Respiratory Management Following Spinal Cord Injury - 25

CLINICAL PRACTICE GUIDELINE

Psychological reactions. Pre-morbid substance abuse. Pain.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

a patient and family treatment withdrawal agreement; consulting with the institution’s ethics committee; understanding what the law requires, permits, and expects of health-care providers; and providing a humane death.

Family Caregiving
34. As appropriate, assess and support family functioning.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

The basis for medically related discussions is informed consent (Caplan, 1998). However, in order for informed consent to have meaning and foundation, the individual with ventilatordependent tetraplegia must be competent to engage in this type of dialog. Decision-making capacity is a complicated issue, often involving an array of factors, all of which should be explored. These include, but are not limited to, organicity, medications, psychological reactions, pre-morbid substance abuse, and pain. Excellent references in this area include Appelbaum and Grisso (1988), Grisso (1988), and Purtilo (1986).

Advance Directives
33. Discuss advance directives, specifically the living will and durable power for medical health care, with the competent patient or the patient’s proxy to determine the validity of the documents post trauma.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Spinal cord injuries rarely exist in a vacuum— individuals come with families. In fact, the presence of a supportive and constructively involved family augurs for a more successful outcome. As such, family education, support, and reassurance are pivotal aspects of quality rehabilitation (Chan, 2000; Elliott and Shewchuk, 1998; Kreuter, 2000). Additionally, in some instances parenting issues might need to be broached (Barker and Maralani, 1997; Rintala et al., 2000).

Intimacy and Sexuality
35. Explore issues of intimacy and sexuality with the patient and other appropriate parties.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Advance directives, specifically the living will and durable power of attorney for medical health care, are instruments that detail the nature and magnitude of desired medical care post trauma. Given the understandable quality of life issues secondary to ventilator-dependent tetraplegia that can emerge, the presence of advance directives can help the treatment team construct a clinical plan. Nevertheless, in light of the fact that individual perspectives can change after physical compromise, it is mandatory to confirm the validity of these instruments post trauma. As a result, discussions should ensue with the competent individual or patient’s proxy regarding the validity of these legal instruments (Caplan et al., 1987). In those thankfully rare situations where the patient and family wish to discontinue and withdraw treatment, Butt and Scofield (1997) present a clinically, legally, and morally sound process. This process involves selecting health-care providers who demonstrate an objective, nonzealous philosophic stance toward treatment withdrawal; establishing the patient’s decision-making capacity; establishing informed consent; determining the consistency of the patient’s decision; exposing the patient to other similarly disabled individuals; ensuring the philosophic compatibility of the setting; obtaining

It is adamantly held that intimacy, irrespective of level of injury, can be maintained. Indeed, there can be considerable misinformation and apprehension about this important aspect of human function. The treatment team should be a significant source of information on this topic. See the following references: Ducharme (1987), Sipski and Alexander (1997), White et al. (1993a, 1993b), and Willmuth (1987).

Establishment of an Effective Communication System
36. Assess the patient’s ability to communicate and ensure that all staff can effectively interact with the patient to determine his or her needs and concerns.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Irrespective of the individual’s level of injury, it is imperative to devote attention to the person’s ability to communicate his or her needs and concerns to others. Often consultation with speech/language pathology personnel will aid this process. Treatment staff across all shifts must be cognizant of the most effective way to interact with the patient.

Respiratory Management Following Spinal Cord Injury

Table of Contents for the Digital Edition of Respiratory Management Following Spinal Cord Injury