Since Florence Nightingale, nurses have agreed that care should be individualized for each patient. Emergency care is no different and texts on this subject instruct the nurse to involve the client in his own care and to recognize that being an emergency victim is physically and psychologically difficult for the client. But just what is client-centered emergency care and are clients getting it?

A client is brought to the emergency room, unconscious, with severe head trauma resulting from a motorcycle accident. In this instance client-centered care consists of the nurse reacting swiftly and probably unemotionally. It is not in the client's best interest at this time for the nurse to try to ascertain that person's values and life views. Here client-centered care is compatible with the values and views of both the nurse and the institution.

Informed consent, as the courts define it, is the patient's right to know, before agreeing to a procedure, what the procedure entails — the hazards, the possible complications, and expected results of the treatment. The patient must understand any reasonable alternatives to the proposed procedure, including, in most cases, the results that can be predicted from nontreatment. The choice among alternative risks involves value judgments falling outside the scope of medical decision-making, including the patient's views on social, economic, and other personal factors of which health professionals cannot possibly be aware.

The negotiations necessary to obtain the patient's informed consent are the responsibility of the person who will perform the procedure. If a physician is in charge, the physician may delegate the discussion to another but retains the legal responsibility to make sure the patient understands.

Nurses have traditionally encouraged people to live, regardless of the meaning or consequences of continued life for the client. Despair profound enough to lead to a suicide attempt is viewed as an illness that must be cured. Nurses, as well as physicians, subscribe to the maxim primum non nocere (first, do no harm), although it may not be as clearly articulated in the canons of the nursing profession as it is in those of medicine. Nurses, for the most part, operate under the belief that suicide is always both mentally unhealthy and morally wrong; thus all efforts are made to prevent suicide. The idea that life is good and worthwhile and must be preserved at all costs applies to a wide variety of clients, including those who engage in behaviors that will probably lead to serious illness or death (e.g., overeating, smaoking, and suicide).

Few healthy people welcome death, but most would welcome a quick, easy death to avoid suffering and the loss of control over their lives. We need to ask: what sort of human environment do we hope for at the end of our lives? What will the world and our own living in it look like when we know we are about to die? What kind of human relationships will sustain us through this most personal of life's experiences when we may become more dependent on others? Do we fear we will either be abandoned through lack of meaningful personal contact with significant others, or be actors in a tragi-comedy of pretense in which authentic forms of human expression are unattainable?

Traditionally the great majority of health care related malpractice suits have involved physicians and hospitals. Increasingly, however, greater attention is being given to nurses as potential defendants and thus as sources for recovery in malpractice suits. As a result, more recognition is emerging for nursing as a profession accountable for its practice. This article will examine the concept of accountability by:

1. 1. reviewing selected legal principles of malpractice;

2. 2. discussing the trend toward increased inclusion of nurses in malpractice actions and the implications of this trend; and

3. 3. describing an Expert Nurse Witness and Consultation Service which was developed to provide nursing opinion on the professionally accepted standard of nursing practice.

On November 4,1979, Iranian terrorists took 53 Americans hostage at the embassy in Tehran and set into motion a national crisis — not only for the individual hostages and their families, but also for the staffs of the governmental agencies involved in the release negotiations. The incarceration of the Americans in Iran for 444 days will clearly be considered a critical life event of significant magnitude for both the returned hostages and for their families. The purpose of this paper is twofold: first, to describe the Task Force on Families of Catastrophe and its role in the Iranian crisis; and second, to identify ways in which nurses can be effective in dealing with victims and families caught in political and social upheaval. It will be useful here to briefly review crisis intervention theory.

In 1972 the California Supreme Court helped set the standard for informed consent in the landmark case of Cobbs v. Grant. That case involved a middleaged gentleman who was operated on for an intractable peptic duodenal ulcer. He suffered complications which included loss of his spleen, a subsequent gastric ulcer, and a 50% gastrectomy. None of these well-recognized potential risks of ulcer surgery had been disclosed to him. The court determined that physicians must disclose the following information to patients, in lay terms, before performing procedures on them:

1. a description of the procedure and its success rates;

2. risks of death or serious bodily harm;

3. alternatives, and the dangers inherent in each; and

4. major problems of recuperation.

In a previous column I discussed the testimony of a number of nurses in the case of Ms. Sharon Siebert. That case was decided by a lower court on February 13, 1981, and this column discusses Judge Lindsay G. Arthur's opinion. Jane Hoyt, a friend, not a relative, of Ms. Siebert, brought suit to enjoin an order not to resuscitate that had been written on Ms. Siebert. The case raised a number of important issues, including whether the court would allow a suit brought by someone in Ms. Hoyt's position vis-à-vis the patient, and if it did, what legal standard the court might require in the writing of Do Not Resuscitate (DNR) orders.

Most nurses not only accept the notion that patients have rights, but also stand ready to help patients assert them. But how far will nurses go? Will they be willing allies as patients press for more recognition of their individuality and autonomy? At the National Conference on Patients' Rights held in Nashville in late September, 1980, I outlined for patient rights activists a five-point agenda for the ‘80s. Since then I have presented this agenda to nursing audiences in Kentucky, Massachusetts, New York, California, and Michigan. The reception has varied, but many nurses are uncomfortable with the proposal. The purpose of this column is to present the agenda in written form to give Nursing Law & Ethics readers an opportunity to comment on it.

In the lead article Cynthia Northrop and Ann Mech discuss the growing role of nurses as expert witnesses in malpractice litigation. As they note, the increasing professionalization of nursing has led to more and more courts accepting the testimony of nurses as authoritative on the question of proper nursing practice. As a supplement to that article it is worth noting that nurses are also being called upon more frequently to testify on a wide variety of health care issues, and accordingly it is important for all nurses to have some familiarity with what goes on in a courtroom so that their testimony will be effective and useful to the judge and jury.

For example, I recently had occasion to sit in on the first day of trial of a case in Minneapolis involving the question of the appropriateness and lawfulness of an order not to resuscitate. During that day testimony was heard from four nurses, two laypersons, and one physician. Of these witnesses, only the physician seemed at home in the courtroom.

Hospitals are often busy places, and in the course of routine procedure many patients have their privacy violated. While patients have a right to privacy, sometimes called a “right to be let alone,” courts will not generally permit a patient to recover money damages unless it can be shown that the invasion was intentional and would be objectionable to a person of ordinary sensibilities. Two cases from the State of Maine illustrate the issues involved. The first is a 1976 case in which a physician, who had operated on a patient twice for cancer of the larynx, was taking a series of photographs of the patient's neck. On the day the patient died, the physician and a nurse came to the patient's room. The physician (or the nurse, at his direction) raised the dying patient's head and placed some blue operating room toweling under it for color contrast and proceeded to take photographs.

She is an attractive woman around 30 with two sons, the same husband she started out with, their mortgage (not the same one they started out with), and a license to practice nursing in Massachusetts.

And her story, anonymous but otherwise undisguised, will tell you more about the nursing shortage, the women's movement, the Medicaid crisis, the conservative revival and social change in America than any compilation of research, analysis, punditry and feminist literature. She is angry and the only reason she is going to take it any more is that she has not discovered a decent alternative.

She works odd, inflexible hours, some nights and Sundays, in the emergency room of a community hospital outside Boston. It is the kind of place to which your kindly old family doctor, interrupting a weekend frolic with the new cookie, refers his less affluent patients.

At a small community hospital, nurses are concerned about what they believe to be questionable medical care of one of the patients. The nurses frequently discuss the matter among themselves, but none of them approaches the patient's attending physician or the hospital administration.

At a large university school of nursing, a faculty member vehemently disagrees with opinions expressed in an article published in a widely circulated nursing journal. The faculty member writes a one-sentence letter to the journal's editors, cancelling her subscription.

And at a conference on legal aspects of nursing, a speaker discusses the entry into practice issue, including, of course, the 1985 proposal. There is very little audience discussion of this issue, although ample time has been allotted. Yet the written conference evaluations, filled out by the attendees, reveal that many of the nurses in the audience reacted strongly to the content. “What does the 1985 proposal have to do with nursing and the law?” wrote one nurse. “The 1985 discussion ruined the whole conference for me,” wrote another.

It is easier to identify an ethical dilemma than to solve it; this is the nature of the beast. In the process of deciding what to do, nurses are often pulled by conflicting demands from employers, patients, physicians, and other nurses: the feeling is that no resolution can be found which will satisfy everyone. A most difficult situation arises when the nurse feels an obligation to act in the best interests of patient care, but knows that to do so may be detrimental to her employer. When this happens, the nurse may fear that action to protect the patient will result in her being fired or some other form of retaliation by the employer. This fear is not entirely unfounded — employers do sometimes fire nurses who speak out against institutional policies. But a recent federal court case demonstrates that a hospital cannot summarily fire a nurse who acts responsibly in seeking to bring about institutional change.