Tag Archives: emergency

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.


Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Hacking Cyberterrorism

Although not particular to cyberterrorism, for this discussion I have chosen hacking as a type, or means, of cyberterrorism. Hacking covers virus loading and denial of service attacks, also. In order to carry out a cyberterrorism attack, it must be based on some sort of hacking. First, however, we must agree on the definitions of hacking and cyberterrorism. US Legal, a website dedicated to providing legal reference, broadly defines hacking as “intentionally accesses a computer without authorization or exceeds authorized access” (Computer hacking law & legal definition, n.d., para 1). Cyberterrorism is, according to Denning (2006):

…[H]ighly damaging computer-based attacks or threats of attack by non-state actors against information systems when conducted to intimidate or coerce governments or societies in pursuit of goals that are political or social. It is the convergence of terrorism with cyberspace, where cyberspace becomes the means of conducting the terrorist act. Rather than committing acts of violence against persons or physical property, the cyberterrorist commits acts of destruction or disruption against digital property. (p. 124)

Arguably, in order to use a computer system to do any of the above, it involves hacking, but without hacking, there can be no cyber- component to cyberterrorism, which leaves mere terrorism. Fortunately, using these definitions, there has never been a cyberterrorism attack ever in history (Brunst, 2008; Conway, 2011). Brunst (2008) goes further using the term terrorism to include the planning (and, even pre-planning) phases of an event. I disagree with this tact in scholarship. Brunst fails to provide the distinction between cybercrime and cyberterrorism. Thinking simply, having a Facebook account in order for ease of communication does not amount to meeting for coffee. Messaging a friend on Facebook and organizing a meeting does not constitute meeting for coffee. The act of two or more persons meeting for coffee is a conventional one, however it was planned. This is the same with terrorism. I argue that, although much planning and radicalization can occur using computer networking (e.g. Facebook, MySpace, general information websites, et al.), any terroristic act that stems from such organization would still be considered conventional terrorism unless the act, itself, is described as being technological in nature (Conway, 2011).

There is potential for a cyber-attack to generate fear, economic impact, and the loss of life. This is why we concentrate on security measures to ensure difficulty in accessing systems without proper credentialing, rapid identification and response to active intrusions and threats, and recovery techniques to identify and repair data, networks, and nodes that were involved. For this reason, networks are designed with human redundancy. Human redundancy, as Clarke (2005) explains, integrates human decision points within a technological operational structure in order to detect, indicate, explain, and correct an error. Additionally, infrastructure, a commonly regarded target by the experts, tends to be resilient by its own nature making cyber-attacks inefficient and ineffectual (Conway, 2011; Lewis, 2002; Wilson, 2005)


Brunst, P. W. (2008). Use of the internet by terrorists: A threat analysis. Responses to Cyber Terrorism, 34(1), 34–60.

Clarke, D. M. (2005). Human redundancy in complex, hazardous systems: A theoretical framework. Safety Science, 43(9), 655-677. doi:10.1016/j.ssci.2005.05.003

Computer hacking law & legal definition. (n.d.). US Legal. Retrieved from http://definitions.uslegal.com/c/computer-hacking/

Conway, M. (2011). Against cyberterrorism: Why cyber-based terrorist attacks are unlikely to occur. Communications of the ACM, 54(2), 26-28. doi:10.1145/1897816.1897829

Denning, D. (2006). A view of cyberterrorism five years later. In K. E. Himma (Ed.), Internet security: hacking, counterhacking, and society (pp. 123-139). Sudbury, MA: Jones and Bartlett.

Lewis, J. A. (2002, December). Assessing the risks of cyber terrorism, cyber war and other cyber threats. Washington, DC: Center for Strategic and International Studies. Retrieved from http://www.steptoe.com/publications/231a.pdf

Wilson, C. (2005, April 1). Computer attack and cyberterrorism: Vulnerabilities and policy issues for Congress (CRS Congressional report No. RL32114). Retrieved from http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA444799&Location=U2&doc=GetTRDoc.pdf

Cyberterrorism vs. WMD

Perhaps in an Orwellian society where computers are independant and there is very little human-to-computer interaction could a cyberterrorist cause such an impact as to be equal with a weapon of mass destruction. This is not true, however, regarding the technology of today. According to James Lewis (2002) from the Center for Strategic and International Studies, “cyber attacks are less effective and less disruptive than physical attacks. Their only advantage is that they are cheaper and easier to carry out than a physical attack” (p. 2). Studies of the implementation of efforts to reduce the effectiveness of infrastructure during war show a resiliency that is poorly respected. Redundant systems in conjunction with a focused human response provides mitigation to reduce the impact of disruptive efforts on infrastructure (Wilson, 2005). It seems the more important the system, the larger and focalized the response.

The northeast blackout of 2003 provides a decent case study, although the cause was a systems failure and not related to terrorism. According to the article by Minkle (2008), within an hour and a half, 50-million subscribers lost power in eight states and parts of Canada for a few days, yet it only contributed to about 11 deaths within the affected area. While the impact was significant, geographically, it was more or less a nuisance for most people.


Lewis, J. A. (2002, December). Assessing the risks of cyber terrorism, cyber war and other cyber threats. Washington, DC: Center for Strategic and International Studies. Retrieved from http://www.steptoe.com/publications/231a.pdf

Minkle, J. R. (2008, August 13). The 2003 northeast blackout — five years later. Scientific American. Retrieved from http://www.scientificamerican.com/

Wilson, C. (2005, April 1). Computer attack and cyberterrorism: Vulnerabilities and policy issues for Congress (CRS Congressional report No. RL32114). Retrieved from http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA444799&Location=U2&doc=GetTRDoc.pdf

Bioweapons of Mass Destruction: Actual Use or Hoax

Weapons of mass destruction (WMDs) provide an alternative impact when compared to conventional weapons (e.g. artillery, firearms, blades and knives, batons, et al.). WMDs can be chemical, biological, radiological, nuclear, or explosive (CBRNE) in nature attacking the human body in manners not typical of conventional weapons (Cameron, Pate, McCauley, & DeFazio, 2000). WMDs can, therefore, have devastating effects on the preparedness of the health care system (Macintyre et al., 2000; Subbarao, Bond, Johnson, Hsu, & Wasser, 2006).

Considering an attack such as a mass contamination of the money supply, there are two possibilities: actual contamination and hoax contamination. In actual contamination, the epidemiology of illness will correspond with the travel of contaminated bills, reaching long distances in short periods of time (as evidenced by the website http://www.wheresgeorge.com). As the contaminated money travels from one consumer to the next (possibly also infecting adjacent bills, wallets, counter-tops, and register drawers), it will do so undetected until the incubation period lapses and the first wave of infected people begin presenting to health care facilities for treatment (presumably, with a difficult diagnosis – an uncommon pathogen). These people should be geographically dispersed so that identification of the terrorist act is yet to be made. Not until epidemiologists track the vector to the money supply will the threat be discovered. Once this occurs, the populace will be suspicious of money, causing an entirely different catastrophe, but the fear will be real.

On the other hand, if the attack is a hoax, there will be no incubation period or actual illness, yet psychogenic effects will be almost immediate, causing many people to seek medical care at once overburdening the health care system (MacIntyre et al., 2000). Arguably, this type of attack will be short-lived; however, the effects can be disastrous.

Regardless of the type of attack, whether actual or hoax, there will be a large, resource-intensive response from national, state, and local levels of government and the private sector (Walsh et al., 2012). This would place a strain on response resources and other infrastructure, such as health care as previously mentioned. In both instances, though, lives could be lost, also. With the real attack, many people could die from the disease, but if resources are taken away from other sick patients, they are at risk of dying also. This holds true for hoax attacks. As many healthy people flood emergency rooms with mysteriously fleeting symptoms, truly sick patients are not being managed efficiently and are put at serious risk.

Though the example attack might not be feasible for one reason or another, it is interesting to think of the many ways in which we as a nation are vulnerable. This leads to the question of how much we value our freedom vs. how many freedoms are we willing to give up in order to feel safe. I have decided that I value my freedom, the freedom that most foreign terrorists despise, so much that I am not willing to part with it to any extent. So long as we live free and without fear, the terrorists cannot win.


Cameron, G., Pate, J., McCauley, D., & DeFazio, L. (2000). 1999 WMD terrorism chronology: Incidents involving sub-national actors and chemical, biological, radiological, and nuclear materials. The Nonproliferation Review, 157-174. Retrieved from https://www.piersystem.com/clients/PIERdemo/ACF1D7.pdf

MacIntyre, A. G., Christopher, G. W., Eitzen, E., Gum, R., Weir, S., DeAtley, C., … Barbera, J. A. (2000). Weapons of mass destruction events with contaminated casualties: Effective planning for health care facilities. Journal of the American Medical Association, 283(2), 242-249. doi:10.1001/jama.283.2.242

Subbarao, I., Bond, W. F., Johnson, C., Hsu, E. B., & Wasser, T. E. (2006). Using innovative simulation modalities for civilian-based, chemical, biological, radiological, nuclear, and explosive training in the acute management of terrorist victims: a pilot study. Prehospital and Disaster Medicine, 21(4), 272-275. Retrieved from http://www.hopkins-cepar.org/downloads/publications/using_sim_modalities.pdf

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Ethics and Decision Making During Critical Incidents

As a paramedic, I am faced with ethical decisions fairly frequently. As an example, I am usually the sole responding paramedic to an incident that might involve a number of seriously ill or injured patients (e.g. car accidents, fires, carbon monoxide). These incidents are challenging in that I have to choose which patient(s) will be treated at the higher level of care that I can provide versus the lower level of care that the basic life support units can provide. Typically, I base my decision merely on which patient is more ill or injured; however, many times I am faced with a number of critical patients and must decide based on ethical criteria, such as who would benefit more from my care in the long run, including the fact that adolescent and adult patients tend to fair better than elderly and infant patients (Broos, D’Hoore, Vanderschot, Rommens, & Stappaerts, 1993; Kypri, Chalmers, Langley, & Wrigh, 2000; McGwin, Melton, May, & Rue, 2000).

One of the problems with attempting to remain ethical while decisions during an emergency response is that the situational picture is almost never as clear as you need it. This is especially true as the scope and scale of the incident increases. As the magnitude of an incident grows, the incident command team become inundated with information, and it is common to be overwhelmed. We do, though, try our best to be just and fair in our determinations. We need to make our decisions based on the current information and not dwell on if they were right or wrong (Walsh et al., 2012), only if we could have approached the problem more effectively and efficiently, and this should be done only in the debriefing.


Broos, P. L. O., D’Hoore, A., Vanderschot, P., Rommens, P. M., & Stappaerts, K. H. (1993). Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury, 24(6), 365-368. doi:10.1016/0020-1383(93)90096-O

Kypri, K., Chalmers, D. J., Langley, J. D., & Wrigh, C. S. (2000). Child injury mortality in New Zealand 1986–95. Journal of Paediatrics and Child Health, 36(5), 431–439. doi:10.1046/j.1440-1754.2000.00559.x

McGwin, G., Melton, S. M., May, A. K., & Rue, L. W. (2000). Long-term survival in the elderly after trauma. Journal of Trauma, Injury, Infection, & Critical Care, 49(3), 470-476.

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Critical Incident Response Plans

The possibility of a large-scale event threatening the health and safety of a large number of residents in Connecticut is sizable. Emergency response plans (ERPs) need to be in place to address concerns including epidemic/pandemic disease, the intentional or accidental release of a hazardous material, contamination of the food and/or water supply, and other incidents that might threaten the 3.4 million residents and could result in mass casualties. For this reason, the State of Connecticut Department of Public Health (DPH; 2005) has developed an ERP to guide the department in the event of a catastrophic threat the lives and safety of the residents of Connecticut. Additionally, the State of Connecticut has developed a State Response Framework, much like the National Response Framework, in order to allow for a modulation of an incident from a local level to a state or federal level (State of Connecticut, Department of Homeland Security, 2010; U.S. Department of Homeland Security, 2008). The ability of an incident response to grow and shrink as an incident dictates follows the natural progression of incidents starting and ending locally, whether involving state or local responses at any time during the response (Walsh et al., 2012).

The ERP (DPH, 2005) that guides the DPH allows for representation in the state EOC while forming a modular incident management team (IMT) to staff the DPH emergency command center. The DPH IMT is designed not only to support the state EOC when activated, but also supports the various local incident commands as a public health and medical service resource. In keeping with the modular aspects of the incident command philosophies and the state and national response framework, the DPS ERP becomes a valuable resource for both initiating a response to a significant threat to the public health and safety and allows for an expert resource when other incidents of magnitude, but not necessarily public health in nature, require or benefit from the availability of public health experts.

One criticism I do have, however, is that the plan (DPH, 2005) does not address the provision of emergency medical services (EMS). For some time, there has been much confusion as to where EMS falls in the realm of emergency service functions. EMS, for many jurisdictions, is a function of the fire department and may fall under the direction of ESF #4, firefighting, especially as many EMTs and paramedics are cross-trained to fight fire. However, ambulances are not firefighting apparatus. As ambulances do transport the ill and injured, perhaps EMS falls to ESF #1, transportation. This is unlikely, though, as the primary need is not the transportation provided but the care rendered. Public health and medical services, ESF #8, seems to me to be the logical category for EMS to fall under, but EMS has an expanded role that also fits ESFs #9, #10 & #13 (search & rescue, oil & hazmat response, and public safety & security, respectively), as well as the aforementioned ESFs #1 and 4. This lack of initial categorization may allow flexibility in the deployment of EMS personnel and equipment, but it could also lead to ineffective deployment strategies resulting in a shortage of EMS in one area and overutilization in another.


State of Connecticut, Department of Homeland Security. (2010, October). State response framework. Retrieved from http://www.ct.gov/demhs/lib/demhs/telecommunications/ct_state_response_framework_v1_oct_10.pdf

State of Connecticut, Department of Public Health. (2005, September). Public health emergency response plan: Emergency Support Function #8 Public health and medical services. Retrieved from http://www.ct.gov/ctfluwatch/lib/ctfluwatch/pherp.pdf

U.S. Department of Homeland Security. (2008, January). National response framework. Retrieved from http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Emergency Operations Center Leadership

The emergency operations center (EOC) is a decentralized and secure place for senior management officials to maintain operational awareness when confronted with a large scale events or disasters (Walsh et al., 2012). Although these events or disasters may dictate the use of local incident commands at various emergencies throughout an area, the EOC allows an incident management team to direct the overall response effort while maintaining complete situational awareness. This allows for increased interoperability and the availability of resources and a centralized planning and intelligence effort (Walsh et al., 2012). During a multi-state event, a joint field office (JFO) might serve as the primary EOC to support other EOCs that have been activated.

Within the EOC, there are a number of leaders and managers responsible for ensuring an effective response strategy for the emergency that is being faced. One of these leaders is the Area Command Logistics Section Chief (or, “Log Chief”). The Log Chief is responsible for procuring and otherwise acquiring the facilities and personnel to support the response initiative. This includes “resources from off-incident locations […] providing facilities, transportation, supplies, equipment maintenance and fuel, food services, communications and information technology support, and emergency responder medical services, including innoculations” (Walsh et al., 2012, p. 60).

In response to an impending an ice storm in Austin, Texas, in 2003, the city’s EOC was activated 24 hours in advance of the storm. One of the crucial area command members activated was the Log Chief. The Log Chief ensured that redundant communications facilities were available as power outages were interferring with some established communications equipment. The Log Chief also ensured that there was food available for delivery to each small-scale incident as it developed. This was important as the available resources were deployed, there was a lack of available manpower during shift change, so feeding hungry crews was a priority. The Log Chief, on this incident, had many other important functions, but as a responder working in these adverse conditions, it was most important for me to be fed and have solid communications in the event I was to be one of the motorists sliding off the road.


Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Motivation: A Career that I Enjoy

I am lucky to work in a career that I absolutely enjoy. As a paramedic in the emergency medical services (EMS), I am called upon to help those in my community in the worst of circumstances to help them when they feel helpless. There are drawbacks, however. Many people rely on EMS for problems that even they do not view as emergent, and others just plainly abuse the system. Still, I enjoy being the one called upon to help. My primary motivations are my sense of community, my ability to reduce suffering, and my ability to raise the standard of care within the system. Maslow (1943) includes some of the earliest accepted work on motivational theory, and more contemporary work is based on the acceptance, rejection or modification of his theories, so I will focus on Maslow to begin. My needs, according to Maslow, are not as important to motivation. Need fulfillment will not motivate me to perform; however, a lack of fulfillment may prevent me from performing. This is especially true for Maslow’s lower-order needs. Maslow discusses how emergency situations can “obscure the ‘higher’ motivations [and create] a lopsided view of human capacities and human nature” (p. 375), and while my career is focused on responding to emergencies, this may hold true for me. While Maslow’s theory is not wholly accepted motivational schema (Robbins & Judge, 2010), EMS managers, and other public safety managers, would do well to understand this exception to motivational theory.

Many EMS managers, it seems, subscribe to McGregor’s (1957/2000) theory X without understanding the ramifications or the competing theory Y. There is a deep-seated belief that the workforce is lazy and will do anything possible to undermine the operation. This results in micromanagement tactics that seem to promote an unwillingness to promote the goals of the employer. McGregor highlights this and cautions that it a result of poor management technique, not a cause that is easily rectified by the chosen technique.

Other theories, such as goal-setting, equity theory, and expectancy theory, as described in Robbins and Judge (2010), are all lacking in one particular constant: there is no constant in human behavior. There are a number of ways that a single motivational factor might influence a particular person on any particular day. For any theory to always be true in every situation, it would cease to be a theory and become a law. This being said, as managers, we need to measure the importance of certain tasks and focus our efforts on communicating this importance to the workforce. It is the manner of this communication that will tend to fail or succeed, based on both the needs of the manager and the needs of the employee at the moment the message is passed.


Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. doi:10.1037/h0054346

McGregor, D. (2000). The Human Side of Enterprise (Reprinted from Adventure in thought and action: Proceedings of the fifth anniversary convocation of the School of Industrial Management, Massachusetts Institute of Technology, Cambridge, 1957, April 9. Cambridge, MA: MIT School of Industrial Management). Reflections, 2(1), 6-14. doi:10.1162/152417300569962

Robbins, S. P. & Judge, T. A. (2010). Motivation concepts. Essentials of organizational behavior (pp. 62-79). Upper Saddle River, NJ: Pearson Prentice Hall.

Long-term care versus acute care

This discussion, again, allows me to ponder some musings of my colleagues and consider them in scholarly reflection. As a paramedic, I frequently respond to skilled nursing facilities (SNFs) to care for patients with minimal medical complaints or exacerbations of chronic conditions. The comments are always the same: What is the point of having nurses here if they cannot care for their patients? As I have never had an acceptable answer to this quandary, I will use this opportunity to explore the usefulness of SNFs based on measured outcomes. I will also compare the abilities of acute care facilities (ACFs) with those of SNFs to weigh the appropriateness of relying on ACFs to care for SNF patients.

The leading number of long-term care facilities are elderly SNFs, and as such, the elderly are the major demographic cared for in SNFs, yet there is a shortage, even within SNFs, of health care providers skilled in geriatric care (Cohen, 2002; Gaugler, Duval, Anderson, & Kane, 2007; Shi & Singh, 2011b). As Gaugler, Duval, Anderson, and Kane (2007) describe, the mere admission of an elderly patient into an SNF is associated with poor outcomes, “questionable quality of care, early mortality for many residents, and psychological or emotional upheaval for caregiving families” (p. 14). As long-term care also includes varying degrees of home care, family care, and limited residential care (e.g. assisted living centers), an international effort has been underway to help determine ways of identifying and limiting SNF admissions in order to limit potential negative outcomes and maintain patients’ self-efficacy and quality of life (Kennedy et al., 2007).

SNFs and ACFs are similar in that they both house patients, have nursing staff, are demographed by the number of beds housed, and, typically, have some sort of medical team responsible for the patients’ overall care. ACFs are numerous in type and offering. General hospitals, specialty hospitals, free-standing emergency clinics, and tertiary care centers are just some of the ACFs available to treat illness and injury (Shi & Singh, 2011a). ACFs tend to focus treatment on acute manifestations of illness and injury, while SNFs (and other long-term care facilities) focus on continuing care for chronic maladies (Shi & Singh, 2011a, 2011b; Singh, 2011). While ACFs rely on outcome measures to improve the care that is offered, such as that in stroke, it appears that SNFs and other long-term care facilities operate on a more traditional sense without regard to their effect on patient outcomes (Ahmed & Ekundayo, 2009; Díez-Tejedor & Fuentes, 2001; Kennedy et al., 2007; Martin & Ancoli-Isreal, 2008).

As I contemplate my original question in light of the available literature, I find that the elderly should only be institutionalized as a last resort (e.g. lay-led self-care, home health care, independant or assited living), training in geriatric care needs to be improved within SNFs, and outcome measures need to be further developed and assessed to fully understand the impact of long-term care on the elderly population (Ahmed & Ekundayo, 2009; Cohen, 2002, Gaugler et al., 2007; Kennedy et al., 2007, Martin & Ancoli-Israel, 2008). Until these three issues are rectified, SNFs will need to rely on ACFs to safely, effectively, and efficiently care for their patients.


Ahmed, A. & Ekundayo, O. J. (2009). Cardiovascular disease care in the nursing home: The need for better evidence for outcomes of care and better quality for processes of care. Journal of the American Medical Director’s Association, 10(1), 1-3. doi:10.1016/j.jamda.2008.08.019

Cohen, J. J., Gabriel, B. A., & Terrell, C. (2002). The case for diversity in the health care workforce. Health Affairs, 21(5), 90-102. doi:10.1377/hlthaff.21.5.90

Díez-Tejedor, E. & Fuentes, B. (2001). Acute care in stroke: Do stroke units make the difference? Cerebrovascular Diseases, 11(Suppl. 1), 31-39. doi:10.1159/000049123

Gaugler, J. E., Duval, S., Anderson, K. A., & Kane, R. L. (2007). Predicting nursing home admission in the U.S: a meta-analysis. BMC Geriatrics, 7(1), 13-26. doi:10.1186/1471-2318-7-13

Kennedy, A., Reeves, D., Bower, P., Lee, V., Middleton, E., Richardson, G., … Rogers, A. (2007). The effectiveness and cost effectiveness of a national lay‐led self care support programme for patients with long‐term conditions: a pragmatic randomised controlled trial. Journal of Epidemiology and Community Health, 61(3), 254–261. doi:10.1136/jech.2006.053538.

Martin, J. L. & Ancoli-Israel, S. (2008). Sleep disturbances in long-term care. Clinical Geriatric Medicine, 24(1), 39–vi. doi:10.1016/j.cger.2007.08.001.

Shi, L. & Singh, D. A. (2011a). Inpatient facilities and services. Current issues in healthcare policy and practice (pp. 1-44). Sudbury, MA: Jones & Bartlett.

Shi, L. & Singh, D. A. (2011b). The future of health services delivery. Current issues in healthcare policy and practice (pp. 123-156). Sudbury, MA: Jones & Bartlett.

Singh, D. A. (2011). Overview of long-term care. Current issues in healthcare policy and practice (pp. 123-156). Sudbury, MA: Jones & Bartlett.

Physician-assisted Suicide

I have always maintained that the best thing that I have ever done for a patient was to hold their hand as they died; however, there are few scenarios that I can posit where I would ever cause the death of another, and I would never do it in my capacity as a medical professional. In the State of Connecticut, assisting a patient in their suicide is illegal (Kasprak, 2003; Saunders & Smith, 2010). Saunders and Smith (2010) describe the use of “semantic ploys” (para. 3) in arguing for physician-assisted suicide and how the court deemed the “issue rests with the legislature, not with the court” (para 4).

Two states have laws permitting physician-assisted suicide, Oregon and Washington (Death with Dignity Act, 1997; Death with Dignity Act, 2008). The other 48 states either have laws forbidding assisted suicide, such as Connecticut, rely on common law, or have no laws permitting or forbidding the practice (Kasprak, 2003). Personally, my thoughts on the matter are clearly reflected in my opening statement. More compelling, however, is a recent discussion on the discontinuation of implanted cardiac devices in patients with a desire to “refuse continued life-sustaining therapy” (Kapa, Mueller, Hayes, & Asirvatham, 2010, p. 989). Many of the respondants to this study viewed the discontinuation of pacemakers akin to physician-assisted suicide, whereas less felt the termination of cardioverter-defibrillator therapy was an ethical issue. Oddly, lawyers indicated less problems discontinuing therapy than did physicians.

There are conditions that are so intractably painful and wrought with suffering that I would not even consider thinking less of a person suffering such a malady who took their own life. Death, for many people, is a fear beyond fear, and for a person (of considerable sound mind) to choose death as a viable alternative to such suffering, I commend their bravery and choose not to judge them negatively. No physician or other health care provider should cause the death of a person directly, but acknowledging the patient’s will to die is another matter. In lieu of providing a chemical means of ending life, a physician could, in my mind, counsel a patient on the means and methods that might be viewed as more effective and humane than other means which might result in unwanted suffering. I do believe that a person has the right to choose an alternative to a surely painful and agonizing death, regardless of the presence of depression. If a person is suffering from depression because of a terminal illness that is causing physical suffering, it is hard to imagine this person will resolve the depression before succumbing to the causal disease process. In these cases, the person has the right to choose a more dignified death. For those cases where the person is incapacitated and cannot make health care decisions, I feel that any friend or family member, or a consensus of available friends and family members, should be able to make the decision to continue or discontinue life-sustaining measures. Even if the decision is wrong for the patient, most of the time the decision is for the benefit of the family and friends and lacks medical relevance aside from resource management, though there are spiritual, emotional, and moral considerations that the next of kin may face which are no less relevant.

Personally, I grant any person permission to end my life if they see me engulfed in flame or if taken on the battlefield by an enemy known for public torture. Beyond these two circumstances, I will always choose to live so long as I have my thoughts. I have heard some people intimate that they would wish to die if they were conscious but perpetually paralyzed (i.e. locked-in syndrome); however, I am not so sure that I would want to die just for lacking the ability to communicate with others. I would want to view the world, though, perhaps by television or radio. I am too curious as to what comes next for the world. As we interfere with the dying process, it does make sense that we address the morality in which we do this. It does not seem right to have brain dead patients connected to ventilators and feeding tubes forever. It’s Orwellian.


Death with Dignity Act of 1997, O.R.S. 127.800 et seq. (1997).

Death with Dignity Act of 2009, R.C.W. 70.245 (2008).

Kapa, S., Mueller, P. S., Hayes, D. L., & Asirvatham, S. J. (2010). Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: Results of a survey of medical and legal professionals and patients. Mayo Clinic Proceedings, 85(11), 981-990. doi:10.4065/mcp.2010.0431

Kasprak, J. (2003, July 9). Assisted suicide (OLR Research Report No. 2003-R-0515). Retrieved from http://www.cga.ct.gov/2003/olrdata/ph/rpt/2003-R-0515.htm

Saunders, W. L. & Smith, M. R. (2010, June 21). Assisted-suicide advocates fail in Connecticut. National Review Online. Retrieved from http://www.nationalreview.com