readmission rates, infection rates, and morbidity and

mortality among the patients they care for. As a result, patient satisfaction increases whereas hospital costs decrease ( Fry, 2011 ). Morris et al. (2012) and Sherwood et al. (2009) found, respectively, that both unit-based and trauma ACNPs provide clearly delineated continuity of care in light of reduction of resident work hours. Walter and Curtis (2015) specifically describe trauma nurse prac- titioners as accomplishing these same standards of care set forth by their institutions and meeting expectations for improved patient outcomes. Additional traits that are noted as unique to the abilities of the trauma ACNP in- clude attention to detail, organization, and flexibility in the work environment ( Lome et al., 2010 ). Trauma nurse practitioners have noticeably acquired the advanced skills that are required in the care of the trauma patient, while cohesively working with the trauma team and delivering expert care that is well-recognized by both patients and their colleagues ( Fry, 2011 ; Lome et al., 2010 ; Sherwood et al., 2009 ; Walter & Curtis, 2015 ).

With their required critical care background, trauma ACNPs are prepared to participate in difficult conversa- tions with patients and families. As previously discussed, decisions surrounding medical interventions and end- of-life care can cause additional stress for conscious and alert patients, as well as their loved ones. The setting of a traumatic injury creates a layer of stress in the case of the trauma patient, as these events occur unexpectedly and therefore act as an obstacle when the health team needs to determine patient and familial wishes. Barri- ers to facilitating a successful conversation surrounding end-of-life care discussions exist, including inadequate time to hold the conversation or rather, having a discus- sion about end-of-life when the patient’s condition sud- denly deteriorates; a misunderstanding between primary and consulting providers on the patient’s prognosis; the lack of a trusting relationship between the patient/family and the provider; the lack of presence of the whole care team or family designated as proxy; and a general level of discomfort with initiation of such delicate conversa- tion ( Aslakson et al., 2012 ; Cooper et al., 2016 ; Gordy & Klein, 2011 ). The greatest barrier, as perceived by pro- viders who must initiate end-of-life care discussions, is a lack of patient or family understanding of prognosis ( Hajizadeh, Uhler, & Perez Figueroa, 2014 ). According to Kryworuchko, Strachan, Nouvet, Downar, and You (2016), there are other influencing factors that can create a more stressful decision-making process for necessity of medical interventions and end-of-life wishes. Some examples of these perceptions that might impede a suc- cessful conversation include viewing death as a failure (both the patient and the health practitioner), needing to process all of the facts surrounding the patient’s prog- nosis, and achieving true consensus among the patient,

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family, and health care team. The ACNP must consider these barriers and findings when attempting to have these difficult conversations with patients and loved ones. Most importantly, health care providers must initi- ate a trusting relationship by being openly communica- tive, even when that means sharing uncertainty about a patient’s illness or recovery from an injury ( Billings, 2011 ; Fridh, 2014 ; Gordy & Klein, 2011 ; Kryworuchko et al., 2016 ). It is difficult to completely standardize the feelings patients and their loved ones may have on this topic; however, taking an unbiased approach and hav- ing an idea of some potential patient and family percep- tions of the situation might allow for a more successful and productive conversation.

Current evidence establishes the degree of difficulty that providers are met with when holding conversations about goals of care or end-of-life wishes with patients and their families ( Cooper et al., 2016 ). Attempting to initiate a discussion around goals of care at the time of admission can improve later decision-making by laying groundwork for the course of hospitalization, without set- ting unrealistic expectations in case the patient’s condi- tion suddenly changes ( Aslakson et al., 2012 ; Belanger et al., 2014 ; Billings, 2011 ; Gordy & Klein, 2011 ). If there is a drastic change in a patient’s condition, practition- ers can turn to the initial goals laid out by the patient and the family as a starting point when new decisions must be made ( Turnbull, Sahetya, & Needham, 2016 ). At times, medical intervention and advanced care planning decisions are left to the patient’s family, who are often in distress related to the gravity of the current situation. Having a trained member of the health care team acting as the liaison for communicating between the family and health practitioners may benefit the family’s psyche and overall distress related to decision-making ( Curtis et al., 2016 ; Fridh, 2014 ; Milic et al., 2015 ). ACNPs, having a critical care background and potential experiences as the bedside nurse related to end-of-life, have the opportunity to develop therapeutic techniques necessary to effective- ly communicate with patients and their families in these delicate scenarios, and have already proven their abil- ity to improve patient satisfaction with their delivery of care ( Fry, 2011 ; Lome et al., 2010 ; Sherwood et al., 2009 ; Walter & Curtis, 2015 ).

Implications for Practice Although the illness trajectory of each trauma patient is usually patient specific, the ACNP is readily prepared to act on behalf of the trauma team in guiding patients and their family members through shared decision- making, especially when discussing end-of-life care. The trauma ACNP has an understanding of the advanced pathophysiology involved with traumatic illness and the

pharmacology necessary to treat said illnesses. Through open and effective communication, the ACNP can explore any psychosocial considerations surrounding the patient’s care, and in using certain communicative techniques, the ACNP can then provide guidance for ethical and shared decision-making for the critically-ill trauma patient.

The ACNP’s Scope in End-of-Life Care Planning According to the American Association of Colleges of Nursing, one of the competencies of the ACNP is prepara- tion in end-of-life discussions and advance care planning ( McRee & Reed, 2016 ). The range of the ACNPs clinical skills, from advanced procedural techniques and manage- ment of high-acuity patients, to advanced communica- tion skills and engagement in health promotion initiatives, demonstrates the diversity in ACNP educational prepar- edness and readiness for facilitating such difficult discus- sions ( Lafferty, 2011 ; Sherwood et al., 2009 ). Unfortunate- ly, many barriers exist that contribute to maintaining a “gray area” in which ACNPs fall for recognition of their professional ability to participate in end-of-life care plan- ning. Across the United States, nurse practitioners are lob- bying for full autonomy practice in the majority of states. In addition, ACNPs work in numerous hospital environ- ments where hospital-level polices do not clearly recog- nize the role of the ACNP in end-of-life decision-making, and although this skill is an educational competency, lim- ited formal continuing education exists for ACNPs to mas- ter this clinical skill ( Dube, McCarron, & Nannini, 2015 ; DuBois, & Reed, 2014 ; McRee & Reed, 2016 ). Overall, the literature suggests limited findings on the ACNP’s involve- ment in advance care planning and clinical outcomes as- sociated with ACNP-led discussions ( Dube et al., 2015 ). However, nurse practitioners, specifically working in both the acute care and hospice settings, as well as with can- cer patients, have shown through multiple studies that they have contributed to improved emotional and men- tal quality-of-life measures for these patients by engaging them and their families in these important conversations ( Dyar, Lesperance, Shannon, Sloan, & Colon-Otero, 2012 ; DuBois & Reed, 2014 ; McRee & Reed, 2016 ). So far, the literature has indicated that if provided adequate educa- tion on end-of-life conversations, the bedside intensive care unit nurse could act as the liaison or patient advo- cate when included in discussions between providers and critically-ill patients and their families ( Fridh, 2014 ; Milic et al., 2015 ). When coupling prior experiences as the bed- side critical care nurse with the advanced knowledge ob- tained when becoming an ACNP, the trauma ACNP is able to engage patients and their families in end-of-life de- cision-making conversations, while keeping in mind the whole patient, and with the intent to benefit the patient’s clinical outcome.

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2016 ). In a differing approach, Allen et al. (2017) imple- mented inclusion of family members in patient rounds in the intensive care unit, which proved to be successful in effective communication among the health care team with patients and family members and increased patient and family satisfaction with care. Through the establishment of the trauma ACNP as a resource for effective commu- nication between the health care team and the patient or patient’s family, the trauma team will be able to set realistic goals for patient care and thus lead to a positive outcome for care delivered.

The ACNP’s Role in Guiding Decision-Making: A Summary As integrated clinical members of the trauma team, ACNPs contribute their combined skill set of critical care knowl- edge and advanced care techniques with their unique ability to establish an open relationship with patients and their families. Having already learned to engage patients and families in their care as bedside nurses results in their innate ability to effectively communicate a plan of care and establish trust with patients and families when difficult questions are asked regarding illness trajectory ( Fridh, 2014 ; Milic et al., 2015 ). ACNPs would encourage active involvement of families in the care of their loved one through participation in rounds ( Allen et al., 201 7) and establish goals of care, which unfortunately means cure is not possible 100% of the time, but creating open and meaningful dialogue helps patients and families bet- ter understand and make informed decisions ( Aslakson et al., 2012 ; Gordy & Klein, 2011 ; Kryworuchko et al., 2016 ). Despite all interventions and efforts made by the trauma team, death remains a prevalent outcome of trau- matic injury. Before approaching a patient or a family to discuss end-of-life wishes, the ACNP must be mindful of their comfort level with such a discussion as well as previ- ous experience with this topic. It is important to engage in such a conversation, as it allows the patient autonomy in decision-making, thus enabling the healthcare team to provide comfort measures rather than engage in unneces- sary or unwanted treatment ( Martin et al., 2014 ). Ultimate- ly, when discussing end-of-life wishes, the patient should be granted the necessary tools to alleviate the stress of such a process, and it begins with the intrinsic ability to “make sense” of one’s illness ( Davidson, 2010 ). ACNPs have already demonstrated their value as members of the trauma team, and more research is necessary to validate their role in facilitating productive decision-making con- versations with patients and their families. Through their altruistic nature and understanding of advanced disease processes, ACNPs should be utilized in assisting patients and family members in end-of-life decision-making, espe- cially in the field of trauma.

Strategies for Guiding Decision-Making When initiating a difficult conversation, such as estab- lishing goals of care or advanced care planning, the ACNP might utilize communication techniques or de- velop a strategy to outline the conversation so that patients and their families have a clear understanding of the purpose of the conversation, and that all might reach a consensus in the patient’s care. Simple conver- sational principles, such as eye contact, allowing for pauses, and asking the patient or family to summarize what was said, are basic means that can ensure patient/ family comfort with the ACNP and understanding of prognosis or treatment options ( Cooper et al., 2016 ). The ACNP should consider outlining the topics needed to be discussed in such a conversation, from delivering the patient’s prognosis and summarizing the patient’s status, to reviewing goals of care and providing rec- ommendations, and finally, offering patient and familial support. Overall, developing such a concise outline is useful not only to the ACNP but also to the patient and the family when such critical information is communi- cated ( Cooper et al., 2016 ).

Certain approaches to shared decision-making that have been applied in other areas may be used when at- tempting to guide conversations with trauma patient (see the Supplemental Digital Content, Table A1, available at: http://links.lww.com/JTN/A5 ), especially when discuss- ing advanced care planning. In a study implemented by Myers et al. (2016), patients diagnosed with prostate can- cer were provided with a decision support intervention (in written format) reviewing treatment options. This tool, which also included contact information for a nurse liai- son as a resource for questions, allowed these patients to engage in their care and provide them with the neces- sary information about treatment modalities to increase their knowledge base while decreasing anxiety and stress surrounding diagnosis ( Myers et al., 2016 ). Although this format is not readily applicable to the world of trauma, having a liaison such as the ACNP for answering ques- tions and allowing open discussion would better facilitate the necessary conversation regarding end-of-life wishes. Another study by Curtis et al. (2016) demonstrated the successful use of a “communication facilitator” to prevent poor communication between health care providers and families, which causes more distress when already coping with the critical illness of a loved one. This further vali- dates that this often-empty role can be filled by the trau- ma ACNP. Additional survey reveals the need to establish goals of care with patients and their families as well as thorough explanation of invasive, life-sustaining proce- dures to ensure that any medical intervention does not go against the wishes of the patient or family members, if they are speaking on behalf of the patient ( Turnbull et al.,

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KEY POINTS

• In the instance of trauma-related critical illness, patients and

families are often faced with the diffi cult discussion topic of

end-of-life wishes.

• The trauma ACNP's scope of practice includes facilitating

complex conversations such as end-of-life decision-making.

• Some techniques that might be useful to the ACNP in such

conversations include the decision support intervention

technique, acting as a communication facilitator, thorough

explanation of procedures, and the inclusion of the family

in patient rounding (see the Supplemental Digital Content,

Table A1, available at: http://links.lww.com/JTN/A5 ).

• Trauma ACNPs are fundamental members of the

interdisciplinary team, and when given the opportunity to

engage patients and their families in end-of-life planning

discussions, it would result in an established trusting

relationship between the team, patient, and family. The

ACNP has the skills necessary to provide the patient and

the family with the information to make an autonomous

decision, leading to overall patient satisfaction.

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