Mental health and end of life

Types of Child Abuse

Neglect Signs of neglect may not always be obvious. The Child, Youth and Family Enhancement Act states that a child is neglected if the guardian is unable or unwilling to: Provide the child with necessities of life; Obtain for the child or permit the child to receive essential medical, surgical, or other remedial treatment that is necessary for the health or well-being of the child; or Provide the child with adequate care or supervision (Government of Alberta, 2014, p. 11). Neglect can affect the child's maturation process and have serious long-term psychological effects. The following table identifies some of the nursing history and physical indicators of neglect. These indicators are often difficult to obtain and interpret in the ED setting. Table 2.1. Indicators of Neglect. History Neglect Indicators Delays in seeking health care History of previous injuries Excessive absenteeism from school Malnourishment or failure to thrive History of being left alone Substance abuse Delinquency Child has unattended medical or dental problems Child is underweight, dehydrated, hungry, or emaciated Child has poor hygiene Child lacks clean or appropriate clothing suitable for the weather ______________ Adapted from Responding to Child Abuse: A Handbook, by Government of Alberta, 2005, p. 5, Author. Review the Behavioural Indicators of neglect in Responding to Child Abuse: A Handbook (Government of Alberta, 2005, p. 5). Physical Abuse Physical abuse is any intentional injury to a child. Children often explain injuries by attributing them to accidents in play or sibling conflict. If you have any doubt, a member of the CAP team or a caseworker at CFSs will assist you in deciding whether to make a report. Table 2.2. Indicators of Physical Abuse. History Physical Abuse Indicators Extreme withdrawal Depression Acting-out behaviours Inconsistent history with injuries No explanation for the injury Vague, unclear, unconcerned, or changing account of how the injury occurred Discrepancy between the caregiver's and child's accounts of the injury Unreasonable delay in seeking medical attention Family crisis or stress History of previous ED visits Unexplained (or poorly explained) bruises and welts A number of scars in a regular pattern Bruises of varying colors the shape of an object (cord, rope, belt, buckle, clothes hanger) Bald spots or missing teeth Human bite marks Unexplained burns, such as cigarette-shaped burns, immersion burns (e.g., glove-shaped or sock-shaped), burns by an electric iron or stove burner Unexplained (or poorly explained) fractures, sprains, dislocations, head injuries, or abdominal trauma Unexplained (or poorly explained) cuts and scrapes Inflamed tissue, suggesting scalding Consumption of a poisonous, corrosive, or non-medical mind-altering substance _____________ Adapted from Responding to Child Abuse: A Handbook, by Government of Alberta, 2005, p. 6, Author. Review the Behavioural Indicators of physical abuse in Responding to Child Abuse: A Handbook (Government of Alberta, 2005, p. 6). Cultural Awareness It is important to be aware of some cultural differences and religious practices that may be confused with signs of child abuse. For example, Southeast Asian groups may use coining or cupping techniques (often on either side of the spine) to remove toxins from an ill child's body, which may leave bruises on the child. Some infants are born with a Mongolian spot, also known as congenital dermal melanocytosis, or dermal melanocytosis. It is a benign, flat congenital birthmark with wavy borders and an irregular shape; it is extremely prevalent among East Asians, Turkic peoples, Polynesians, Native Americans, and East Africans. It normally disappears 3-5 years after birth and almost always by puberty. The most common color is blue, although these marks can be blue-gray, blue-black, or even deep brown. Sexual Abuse Sexual abuse is inappropriate exposure or subjection to sexual contact, activity, or behaviour, including prostitution-related activities. Exposing children to child pornography or luring children through the Internet are also forms or sexual abuse. The single most important indicator is a child telling someone about the abuse, the disclosure of which may be direct or indirect (although children commonly delay telling anyone). All disclosures should be taken seriously, noting that physical signs of sexual abuse may be absent. Table 2.3. Indicators of Sexual Abuse. Physical Indicators Sexual Behaviour Indicators Physical trauma or irritations in the anal and genital area Genital discharge, bleeding, or infection Bleeding from the rectum Foreign bodies in the vagina, urethra, or rectum Vaginal or rectal pain, discomfort, or itching Pain on urination or defecation Difficulty walking or sitting due to genital or anal pain Sexually transmitted infection (STI) Pregnancy in a young adolescent Stomach pain, headaches, or other psychosomatic complaints Premature or inappropriate understanding of sexual behaviour Inappropriate, unusual, or aggressive sexual behaviour with peers or toys Compulsive masturbation Excessive curiosity about sexual matters or genitalia of others or self Unusually seductive behaviour with classmates, teachers, or other adults Excessive concern about homosexuality (especially in boys) Review additional Behavioural Indicators (young vs. older child) of sexual abuse in Responding to Child Abuse: A Handbook (Government of Alberta, 2005, p. 8). _____________ Adapted from Responding to Child Abuse: A Handbook, by Government of Alberta, 2005, p. 7, Author. Emotional Abuse Emotional abuse is the impairment of a child's mental or emotional functioning or development, resulting in emotional injury. Some causes of emotional abuse include: rejection; deprivation of affection and/or cognitive stimulation; exposure to domestic violence or severe domestic disharmony; inappropriate criticism, threats, humiliation, accusations, or expectations; the mental or emotional condition of the guardian of the child or of anyone cohabitating with the child; and chronic alcohol or drug abuse by anyone living in the child's home (Government of Alberta, 2005, p. 9). Emotionally abused children may appear clean, well-groomed, and well-nourished; however, they may seem sad, depressed, timid, angry, or withdrawn. If possible, try to determine if the parents are displaying behaviours that could be causing the child's impairment. Table 2.4. Indicators of Emotional Abuse. Parent's/Guardian's Behavioural Indicators Child's Behavioural Indicators Blaming or belittling the child Withholding comfort when the child is frightened or distressed Treating other children in the family better Describing the child in negative ways Holding the child responsible for the parent's problems and disappointments Identifying the child with disliked relatives Acting overly compliant, passive, or shy Episodes of aggressive, demanding, and/or angry behaviour Fear of failure; difficulty listening and concentrating Giving up easily Boasting or speaking negatively about him- or herself Constantly apologizing Crying without provocation Excessively demanding of adult attention ___________ Adapted from Responding to Child Abuse: A Handbook, by Government of Alberta, 2005, p. 9, Author.

Case Study (Questions 1-12) child abuse

A father carries his 20-month-old toddler, Phoebe, into the ED. The father states she has a slight cold with cough, fever, irritability, and decreased "playfulness." While her ABCDs appear stable, she has a runny nose, upper airway congestion, and rapid but unlabored respirations. She cries but does not resist the assessment. Her father tries to comfort and distract her, but she is not comforted by his efforts and pushes him away. Her skin is pale, but flushed and warm to touch. Her vital signs are as follows: Heart rate (HR): Respiratory rate (RR): Blood pressure (BP): Temperature: Oxygen saturation (SpO2): Weight: 160 beats/min 50 breaths/min 90/50 mmHg 38.3°C (axillary) 93% on room air 10.8 kg During the head-to-toe examination a dark reddish-purple discoloured area is noted behind her right ear. The father states she hasn't fallen and he thinks it is a birthmark. He also states that Phoebe is just beginning to walk and she probably ran into a table. He seems anxious for the examination to be finished, and he avoids eye contact. Is it necessary to document the bruise or mention it to the physician? Why or why not? The most important findings are obtained by: the history. the physical exam. the behaviour of the father. all of the above. List two (2) or more findings from the initial examination that raise suspicions of child abuse. Feelings of confusion, denial, embarrassment, empathy, and anger are common emotions for health care providers when faced with suspected child abuse. True False Suggest at least three (3) coping strategies that health care professionals can utilize when confronted with suspected child abuse. Is a focused neurological and respiratory assessment appropriate at this time? Why or why not? On examination, Phoebe appears appropriately developed for stated age and well-nourished; she is alert but irritable. Her pupils are equal and reactive to light (PERL). The bruise-like area behind her right ear is reddish-purple, slightly edematous, tender, and measures 2 x 3 cm. There is slight rhinorrhea with drainage from the nares, and the tympanic membranes are dull and intact bilaterally without drainage. Phoebe's RR is rapid and slightly irregular, with no retractions. She no longer resists examination or cries. Two parallel, slightly curved greenish-yellow areas measuring 0.5-2.5 cm are noted on the left posterior lateral aspect of her chest. Her abdomen is soft and non-distended. There are no obvious injuries or areas of swelling of the bones or joints, and no apparent limitations in range of motion (ROM). Her left forearm appears slightly curved in comparison with the right forearm. Her left lateral thigh reveals a small 1 x 0.75 cm healed oval lesion suggestive of either an infected insect bite or an old burn. Her external genitalia and rectum appear normal for a 20-month-old female. The diaper is wet with urine, but there is no sign of discharge or bleeding. The physician's assessment concurs with yours, and he tells the father that Phoebe has a respiratory infection and a chest x-ray (CXR) is necessary. The physician follows you to the charting area and quietly orders a skeletal survey, including full views of skull, ribs, and extremities. While processing the orders and charting the assessment on the emergency record, you note the family's address is in a good neighborhood. During the assessment, the father appeared educated and articulate. The greatest incident of child abuse occurs in which of the following? Families with Hispanic and Asian origins Families with lower socioeconomic status Families living in urban settings None of the above. Identify two (2) or more findings in the examination that require further assessment. What should be included in the documentation of suspected abuse? Choose all that apply. Objective, specific descriptions or sketches of the physical findings Descriptions of the child's behaviour Suspicions that the father may have injured the child The father's actual explanation for the bruises in quotation marks Detailed, objective descriptions of the father's behaviour A full skeletal x-ray is ordered to: determine if growth is age-appropriate. rule out intracranial hemorrhage. determine if there are multiple fractures in various stages of healing. evaluate lymphoma as the cause of rhinorrhea. The CXR shows clear lung fields with recent left lateral rib (4-7) fractures. The skeletal survey reveals a right parieto-occipital skull fracture and an old fracture of the left humerus that has healed at a slight angulation. What is the priority of care at this time? Choose all that apply. Treatment for post-traumatic stress disorder Assessment of gas exchange Protection from possible injury Analysis of the family dynamics The physician contacts the CAP team. Once the team arrives, the father is told that the emergency staff do not think Phoebe's cold is causing her irritability, but that she has been physically injured. The physician explains the concern about finding fractures and bruises at different stages of healing. As he introduces the child protection worker, the physician emphasizes the concerns for Phoebe's safety and the ED staff's legal obligation to report suspicious findings. The physician adds that due to Phoebe's need for continuous observation, she will be admitted to the hospital. The emergency staff know that even when there are no acute injuries, hospitalization is required when safety of the child cannot be ensured. While the physician is speaking, the father's posture becomes very still and he glares at everyone; however, he agrees to the admission. Medical and CAP staff are relieved that he did not try to remove Phoebe from the hospital against medical advice, which would have necessitated involving hospital security and the police. Suggest at least three (3) strategies to assist heath care professionals in providing nonjudgmental care to this family. Phoebe's condition is stable; her SpO2 is 95% with O2 at 2 litres via nasal cannula and there are no changes in her neurological status. She is subsequently transferred to a pediatric unit, with the hope that the cycle of abuse has been broken and that she finds a way to cope with the many psychological and physical sequelae she may endure as a result of the abuse. Answer Key (Case Study) Yes, the bruise should be documented as it is our legal and professional responsibility to do so. Although the bruised area is fairly small, it warrants further investigation as the presentation of child maltreatment may be subtle. (d) History, physical examination, and behaviour are all important sources of information. Early recognition and management of suspected child abuse involves putting together clues from a pattern of indicators that arouse suspicion and warrant further investigation. Any of the following answers are appropriate: Suspicious area of bruising to the head. Lack of credible history for the bruise. If Phoebe had a birthmark, the father would be aware of it; if she bumped into a table, the bruise would probably be on her forehead. The father appeared anxious and avoided eye contact. The history of irritability and lack of playfulness, combined with her passivity during the assessment and resistance to being comforted by her father, are all atypical toddler behaviours. True. All of these feelings are common among professionals confronted with suspected (or confirmed) child abuse. Ethical dilemmas are related to the need to protect the child and treat the family justly, the uncertainty of the diagnosis, the possibility of violating confidentiality, and the risk of separating a child from his or her family. The ability to cope effectively with these issues is critical to working successfully with suspected child abuse victims and their families. Any of the following answers are appropriate: Acknowledge personal feelings and recognize their potential effects on the care of abuse victims and families. Emphasize assessment and treatment rather than punishment. Avoid placing blame. Your responsibility is not to prove that abuse occurred, but to file a report of suspicion. Share responsibility for the recognition and management of abuse with other team members (social workers, child protection agencies, physicians, and nurses). Develop and implement written policies/procedures related to the care and safety of children and families. Learn more about child abuse and become involved in prevention efforts to help combat feelings of powerlessness and frustration. Neurological and respiratory assessments are necessary. Child abuse can affect any body system and present with a wide range of physical findings, so it is very important that a detailed and thorough head-to-toe assessment be completed. Multiple indications of injuries may be found, such as bruises in various stages of healing. (d) The incidence of child abuse does not vary according to race, socioeconomic status, or urban vs. rural settings. Any of the following examination findings indicate a need for further assessment: Passive behaviour during the assessment Persistent, rapid respirations Bruise behind ear Greenish-yellow areas on the posterior-lateral chest Lesion on thigh Slightly curved left forearm All except (c) It is important to document observations accurately and objectively. Document only what can be seen, heard, smelled, or touched. Do not document "suspicions." Record the following, using sketches, body diagrams, or photographs as necessary, to clarify descriptions: History of the injury: date, time, place, sequence of events, and any time lapses between occurrence and arrival for care. The child's and parent's/caregiver's accounts must be in their exact words with quotation marks. Actual behaviours: the child's and parent's/caregiver's responses to the injury, each other, and the hospital setting. Physical findings related to injuries: their number and location, measured size, shape and symmetry, colour, distinguishing characteristics, and any evidence of previous injuries. (c) The skeletal survey is ordered to determine whether there are multiple fractures. Multiple fractures in various stages of healing, combined with history, physical, and behavioural findings, may indicate chronic injury from recurrent abusive episodes. (b) and (c) The mild tachypnea and irregularity of respirations require further assessment. Gas exchange may be impaired by the upper respiratory infection, head injury, or fractured ribs. Interventions include O2 via nasal cannula or face mask (blow-by also acceptable). Phoebe's pain level must also be assessed and comfort measures, such as positioning and analgesic/antipyretic (e.g., Acetaminophen for fever), administered. The child and father must be in a location where they can be observed continuously until child protective services can assume responsibility. The irritability combined with a skull fracture also indicates the necessity for a full neurological examination and continued frequent neurological assessments to detect any deterioration. Any of the following answers are appropriate: Recognize that the family may be seeking help for themselves, as well as for the child Anticipate a wide range of emotional responses from confronted families Avoid extreme reactions (e.g., ignoring or confronting family members) De-escalate intense emotional reactions by focusing on concern for the child Give simple, concrete instructions Explain the different responsibilities of hospital care providers and the child protection agency

Abusive Head Trauma

Between 2006 and 2016, 8% of family-related homicides against children were the result of being shaken, tossed, or thrown, with all cases occurring under the age of 3 years (Statistics Canada, 2018). The term 'shaken baby syndrome' has been the subject of much controversy due to the precise cause(s) of head injury and myriad of clinical findings; therefore, this 'syndrome' of injuries is now referred to as abusive head trauma (AHT). The ED is often the first point of contact with the health care system for families with infants; therefore, it is imperative that emergency health care providers have a comprehensive understanding of AHT, including related prevention strategies. Mechanism of Injury Violent, rapid acceleration/deceleration forces of the head are common mechanisms of injury resulting in AHT, resulting in shearing and tearing of blood vessels and tissue. As stated by Nadarasa et al., (2014), "The act of shaking seems to be benign and innocent, though the injuries are worse than in road or domestic accidents" (p. S566). The authors further emphasize that this shaking is violent in nature, resembling that of severe 'whiplash'. The 'tossing' and 'throwing' of a child are also identified as mechanisms involved in AHT. Given the immature development of infants and young children, the injuries sustained can be catastrophic. Signs/Symptoms It is not uncommon for the child to have no external signs of traumatic injury, thus "[AHT] should always be considered in infants without a definite diagnosis to allow for earlier recognition of the often non-specific initial presentation of this condition" (Bennett et al., 2007, p.9). Signs/Symptoms can range in severity, but often include the following: lethargy, irritability; seizures, altered level of consciousness (LOC); respiratory distress, apnea; and decreased feeding, vomiting. The parent or caregiver may have no explanation for the child's signs/symptoms, or may appear to provide an inaccurate or incomplete history. The following clinical findings warrant complete assessment for, and suspicion of, AHT: acute/chronic injury with inadequate, inconsistent, evolving or no explanation for the related MOI; severe head injury allegedly the result of a short fall or minor trauma; unexplained symptomatic head injury in a child who was well when he/she was last seen; subdural hemorrhage (more likely bilateral, can be unilateral)...most common injury seen in AHT unmyelinated infant brain, supple skull, larger fontanels, pliable structure, and weak neck muscles....easily deformable brain retinal hemorrhage (also usually bilateral); retinoschisis (splitting of retinal layers) rib, skull or metaphyseal fractures (e.g., long bones [ > humerus] at growth plates); and spinal fractures (> cervical and lumbar) particularly cervical fractures, as injury to this area may result in cardiopulmonary arrest (Bennett et al., 2007, p. 9-10; Nadarasa et al., 2014, p. S565-S569). Farrell (2013) classifies the severity of head trauma according to the patient's [pediatric] Glasgow Coma Scale (GCS) score as follows: Minor head trauma = GCS 14-15 Moderate head trauma = GCS 9-13 Severe head trauma = GCS ≤ 8 Diagnostics The following investigations are warranted for any child with suspected or confirmed AHT: complete blood count (CBC) with platelets; coagulation studies; and potentially the following, in order to rule out other diagnoses: electrolytes, glucose; metabolic screen; toxicology screen; microbiology screen; computed tomography (CT) scan of the head; magnetic resonance imaging (MRI) of the head (to further delineate presence/location of intracranial injuries); and skeletal survey and/or nuclear medicine bone scan, which may need to be repeated at 10-14 days (Bennett et al., 2007, p. 9). Medical and Nursing Management Medical and nursing management of the AHT-injured child is dependent upon the severity of brain (and concomitant) injury. Transfer to a tertiary care facility with neurosurgical consultation and intervention may be warranted. General management of the AHT-patient includes the following: Assessment and stabilization of vital signs intubation/mechanical ventilation, if GCS ≤ 8 maintenance of core temperature fluid administration to avoid hypovolemia/hypotension (maintain normovolemia and cerebral perfusion....caution with increased intracranial pressure [ICP]) Monitor for seizures, and treat accordingly Obtain history (e.g., mechanism; medical history, including head injury/ neurological disorders, coagulation dysfunction) Accurate, timely documentation in the patient's chart (see documentation guidelines discussed above in Part A) Determination if any other children in the home are at risk Communication with family and ongoing discussion with investigators (CFSs, police agency) Discussion of prevention strategies with family/caregivers stress/anger management, parenting skills assistance in accessing social supports (e.g., financial, housing) referral for culturally-sensitive social programs linking child's development level to parent's/caregiver's enhancement education (e.g., learning what is age-appropriate behaviour) Discharge planning, in consultation with CFSs In the event of child death, post-mortem care and autopsy must be conducted in accordance with established hospital policies and provincial legislation grief support for family, as well as ED staff

Patients with Borderline Personality Disorder

According to the DSM-5, a personality disorder is defined as an "...enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture" (APA, 2013a, p. 321). It is also pervasive and inflexible, has an onset in adolescence or early adulthood and is stable over time, leads to distress or impairment, and is not attributable to any other mental or physiological condition (APA, 2013a). Cluster B disorders (e.g., borderline personality disorder) are characterized by overly emotional, dramatic, and unpredictable behaviours. These patients are more likely than those with other types of personality disorders to seek help in the ED. Symptoms of borderline personality disorder include flamboyance, egocentricity, impulsivity, and dramatization. They seek immediate gratification and become emotionally distressed if their needs are not met. Their actions are often reactive and impulsive, and they rarely think about the consequences of their behaviour. People with borderline personality disorder will act impulsively on their threats, thus do not take threats of self-harm lightly. Their relationships are "all or nothing": they either love or hate another person. Nurses need to be aware of their feelings and attitudes toward people with borderline personality disorder. Be firm, nonjudgmental, calm, and thoughtful in your interactions with these patients. Reinforce limits that have been set on their behaviour. If you feel yourself becoming angry with a patient, pause to examine your own emotions and consider asking another nurse to assume the patient's care. A patient with borderline personality disorder often arrives in the ED after an impulsive overdose, slashing, or other crisis. The aim is to stabilize the patient medically and psychiatrically, ensure social supports are in place, schedule a follow-up visit, then discharge the patient.

Psychiatric Emergencies

Acute Dystonia Impairment in muscle tone is generally the first extrapyramidal symptom to occur, usually within a few days after an antipsychotic medication is initiated. Dystonia is characterized by involuntary muscle spasms, especially of the head and neck. Patients may experience torticollis, oculogyric crisis, or a sensation that the tongue is swelling. The treatment of choice is benztropine (Cogentin) per os (PO) or IM. Please watch the following short video of a patient experiencing severe cervical dystonia; other antipsychotic side effects are also illustrated. https://www.youtube.com/watch?v=ucrV4ljDKuE Akathisia Akathisia is an extrapyramidal side effect of phenothiazine medications. It includes restlessness that is easily mistaken for anxiety or increased psychotic symptoms. The treatment of choice is lorazepam (Ativan) PO. Agranulocytosis Agranulocytosis is a reduction in the number of circulating granulocytes, and decreased production of granulocytes in the bone marrow, that limits the ability to fight infection. It is a severe side effect of clozapine (an atypical antipsychotic medication), thus patients taking clozapine should be monitored regularly for agranulocytosis. Anticholinergic Crisis Anticholinergic crisis is a delirium that may be caused by an overdose of antimuscarinic drugs such as atropine, scopolamine, or belladonna alkaloids. It may also occur in psychiatric patients who are receiving therapeutic doses of anticholinergic drugs (e.g., TCAs). Signs and symptoms are confusion, recent memory loss, incoherent speech, delusions, ataxia, hyperactivity, paranoia, hallucinations, picking motions, nonreactive dilated pupils, and an unstable autonomic nervous system (ANS). An anticholinergic crisis can be life-threatening. Hypertensive Crisis due to MAOIs Patients taking MAOI medications should avoid foods containing tyramine, such as Marmite, beer, fermented sausage meat, fava beans, sauerkraut, and soy sauce. Consuming these items may lead to a spike in blood pressure, debilitating headache, CVA, or death. Lithium Toxicity Early signs of Lithium toxicity include diarrhea, vomiting, drowsiness, muscular weakness, and loss of coordination. Late signs of toxicity include cardiac arrhythmias, blackouts, nystagmus, coarse tremor fasciculations, hallucinations, renal failure, peripheral vascular collapse, confusion, seizures, coma, and death. Neuroleptic Malignant Syndrome (NMS) NMS occurs when too much dopamine is available in the brain; therefore, it is typically caused by antipsychotic medications. Symptoms include autonomic instability (rising temperature, fluctuating blood pressure, rapid heart rate), fluctuating LOC, increased creatine kinase (CK) level due to muscle breakdown, lead-pipe rigidity, and Parkinson-like symptoms. If a patient develops NMS, antipsychotic medications are discontinued. Treatment includes a dopamine agonist (e.g., bromocriptine) and a muscle relaxant (e.g., dantrolene or a benzodiazepine); some patients respond to electroconvulsive therapy. Untreated NMS is fatal. Serotonin Syndrome Serotonin syndrome is due to the excessive availability of serotonin in the brain. Signs and symptoms include changes in mental status, agitation, ataxia, myoclonus, hyperreflexia, fever, shivering, diaphoresis, and diarrhea. Treatment includes cooling blankets, monitoring of vital signs, IV fluids, antipyretics, and discontinuation of all serotonergic medications. Please watch the following short video on Emergencies Caused by Psychiatric Drugs: http://www.youtube.com/watch?v=C8TZLxxjreU

Family Presence During Resuscitation

Allowing and even encouraging family presence during resuscitation (FPDR) has been increasingly recognized as a positive effort in North American EDs for a few decades now (ENA, 2018b). Most EDs have a policy for this, and you are encouraged to seek out and ensure you are familiar with that of your institution. Little evidence supports fears related to family presence such as increased lawsuits, family interference with the efforts, or worsening psychological effects on the family (ENA, 2018b). In fact, there are some very powerful benefits to allowing family to be present during this time. The Canadian Critical Care Society has taken a position on this practice as ethically sound and something that does not negatively contribute to the family's psychological distress, nor the process or outcome of the resuscitation for either pediatric or adult patients (Oczkowski et al., 2015). Keep in mind that families should also be provided with additional supports such as social work and spiritual support to assist them while they witness the staff's efforts to save their loved one.

Discussing Prognosis at End of Life

Although it is not directly an RN's role to discuss prognosis with a patient, we must advocate for patient awareness of prognosis. Known trajectories can help us have discussions with patients and their families about prognosis and how end-of-life typically transpires, for example in the case of chronic organ failure such as COPD, chronic liver failure or chronic renal failure, frailty, and terminal illness such as cancer (see figure below, Grewal, 2015). Of course, we also see sudden death - the most dramatic of trajectories, where someone who was previously healthy experiences a sudden and fatal trauma, stroke, heart attack, or aneurysm.

Eating Disorders

Anorexia Nervosa Severe weight loss can lead to significant physiological complications, which is characteristic of anorexia nervosa. The DSM-5 specifies the following criteria for the diagnosis of anorexia nervosa: Restriction of energy intake relative to requirements, leading to a significantly low body weight [less than minimally normal] in the context of age, sex, developmental trajectory, and physical health. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight (APA, 2013a, p. 171). Note that 'amenorrhea' has been removed as a diagnostic criterion, as it does not apply to certain populations (e.g., males, pre-menarchal females, females taking contraceptives, post-menopausal females) (APA, 2013c, para. 6). Anorexia nervosa is further classified as the 'restricting type' or 'binge-eating/purging type', as well as in terms of severity based on body mass index (BMI). Assessment involves a thorough head-to-toe approach, as well as a comprehensive mental health history (strong correlation with substance abuse and depression). The physiological effects of anorexia nervosa include the following: Protein deficiency due to malnutrition: results in hypoalbuminemia, third-spacing, peripheral edema; multiple organ disruption; thinning hair, hair loss (growth of lanugo), dry skin Hypoglycemia; other vitamin deficiencies Fat stores significantly diminished; extreme sensitivity to cold Neurological: confusion, impaired memory; depression Cardiovascular effects: dehydration; atrial/ventricular tachydysrhythmias, bradycardia, postural hypotension; circulatory collapse, shock Renal effects: decreased glomerular filtration rate (GFR), azotemia; metabolic acidosis; electrolyte imbalances (e.g., hypokalemia, hyponatremia, hypomagnesemia) GI effects: hypochloremic alkalosis (vomiting); constipation, delayed gastric emptying, gastric dilation/rupture; dental erosion, esophagitis, Mallory-Weiss tear (if vomiting); jaundice Hematological: bone marrow suppression (thrombocytopenia, erythrocyte/ leukocyte abnormalities); alteration in bone marrow morphology (direct correlation to amount of weight loss....gelatinization of marrow, reversible with food intake) (Abella et al., 2002) Musculoskeletal: osteoporosis, muscle wasting Hormonal: may have amenorrhea Laboratory investigations include complete blood count with differential (CBC/Diff), electrolytes, lactate, erythrocyte sedimentation rate (ESR) and thyroid function. Human chorionic gonadotropin (HCG), urinalysis, and electrocardiogram (ECG) are also likely warranted. Treatment is focused on rehydration with IV fluids, correction of electrolyte imbalances, and referral for ongoing psychiatric and medical follow-up. Bulimia Nervosa Bulimia nervosa is characterized by recurrent episodes of binge eating, which are further described by the following criteria: Eating, in a discrete period of time (e.g., 2 hours), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. A sense of lack of control over eating during the episode. Recurrent, inappropriate compensatory behaviours to prevent weight gain (e.g., self-induced vomiting, misuse of laxatives, fasting, exercise). Binge eating and inappropriate behaviours occur, on average, at least once a week for 3 months. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of anorexia nervosa (APA, 2013a, pp. 172-173). Like anorexia nervosa, bulimia nervosa is further classified according to severity based on frequency of inappropriate behaviours (e.g., episodes per week). Patients with anorexia nervosa may exhibit bulimia nervosa as well; however, patients with bulimia nervosa are most often normal weight or overweight. The disease course tends to be one of waxing and waning, reflecting its chronic nature. Assessment involves a thorough head-to-toe approach, as well as a comprehensive mental health history (common comorbidities include affective or personality disorders, anxiety disorders, and substance abuse). Clinical signs/symptoms may be similar to those of anorexia nervosa (dizziness, dehydration, electrolyte abnormalities, cardiac arrhythmias, decreased muscle strength), with vomiting leading to chest pain, hematemesis, Mallory-Weiss tear or gastric/esophageal rupture. Deaths due to Ipecac-induced vomiting have also been reported. Laboratory investigations include CBC/Diff, electrolytes, lactate, liver function tests (LFTs), and thyroid function. HCG, urinalysis, fecal occult blood test (FOBT), and ECG are also likely warranted. If gastric or esophageal rupture is suspected, a chest x-ray (CXR) will also be obtained. Treatment is focused on rehydration with IV fluids, correction of electrolyte imbalances, and referral for ongoing psychiatric and medical follow-up.

Aggressive Behaviour

As aforementioned, staff education (e.g., de-escalation course) is paramount for nurses working in the ED. Specific policies and procedures, such as the Adult Psychiatric Non-Combative and the Adult Combative Behaviour algorithms, for managing the care of a patient who is aggressive may also be available in your respective workplace. The most important predictor of aggression is a history of aggression or violence; intoxication is another predictor for aggression. Males are more likely to be physically aggressive than females. Mental illness is generally not a good predictor of aggression; in fact, people with mental illnesses are more likely to be victims than perpetrators of verbal and physical aggression and abuse. Triggers for aggression include: Intoxication by alcohol and/or drugs Non-remitting pain Anxiety, fear Physiological deficiencies (e.g., fatigue, hunger, thirst) Perceived mistreatment (e.g., disrespect, dishonesty) Loss of personal control Broken relationships Perceived needs not being met Uncontrolled frustration (e.g., due to waiting for treatment in the ED) Most aggressive incidents are preceded by a change in verbal behaviours and interactions. The patient may start to speak increasingly loudly and expressively, with a confrontational edge, and may make verbal threats. Make sure other patients are moved to a safe area, and maintain a safe distance from the patient. Take control of the situation and attempt to defuse the verbal posturing with a calm, firm voice. Be nonjudgmental and use the person's name. Offer choices, such as, "John, would you like to sit in a quiet room or have some medication to help you calm down?" The patient may begin to settle or may become increasingly agitated. Summon assistance (more staff or security personnel) if necessary. Most episodes of violence are preceded by an altered activity level. The patient may begin to pace, gesture with a fist, hit a wall or table, or select an object to throw or use for self-protection. Generally, at this point, verbalizations have escalated, and the patient may present a serious physical threat to staff. Allow the staff member with the best rapport to take the lead with the person, while other staff stand by and wait for further direction from the leader. To ensure the safety of the patient and staff, it may be necessary to seclude the patient and administer medications immediately to control the aggression. An incident involving violent behaviour should always be followed by a debriefing. A debriefing may include: Ensuring no one was injured Discussing what led up to the incident Discussing how the incident was managed Discussing what went well and what could have been done differently A post-incident debriefing should also take place with the patient after she or he has settled down, and may include the following: Ensuring the patient was not injured Discussing what led up to the change in the patient's behaviour Discussing how the situation could have been managed differently Discussing how the patient could learn to voice concerns, feelings, or thoughts in a non-aggressive manner

Child Abuse and Neglect

Children are completely dependent upon others for their safety and well-being, and have the right to be protected from abuse and neglect. As front-line care providers, nurses play a crucial role in the early recognition and management of suspected child abuse. In order to ensure the safety and well-being of children, an understanding of how child abuse and neglect are conceptualized, as well as how to take appropriate action, is essential.

Family violence

a significant public health concern. The term family violence encompasses the broad spectrum of maltreatment and abuse that occurs between partners in intimate relationships, such as family, marriage, cohabitation, dating, or friendship. Sexual assault refers to any unwanted behavior or touching, without the explicit consent of the recipient. This study guide consists of four (4) Modules: domestic violence; child abuse, including abusive head trauma (formerly known as 'shaken baby syndrome'; elder abuse, and sexual assault.

Domestic Violence

Domestic violence is a pattern of violent and coercive behaviours whereby one person seeks to control the thoughts, beliefs, and conduct of an intimate partner and/or to punish the partner for resisting control. A healthy relationship is based on trust and respect; an abusive relationship is based on power and control. Domestic violence often refers to violence between spouses, but can also occur between cohabitants and non-married intimate partners. Domestic violence knows no boundaries and occurs in all cultures; people of all races, ethnicities, religions, and socioeconomic classes are affected by domestic violence. It is perpetrated by both men and women, occurring in both same-sex and opposite-sex relationships. Spousal, dating, and intimate partner violence categories include victims between the ages of 15 and 89 years (Burczycka & Conroy, 2018). Incidence of Domestic Violence "Approximately every six days, a woman in Canada is killed by her intimate partner" (Canadian Women's Foundation, 2016, p. 2). In the 2014 General Social Survey, self-reported data indicated that 4% (760,000) of Canadians aged 15 years and older experienced current or former partner violence, with the prevalence of spousal violence among men and women being equal at 4% (Canadian Centre for Justice Statistics, 2016, p. 4). Although the rates of police-reported family-related physical assault are generally on the decline in most provinces (Canadian Centre for Justice Statistics, 2015), it is likely you know someone affected by domestic violence. Whenever statistics are cited, it is important to remember that due to the wide range of definitions and under-reporting of family violence, it is difficult to obtain accurate prevalence and incidence data. Nevertheless, according to Family Violence in Canada: A Statistical Profile, more than 93,000 incidents of intimate partner violence (including spousal and dating partners) were reported to police in 2016, of which the vast majority were women (79%) (Burczycka & Conroy, 2018, p. 56). Even in countries where the investigation and prevention of domestic violence have been supported, studies by Statistics Canada and other agencies indicate that only about one-third of all cases are actually reported. Note: Incidents that are not Criminal Code offences (deemed not to be at the 'criminal' level, such as emotional/psychological abuse, fraud) are not included in the above-cited reports; only police-substantiated reports of family violence are included. Myths about Domestic Violence Domestic violence is often a hidden and taboo subject, and because of this it is surrounded by myths and misconceptions. It is important to examine some of these myths and our own beliefs and barriers so we can provide safe and knowledgeable care. Myth 1: Abuse doesn't happen in our community. As mentioned above, domestic violence knows no boundaries; people of all races and income levels, both men and women, can be affected. Myth 2: Domestic violence is a private matter. Research has shown that people coming into the ED appreciate sensitive questioning about the subject. Myth 3: Intervening in cases of domestic violence is too time-consuming. It takes only a couple of questions and a few minutes of your time to help patients who are being abused. Myth 4: People should be advised to leave an abusive relationship; they are free to leave at any time, and leaving will end the violence. Leaving an abusive relationship can be very dangerous, resulting in threats, stalking, harassment, and even death. Leaving the relationship safely takes adequate finances, support, and considerable planning. An abused person may stay in the relationship because of children, family pressure, the hope or belief that the abuser will change, love, and self-blame ("If only I had the dinner on the table, this wouldn't have happened"). Myth 5: The abused person "asked for it" and "deserves it". This myth reflects the desire to blame the victim, insulating us from the problem by providing rationalization and allowing us to believe we are not at risk. Types of Domestic Violence Domestic violence includes threatening or carrying out any of the following forms of abuse: Physical violence: actions that cause pain and/or injuries (e.g., hitting, kicking, biting, shoving, restraining, throwing objects). It also includes destroying possessions and harming pets. Sexual abuse: the act of sexual contact by coercion, threat, or force. It includes degrading treatment, unwanted touch, and a lack of respect for privacy. Emotional abuse: actions or statements that cause fear, isolation, and/or decreased self-esteem. Emotional abuse also includes verbal abuse (e.g., name-calling, blaming, put-downs), isolation (e.g., monitoring phone calls, controlling activity), diminished trust, and jealousy. Financial abuse: incurring debts in the name of the person being abused, interfering with the person's work, controlling his or her finances, and sabotaging the person's attempts to advance financially or professionally. Spiritual abuse: denying access to religious events or practices, or forcing an individual to behave in ways contrary to his or her beliefs. Criminal harassment (stalking): willfully and repeatedly engaging in a knowing course of harassing conduct that alarms, torments, or terrorizes another person. According to the Canadian Centre for Justice Statistics (2015), 42% of victims of a former intimate partner had experienced threats, criminal harassment, and/or harassing/indecent phone calls (90% of these incidents occurred after separation) (p. 26). In Hidden Hurt, an abuse information and support site based in the United Kingdom, Kim Eyer's Power and Control Wheel depicts tactics used to control partners in abusive relationships. Please take a minute to view it at the following address: http://www.hiddenhurt.co.uk/power_and_control_wheel.html Domestic violence takes many forms; it ranges from occasional to chronic, with injuries ranging from mild to moderate and transitory, or severe and permanent. For many, the relationship follows the cycle of violence shown below. image01 Figure 1. The cycle of violence. Reprinted from Women's Center: Cycle of Violence, by Marshall University, n.d. (https://www.marshall.edu/wcenter/domestic-violence/cycle-of-violence/) It is important to remember that the cycle of domestic violence may vary within abusive relationships. For example, there may not be a honeymoon phase and verbal abuse may be present throughout the cycle. Persons who are abused may be seen in the ED during any phase of this cycle. Triggers of Abusive Incidents An abusive incident may occur when someone in a relationship is experiencing stress or feels he or she is losing control. This may happen due to a pregnancy, relocation, or new job or friend, for example. When caring for pregnant patients, health care providers should be vigilant for signs of abuse. People who abuse others often have poor coping skills, confusion about power, personality disorders, and/or substance abuse issues; they may also have been abused as children.

Domestic Violence

Domestic violence, also known as domestic abuse, spousal abuse, or intimate partner violence, occurs when one family member, partner, or former partner attempts to physically or psychologically dominate another. The purpose of this module is to educate emergency nurses about domestic violence and provide tools for recognizing, screening, intervening in, and documenting cases of domestic violence in order to prevent injury, illness, and death.

Institutional Response to Domestic Violence

EDs should have appropriate and up-to-date policies and procedures relative to domestic violence. Information about how to keep patients and staff safe is vital, including security procedures for removing threatening or violent individuals, if necessary, and the role of law enforcement agencies. A clear process for patient referrals to social workers, health care providers, and the community is important, as well as a plan and resources for employees who are in abusive relationships or have restraining orders. Posters and brochures providing information about domestic violence should be visible and available to staff and patients. The institutional environment should be one of support and empowerment, conveying the message that entering into discussions surrounding abuse is not only acceptable, but also expected practice. Screening The best way to know if a patient is in an unsafe relationship is to ask. Ideally, screening programs should be routine and universal for everyone over the age of 12 years at every visit. Once patients understand the scope of the problem, they most often do not resent being asked. Generally speaking, it is not what you ask, but how you ask it. Questioning about abuse in a relationship must be done privately and discretely, and without judgment. Controlling partners may refuse to leave the room during your nursing assessment and may even enlist the assistance of children, friends, and relatives in monitoring the patient. If a patient says it is okay to talk in front of visitors, reply that the institution's policy is that all patients are assessed in private. Asking questions about domestic violence in front of a perpetrator can trigger an abusive episode. It may be difficult to speak privately with a patient in the presence of a controlling partner. In these situations, a nurse may need to think of creative strategies, such as involving the visitor in paperwork or meeting the patient in the bathroom. It is very important to remain nonjudgmental while observing the patient's body language, tone of voice, and choice of words. Avoid labels such as "abused" and "victim" and negative questions, such as, "He doesn't hit you, does he?" If there are language barriers, use an interpreter. A very effective way to approach the subject with patients is to use layered questioning, which consists of the following: An icebreaker, for example, "Because violence has become a part of many people's lives, we ask everyone who comes into our emergency department about domestic violence." Specific information, for example, "Did you know that 6% of men and 7% of women are in abusive relationships?" Simple key questions, for example, "Has anyone made you feel unsafe or frightened?" or "Have you been hit, punched, slapped, kicked, pushed, shoved, forced to have sex, or otherwise hurt by anyone?" Intervention If the patient answers "No" to the screening questions, simply say, "I'm glad this isn't happening to you. It is happening to many people, and we want everyone to know that no one deserves to be hurt and that help is available." If the patient answers "No" but you suspect that the relationship is abusive, let the patient know that the ED is open 24 hours and repeat the message that everyone deserves to be treated with respect. If the patient answers "Yes" to the screening, quickly perform a safety risk assessment by asking if the perpetrator is in the ED. The risk assessment includes asking whether life-threatening injuries have occurred, if children or seniors are being harmed, if the threats involve a weapon or the intent to kill or if the perpetrator has access to a gun, and if the person who is being abused has recently left or is considering leaving the relationship. A safety protocol involving hospital security personnel and/or the police may have to be implemented. After safety concerns are addressed, the intervention includes validation of the patient's feelings by using statements such as the following: This is not your fault. You did not deserve this. There is no excuse for this. You are not alone. You do not have to end your relationship. I know it must be difficult to decide what to do. There are options, and I will support your choices. I am here to listen. Help the patient plan for her or his personal safety, and the safety of any children involved. The following questions may be asked: Is it safe for you to go home? Do you need immediate shelter? Are your children safe? Do you have a friend or family member you can call? Do you know you can come here if you feel unsafe or afraid? Are you aware of 211 or 310-1818 numbers? Dialing 211 (Edmonton, Calgary, regional municipality of Wood Buffalo) will connect the patient to The Support Network (access to services/referrals). Dialing 310-1818 will connect the patient to the Alberta-wide 24-hour Family Violence Information Line. They should be provided discretely (e.g., barcode) because the abuse may escalate if the abuser discovers the person being abused has sought help. It is very important to respect and support patients' decisions. If they decide to return to an abusive situation, let them know you are concerned and that the abuse is harmful to them as well as their children. Inform them that the violence does not get better; it always gets worse. Validate victims' strengths and recognize the courage they have demonstrated in disclosing. Help them to recognize they are not alone and to explore supports, such as friends or family, and community resources, such as shelters, social services, law enforcement agencies, and support groups. Develop a safety plan, including information about what to do during an incident and where to go. People being abused may be advised to store a suitcase containing the following items in a safe location: Identification Medications Clothes Keys Items for the children Phone numbers Cash Important documents, such as custody and restraining orders and income tax forms Photo of the abuser Documentation The documentation of abuse in the patient's chart or health record must be precise, legible, and professional. It should include written descriptions along with body maps and/or photographs of injuries, where possible. It is imperative that you become familiar with documentation policies and procedures related to domestic violence in your workplace; however, descriptions generally include the following: Chief complaint and description of the incident using the patient's own words in quotation marks. Include any statements about non-physical abuse. Your own assessment of objective/subjective/demographic data per hospital policy (e.g., age, ethnicity) Patient's condition on arrival in ED, including physical assessment and description of injuries (e.g., type, number, size, location) Medical treatment, interventions provided Relationship to alleged perpetrator (e.g., husband, boyfriend) Any weapons used Other persons directly experiencing abuse (e.g., children) Medical history Evidence of advocacy undertaken by the nurse on behalf of the patient Support services teaching (e.g., counseling services, support groups) Evidence of safety planning (e.g., emergency numbers, safe accommodation options) Referral(s) prior to discharge (e.g., social worker, victims' services, shelters) Details of police involvement, if any (Etheridge et al., 2014, p. 14) ***See Etheridge et al. (2014, pp. 14-16) for a comprehensive review of documentation requirements, as well as documentation examples*** Salient points: The emergency nurse's role is to objectively document the physical and mental/emotional condition of the patient. Avoid legalese (e.g., "alleges"), as well as your own conclusions. Also, refrain from using terms such as "domestic violence", as it is the court's responsibility to determine if domestic violence has occurred. Instead, document the specifics of how the patient states the injuries were sustained (e.g., "I was hit on the head [by my boyfriend] with a bat.") It is not the emergency nurse's responsibility to, nor are we qualified to, document whether our assessment findings are (in)consistent with the stated mechanism of injury. Photographs of injuries (and other evidence) are generally obtained by the law enforcement agency (if the patient has requested their involvement). If the emergency nurse or other health care provider is obtaining the photographs, the patient must provide his/her consent and the photographs must be labeled accordingly (e.g., patient's name, location of injuries, date/time, photographer's name/signature). Ensure to consult your institution's policies and procedures regarding the taking of photographs prior to doing so.

Special Populations mental health

Elderly Patients Elderly people are often confused when they arrive in the ED, thus it is imperative that the source of confusion be promptly identified. Is it one of the 3 Ds (delirium, dementia, or depression)? The following chart provides guidance for assessment. Table 3. Diagnosing confusion in elderly patients. Symptoms Delirium Dementia Depression Onset Usually rapid Slow, subtle changes Can be insidious or rapid following an upsetting event Etiology Acute physical illness Urinary tract infection (UTI) Metabolic changes Pharmaceuticals** Changes in brain matter Plaques Tangles Lewy bodies Thought to be changes in neurotransmitters Course of Symptoms Fluctuates throughout the day, typically worse at night and on wakening Generally stable during the day Worsening toward sundown Typically worse in the morning Generally more hopeful in the evening Time Interval Days or weeks Months to years Weeks to years LOC Fluctuates Generally alert and stable Generally alert, but may lack energy Memory Impaired for immediate and recent recall Progressively impaired Impaired for recent events Thought Processes Incoherent, confused, fragmented Poverty of thought Inability to make decisions May be slowed and have a negative focus **Pharmaceuticals include cimetidine, ranitidine, lithium, opioids, warfarin, calcium channel blockers (CCBs), digoxin, diuretics, and antibiotics. Nursing care of an elderly patient includes obtaining a complete history, performing appropriate diagnostic tests, maintaining safety, ensuring hydration, and managing behaviours. The history may have to be obtained from a family member or friend, or from previous health records. The patient should not be permitted to wander alone, but safety rails on the bed should be used with caution as some confused patients will attempt to climb over them. The management of delirious behaviour may include medication administration (e.g., loxapine, risperidone, olanzapine), one-to-one nursing care, physical restraints, or immediate transfer to a hospital bed; of note, adequate hydration may speed up resolution of a delirium. In addition, it may be necessary, and helpful, to assist the patient in re-establishing a normal sleep-wake cycle. Measures for managing the behaviours of dementia depend on the severity of the disease, and may include one-to-one nursing care and medications. Safety concerns must be considered. Regardless of age, patients with an acute clinical depression generally require a suicide assessment, referral to a psychiatrist, or admission to a psychiatric unit. Patients Affected by Psychological Trauma The experience of trauma can be overwhelming. Symptoms are often immediate and experienced as unreal and devastating; the person may feel emotionally exhausted and numb. At other times, the effects of trauma may be more insidious. Symptoms may build up gradually until they culminate in a loss of emotional control. People with post-traumatic stress disorder (PTSD) may experience memory loss, flashbacks to the event, amnesia, dissociative periods, distressing dreams, and hypervigilance with associated anxiety. EDs typically have processes to follow in response to sexual assaults, vehicular collisions, and workplace accidents, but what about the more insidious forms of psychological trauma? These include physical abuse by a partner, child abuse, military-related combat action, or delayed response to a trauma that occurred years ago. It is important to keep patients informed about what is happening, what is going to be happening, and what will be expected of them. Do not interrogate them or force them to open up to you; ask only pertinent open-ended questions, and listen carefully to the answers. Establishing a therapeutic relationship is essential, and assessment by the mental health unit is imperative. People who have experienced psychological trauma need ongoing support and assistance from mental health therapists.

How to Facilitate a "Good Death"

Etland (2022) outlines "the principles of a good death," which highlight the following elements: Being able to prepare for death and retain some control (such as through ADs) Being afforded dignity and privacy Being able to choose our place of death, and who is present Having symptom control, such as pain relief Having access to information and expertise Having emotional and spiritual support Having some time to say good-bye to loved ones Being able to choose to die, instead of pointlessly prolonging life (p. 152) Many EDs have a poor design that does not allow for some of the elements that can lead to a "good death." This may include lack of private rooms or quiet areas, close proximity of palliative or end-of-life patients to resuscitation rooms, which can be distressing for patient and family, short-staffing issues that can lead to less time for nurses to tend to those at end of life, and a culture that has historically been to promote aggressive medical care, which can be a difficult tendency for staff to turn off (Glass, 2017). Qualitative research studies examining nurses' views on this topic reveal consensus that the ED environment is not conducive to facilitating a "good death," and as such is a source of ethical stress for nurses (Decker et al., 2014). Nurses describe an environment conducive to a good death as: Quiet, peaceful Including a private room and space for family Having time for basic hygiene provision (such as mouth care) Having time to talk with family, offer information Being able to offer regular pain management The typical ED environment is described as: Noisy, alarms, buzzing machines Busy staff with time constraints Little time to devote to family Improper stocking of appropriate medications, supplies (Decker et al., 2014)

Answer Key end of life questions

Family Presence During Resuscitation (FPDR): Allowing family to be present during resuscitation efforts can lead to: A family's greater appreciation for completion of many tasks and assessments Enhanced understanding of the patient's condition Reduced family guilt and anxiety post-event Ensuring professional behaviour and teamwork among the healthcare team Focusing staff attention on the patient's privacy and dignity Supports staff to provide more holistic care (NENA, 2014b, p. 1). Physicians have been historically less supportive of this practice compared to nurses; they have voiced more fears about family interference with the process, more psychological damage to families, and more medico-legal ramifications. However, there is growing consensus among all involved-MDs, nurses, and families-and growing literature to support the view that FPDR is an important option to offer families, and is ethically sound (Oczkowski et al., 2015). FPDR would be reconsidered in the case of intoxicated or disruptive family members, or if family members are particularly distressed by the resuscitation to the point that their distress may inadvertently cause early termination of efforts by the staff, but all of these instances are rare (Oczkowski et al., 2015). Organ and Tissue Donation Deceased organ or tissue donation and living donor donation are the two main types. Organ donation can occur in the case of neurological death, with mechanical ventilation, as perfusion of the organs is essential. Tissue donation is possible in the case of either neurological or circulatory death, as perfusion of tissues is not essential to viability for transplantation. Generally the nurse should not initiate the conversation about organ or tissue donation. Donation coordinators are trained at initiating this important conversation, and providing all the information families need, but the nurse is responsible for activating the system in accordance with hospital policy. Note: this differs between provinces and hospitals. Know your organization's policy. The donation coordinator should be notified within one hour of neurological death being confirmed, with or without circulatory death. Many hospitals have implemented a "routine notification" policy, where impending deaths trigger notification of the donation coordinator, in order to initiate that conversation with the families. Yes, in most provinces and territories, the donation coordinator is legally allowed to obtain consent for organ or tissue donation from the family over the phone. Death Notification and Bereavement Care The writer recommends saying what comes naturally and not avoiding this phrase, which is something we would say to anyone who has experienced loss. The writer recommends you gather your thoughts, check over the chart, ensure you know the patient's name, ensure you have no blood on your clothes, and ensure you aren't alone in delivering the news if possible. He recommends you ensure there is some silence after the family is told the bad news to allow them to process it, sit and be present, not hurried if possible, then offer chance to ask questions, and finally tell them what happens next. Discussing Prognosis at End of Life One of the myths around DNR discussions is that we should focus on graphic descriptions of the trauma that occurs during CPR, such as broken ribs, in order to give people a brutally honest view of this procedure so that they don't choose resuscitation lightly. However, in reality discussion should be focused on the risks of non-beneficial resuscitation such as incomplete recovery, prolonged death, unnecessary aggressive investigations, and ventilator dependence. True. Interestingly, good palliative care can lead to longer lifespans than aggressive, non-beneficial or futile care. This is counterintuitive, but exemplifies the importance of having these discussions before the patient deteriorates, because with good symptom management people tend to live longer, and the remainder of life is of better quality. When having discussions with patients and families about end-of-life care planning, never argue, and don't get into power struggles with clients or their family members. Nurses are there to inform and to discuss with them issues around realistic care, not to make decisions for them. There are some unmistakable signs of death: Delirium with hypotension and tachycardia - median survival 10 days Death rattle - median survival one day Respirations with mandibular movement - median survival 2.5 hours Cyanosis to extremities - medial survival one hour Palliative Care and Symptom Management Benzodiazepines are very effective treatments for shortness of breath and anxiety or agitation. There is value to treating a fever at end of life, as fever can often result from thermo-dysregulation at end of life; treating the fever with antipyretics can provide comfort for the patient and symptom management from feelings such as chills and sweats. Haloperidol and benzodiazepines are the gold-standard medications for treating symptoms of delirium. How to Facilitate a "Good Death" for ED patients at End of Life Some strategies for ensuring a good death that came from this study were: removing patients from the department as early as possible, encouraging early communication to clarify wishes with patients and their family, and educating ED nurses about palliative and end of life care-strategies. Medical Assistance in Dying Dr. Ball reports that in his experience, MAID can offer patients some control over their death, because even in the presence of good palliative care patients may still be suffering. Self-Care for Nurses Some psychological manifestations of compassion fatigue include anxiety, avoidance, depression, hyperarousal, memory problems, poor concentration, poor judgment, restlessness, mood swings, intrusive thoughts, and lack of compassion or numbness. Some physical manifestations of compassion fatigue include fatigue, gastrointestinal problems, muscle tension, headache, cardiac symptoms, and sleep disturbances. Compassion fatigue can manifest at the workplace as high absenteeism, frequent use of sick days, lack of joy in work and lack of empathy toward patients, decreased productivity, increased turnover, and avoidance of working with specific groups of patients. Some of the long-term effects on nurses from exposure to an extreme situation such as sudden death of a child include chronic stress, anxiety, depression, detachment, PTSD, and physical disorders. Some nurses and physicians even leave the profession. Some key ways of proactively addressing stress and grief before they cause long-term problems include "defusion," which is an informal discussion right after the event, and "debriefing," which is a more formal organized discussion after the event to discuss one's action and reactions. There is also a movement away from encouraging emotional detachment, something that has proven to be an unhealthy coping mechanism. Demonstrating compassion, allowing one to experience the situation, and being a "humane professional" is the goal. Self-care is encouraged; nurses should identify activities they feel are therapeutic and stress-relieving (such as yoga or running) and should engage in those activities regularly.

Anxiety Disorders

Feelings of anxiety and panic may be brought on by various situational life events (e.g., medical emergency) or they may be the result of ineffective coping strategies. The 'fight-or-flight' response is often associated with anxiety, which may lead to severe panic reactions. Patients may present with symptoms of anxiety that are self-limiting, such as those related to a situational event. General anxiety disorder (GAD), on the other hand, "...is defined by symptomatic and extreme worry for over 6 months" (Pitner, 2018, p. 439). Panic disorder is often characterized by sudden and repeated panic attacks (National Institute of Mental Health [NIH], 2016), which are described as "a fear of losing control, death, or catastrophe when no real danger exists" (Pitner, 2018, p. 439). Signs and Symptoms This subjective experience may be characterized by a wide range of psychological symptoms, from mild worry or concern to severe functional incapability. Patients may also present with physical signs or symptoms, such as tachycardia, dyspnea, dizziness, weakness, paresthesia, nausea, as well as chest and/or abdominal pain (NIH, 2016). ***Medical causes for physical signs and symptoms, such as tachycardia and dyspnea, must be ruled out first.*** Treatment Regardless of clinical presentation (e.g., psychological vs. physiological), the priorities of care for all emergency patients involve the primary assessment. Management for anxiety and/or panic reactions include the following: Maintain airway, breathing, circulation (ABCs) Encourage slow, diaphragmatic breathing Paper-bag rebreathing and application of oxygen (O2) facemask without O2 should never be used Provide O2, as needed Establish intravenous (IV) access for crystalloid fluids and/or medications (e.g., benzodiazepines, such as lorazepam; anti-panic drugs, such as clonazepam), as needed Initiate cardiorespiratory monitoring, as applicable Utilize calm communication techniques with simple, understandable language Reorient patient to current reality Assist with stress reduction (e.g., expression of feelings, problem-solving) Assess safety concerns (e.g., potential for self-harm, harm to others) Ensure patient is placed in a location that facilitates close observation Perform suicide risk assessment, as needed Collaborate with health care team to develop most appropriate discharge plan (e.g., psychiatric evaluation, referral to community resources) Patient education (e.g., knowledge deficit, signs and symptoms, triggers, self-care, community resources available) (Pitner, 2018, pp. 440-441)

Depression

In Canada, approximately 11% of men and 16% of women will experience major depression during their lives, which may affect personal relationships, loss of time at work or school, or one's overall physical health (Health Canada, 2009, p. 1). Research shows that mood and anxiety disorders are most prevalent among the 15-to-24-year-old age group, of which approximately 7% had reported having depression within the previous 12 months (Findlay, 2017). Although treatable in most cases, major depression may also lead to suicide or suicidal behavior. Feelings of unhappiness or grief due to situational events, such as the death of a loved one or loss of a job for example, are unfortunately a natural part of life and must not be confused with major (clinical) depression. "Major depression is a clinical term used by psychiatrists to define a time period that lasts more than two months in which a person feels worthless or hopeless" (Health Canada, 2009, p. 1). The Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) (American Psychiatric Association [APA], 2013b) is the 'bible' for diagnosing mental illness. A thorough examination of the DSM-5 is beyond the scope of this course; however, nurses working with mental health patients should be aware of this resource. Several risk factors may play a role in the development of major depression, and are described as follows: Biochemistry (e.g., certain chemicals in the brain); Genetics (e.g., identical twins: if one twin has major depression, the other twin has a 70% chance of developing the illness during their lifetime); Personality (e.g., low self-esteem, easily overwhelmed by stress, pessimistic); and Environment (e.g., continuous exposure to violence, neglect, abuse, or poverty) (APA, 2017, para. 9). Other factors that may make an individual more vulnerable to major depression include the following: Death or illness of a spouse, family member, or friend; Difficulties or stress at work; Difficulties or stress in a personal relationship; Financial difficulties; Addictions or substance abuse disorders; Other mental health conditions (e.g., Seasonal Affective Disorder); and Hormonal changes (e.g., post-partum, menopause) (Health Canada, 2009, p. 1). Signs and Symptoms The symptoms of major depression present as alterations in mood, self-concept, physical health, and activity and interest levels (Pitner, 2018). If at least five of the following symptoms are present during the same 2-week period, major depression may be suspected: Loss of interest in usual activities; Feeling sad or having a depressed mood; Changes in appetite (e.g., weight gain or loss unrelated to dieting); Loss of energy or increased fatigue; Trouble sleeping (insomnia) or sleeping too much (hypersomnia); Increase in purposeless physical activity (e.g., hand-ringing, pacing) or slowed movements and speech; Difficulty thinking, concentrating, or making decisions; Feeling worthless or guilty; and Thoughts of death or suicide (APA, 2017, para. 2). It is important to note that patients with major depression may also present with physical or somatic complaints. Hoyer and David (2012) found that patients who screened positive for symptoms of depression presented to the ED with the following chief complaints: Chest pain Abdominal pain Back pain Seizure Dyspnea Vomiting and diarrhea Skin rash HIV-related concerns Diabetes Headache *** Some medical conditions (e.g., thyroid dysfunction, vitamin deficiency) "can mimic symptoms of [major] depression so it is important to rule out general medical causes." ***(APA, 2017, para. 4) Treatment Medications used in the treatment of depression mainly include antidepressants. The three main groups of antidepressants are tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake inhibitors (SSRIs). Antidepressants positively affect poor self-concept, degree of withdrawal, vegetative signs of depression, and activity level; however, it may take up to 3 - 4 weeks to achieve therapeutic benefit, depending on the medication. Tricyclic Antidepressants (TCAs) TCAs inhibit the reuptake of norepinephrine and serotonin by the presynaptic neurons in the central nervous system (CNS), and thus increase the availability of both at the postsynaptic receptors. This increase may be responsible for mood elevations when a depressed patient receives these medications. Monoamine Oxidase Inhibitors (MAOIs) "The enzyme monoamine oxidase is responsible for inactivating, or breaking down, certain monoamine transmitters in the brain, such as norepinephrine, serotonin, dopamine, and tyramine" (Varcarolis & Halter, 2010, p. 266). The increase in norepinephrine, serotonin, and dopamine is believed responsible for mood elevations. The increase in tyramine, however, causes a problem. An increase in the amine tyramine that is not inactivated by MAO can result in high blood pressure, hypertensive crisis, and, as it progresses, a cerebrovascular accident (CVA). MAOIs interact with many foods and drugs, including other antidepressants, dextromethorphan, aged cheese, chocolate, beer, and wine (Shives, 2008). Selective Serotonin Reuptake Inhibitors (SSRIs) This class of antidepressants is presumed to inhibit the reuptake of serotonin in the presynaptic nerve ending, allowing serotonin to remain longer in the synaptic cleft and enhancing the action of the neurotransmitter on synaptic receptors, resulting in a clinically significant antidepressant effect. "Concurrent use of the herbal supplement St. John's Wort...can lead to the accumulation of serotonin" (Shives, 2008, p. 233) and subsequent serotonin syndrome. In addition to SSRIs, serotonin syndrome may be due to administration of TCAs, MAOIs, lithium (antimanic agent), and trazodone (serotonin antagonist reuptake inhibitor [SARI] (Shives, 2008). Nonpharmacological treatment for depression may consist of patient education (e.g., knowledge and understanding of depression; self-help strategies, such as exercise and healthy nutritional choices), psychotherapy, and electroconvulsive therapy (ECT, used in refractory major depression or bipolar disorder) (APA, 2017). Bipolar Disorder Also known as manic-depressive illness, bipolar (affective) disorder is typically characterized by alternating manic or euphoric moods and periods of depression. One affective state does not have to immediately precede or follow the other; affective presentation can be unpredictable with varying lengths of time between each affective state. Risk factors for the development of bipolar disorder are described as follows: Family history Repeated cycles of mania, depression Antidepressant therapy Substance abuse Organic problems Pregnancy (history of manic-depressive disease increases pregnant woman's risk of developing postpartum psychosis) (Pitner, 2018, p. 441) Signs and Symptoms The signs and symptoms of depression are described in the previous section. The manic state typically has a rapid onset, within a 2-week period, and may present with any or all of the following symptoms or behaviors: Euphoria, highly social Sexual inappropriateness Impairment in thinking Flight of ideas, grandiosity Sexual inappropriateness Poor social judgment Inflated self-esteem, arrogance Paranoia Altered speech pattern (rapid, pressured) Irritability, hostility Flamboyance, impulsivity Auditory hallucinations Poor hygiene, unkept appearance Altered sleep pattern, often requiring very little sleep (Pitner, 2018, p. 441-442) Treatment As previously discussed, management of psychological disorders begins with ensuring the hemodynamic stability of the patient. The treatment of depression is described above, thus will not be covered again here. The cornerstone of bipolar management involves medication (i.e., mood stabilizers) and counselling (e.g., cognitive-behavioral therapy [CBT]). While medications may help stabilize mood, patients most often require counselling to address "...the thinking patterns or beliefs that can drive mood problems" (Canadian Mental Health Association [CMHA], 2014, para. 1). General management options in the treatment of mania are outlined as follows: Orient patient to reality Ensure safety of patient (e.g., physical restraints, close observation) Treat injuries due to psychotic behavior, if present Utilize calm communication techniques Ensure quiet, non-stimulating environment Assess compliance with treatment regimen (e.g., medications) Administer pharmacologic therapy, as ordered Antimanic agents (e.g., Lithium) Anticonvulsants (e.g., valproic acid [Epival], lamotrigine [Lamictal], carbamazepine [Tegretol]) Antipsychotic agents (e.g., clozapine [Clozaril], quetiapine [Seroquel]) Antianxiety agents (e.g., benzodiazepines) Treat sequelae of malnutrition, if present (e.g., electrolyte imbalances, dehydration) Collaborate with health care team to develop appropriate discharge plan (e.g., psychiatric admission, referral to community resources) (Pitner, 2018, p. 442) Suicide or Suicidal Behavior In Canada, more than half of all suicides involve individuals aged 45 years or older (Statistics Canada, 2018b). Most suicides involve men; however, women attempt suicide 3 to 4 times more often (Statistics Canada, 2018a). Fourteen percent of individuals in the 15-to-24-year-old age group reported having suicidal thoughts at some point during their life; 5% had made a suicide plan and 3.5% had attempted suicide (Findlay, 2017, p. 7). Suicide is a leading cause of death among this age group, second only to accidents (Statistics Canada, 2018a). It should be noted that suicide rates among First Nations youth are 5 to 7 times higher than for non-Aboriginal youth. Suicide rates among Inuit youth are 11 times the national average and are reportedly among the highest in the world (Government of Canada, 2018, para. 3). Significant numbers of people who complete a suicide attempt had visited healthcare professionals in the preceding weeks, often with complaints not related to their suicide plan, such as those previously described (Luoma, Martin, & Pearson, 2002). A positive score on a depression screening tool is not sufficient for a diagnosis of clinical depression, but anyone who experiences a major depressive episode (or who is suspected of having such an episode) must be assessed for risk of suicide. A person who voices suicidal ideation should always be taken seriously. For some patients with mental disorders, this is the only way they know to get urgently-needed attention. Unfortunately, no tool is infallible in identifying people who will end their lives. Nurses do the best they can to keep patients safe and free from self-harm. Who is at greatest risk for suicide? The acronym SAD PERSONS is one tool that can be used to assess risk. Sex - Males have more serious and successful attempts than females, although females make more attempts. Age - Teens, young adults, and elderly people are more likely to commit suicide than the rest of the population. Depression - Feelings of hopelessness, helplessness, and sadness increase risk of suicide. Previous attempt - A history of suicide attempt(s) increases the risk of another suicide attempt. Ethanol abuse - The outcomes of alcohol abuse often lead to profound depression and subsequent suicide attempts. Rational thinking lost - People whose lives are severely disrupted may act impulsively. Social support lacking - The lack of family and friends may lead to intense feelings of loneliness and possible suicide attempts, particularly for elderly widowed males. Organized plan - A suicidal person who has developed a plan to commit suicide and has the means to carry it out is at extremely high risk. No spouse - Single people are at higher risk of suicide than those in stable relationships. Sickness - People with chronic or debilitating illnesses are more likely to commit suicide than those in good health. Suicide Risk Assessment The steps involved in conducting a suicide risk assessment are outlined below: 1. Assess current suicidal ideation. Is suicidal ideation present now? Is there a plan? Is there intent? 2. Obtain details if the person has a suicide plan. How lethal is the plan? Is there access to means? Has the person chosen a time and/or place? Has the person made final arrangements? 3. Gather details on current and previous attempts. Triggers of present attempt Triggers of past attempts Lethality Impulsivity Intoxication Expectations of dying Feelings about survival 4. Obtain information on psychiatric and other history. 5. Conduct an MSE (or 'mini' version, rapid assessment). 6. Evaluate the person's problem-solving capacity. 7. Assess level of hope. 8. Communicate with family and/or significant others. Assisting a Suicidal Person Some basic nursing interventions that may assist suicidal patients are described as follows: Provide support by helping the patient identify or develop coping strategies; reinforce coping skills used in the past. Emphasize the importance of treatment. Address ambivalence in order to instill hope. Safety contracts have been used for many years with the intent of keeping patients safe in their environment. Alberta Health Services, for example, has made the decision to no longer use safety contracts to ensure patient safety when at risk for suicide. Instead, there is a recommendation to conduct a thorough face-to-face discussion with the patient often throughout the nurse's shift. Ensure the patient has a follow-up appointment with a health-care provider, and a follow-up phone call within 48 hours.

Sexual Assault

Introduction This self-study guide was designed to provide basic information for emergency nurses who may care for patients who have been sexually assaulted. The guide will introduce you to general principles of caring for this special patient population. It will not prepare you to conduct a thorough history and examination of a person who has experienced a sexual assault - this is a specialized skill set requiring further on-site training. For a deeper understanding of this topic, you are encouraged to familiarize yourself with the policies, procedures, and resources available at your site.

Palliative Care and Symptom Management

It is becoming increasingly common for emergency nurses to care for palliative patients in the ED. In fact, in 2018 in Ontario, 62.7% of palliative patients visited an ED within their last 30 days of life (Health Quality Ontario, 2018). This of course is not an ideal setting to receive palliative patients due to the chaotic and busy nature of the department, and the comfort level of emergency nurses with palliative care. Research suggests that the majority of ED visits for palliative patients are due to unmanaged symptoms and poor access to palliative and end-of-life care in the community, deducing that increasing these community resources could decrease unnecessary ED visits and admissions of those wanting to be managed and die at home (Salam-White et al., 2014). The three most commonly unmanaged symptoms that bring these patients to the ED are shortness of breath, nausea, and pain (Green et al., 2016). Transitioning patients to palliative care and symptom management can and should be seen as a proactive approach and not as failure (Etland, 2022). It is paramount that nurses help to initiate palliative-care referrals as appropriate to the community or to hospice care. Many EDs have an onsite community resource person or homecare coordinator who can expedite referrals to the community for palliative care. According to Etland (2022), withdrawal of treatment and transitioning to comfort care in a critical-care setting should be done in stages, for both the benefit of the patient and for the family. Generally, the order includes: Cessation of all routine testing and monitoring, such as labs and cardiac monitoring. Respiratory devices as applicable are discontinued next (such as extubation), while ensuring that symptoms are managed appropriately. If the patient is at end of life, we should discuss with family withdrawal of fluids and nutrition, which can prolong suffering if continued. Withholding or withdrawing non-beneficial care can be very challenging in the ED. Read the following article that walks the reader through the decision-making process of withholding or withdrawing emergent care and considering new treatment plans and palliation, the issue of organ donation, and organizing palliative care in the community. This is an article from France, but the issues are highly transferrable to those we face in Canada. Palliative care is itself a specialty, and so it is understandable that nurses who work in critical-care areas such as the ED may feel less prepared to provide sound, up-to-date palliative care to their patients, especially with all the time and resource constraints they face. For more learning on palliative care and symptom management, there is an excellent course called "LEAP," offered through Pallium Canada, as well as a free online module that introduces some key concepts of palliative care. There are also many educational opportunities, online learning, and webinars available through the Canadian Hospice and Palliative Care Association. You are encouraged to develop your knowledge in this area.

Substance Abuse and/or Addiction

It is not uncommon for people with substance addictions to attempt to obtain drugs from EDs. In many hospitals, steps have been taken to reduce drug-seeking behaviour through measures such as writing prescriptions in triplicate, tracking hospital visits, and keeping electronic health records. It is important for nurses to be able to assess the need for medications that can be addictive, and to recognize the physical signs of substance use and intoxication. Any of the symptoms in the following list may be due to intoxication. Aggression Amnesia Anger Anxiety Ataxia Belligerence Bradycardia / Tachycardia Chills / Diaphoresis Delirium Diarrhea Drowsiness Dysphoria / Euphoria Hypertension Hyperthermia Hypervigilance Hypotension Impulsiveness Joint aches Labile mood Nystagmus Palpitations Seizures Slurred speech Panic attacks Pupillary constriction or dilation Tremors Weight loss Substance Withdrawal The DSM-5 (APA, 2013b) classifies substance withdrawal as a 'substance-induced disorder', consisting of the following five criteria: Cessation of (or reduction in) use of a substance that has been heavy and prolonged. The development of a substance-specific syndrome shortly after the cessation of (or reduction in) substance use. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including withdrawal from another substance. The substance involved cannot be classified under any of the other substance categories (alcohol; caffeine; cannabis; opioids, sedatives, hypnotics, or anxiolytics; stimulants; or tobacco) or is unknown. Table 2. Commonly abused drugs and symptoms of withdrawal. Anxiety Nausea Autonomic activity Cognitive Mood Fatigue Impaired speech Seizure activity Memory loss Hallucinations/ Delusions Impaired psychomotor activity Sleep disturbance Depressants - opioids (e.g., codeine, opium, morphine, heroin, methadone) X X X X X Depressants -prescription tranquillizers, sleep aids, and other depressants (e.g., Valium, Xanax, Ativan, Gamma-hydroxybutyrate, alcohol, inhalants) X X X X X X X X X X X X Stimulants (e.g., cocaine, dextro-amphetamine, methamphetamine, tobacco, caffeine) X X X X X X X X Anabolic steroids (e.g., oxymetholone, stanozolol, nandrolone) X X X X Cannabis (e.g., marijuana, hashish, hash oil) X X X X X Adapted from Drugs of Abuse: An Identification Guide, by Sunshine Coast Health Centre, 2009, Author.

Medical Assistance in Dying

Medical assistance in dying (MAID) became legal in Canada in 2016, and since then 6,749 Canadians have participated in MAID, including six cases of self-administration (Health Canada, 2019). And although it has been considered an important legal milestone and great achievement in the world of healthcare, "the difficult issues do not finish with passing the law - the baton merely passes to the doctors, nurses, hospital administrators, clergy and anyone else who chooses to play a part, large or small, in helping end a human life" (Cornise, 2017, p. 1). Physicians and nurse practitioners are the only healthcare professionals who can perform MAID, but pharmacists, nurses, and family members can assist. The legal ramifications of not following processes are significant, such that practice that does not follow the explicit guidelines would be deemed criminal under the Criminal Code of Canada (Government of Canada, 2019). Although it is not likely that MAID itself will actually occur in the ED proper, it is important for nurses to be familiar with the new laws regarding MAID in Canada and what their role is in accordance with their licensing college, as you will encounter patients in the ED at the end of their life who have chosen to participate in MAID. You may work in a hospital that admits patients who are assessed, become eligible for, and complete MAID. There are as many medically assisted deaths in-hospital as there are at home; of the 2,614 people who participated in MAID in Canada in 2018, 1,148 were admitted to hospital, compared to 1,107 whose death occurred at home (Health Canada, 2019). The average age for MAID is 72 years, there is no marked difference in the rate of males versus females, and the main condition leading to the request for MAID is cancer (Health Canada, 2019). MAID eligibility is explicitly outlined by our Canadian legal system, and specifies that persons requesting MAID must: be eligible for health services funded by the federal government, or a province or territory. be at least 18 years old and mentally competent. have a grievous and irremediable medical condition, where natural death is reasonably foreseeable BUT it does not have to be considered a terminal or fatal illness. make a voluntary request for medical assistance in dying that is not the result of outside pressure or influence. give informed (written) consent to receive medical assistance in dying. must undergo a medical assessment. must wait a 10-day waiting period prior to completing MAID, to provide time for reflection (Government of Canada, 2019). **It is important to highlight the fact that patients and family must voluntarily request information on MAID, and it is not something that healthcare professionals can initiate, suggest, or coerce in any way. In the case of MAID, nurses have no legal or ethical obligation to participate, but they have a professional obligation to help refer patients who express an interest in having their eligibility determined (Canadian Nurses Association, 2017). Medically assisted death evokes some unsettling feelings for healthcare professionals who don't agree with the concept, and may even spark a conscientious objection to the process. However, even if strongly opposed, we still have the aforementioned professional obligation to our patients.

Psychotic Behavior

Psychosis is defined as "a bizarre state of profoundly altered thinking and behaviour involving deterioration of thought processes, effective responses, and the individual's ability to maintain connection with reality" (Manton, 2013, p. 511). Psychosis may also include delusions (false beliefs), hallucinations (seeing/hearing things that are not there), disorganized thoughts (loosening of associations, thought blocking, making up new words, perseveration), disorganized speech (echolalia, perseveration), disorganized behaviours (agitation, echopraxia, waxy flexibility), and loss of contact with reality. Psychosis is not synonymous with schizophrenia, as many disorders include psychotic symptoms. Some of the most common disorders are listed below: Schizophrenia Depression Delirium Dementia Abuse of illegal or prescription drugs Bipolar disorder Brief psychotic disorder Schizoaffective disorder Delusional disorder Rapid Assessment for Command Hallucinations All persons presenting with a psychosis should be assessed for hallucinations. Although command hallucinations are rare, it is imperative to ask these patients if any voices or visual images are directing them to harm themselves or others. Anyone experiencing command hallucinations warrants further investigation and treatment. Management of schizophrenia includes the administration of antipsychotic medications such as chlorpromazine (CPZ, Largactil), haloperidol (Haldol), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal). Medications to treat Parkinson's disease (i.e., anticholinergics, such as benztropine [Cogentin]) may be added in order to decrease the extrapyramidal side effects (e.g., muscle stiffness, tremors) associated with primary antipsychotic medications (Gagnon, 2010). Restraints The Canadian Nurses Protective Society (CNPS) defines restraints as, "...[any] measures used to limit the activity or control the behaviour of a person or a portion of their body" (CNPS, 2004, para. 1). The CNPS identifies three types of restraints: environmental (e.g., seclusion, restricted to an area with a security guard), mechanical/physical (e.g., use of a technique or device), and chemical (e.g., medications). Generally speaking, most EDs have 'least restraint' policies, meaning less invasive or aggressive measures are attempted first. Depending on the situation, the patient may be confined to a room with a security guard, then administered medication (e.g., haloperidol), followed by physical restraints as a last resort. The use of patient restraints is warranted when the situation requires the prevention of self-harm, or harm to others. They should NEVER be used as a form of punishment. If used incorrectly, or inappropriately, physical restraints put the patient at risk for injury (e.g., falls, strangulation) and adverse side effects (e.g., abrasions, pressure ulcers). Every ED should have restraint policies and procedures, including how they are ordered (e.g., time-specific) and documented (e.g., 'well-being' checks), as well as mandatory training regarding their use. It is essential that the emergency nurse become familiar with these policies within his/her workplace.

Death Notification and Bereavement Care

Nurses often feel unprepared to notify survivors about death" (Chan, 2018, p. 63). Being the bearer of terrible news in the ED, such as the death of a loved one, is not a skill that is taught very well in nursing school, or even medical school for that matter. Often this skill comes with experience. As a result, "nurses often feel unprepared to notify survivors about death" (Chan, 2018, p. 63). Physicians typically break such news to families, but this great responsibility can fall on nurses too at times, and nurses often join the physician in delivering the news. What we fear as professionals are the intense reactions to grief such as anger, disbelief, sadness, crying, agitation, or even chest pain (Chan, 2018). Some suggestions on how to deliver bad news include: Using clear, simple language, and be prepared to repeat what you have told the survivors a few times Be present with the individuals you are notifying in order to help them cope with the situation, allow time for their reactions to news but stay present, and only intervene with their grief if it is a matter of self-harm or harm to others. Encourage survivors to view their loved one, and avoid words such as "body." Assist survivors in obtaining spiritual support as applicable. Describe to the survivors what they will see before they enter the room. Provide survivors with information on what to do next, such as assisting them in notifying a funeral home as applicable. If available, offer a printed handout of the process (Chan, 2018; Etland, 2022). The death of a pediatric patient in the emergency department is arguably one of the most difficult challenges nurses will ever face at their work (ENA, 2014b). The death of a child is often sudden and traumatic in nature, which compounds the grief associated with it (Jackson, 2017). Albeit an increasingly rare occurrence, inadequate time and space, and resource constraints, can make it very difficult to provide unhurried and sensitive bereavement care to the surviving loved ones (O'Meara & Trethewie, 2016). Few EDs have a quiet, dedicated space to which the deceased child can be moved and where the family can be allowed to grieve and be supported (O'Meara & Trethewie, 2016).

Nursing Interventions child abuse

Nursing interventions consist primarily of implementing care in collaboration with other members of the health care and child protection teams; it is vital to involve experts in the field as soon as possible. Any life-threatening injuries are cared for as with any other patient in the ED. Preparation of the child who has been sexually abused includes: Vaginal, cervical, or rectal cultures for chlamydia and gonorrhea Vaginal and rectal fluids for spermatozoa and prostatic acid phosphatase Pregnancy testing Saliva for ABO-antigen typing Hair specimen antibodies (human immunodeficiency virus [HIV]) or sexually transmitted infections (STIs) Photographs of all visible external injuries Accurate and detailed documentation is very important. Nursing assessment findings must be documented in the patient's chart, with the patient's words written verbatim and enclosed in quotation marks.

Child Abuse Emergencies

One of the most difficult situations faced by health care providers is the abuse or neglect of a child. Child maltreatment or abuse refers to any adult behaviour that is destructive to the normal growth, development, and well-being of a child. It includes both actions and inactions that result in the physical, sexual, emotional, or neglectful abuse of infants, children, and adolescents (≤ 14 years of age). In 2016, children and youth (aged 17 years and younger) represented 16% of victims of violent crime in Canada, with 59% being victimized by a parent (Burczycka & Conroy, 2018, p. 70). As of 2008, there were over 25,000 investigations related to child maltreatment (and risk thereof) in Alberta. Of these investigations that were deemed 'substantiated', the categories of abuse are broken down as follows: physical, 13%; sexual, 2%; neglect, 37%; emotional maltreatment, 14%; and exposure to intimate partner violence, 34%. Eighty-seven percent (87%) of child welfare investigations did not result in placements for the child(ren) (e.g., stayed in the home), whereas 13% resulted in a change of residence (i.e., child with relative [not formal child welfare placement], 4%; foster care [formal foster or kinship care, such as family], 7%; group home/residential secure treatment, 2%) (MacLaurin et al., 2013, p. 23). In Alberta, as in other provinces, anyone who has reason to believe that a child has been abused, or that there is substantial risk that he or she will be abused or neglected by a parent or guardian, has a legal duty under the Child, Youth, and Family Enhancement Act (or other respective provincial legislation) to promptly report the matter. How to Report Suspected child abuse must be reported to caseworkers at the local Child and Family Services (CFSs) agency, Child and Adolescent Protection (CAP) Centre, First Nations Child and Family Services, or the Child Abuse Hotline (1-800-387-5437). While it is appropriate to relay your findings to emergency team members and social workers, it is your professional responsibility to make sure the abuse is reported to one of these agencies. The caseworker at CFSs or other agency will determine if the child can benefit from family enhancement or protection services, if criminal investigation is required, and if other agencies should be involved. What to Report A report of child abuse should include the following information: Your name, phone number, and relationship to the child (e.g., emergency nurse [this information remains confidential] The child's name, age, current location, and safety Information about the abusive situation, if known Description of injuries and/or signs of neglect Any other relevant information (see MacLaurin et al., 2013, p. 13 for a comprehensive description of information to be reported)

Mental health Part C and D: Review Questions (answers at end of page)

Part C and D: Review Questions (answers at end of page) 1. Which of the following statements about bipolar disorder is False? a. A manic episode is always followed by a depressive episode. b. Bipolar disorder may be mild, moderate, or severe. c. Drowsiness is a symptom of a manic episode. d. People with bipolar disorder usually have grandiose ideas. 2. Which of the following statements about a major depressive disorder is True? a. Depression does not occur in children younger than 10 years of age. b. Depression rarely reoccurs after treatment. c. There is lower incidence of depression among First Nations people than among other minority cultural groups. d. Depressive disorders often co-occur with other psychiatric disorders and substance abuse. 3. Psychiatric patients' experiences in the ED are generally negative due to: a. increased stimulation. b. lack of appropriate resources. c. attitude of staff. d. all of the above. 4. When caring for psychiatric patients in the ED, nurses must ensure their own safety by all of the following except: a. ensuring all doors are closed when providing patient care. b. always having an exit route. c. knowing where the panic buttons are located. d. communicating with colleagues. 5. General appearance is included in the mental status assessment, and is assessed by noting which of the following? a. Attitude b. Thought stream c. Malodorous presentation d. Eye contact 6. Michael is suffering from an anxiety attack and is admitted to the ED. What should the nurse remember when communicating with Michael? a. Tackle potentially volatile issues at the beginning of the conversation b. Guide Michael to focus on his present situation c. Speak loudly and firmly d. Avoid small talk 7. Extrapyramidal side effects are common in patients taking antipsychotic medications. Signs and symptoms of these side effects include all of the following except: a. spasms of the neck, jaw, face, and body. b. involuntary movement of the tongue. c. decrease in white blood cell (WBC) count. d. restlessness. 8. Which of the following goals is most important when caring for a suicidal patient? a. Reduction of anxiety b. Normalization of sleep pattern c. Enhancement of self-esteem d. Protection from self-harm 9. Planned interventions for a severely depressed patient should include which of the following? a. Allowing him to remain alone if he prefers b. Providing careful unobtrusive observation around the clock c. Encouraging him to spend a major portion of each day in bed d. Offering opportunities to assume a leadership role in the therapeutic milieu 10. A depressed patient is being treated with selective serotonin reuptake inhibitors (SSRIs). She tells the nurse she formerly took monoamine oxidase inhibitors (MAOIs) for depression, and she thinks she should start taking them right now instead of her current medication. What information should the nurse provide? a. Mixing the medications is not a problem b. Adding St. John's Wort to SSRIs is recommended c. Dietary restrictions are required when taking MAOIs d. All of the above 11. Most people who commit suicide do which of the following? a. Attempt suicide only in a controlled environment b. Never give clues about their intention of harming themselves c. Attempt suicide only in the hyperactive stage of their illness d. Give a direct or indirect indication of their plan to harm themselves 12. During the night, a patient with paranoid disorder screams that the police are coming to get him. What would be the nurse's best response? a. "I'm Mary, your night nurse. You are in the hospital." b. "You sound really upset. I understand how you must be feeling." c. "I'll get a glass of warm milk for you. It'll help you sleep better." d. "I'll put on more lights. You'll feel more secure if you can clearly see your surroundings." 13. Which of the following extrapyramidal signs or symptoms is usually the first to present following initiation of an antipsychotic medication? a. Hypertension b. Dystonia c. Agranulocytosis d. Akathisia 14. A patient with a fluctuating LOC, disturbed orientation, and perceptual alterations begs to have someone get the bugs off her. What would be the nurse's most appropriate response? a. "There are no bugs on your legs. Your imagination is playing tricks on you." b. "Try to relax. The crawling sensation will go away sooner if you can relax." c. "Don't worry, I will have someone stay here and brush away the bugs for you." d. "I don't see any bugs, but I know you are frightened, so I will stay with you." 15. Which of the following is the most appropriate nursing intervention for patients with personality disorders who use manipulation to have their needs met? a. Supporting behavioural change b. Using aversive therapy c. Maintaining consistent limits d. Monitoring suicide attempts 16. A patient with a history of alcohol abuse has just been transferred to your treatment area in the ED. Which of the following questions should you ask first? a. "Has drinking caused you any problems?" b. "Have you ever had blackouts?" c. "When did you take your last drink?" d. "When did you decide to seek treatment?" Part C and D: Answer Key 1. c. 2. d. 3. d. 4. a. 5. c. 6. b. 7. c. 8. d. 9. b. 10. c. 11. d. 12. a. The statement that drowsiness is a symptom of a manic episode is false. Depressive disorders often co-occur with other psychiatric disorders and substance abuse. All of the choices are true. For psychiatric patients, experiences in the ED are generally negative due to: • increased stimulation. • lack of appropriate resources. • attitude of staff. Nurses must not close all doors when caring for psychiatric patients in the ED. They should always have an exit route, know where the panic buttons are located, and remain in communication with colleagues. General appearance is assessed by noting malodorous presentation. When communicating with a patient suffering from an anxiety attack, guide the patient to focus on his or her present situation. A decreased WBC count (agranulocytosis) is not an extrapyramidal side effect of antipsychotic drugs. In caring for a suicidal patient, the most important goal is protection from self-harm. Planned interventions for a severely depressed patient should include providing careful unobtrusive observation around the clock. Dietary restrictions are required when taking MAOIs. Most people who commit suicide give a direct or indirect indication of their plan to harm themselves. If a patient with a paranoid disorder screams that the police are coming to get him, the nurse's best response would be to identify her- or himself and attempt to orient the patient to the situation. ("I'm Mary, your night nurse. You are in the hospital.") 13. b. 14. d. 15. c. 16. c. Impairment in muscle tone (dystonia) is generally the first extrapyramidal symptom to present, usually within a few days after an antipsychotic medication is initiated. If a patient is having perceptual alterations, the nurse's most appropriate response is a thoughtful attempt to encourage reorientation and reassurance without reinforcing the patient's illusion. ("I don't see any bugs, but I know you are frightened, so I will stay with you.") When people with personality disorders are manipulative, the most appropriate intervention is to maintain consistent limits. When a patient has a history of alcohol abuse, the nurse's first question should be,when did you have your last drink?

Rapid Assessment of Mental Health Status

People with mental disorders can be intimidating, thus approaching a patient with a clear plan will help you to evaluate the patient's current condition as rapidly as possible. The following guide describes five steps that most often occur in sequence, but may be individually implemented as needed. Following the diagram, examples of each step are outlined, beginning with Assessing the Situation in the lower left corner. Assessing the Situation Establish rapport while being respectful, open-minded, thoughtful, empathetic, and non-judgmental. Avoid making assumptions. Ask the following questions: Does the person have a physical concern? Is the person alone? Is the person agitated? Is the person known to the ED? Asking the Right Questions As with other patients, explore the problem by asking, "What brings you to the emergency department today?" and "Has this happened to you before?" Other questions include: "Are you feeling safe here?" If the answer is NO, ask, "What can we do to make you feel safe while you wait?" "Are you thinking about harming yourself?" If the answer is YES, do a suicide risk assessment immediately. Listening Carefully Listen carefully to the answers the person provides. Observe for verbalizations or behaviours that may indicate frustration, anxiety, or fear. If any family members are present, listen to their stories as well. Try to identify the patient's and family's strengths. Negotiating a Plan Negotiate a plan of action with the patient by asking the following questions and by acting as an advocate for the individual (a distressed person may be unable to answer some or all of these questions). You may be able to draft tentative answers to some questions yourself based on the patient's behaviour or information from the family. "What are your usual coping strategies?" "Do you live alone?" "Do you have a place to go to?" "Is your family in crisis?" "Can you wait until tomorrow to see your nurse or doctor?" "Do you need immediate attention?" "Do you think you need psychiatric assessment by the mental health team?" Following Up Patient follow-up after discharge from the ED can be a challenge for several reasons, such as lack of a family physician or coordination with community services. If the patient is discharged home, try to arrange for a follow-up phone call or contact. Assure the person that he or she can return to the ED if the situation changes. If the patient does not go home, try to provide an estimate of the length of time he or she will have to wait before being seen by a physician (while it is important to keep patients updated with waiting and throughput processes, use caution with providing definitive time frames). Maintain contact and continue to reassess the patient for increasing signs of frustration, anxiety, or fear. If you have concerns or questions about a mental health patient's condition, do not hesitate to involve the mental health team, if one is available. This team has expertise in managing people who present with signs of a mental illness. Most health care institutions and/or regions in Canada have access to a course in how to manage an aggressive patient. All nurses are encouraged to enroll in such courses to develop competency in techniques for keeping patients, fellow nurses, visitors, and others safe. Quick safety tips Do not wear anything around your neck (even "break-away" lanyards). Do not let the patient get between you and the door. Observe the patient for signs of increasing restlessness, anxiety, or anger. Learn how to de-escalate situations that could lead to violence. Be aware of your surroundings. Know the location of your colleagues. Thorough Assessment of Mental Health Status The mental status examination (MSE) is to nurses working in psychiatry what the primary assessment is to emergency nurses. The MSE provides a framework for thoroughly assessing the mental state of patients. In the ED, you may find that you have time to complete only portions of the MSE. The MSE consists of 11 domains: appearance, attitude, behaviour, mood and affect, speech, thought process, thought content, perceptions, cognition, insight, and judgment. These are outlined in the table below. Table 1. Assessment of mental health domains. Domain Examples Appearance Cleanliness, grooming Attitude Suspicious, detached Behaviour Tics, speeded, retarded Mood and affect Worried, depressed, sad Flattened, blunted, restricted Speech Rambling, pressured Thought process Logical stream of thought, congruent with conversation Tangential, loose associations Thought content Thought control, delusions, preoccupations Perceptions Hallucinations Cognition Level of consciousness (LOC) Orientation to person, place, and time Memory • Immediate retention and recall • Recent • Short-term • Long-term Attention and concentration Comprehension and abstract reasoning Reasoning Insight How does the patient view her- or himself in terms of illness? Is the patient aware of problems? Judgment Ability to link consequences with actions

Postmortem Care and Preparing for Coroners' Cases

Postmortem procedures are institution-specific, and should take into consideration the spiritual beliefs of the deceased and that of the family. You must know your institution's policies. In general, most deaths in the emergency department would qualify for an autopsy, or a coroner's investigation. These are warranted if: Death was suspicious or a result of criminal activity. Death was sudden, unexpected, and/or traumatic. Death occurred during pregnancy. Death from any cause other than disease (Chan, 2018, p. 66; Keatings & Smith, 2010). Nurses must be familiar with their hospital policy for postmortem care and preparing for coroners' cases, but generally the nurse must leave all of the equipment used in resuscitation in situ (for example, endotracheal tubes, nasogastric tubes, urinary catheters, and IVs). The deceased can be taken off the monitor and a sheet draped over exposed areas, as this will make it less distressing for the family. After the family has had enough time to be with their loved one after death, the body must be prepared for transfer to the morgue in accordance with hospital policy.

Knowledge and Skills for Emergency Nurses

Scenario: On my first evening shift in the ED, I was bandaging a sutured laceration on a woman's forehead. She told me, "My husband did this to me with a car key." I had received no training about how to respond to abuse; I did not know what to do. The physician did not want to get involved, and the patient did not want to involve the police or social workers. I let her leave the ED without questioning her safety or providing her with any support or resources. I gave poor care. I have regrets. Knowledge and skills in an ED are very important. Consider the following situations: A young male diagnosed with acute depression tells you that his partner is accusing him of being too friendly with a classmate. He says his partner often threatens him. A woman with back pain is in the ED for the third time in a month. You ask her if anyone has made her feel unsafe or frightened. She tells you she has been coming to emergency to get away from her boyfriend. A man whose legs are swollen and red from cellulitis tells you a bookcase fell on him. When asked again about his injuries after his wife leaves the room, he tells you she hits his legs with a stick when she is angry. A newly-immigrated woman says she has no friends in Canada; she is confined to a bedroom and not allowed to make phone calls. She tells you her family says it would be wrong for her to leave her husband. The sister of the woman who was cut with a key (in the above scenario) comes to the ED and asks how her sister could be sent back to a situation in which she was being beaten without receiving any help. A 75-year-old woman discloses being abused by her husband, and says she wishes someone had asked her about it years ago. The following facts reinforce the importance of recognizing and responding appropriately when patients are suspected to be victims of domestic violence. Abused persons come to EDs because of physical injuries or illness and/or for protection. Abused women may visit an ED many times before they disclose abuse. People who are being abused do not usually disclose without being asked. Women exposed to domestic violence are at risk for multiple complex health issues (e.g., injuries, depression, substance abuse, gynecological problems), thus early recognition is crucial for their health and safety. Unrecognized symptoms can exacerbate the sense of entrapment, the belief that no one can help, the loss of self-esteem, and the dangers involved. Children are also affected; witnessing domestic violence increases emotional and behavioural problems and perpetuates the pattern of violence. Emergency nurses can (and do) make a difference! In preparation for domestic abuse screening, developing competency in the knowledge and skills outlined in this Module is essential. It is important to concentrate on empowering the patient rather than "fixing" the situation. It is also necessary to be aware of ethical issues and ensure that all screening is respectful, private, safe, and confidential. Exploring personal biases, prejudices, and knowledge will increase your cultural awareness. Remain open and respectful toward cultural differences. Avoid making assumptions based on appearance. Monitor your attitude and responses to patients of diverse cultures. Do not impose your own values. Learn about the cultural beliefs of the patient population(s) in your area. Ask about patients' cultural norms regarding access to health care, roles in the family, privacy, and dignity. Be aware that immigrant partners may threaten deportation. Use language that is familiar to the patient, or attempt to obtain an interpreter. Allow victims to give their history, ask questions, verbalize concerns, and participate in planning their care. Develop links with the community. Provide culturally-sensitive information whenever possible. Knowledge of legal issues is also important, especially since the reporting of domestic violence is not mandatory in Canada. Decisions made by the abused person must be respected and free from judgment. The person who is being abused must consent before the police can be involved. The first steps in providing comprehensive care include self-awareness and self-assessment, by asking questions such as the following: How do I ensure privacy and confidentiality, elicit information from patients, deal with family members, and facilitate the development of a plan of care? How do I respond to danger and to patients who are using drugs or alcohol? What are my views and beliefs regarding family, domestic violence, and law enforcement? Do my personal experiences affect my responses and the care I provide to patients? If so, how?

Organ and Tissue Donation

Statistics have shown that the deceased organ donor rate in Canada increased by 51% between 2008 and 2017. However, we still have a long way to go in Canada when it comes to consistent referral for organ and tissue donation. The most recent tally as reported by the Canadian Institute for Health Information (CIHI) is 21.9 donors per million population (CIHI, 2018). To bolster this rate even more, all provinces and territories in Canada with the exception of Saskatchewan and Newfoundland and Labrador have implemented a mandatory reporting system when there is an imminent death in hospital (Norris, 2018). A recent systematic review in Canada revealed a variable and (most times) low rate of referral for organ and tissue donation in a timely fashion in the case of neurological and circulatory death (McCallum et al., 2019). Many missed referrals for donation are due to missed opportunities in the ED, mainly from systematic problems (McCallum et al., 2019). It is important to know your facility's policy on organ and tissue donation and the resources that are accessible. Generally, for all provinces and territories, a donor coordinator can be accessed to carry out the process of obtaining consent for and arranging organ or tissue donation. The National Emergency Nurses Association (NENA) encourages emergency nurses to know their institution's policies and procedures for organ and tissue donation, become educated on the subject, and recognize that nurses are responsible for helping to ensure that families are given every opportunity to choose organ or tissue donation if the situation arises (NENA, 2014a). Ontario's program for donation, the Trillium Gift of Life Network (TGLN), has an excellent resource for healthcare professionals that outlines the preferred order for this process, but always in conjunction with hospital policy. It highlights the importance of process and consistency when it comes to activating the donor system. Please follow the link to this resource:

Alcohol Abuse and/or Addiction

The CAGE questionnaire provides a simple and effective screening tool for the assessment of alcohol (ethanol) abuse. C - Have you ever felt you should CUT down on your drinking? A - Have people ANNOYED you by criticizing your drinking? G - Have you ever felt bad or GUILTY about your drinking? E - Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE-opener)? A "yes" answer to one of the four questions raises the possibility of alcohol dependence, whereas a "yes" answer to two of the questions indicates alcohol dependence is likely. During the withdrawal from alcohol, patients may display disinhibition, aggression, and a lack of insight into their illness. They may also begin to display signs of delirium tremens (DTs) within a few hours of their last drink. Untreated DTs has a 15% mortality rate. Signs and symptoms of DTs include confusion with periods of severe panic, agitation, visual and tactile hallucinations, disorientation; tremors, seizures; elevated temperature; tachycardia, hypertension (HTN), and diarrhea. Treatment of DTs includes high doses of benzodiazepine medications, such as chlordiazepoxide (Librium), lorazepam (Ativan), and diazepam (Valium). Dosages of benzodiazepines are titrated according to the level of autonomic instability. The Clinical Institute for Withdrawal Assessment (CIWA) scale is used to follow the progression of withdrawal from alcohol. View the scale at the following website: https://umem.org/files/uploads/1104212257_CIWA-Ar.pdf Wernicke's Syndrome is an encephalopathy characterized by disorientation, confusion, ataxia, and nystagmus; this syndrome can progress to Korsakoff's psychosis. The hallmark sign of Korsakoff's psychosis is confabulation, but the syndrome also includes short-term memory loss and dementia. Individuals who abuse alcohol often do not eat well and have poor gastrointestinal (GI) absorption; therefore, they may have a thiamine deficiency. Initial treatment with intramuscular (IM) injections of thiamine is recommended, followed by daily oral doses, as well as multivitamins and folic acid. In the ED, these medications are often added to crystalloid infusion (e.g., 0.9% sodium chloride [0.9% NaCl]) and administered intravenously. Nursing care includes fluid replacement, nutrition, and measures to provide comfort and safety. If a patient is agitated, it may be necessary to provide one-to-one nursing care, seclusion, or physical restraints. Patients experiencing DTs generally prefer a room that is well lit because this diminishes the chance of illusions.

Mental Health Act of Alberta

The Mental Health Act (MHA) of Alberta was proclaimed on January 1, 1990. Several revisions have occurred, leading to the Mental Health Amendment Act being proclaimed in two stages, on September 30, 2009, and January 1, 2010. The MHA addresses formal patients as well as those under community treatment orders. A formal patient is one who has been involuntarily detained in a facility on the authority of two admission certificates or two renewal certificates. A community treatment order (CTO) is primarily intended and designed for a unique and small number of patients with serious and persistent mental disorders who have demonstrated that, without treatment and intensive supports in the community, they relapse and require hospitalization. A CTO is also intended for individuals who currently reside in the community but may pose a risk to public safety without the intensive case management provided under a CTO. Since it is imperative for nurses caring for patients with mental disorders to be familiar with legislation pertaining to their treatment, please visit the following websites to review the documents identified below. The documents provide an overview of the amendments to the MHA, along with information regarding the certification of patients. The Appendix at the end of the module provides URLs for mental health acts in all Canadian provinces and territories.

Mental health Introduction

The World Health Organization (WHO) defines mental health as "...a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" (WHO, 2014, para. 1). From this module, emergency nurses will gain a better understanding of patients with mental illness or mental health concerns. The skills needed to manage psychiatric emergencies are essential for all nurses working in the emergency department (ED). Psychiatric patients are often labeled as 'disruptive' or 'nuisances'. Aggression and violence, risk for self-harm, bizarre behaviours, and non-adherence to treatment plans are often assumed to be very common among these patients. It is important to remember that mental illness is just as devastating as physical illness, and that all patients deserve to be treated with kindness and respect. Nurses must be cognizant of the need to address both the physical and mental health concerns of all patients. People with mental illness or mental health concerns generally arrive at the ED in one of the following ways: They are unaccompanied and not referred by a medical professional (self-report). They are directed to the hospital by a medical professional (physician, psychologist, mental health clinic, or mental health nurse). They are brought in by a parent, relative, or friend. They are accompanied by police. They arrive via ambulance. Think, for a few minutes, about the atmosphere of your ED when these new patients arrive: Is there increased stimulation? What does this do to anyone who feels unwell, whether it is a person with a headache or a person suffering hallucinations? What are the attitudes of the staff toward people with mental illness? What do you think about mental illness? Do you value the worth of all of your patients? How would you like to be seen by the medical professionals in your ED? Wait times cannot always be avoided. Crowded waiting areas, crying babies, agitated people, people in pain, and disoriented persons add to the stress of all patients waiting to be seen. Brainstorm with your team to assess whether the waiting area could be reorganized to optimize the comfort of patients and staff. Needed resources may not be available. For example: You contact the psychiatric unit to move an admitted patient up to the unit. The unit is not ready for a new patient. The nurse on the other end of the phone is rude to you, stating it is time for shift change and a new patient cannot be admitted right now. You try to contact the on-call mental health team; they are not available. The waiting room is full, the Oilers game is over and the fans who got into fights are heading in, and a code is on the way. What do you do? This module is designed to provide the information and tools emergency nurses need to respectfully and kindly manage patients with mental illness or mental health concerns. It is beyond the scope of this module to present a complete overview of all mental health disorders, thus content will focus on a brief overview of the formal admission process, including related Mental Health Act of Alberta guidelines, and the mental health presentations most commonly seen in the ED. Note: If you are not located in Alberta, please consult your provincial/territorial Mental Health Act for guidelines related to your workplace (see Appendix).

Self-Care for Nurses

The chaotic, high-stress environment of the emergency setting, coupled with frequent exposure to trauma and death, leads to the real potential for healthcare providers in such settings to develop burnout and compassion fatigue and to suffer from post-traumatic stress. The concept of compassion fatigue and burnout is not a phenomenon unique to emergency nurses, but the risk of developing it can be higher in this population due to the busy, high-stress environment with regular exposure to painful situations, trauma, and death (ENA, 2014a). This of course can be compounded by personal stressors or having to be a caregiver outside of work, such as having a child with disabilities, a disabled partner, or caring for aging parents (ENA, 2014a). Nurses are often faced with ethical distress. An example of this may be having to exercise aggressive care they may view as futile or non-beneficial care for patients at the end of life, especially in cases where patient wishes and ADs are not clear. This distress can have similar manifestations and can induce burnout, practice errors, compassion fatigue, feelings of powerlessness, patient avoidance, lateral violence, frustration, overall job dissatisfaction, and often attrition (Fernandez-Parsons et al., 2013). Jackson (2017) highlights the particular impact that the death of a child can have on nurses in the ED, and the sense of guilt and failure that can accompany these tragic events. ENA highlights some key points for nurses to promote self-care and combat compassion fatigue: Ensure adequate sleep, exercise, and personal interests. Practice mindfulness, which is a focus on being present in the moment. Self-reflection, trying to remember WHY you went into nursing, helps you stay grounded. Try and self-regulate your responses to highly emotional or stressful situations. Focus on patients as being the overarching priority, and try to let go of environmental factors out of your control. Develop strong working relationships, connect with peers (ENA, 2018a). Take Away Points of Module Know your institution's policies on organ and tissue donation, MAID, and postmortem care. There are some key ways nurses and physicians can approach death notification and bereavement care for the benefit of the survivors: ensure language is simple and clear, remain present, don't say more than you have to out of nervousness (makes it worse). Encourage and facilitate good communication with patients and family members when it comes to their wishes, and encourage ADs. Clarify DNR status as soon as possible, and engage in frank discussions with patients and family about realistic outcomes. If palliative care is the chosen path, focus on symptom management, consider illness trajectories, and ensure referrals for community palliative care or hospice care. Keep in mind the principles of a good death for end-of-life patients, and strive for ways of facilitating these in the ED, such as having a quiet place to transfer patients. It is important to ensure optimal care of our patients and their families, but nurses must also ensure optimal self-care in order to stave off compassion fatigue and burnout, which can impact our own health and our professional practice.

Do Not Resuscitate Orders

The concept of advanced directives (AD) are synonymous with living wills, which can be verbal (but are usually written) instructions that outline a person's specific wishes for care if they are rendered incapacitated (Keatings & Smith, 2010). The most prominent example of an AD is a do-not-resuscitate (DNR) order (Keatings & Smith, 2010). In the ED, a resuscitation-focused department by its very nature, DNR is a pervasive issue, but it is not as simple as a piece of paper stating "DNR." Advanced directives such as DNR orders are still greatly underutilized in Canada, and their vague nature leads to much confusion about the individual's wishes, especially when facing end of life in an place where patients are usually unfamiliar to staff. Decisions about resuscitation often take place when a person has deteriorated, making decisions around DNR challenging for everyone involved (ENA, 2018b). A 2012 study examined the prevalence of elderly patients with ADs presenting to Canadian emergency departments, and revealed that fewer than 20% of elderly patients in this study had ADs, and only 35% were even aware of the concept (Gill et al., 2012, p. 93). These statistics reinforce that emergency nurses have an important role in advocating for advanced care planning, and educating patients and their families about planning options. The concept of DNR is not always clear, and often leaves open to interpretation whether it implies no resuscitation efforts at all (such as intubation, fluids, and transfusion), or just no CPR. One of the worries with DNR is that patients sometimes perceive that they will not get any treatment, such that the document implies "do not treat." This can make conversations with patients and families even more difficult as we try to ascertain their wishes in this respect (Grewal, 2015). Healthcare providers can be guilty of this misconception as well, where DNR status can be falsely seen as a relief in not having to actively treat that patient. Another common misconception surrounding resuscitation is perpetuated by the media, where TV shows and movies portray an unresponsive patient waking up immediately after a brief attempt at resuscitation; in reality there is a very small chance that a person can be revived - and that is only if efforts are started almost immediately (Etland, 2022). This misperception by the public makes the conversation around DNR even more difficult, as unrealistic expectations of resuscitation can greatly influence their decisions. Recently, there has been debate or discussion about changing the language we use around DNR to envision a more positive and proactive measure, such as "allow natural death" (AND) in place of DNR, and "withholding non-beneficial treatment" in place of providing "futile care" (Etland, 2022, p. 150). This changes the perception of these choices of care to seem less of a failure and more a humane, thoughtful, and realistic approach to care. It is very important that nurses and physicians ascertain a patient's DNR status as soon as possible in the emergency department, and that patients understand the implications of DNR. If the patient does not have the capacity to determine his or her status and there is no written DNR order, we must determine who has the legal authority to make decisions for that patient. Emergency nurses need to know their own provincial and territorial regulations for DNR: some provinces such as Ontario legally allow substitute decision makers (SDM), power of attorneys (POA), or others with legal decision-making power to oppose a DNR order after a patient no longer has capacity to decide or is unconscious (Government of Ontario, 2018; Wright, 2015). That being said, most provincial and territorial laws make it illegal for legally binding DNR orders made when a patient was of sound mind to be disregarded by POAs or physicians. Case Study: DNR The following case study was adapted from Cruz-Carreras et al. (2018): A 40-year-old female with advanced metastatic adenocarcinoma presented to the ED in respiratory failure. On her arrival, the attending physician discussed code status with the patient's husband, who was present by her bedside. The patient's husband expressed that the patient had told him on multiple occasions that she wished to die peacefully and that she did not wish to have aggressive care if she were to get worse. She expressed to her husband that she wanted DNR status, but they had not formalized this in any way. In accordance with the patient's wishes expressed by her husband and legal substitute decision maker, a DNR order was written by the physician. Shortly after, the patient's aunt and sister arrived and expressed their disagreement with the husband's decision, stating the patient did want to be resuscitated. The patient's aunt and sister were visibly upset and raising their voices. The patient was also becoming more and more hemodynamically unstable at this time. Feeling pressured by the other family members and his wife's deteriorating status, the husband asked the medical team to revert the DNR and agreed for aggressive care to be provided.

Medical and Nursing Management

Victims of sexual assault often present to the emergency department (ED) for initial treatment. While these patients account for a small proportion of ED visits, caring for individuals who have been sexually assaulted requires specialized knowledge and skills. Disclaimer Many EDs or regional health authorities employ specialists, such as a sexual assault response team (SART) or sexual assault nurse examiner (SANE), to care for patients who have been sexually assaulted, thus the responsibility of the emergency nurse will vary depending on resources. This module is a general introduction and overview for emergency nurses who will encounter victims of sexual assault. Please consult your site policies/procedures and be aware of available resources. This module does not constitute specialized training to assess or care for a sexual assault victim. When an individual who has been sexually assaulted arrives in the ED, the emergency nurse (or a provider trained in caring for sexual assault victims) must complete a history and physical exam. The patient should be triaged quickly to a private room, preferably with solid walls, and should not be left alone to wait for care. Prioritize the following steps to reflect the most appropriate approach to a person who has been sexually assaulted. _____ Prepare for a head-to-toe examination. _____ Ask if the patient would like to have a support person present. _____ Obtain consent for the history and examination. _____ Proceed with general questions pertaining to the assault. Identify the following statements as True or False. Correct those that are False. _______ A sexual assault history and exam are not needed if the assault occurred more than 72 hours earlier. _______ A sexual assault examination may include the collection of evidence. _______ The written history could be used in court, and the nurse could be called upon to testify based on the examination. _______ Involving a member of the specialized sexual assault response team (if available) is best done after the nurse conducts a thorough examination. _______ If a specialized assault team member is consulted, ask the patient to remove his or her clothing and change into a hospital gown. _______ Counseling to prevent sequelae related to the assault begins during the history. _______ The history must be completed in the presence of a police officer. _______ The physical examination requires specialized equipment. _______ The examination should include physical and mental components. _______ If a patient wants to report the incident to police during the history, the nurse should facilitate reporting. _______ Men can be victims of sexual assault. _______ The legal age of consent for sexual activity in Canada is 14 years. Suggest at least two (2) techniques an emergency nurse can use to develop a trusting relationship with sexual assault victims. What steps can emergency nurses take to ensure they are providing care that adheres to legal and regulatory requirements? As mentioned above, specialized services may be available to assist in the care of sexual assault victims. With patient consent, the SART or SANE should be contacted immediately. Regardless of whether SART or SANE services are available, the priority is always attending to the patient: assessment of vital signs and any acute injuries, as well as a minimal history depending on the situation and patient's condition. That being said, there is only one opportunity for evidence collection. The SART or SANE is usually responsible for completing the assessment and initiating treatment. Prior to their arrival, the emergency nurse should try to place the patient in a quiet room, attend to the patient (as described above), and keep the patient in his or her own clothing, as well as nil per os (NPO). Unless initiated and requested by the patient, allow the SART or SANE to discuss police involvement with the patient. The assessment usually includes a head-to-toe examination with an emphasis on certain systems, as indicated by history. A full inspection (often with ultraviolet light) is required for the detection of injury(ies), and palpation should be completed for areas of tenderness. Physical injuries resulting from sexual assault can vary in severity. A mnemonic to aid in the assessment of injuries is TRACS, which stands for Tear and/or Tenderness, Redness, Abrasions, Contusions, and Swelling. Photographs should also be obtained by the SART/SANE or police agency, with the patient's consent. Written documentation should be completed promptly and should include illustrations to document injuries. Clean clothing and a shower should be provided after the exam, upon consultation with the SART/SANE and police agency. Why is an ultraviolet light used during inspection? In sexual assault cases with severe traumatic injury, in which the patient requires resuscitation or critical medical intervention, there may not be an opportunity to contact the SART or SANE for assessment and evidence collection. The following basic principles of sexual assault evidence collection should be adhered to, while maintaining the chain of custody, whenever possible: Unbutton or unzip (rather than cut with scissors) clothing for removal. If clothes must be cut, do not cut through stains, holes, tears, or buttonholes. Ensure all clothing is placed on top of a sheet (e.g., bed sheet). Trace evidence will remain on the sheet, which can then be preserved. As much as possible, try to separate items as they are placed on the sheet so as to not cross-contaminate. Fold clothing, without shaking. All physical evidence should be air-dried when possible (heat degrades biological samples). Never place moist evidence in plastic or glass containers, as this promotes the growth of mold and other organisms. Collect biological samples before any procedures or interventions (when possible, depending on patient condition). When moisture is needed to collect samples, slightly moisten the tip of a cotton swab with sterile water (avoid saturating as moisture dilutes biological samples). Do not touch objects that may contain fingerprints (i.e. knife, bullet, cartridge case). Sterile collection is not essential, BUT it is important to change gloves between sites to avoid cross-contamination. Use paper bags or envelopes to store individual samples of evidence (Weintraub, 2013, pp. 539-540). The risk of contracting a sexually transmitted infection (STI) from a sexual assault is relatively low, but nonetheless a very frightening reality. STI prophylaxis is often initiated, and appropriate urine and serum testing (e.g., Hepatitis B, human immunodeficiency virus [HIV]) is completed. Five percent (5 %) of women who are sexually assaulted become pregnant (Centers for Disease Control and Prevention, as cited in Weintraub, 2013), thus female patients should also be offered pregnancy testing and emergency contraception. Emergency nurses should be familiar with community agencies available to sexual assault victims. Each site should have a list of community resources and contact information; in Alberta, for example, the Alberta Association of Sexual Assault Services website is useful for compiling this list. Discharge teaching should include patient safety, when to return to the ED, medical follow-up and plan of care, and signs to watch for related to post-traumatic stress disorder (PTSD) and depression. Medical and Nursing Management Suggested answers Priorities in examining a person who has been sexually assaulted __4__ Prepare for a head-to-toe examination. __2__ Ask if the patient would like to have a support person present. __1__ Obtain consent for the history and examination. __3__ Proceed with general questions pertaining to the assault. False - A sexual assault history and exam are needed even if the assault occurred more than 72 hours earlier. True - A sexual assault examination may include the collection of evidence. True - The written history could be used in court, and the nurse could be called upon to testify based on the examination. False - Involving a member of the specialized sexual assault response team (if available) is best done before the nurse conducts a thorough examination. False - If a specialized assault team member is consulted, ask the patient not to remove her or his clothing and change into a hospital gown. True - Counseling to prevent sequelae related to the assault begins during the history. False - It is not necessary to complete the history in the presence of a police officer. True - The physical examination requires specialized equipment. True - The examination should include physical and mental components. True - If a patient wants to report the incident to police during the history, the nurse should facilitate reporting. True - Men can be victims of sexual assault. False - The legal age of consent for sexual activity in Canada is 16 years. Techniques that an emergency nurse can use to develop trusting relationships with sexual assault victims Be calm and confident Show concern for patients Listen to patients and provide explanations and information of what will transpire, reinforcing that nothing will occur without his/her consent (e.g., physical examination, sexual assault kit) Inform patients that their strength and actions helped them get through the ordeal, regardless of what actions were taken Steps emergency nurses can take to ensure they are providing care that adheres to legal and regulatory requirements Ensure advocacy for the patient, respecting his/her decisions Become familiar with policies and procedures at your site Consult as needed (do not assume) Contact a SART or SANE with patient's consent, if this service is available in the area Consult external resources (e.g., Alberta Association of Sexual Assault Services) Become familiar with mandatory reporting laws (e.g., the assault of a person in care, child protection, age of consent) Ensure documentation adheres to institutional and regulatory guidelines Ultraviolet light is useful in the collection of dried or moist secretions (e.g., semen, blood, saliva, urine) that may not be visible under white light. It can also detect stains, fluorescent fibers, and subtle injuries (e.g., rope marks, contusions) that are difficult to otherwise visualize (Linden et al., 2007, p. 96).