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The ethical issues involved in the practice of surgery on unanesthetized infants
DECEMBER 1987, VOL 46, NO 6
AORN JOURNAL
Ethics The ethical issues involved in the practice of surgery on unanesthetized infants
T
he practice of not using anesthesia on infants undergoing surgery is creating controversy. Although some health care professionals characterize this situation as strictly a scientific controversy, an ethical controversy also exists. Because of the close involvement some OR nurses have with unanesthetized but paralyzed newborns and infants undergoing surgery, OR nurses have a special responsibility and opportunity to consider such procedures from the moral perspectives promulgated in the American Nurses’ Association Code for Nurses with Interpretive Statements.’
The Problem
I
to get permission, the parents say they were available in the waiting room during the surgery. The parents, who believe that the surgeons prevented them from protecting their son from needless suffering, have filed a lawsuit seeking damages for the emotional distress they suffered. According to pediatric pain management expert Joann Eland, RN, PhD, College of Nursing, University of Iowa, Iowa City, performing surgery on infants without using anesthesia is a widespread practice. Last year, Dr Eland told a National Institutes of Health conference that in 1986, an infant from 12 to 15 months of age who is taken to the OR in most hospitals in this country will be paralyzed for surgery but not anesthetized!
n early 1985, a surgeon at Children’s Hospital National Medical Center, Washington, DC, performed surgery to correct a patent ductus arteriosus in a premature infant. Although the infant’s mother was assured that anesthesia would be used and she signed the surgery consent stating such, she later discovered that the anesthesiologist used the neuromuscular block pancuronium bromide (Pavulon)but did not use anesthesia.Both the infant’s referring neonatologist and the surgeon were also unaware of the anesthesiologist’s general Nance Cunningham Butler, MA, is the protocol not to use anesthesia during such president/consultantfor Applied Analysi~Assoprocedures.2 ciates, h e , Denver. She earned a bachelor of a m In early 1986, physicians at Children’s Hospital degree in English/philosophy at Colorado State Medical Center of Northern California, Oakland, University,Ft Collins: a master of arts in education performed major abdominal surgery on a premature infant without using ane~thesia.~ at the University of Colorado, Boulder; and a master of arts in applied philosophy at Bowling Although hospital officials insist that there was Green (Ohio) State University. not enough time to consult the infant’s parents 1136
DECEMBER 1987, VOL. 46, NO 6
AORN JOURNAL
Of the infants undergoing patent ductus arteriosus surgery, 77%had received only a paralyzing drug or a paralyzing drug and nitrous oxide. In a review of 40 articles on surgery to correct patent ductus arteriosus published in international medical literature between 1970 and 1983, researchers found that 77% of the infants undergoing such surgery had received only a paralyzing drug or a parlayzing drug and intermittent nitrous oxide? An informal survey conducted by the American Academy of Pediatrics (AAP) showed that cases of unanesthetized surgery on infants are not rare? In response, the AAP developed a statement on neonatal anesthesia? According to the statement, traditional reasons for withholding anesthetic or analgesic agents are not valid. These are that (1) danger to the unstable infant outweighs possible benefits of pain relief, (2) infants’ neural pathways are not developed enough to transmit pain, and (3) infants do not have the cortical function required to have a memory of painful events. The AAP statement, however, states the opposite: (1) safe anesthetic agents are available for use on infants in most situations, (2) infants do demonstrate the same physiological stress responses to injury that adults do (their adverse responses may increase complications such as intraventricular hemorrhage), and (3) new evidence shows that even premature infants have the physical capacity for memory and may suffer both short-term and long-term negative affects of early painful experiences. The AAP statement makes a special effort to acknowledgethat adult patients who have suffered significant trauma and who must undergo lifesaving surgery are sometimes denied anesthesia when it may further damage already compromised physiologic stability. According to the statement, there are analogous situations in newborns and infants. “However, the decision to withhold such medication should be based on the same medical criteria used for older patients. The decision should not be based solely on the infant’s age or perceived degree of 1138
cortical maturity.”s Although the ANA Codefor Nurses states that the language is not open to change, implications of the code and its interpretive statements to a particular issue are not always immediately clear. The purpose of this article is to discuss the possible implications of some sections of the code in light of the current controversy about infant pain control.
Respect for Human Digniv
T
he primary emphasis of section 1.1 of the ANA Code for Nurses is on the respect for persons through support of their selfdetermination. Section 1.1 states that, “Clients have the moral right to determine what will be done with their own person; to be given accurate information, and all the information necessary for making informed judgments. . . . Each nurse has an obligation to . . . support those rights. In situations in which the client lacks the capacity to make a decision, a surrogate decision maker should be designated.” In other words, the code prohibits misinforming parents, even if the purpose is to protect the parents. A surgical consent form that neglects to mention the possibility that an infant will receive little or no anesthesia but mentions the risks associated with administration of anesthesia would not constitute accurate information. A more accurate informed consent form and/or conversationwould include information such as conflicting data about pain perception and memory in infants, new and old views about the safety of anesthesia, and the skills, attitudes, and practices of the assigned anesthesiologist. Such information would make possible what has been called “informed dissent.’v According to the ANA Code for Nurses, parents should be able to refuse unanesthetized surgery on their child even if the surgeon believes that the infant has
DECEMBER 1987, VOL. 46, NO 6
AORN JOURNAL
‘If ethically opposed to interventions in a particular case because of the procedures to be used, the nurse is justified in refusing to participate.’ a slight chance of survival if unanesthetized surgery is performed. Courts have upheld the rights of parents to make decisions for their children. The Baby Doe rule supports the responsibility of parents to make decisions and suggests a procedure to follow when parents disagree with physicians.1° If parents refuse consent for surgery without anesthesia and the surgeons insist on it, then legal procedures, such as those used in Jehovah’s Witnesses cases pertaining to blood transfusions, would be appropriate. Even if this process results in surgery without consent, it would not justify misinforming or failing to inform parents at the beginning of the process, according to the ANA Code for Nurses.
Possible Prejudices ection 1:2 of the ANA Code for Nurses states S t h a t , “Nursing care is delivered without prejudicial behavior.” Although the code does not mention age as one of the possible prejudices, the statement clearly includes age. According to the AAP statement, decisions regarding the use of anesthesia may not be based solely on the child’s age. One reason for assuming that infants may not feel pain is that they cannot tell the caretaker that they hurt. Willis McGill, MD, chief of anesthesiology, Children’s Hospital National Medical Center, said that what appears to be an infant’s withdrawal from a painful stimulus or even crying might be a simple reflex.” But the implications of the ANA Code of Nurses seem to be that because the behavioral and physiologic correlates of pain in adults are accepted as signs of pain in adults who cannot talk, these correlates ‘should be accepted as signs of pain in infants who also cannot talk. Unless other data is persuasive, declining to accept this analogy would reflect prejudice because of age. 1140
Pressure to Conform
G
ood patient care in the operating room and elsewhere requires cooperation and teamwork; however, there may be heavy pressure to conform to commonly held beliefs or to the heirarchy within a particular medical culture. One nurse said that she sometimes has to urge surgeons to use anesthesia on infants and is ridiculed for her efforts.12 The ANA Code for Nurses addresses such situations in section 1.3: “If ethically opposed to interventions in a particular case because of the procedures to be used, the nurse is justified in refusing to participate.” Furthermore, section 1.3 notes that one of the purposes of nursing is “the prevention and relief of suffering commonly associated with the dying process.” To the extent that a nurse perceives the decision for unanesthetized surgery on infants as a reflection of the involved physicians’ inability to define them as dying infants, the nurse who refuses to participate may give everyone involved support for defining the infant’s status more accurately. Section 3.1 of the ANA Codefor Nurses states that, “The nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, or illegal practice by any member of the health care team or the health care system, or any action on the part of others that places the rights or best interests of the client in jeopardy.” Anesthesiologists who do not use anesthesia, however, are not performing actions considered incompetent or illegal. According to Charles Lockhart, MD, director of anesthesia, Children’s Hospital, Denver, when caring for an infant or newborn, an anesthesiologist can choose to provide no anesthesia, provide the pain relieving part of anesthesia, or provide full anesthesia and
DECEMBER 1987, VOL. 46, NO 6
AORN JOURNAL
stay within the current legal standard of practice. Because the practice is within the legal standards, nurses can assume that anesthesiologists who do not use anesthesia will not be considered incompetent by their colleagues. Nurses, however, have a responsibility to protect their clients from unethical persons. Although the informed consent laws in a particular state may not protect parents from inaccurate consent forms, nurses have a moral responsibility to act in support of substantive informed consent. If unnecessary pain is against the best interests of newborns and infants, then nurses should advocate pain prevention and/or relief for the patients according to established processes no matter how awkward and uncomfortable that process might be.
strategies vary. Factors related to a nurse’s understanding of pain management include the type of unit in which he or she works and attendance in classes on pain. Section 5.1 of the ANA Code for Nurses suggests, however, that nurses do have a responsibility to be familiar with the increasing amount of literature about pain perception in infants, about techniques for assessing this pain, and about possible damage to patients who suffer significant stress during major or minor surgery. Section 5.1 states that, “For the clients optimum well-being and for the nurse’s own professional development, the care of the client reflects and incorporates new techniques and knowledge in health care as these develop, especially as they relate to the nurse’s particular field of practice.”
Nursing Responsibilities Conclusion
S
tudies quoted in the beginning of this article suggest that unanesthetized surgery on infants and newborns may be an established practice in many institutions where OR nurses work. The accountability section (section 4.3) of the ANA Codefor Nurses states that accountability “means providing an explanation or rationale to oneself, to clients, to peers, to the nursing profession, and to society. . . .Nurses are accountable for judgments made and actions taken in the course of nursing practice. Neither physicians’ orders nor the employing agency’s policies relieve the nurse of accountability for actions taken and judgments made.” If it has been shown that it is possible to provide anesthesia (and postoperative pain relief) safely to most infants and newborns with appropriate administration of drugs and use of monitoring techniques, then the code suggests that nurses have a responsibility to people in communities where they work to explain why the anesthesia cannot be used in their institutions. Nursing education specialist Mary Halvorson, RN, MSN, and colleagues at Children’s Hospital of Los Angeles are in the process of completing a major study to determine nurses’ attitudes and strategies in assessing and controlling pain in preverbal infants. According to Halvorson, preliminary results indicate that these attitudes and 1142
T
he standard in anesthesia care for newborns is changing, partly because of the results of new scienfic studies. For example, a recent study shows that infants and newborns undergoing patent ductus arteriosus surgery demonstrate massive stress responses under weak anesthesia.13 Although such studies are an important element of change, the motivation to do such studies comes out of a change in moral sensitivity. Science alone cannot produce major changes in practice. Documents such as the ANA Code for Nurses have been written to introduce another element into that process of change. OR nurses involved in the care of infants now have both the challenge and the support to apply the values incorporated in the document as far as possible to their own working situation. NANCECUNNINGHAM BUTLER,MA PRESIDENT/CONSULTANT APPLIEDANALYSIS ASSOCIATES, INC DENVER Notes 1. Code for Nurses with Interpretive Skatementr (Kansas City, Mo: American Nurses’ Association, 1985). 2. J R Lawson, (Letter) Birth 13 (June 1986) 124125. 3. S Stem, “Shielding infants from surgical pain,”
AORN JOURNAL
The (Oakhnd) Wbune (Feb 5, 1987) sec C, 2. 4. “Pain in children misunderstood State of management ‘shocking,’ ” Pediatric News 20 (August 1986) 58. 5. K J S Anand, A Aynsley-Green, “Metabolic and endocrine effects of surgical ligation of patent ductus arteriosus in the human preterm neonate: Are there implications for further improvement of postoperative outcome?” Modern Problem in Paediatrics 23 (1985) 143-157. 6. Stem, “Shielding infants from surgical pain.” 7. R L Poland, Committee on Fetus and Newborn et al, “Neonatal anesthesia,” Pediatnks 80 (September 1987) 446. 8. Ibid. 9. H Harrison, “Neonatal intensive care: Parents’ role in ethical decision making,” Birth 13 (September 1986) 167. 10. Department of Health and Human Services, “Child abuse and neglect prevention and treatment program,” FederalRegkter 50 (April 15, 1985) 14878. 11. S Rovner, “Surgery without anesthesia: Can preemies feel pain?“ The Washington Post (Aug 13, 1986) sec “Healthtalk,”7. 12. Lawson, (Letter). 13. K J S Anand, W G Sippell, A Aynsley-Green, “Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: Effects on stress response,” The Lancet (Jan 31, 1987) 243-248. Suggested reading
Berry, F A, ed. Anesthetic Management of Di@ult and Routine Pediatric Patiem. New York City: Churchill Livingstone, 1986. Berry, FA; Gregory, G A. “Do prematureinfants require anesthesia for surgery?” (Letter) Anesthesiology 67 (September 1987) 291-293. Bradshaw, C; Zeanah, P D. “Pediatric nurses’ assessments of pain in children.” Journal of Pediatric Nursing 1 (October 1986) 314-322. Brazelton, T B. “Behavioral competenceof the newborn infant.” Seminars in Perinatology 3 (January 1979) 35-44. Dixon, S,et al. “Behavioral effects of circumcision with and without anesthesia.” Journal of Developmental and Behavioral Pediatrics 5 (October 1984) 246250. Gregory, G A. “Anesthesia for premature infants.” In Pediatric Anesthesia New York Churchill Livingstone, 1983, 587-606. Hemg, J M. “A neonatal intensive care syndrome: A pain complex involving neuroplasticity and psychic trauma.” In Frontiers of Infant Psychiany, eds. J D Call, E Galenson, R L Tyson. New York City: Basic Books,Inc, 1983,291-300. Owens, M E. “Pain in infancy: Conceptual and methodological issues.’’ Pain 20 (November 1984) 2 13-230. 1144
DECEMBER 1987, VOL. 46, NO 6
Richards, M P Bernal, J F; Brackbill, Y. “Early behavioral differences: Gender or circumcision?” Developmental Psychobiology 9 (January 1976) 8995. Robinson, S; Gregory, G A. “Fentanyl-air-oxygen anesthesia for ligation of patent ductus arteriosus in preterm infants.” Anesthesia and Analgesia 60 (May 1981) 331-334. Scanlon, J W. “Barbarism.” Pennatal Press 9 (1985) 103-104. Stele, B F. ‘The reconstruction of trauma and child abuse.” In The Reconstruction of Trauma: kfonograph ZZ, ed. A Rothstein. Madison, Conn: International Universities Press, Inc, 1986. Vacanti, J P, et al. “The pulmonary hemodynamic response. to perioperative anesthesia in the treatment of high-risk infants with congenital diaphragmatic hernia.” Journal of Pediatric Surgery 19 (December 1984) 672-679. Volpe, J J. “Intracranial hemorrhage: Periventricularintraventricular hemorrhage of the premature infant.” In Neurology of the Newborn second ed. Philadelphia: W B Saunders, 1987,262-298.
Japanese Surgeons Implant Hearing Aid Japanese surgeons have reported excellent results from a partial implantable hearing aid used by a 61-yeardd man, according to the August issue of Archives of Otokuyngologv-Head and Neck Surgery. The m i d d l m hearing aid uses a vibrator mechanism that is in direct contact with the stapes (the stirrup bone of the middle ear).The vibrator picks up sound waves through an implantable amplifier attached to a tiny, implantable microphone. After using the device for more than one year, the surgeons reported that their patient was receiving a superior quality of electroacoustic signals to the inner ear that could not be obtained by other surgical or rehabilitative means.
AORN JOURNAL
Ethics The ethical issues involved in the practice of surgery on unanesthetized infants
T
he practice of not using anesthesia on infants undergoing surgery is creating controversy. Although some health care professionals characterize this situation as strictly a scientific controversy, an ethical controversy also exists. Because of the close involvement some OR nurses have with unanesthetized but paralyzed newborns and infants undergoing surgery, OR nurses have a special responsibility and opportunity to consider such procedures from the moral perspectives promulgated in the American Nurses’ Association Code for Nurses with Interpretive Statements.’
The Problem
I
to get permission, the parents say they were available in the waiting room during the surgery. The parents, who believe that the surgeons prevented them from protecting their son from needless suffering, have filed a lawsuit seeking damages for the emotional distress they suffered. According to pediatric pain management expert Joann Eland, RN, PhD, College of Nursing, University of Iowa, Iowa City, performing surgery on infants without using anesthesia is a widespread practice. Last year, Dr Eland told a National Institutes of Health conference that in 1986, an infant from 12 to 15 months of age who is taken to the OR in most hospitals in this country will be paralyzed for surgery but not anesthetized!
n early 1985, a surgeon at Children’s Hospital National Medical Center, Washington, DC, performed surgery to correct a patent ductus arteriosus in a premature infant. Although the infant’s mother was assured that anesthesia would be used and she signed the surgery consent stating such, she later discovered that the anesthesiologist used the neuromuscular block pancuronium bromide (Pavulon)but did not use anesthesia.Both the infant’s referring neonatologist and the surgeon were also unaware of the anesthesiologist’s general Nance Cunningham Butler, MA, is the protocol not to use anesthesia during such president/consultantfor Applied Analysi~Assoprocedures.2 ciates, h e , Denver. She earned a bachelor of a m In early 1986, physicians at Children’s Hospital degree in English/philosophy at Colorado State Medical Center of Northern California, Oakland, University,Ft Collins: a master of arts in education performed major abdominal surgery on a premature infant without using ane~thesia.~ at the University of Colorado, Boulder; and a master of arts in applied philosophy at Bowling Although hospital officials insist that there was Green (Ohio) State University. not enough time to consult the infant’s parents 1136
DECEMBER 1987, VOL. 46, NO 6
AORN JOURNAL
Of the infants undergoing patent ductus arteriosus surgery, 77%had received only a paralyzing drug or a paralyzing drug and nitrous oxide. In a review of 40 articles on surgery to correct patent ductus arteriosus published in international medical literature between 1970 and 1983, researchers found that 77% of the infants undergoing such surgery had received only a paralyzing drug or a parlayzing drug and intermittent nitrous oxide? An informal survey conducted by the American Academy of Pediatrics (AAP) showed that cases of unanesthetized surgery on infants are not rare? In response, the AAP developed a statement on neonatal anesthesia? According to the statement, traditional reasons for withholding anesthetic or analgesic agents are not valid. These are that (1) danger to the unstable infant outweighs possible benefits of pain relief, (2) infants’ neural pathways are not developed enough to transmit pain, and (3) infants do not have the cortical function required to have a memory of painful events. The AAP statement, however, states the opposite: (1) safe anesthetic agents are available for use on infants in most situations, (2) infants do demonstrate the same physiological stress responses to injury that adults do (their adverse responses may increase complications such as intraventricular hemorrhage), and (3) new evidence shows that even premature infants have the physical capacity for memory and may suffer both short-term and long-term negative affects of early painful experiences. The AAP statement makes a special effort to acknowledgethat adult patients who have suffered significant trauma and who must undergo lifesaving surgery are sometimes denied anesthesia when it may further damage already compromised physiologic stability. According to the statement, there are analogous situations in newborns and infants. “However, the decision to withhold such medication should be based on the same medical criteria used for older patients. The decision should not be based solely on the infant’s age or perceived degree of 1138
cortical maturity.”s Although the ANA Codefor Nurses states that the language is not open to change, implications of the code and its interpretive statements to a particular issue are not always immediately clear. The purpose of this article is to discuss the possible implications of some sections of the code in light of the current controversy about infant pain control.
Respect for Human Digniv
T
he primary emphasis of section 1.1 of the ANA Code for Nurses is on the respect for persons through support of their selfdetermination. Section 1.1 states that, “Clients have the moral right to determine what will be done with their own person; to be given accurate information, and all the information necessary for making informed judgments. . . . Each nurse has an obligation to . . . support those rights. In situations in which the client lacks the capacity to make a decision, a surrogate decision maker should be designated.” In other words, the code prohibits misinforming parents, even if the purpose is to protect the parents. A surgical consent form that neglects to mention the possibility that an infant will receive little or no anesthesia but mentions the risks associated with administration of anesthesia would not constitute accurate information. A more accurate informed consent form and/or conversationwould include information such as conflicting data about pain perception and memory in infants, new and old views about the safety of anesthesia, and the skills, attitudes, and practices of the assigned anesthesiologist. Such information would make possible what has been called “informed dissent.’v According to the ANA Code for Nurses, parents should be able to refuse unanesthetized surgery on their child even if the surgeon believes that the infant has
DECEMBER 1987, VOL. 46, NO 6
AORN JOURNAL
‘If ethically opposed to interventions in a particular case because of the procedures to be used, the nurse is justified in refusing to participate.’ a slight chance of survival if unanesthetized surgery is performed. Courts have upheld the rights of parents to make decisions for their children. The Baby Doe rule supports the responsibility of parents to make decisions and suggests a procedure to follow when parents disagree with physicians.1° If parents refuse consent for surgery without anesthesia and the surgeons insist on it, then legal procedures, such as those used in Jehovah’s Witnesses cases pertaining to blood transfusions, would be appropriate. Even if this process results in surgery without consent, it would not justify misinforming or failing to inform parents at the beginning of the process, according to the ANA Code for Nurses.
Possible Prejudices ection 1:2 of the ANA Code for Nurses states S t h a t , “Nursing care is delivered without prejudicial behavior.” Although the code does not mention age as one of the possible prejudices, the statement clearly includes age. According to the AAP statement, decisions regarding the use of anesthesia may not be based solely on the child’s age. One reason for assuming that infants may not feel pain is that they cannot tell the caretaker that they hurt. Willis McGill, MD, chief of anesthesiology, Children’s Hospital National Medical Center, said that what appears to be an infant’s withdrawal from a painful stimulus or even crying might be a simple reflex.” But the implications of the ANA Code of Nurses seem to be that because the behavioral and physiologic correlates of pain in adults are accepted as signs of pain in adults who cannot talk, these correlates ‘should be accepted as signs of pain in infants who also cannot talk. Unless other data is persuasive, declining to accept this analogy would reflect prejudice because of age. 1140
Pressure to Conform
G
ood patient care in the operating room and elsewhere requires cooperation and teamwork; however, there may be heavy pressure to conform to commonly held beliefs or to the heirarchy within a particular medical culture. One nurse said that she sometimes has to urge surgeons to use anesthesia on infants and is ridiculed for her efforts.12 The ANA Code for Nurses addresses such situations in section 1.3: “If ethically opposed to interventions in a particular case because of the procedures to be used, the nurse is justified in refusing to participate.” Furthermore, section 1.3 notes that one of the purposes of nursing is “the prevention and relief of suffering commonly associated with the dying process.” To the extent that a nurse perceives the decision for unanesthetized surgery on infants as a reflection of the involved physicians’ inability to define them as dying infants, the nurse who refuses to participate may give everyone involved support for defining the infant’s status more accurately. Section 3.1 of the ANA Codefor Nurses states that, “The nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, or illegal practice by any member of the health care team or the health care system, or any action on the part of others that places the rights or best interests of the client in jeopardy.” Anesthesiologists who do not use anesthesia, however, are not performing actions considered incompetent or illegal. According to Charles Lockhart, MD, director of anesthesia, Children’s Hospital, Denver, when caring for an infant or newborn, an anesthesiologist can choose to provide no anesthesia, provide the pain relieving part of anesthesia, or provide full anesthesia and
DECEMBER 1987, VOL. 46, NO 6
AORN JOURNAL
stay within the current legal standard of practice. Because the practice is within the legal standards, nurses can assume that anesthesiologists who do not use anesthesia will not be considered incompetent by their colleagues. Nurses, however, have a responsibility to protect their clients from unethical persons. Although the informed consent laws in a particular state may not protect parents from inaccurate consent forms, nurses have a moral responsibility to act in support of substantive informed consent. If unnecessary pain is against the best interests of newborns and infants, then nurses should advocate pain prevention and/or relief for the patients according to established processes no matter how awkward and uncomfortable that process might be.
strategies vary. Factors related to a nurse’s understanding of pain management include the type of unit in which he or she works and attendance in classes on pain. Section 5.1 of the ANA Code for Nurses suggests, however, that nurses do have a responsibility to be familiar with the increasing amount of literature about pain perception in infants, about techniques for assessing this pain, and about possible damage to patients who suffer significant stress during major or minor surgery. Section 5.1 states that, “For the clients optimum well-being and for the nurse’s own professional development, the care of the client reflects and incorporates new techniques and knowledge in health care as these develop, especially as they relate to the nurse’s particular field of practice.”
Nursing Responsibilities Conclusion
S
tudies quoted in the beginning of this article suggest that unanesthetized surgery on infants and newborns may be an established practice in many institutions where OR nurses work. The accountability section (section 4.3) of the ANA Codefor Nurses states that accountability “means providing an explanation or rationale to oneself, to clients, to peers, to the nursing profession, and to society. . . .Nurses are accountable for judgments made and actions taken in the course of nursing practice. Neither physicians’ orders nor the employing agency’s policies relieve the nurse of accountability for actions taken and judgments made.” If it has been shown that it is possible to provide anesthesia (and postoperative pain relief) safely to most infants and newborns with appropriate administration of drugs and use of monitoring techniques, then the code suggests that nurses have a responsibility to people in communities where they work to explain why the anesthesia cannot be used in their institutions. Nursing education specialist Mary Halvorson, RN, MSN, and colleagues at Children’s Hospital of Los Angeles are in the process of completing a major study to determine nurses’ attitudes and strategies in assessing and controlling pain in preverbal infants. According to Halvorson, preliminary results indicate that these attitudes and 1142
T
he standard in anesthesia care for newborns is changing, partly because of the results of new scienfic studies. For example, a recent study shows that infants and newborns undergoing patent ductus arteriosus surgery demonstrate massive stress responses under weak anesthesia.13 Although such studies are an important element of change, the motivation to do such studies comes out of a change in moral sensitivity. Science alone cannot produce major changes in practice. Documents such as the ANA Code for Nurses have been written to introduce another element into that process of change. OR nurses involved in the care of infants now have both the challenge and the support to apply the values incorporated in the document as far as possible to their own working situation. NANCECUNNINGHAM BUTLER,MA PRESIDENT/CONSULTANT APPLIEDANALYSIS ASSOCIATES, INC DENVER Notes 1. Code for Nurses with Interpretive Skatementr (Kansas City, Mo: American Nurses’ Association, 1985). 2. J R Lawson, (Letter) Birth 13 (June 1986) 124125. 3. S Stem, “Shielding infants from surgical pain,”
AORN JOURNAL
The (Oakhnd) Wbune (Feb 5, 1987) sec C, 2. 4. “Pain in children misunderstood State of management ‘shocking,’ ” Pediatric News 20 (August 1986) 58. 5. K J S Anand, A Aynsley-Green, “Metabolic and endocrine effects of surgical ligation of patent ductus arteriosus in the human preterm neonate: Are there implications for further improvement of postoperative outcome?” Modern Problem in Paediatrics 23 (1985) 143-157. 6. Stem, “Shielding infants from surgical pain.” 7. R L Poland, Committee on Fetus and Newborn et al, “Neonatal anesthesia,” Pediatnks 80 (September 1987) 446. 8. Ibid. 9. H Harrison, “Neonatal intensive care: Parents’ role in ethical decision making,” Birth 13 (September 1986) 167. 10. Department of Health and Human Services, “Child abuse and neglect prevention and treatment program,” FederalRegkter 50 (April 15, 1985) 14878. 11. S Rovner, “Surgery without anesthesia: Can preemies feel pain?“ The Washington Post (Aug 13, 1986) sec “Healthtalk,”7. 12. Lawson, (Letter). 13. K J S Anand, W G Sippell, A Aynsley-Green, “Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: Effects on stress response,” The Lancet (Jan 31, 1987) 243-248. Suggested reading
Berry, F A, ed. Anesthetic Management of Di@ult and Routine Pediatric Patiem. New York City: Churchill Livingstone, 1986. Berry, FA; Gregory, G A. “Do prematureinfants require anesthesia for surgery?” (Letter) Anesthesiology 67 (September 1987) 291-293. Bradshaw, C; Zeanah, P D. “Pediatric nurses’ assessments of pain in children.” Journal of Pediatric Nursing 1 (October 1986) 314-322. Brazelton, T B. “Behavioral competenceof the newborn infant.” Seminars in Perinatology 3 (January 1979) 35-44. Dixon, S,et al. “Behavioral effects of circumcision with and without anesthesia.” Journal of Developmental and Behavioral Pediatrics 5 (October 1984) 246250. Gregory, G A. “Anesthesia for premature infants.” In Pediatric Anesthesia New York Churchill Livingstone, 1983, 587-606. Hemg, J M. “A neonatal intensive care syndrome: A pain complex involving neuroplasticity and psychic trauma.” In Frontiers of Infant Psychiany, eds. J D Call, E Galenson, R L Tyson. New York City: Basic Books,Inc, 1983,291-300. Owens, M E. “Pain in infancy: Conceptual and methodological issues.’’ Pain 20 (November 1984) 2 13-230. 1144
DECEMBER 1987, VOL. 46, NO 6
Richards, M P Bernal, J F; Brackbill, Y. “Early behavioral differences: Gender or circumcision?” Developmental Psychobiology 9 (January 1976) 8995. Robinson, S; Gregory, G A. “Fentanyl-air-oxygen anesthesia for ligation of patent ductus arteriosus in preterm infants.” Anesthesia and Analgesia 60 (May 1981) 331-334. Scanlon, J W. “Barbarism.” Pennatal Press 9 (1985) 103-104. Stele, B F. ‘The reconstruction of trauma and child abuse.” In The Reconstruction of Trauma: kfonograph ZZ, ed. A Rothstein. Madison, Conn: International Universities Press, Inc, 1986. Vacanti, J P, et al. “The pulmonary hemodynamic response. to perioperative anesthesia in the treatment of high-risk infants with congenital diaphragmatic hernia.” Journal of Pediatric Surgery 19 (December 1984) 672-679. Volpe, J J. “Intracranial hemorrhage: Periventricularintraventricular hemorrhage of the premature infant.” In Neurology of the Newborn second ed. Philadelphia: W B Saunders, 1987,262-298.
Japanese Surgeons Implant Hearing Aid Japanese surgeons have reported excellent results from a partial implantable hearing aid used by a 61-yeardd man, according to the August issue of Archives of Otokuyngologv-Head and Neck Surgery. The m i d d l m hearing aid uses a vibrator mechanism that is in direct contact with the stapes (the stirrup bone of the middle ear).The vibrator picks up sound waves through an implantable amplifier attached to a tiny, implantable microphone. After using the device for more than one year, the surgeons reported that their patient was receiving a superior quality of electroacoustic signals to the inner ear that could not be obtained by other surgical or rehabilitative means.