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Running head: CLINICAL EXEMPLAR 1

Clinical Exemplar:

Therapeutic Hypothermia and Therapeutic Communication

Rebecca Netjes

University of South Florida


CLINICAL EXEMPLAR 2

Clinical Exemplar:

Therapeutic Hypothermia and Therapeutic Communication

The profession of nursing is unique in that it requires a special blend of concrete, linear

thought processes, as well as abstract, creative intuition. It can be challenging for students and

novice nurses to understand the duality of these two methods of interpretation, but it is critical to

providing high level patient care. Gillespie and Peterson (2009) suggest that using a written

framework, that emphasizes retrospective analysis of decision-making, can lead to an increased

confidence of novice nurses as they transition to the role of a professional nurse. This written

record, occasionally referred to as a clinical exemplar, is often written in the first person, that

allows the writer to describe a clinical situation, identify their feelings, the factors leading up to a

decision, the decision, and the outcome (Pacini, 2006).

Patient History

A month after admission for a GI bleed, a 57-year-old male patient was found in pulseless

electrical activity, was coded for 8 minutes prior to return of spontaneous circulation, and was

placed on therapeutic hypothermia. After 24 hours, the patient was re-warmed. However, the

patient showed no purposeful neurologic activity.

He did not track movement with his eyes, grimace to painful stimuli, or show any

purposeful movement. The patient did not require sedation, but required hemodynamic support

with vasopressors, and respiratory support as he had a permanent tracheostomy but was being

ventilated with mechanical ventilation. Additionally, he was placed on the assist-control mode on

the ventilator, which would allow for initiation of spontaneous breaths above the set rate;

however, he did not have instances of spontaneous breaths.


CLINICAL EXEMPLAR 3

The main goal as we were caring for this patient was to firmly establish what his wishes

would be regarding his plan of care. The patient did not have an advanced directive outlining his

wishes, so we relied on his daughter to speak on his behalf. His daughter was struggling with this

decision, as she believed he would not want to live this way, but was hoping “for a miracle”. Not

only was she struggling with how to balance these two considerations, her siblings did not live in

the local area and were estranged from her father, so on many occasions she reported to my

preceptor and I that she felt as though she was “alone in this decision”.

Interpretation

It was clear that the patient’s daughter was experiencing significant emotional distress

regarding how to proceed with her father’s plan of care. My preceptor and I had many

conversations with her regarding this, and it became clear that we needed to escalate these

conversations to other team members. We chose to ask the intensivist if he could consult the

palliative medicine team at our hospital, as they are specialized in end-of-life conversations and

decision making. However, we continued to set aside time in our day to speak with his daughter

as it is the responsibility of the nurse to be intentional and offer self for end-of-life conversations

(American Nurses Association, 2012).

Responding

We could not delay having these conversations with his daughter, as we were striving to

protect the patient’s autonomy, by honoring and keeping his wishes a priority (Guido, 2014). We

did not delegate these conversations to another team member, but did seek support from the

palliative care team. Our next step was to speak with a hospice team member regarding the

different types of goals of care the patient’s daughter could choose from.

Reflecting
CLINICAL EXEMPLAR 4

Overall, I believe we did make the right decision to escalate the conversation to more

specialized team members. When it became clear to us, that the patient did not have an adequate

support system to see her through this challenging time, I wanted to be sure that we gave her

access to all resources our hospital could offer her. One of the most pivotal concepts I have come

to understand through clinical rotations in the intensive care unit, is that nursing care is not

limited to the patient, but should also extend to the family. With special attention to this

situation, it was mandatory that we focus a great deal of our energy on supporting the daughter’s

cognitive and emotional understanding, as our interventions for the patient were limited to his

physical condition.

At times, I felt frustrated implementing medical interventions for a patient that had little

chance at recovery without deficits. On the surface it seemed counterintuitive, knowing the staff

was able to resuscitate him, but only to leave him with a poor quality of life. Additionally, the

discussions with the patient’s daughter significantly challenged my skills regarding therapeutic

communication. I often found myself wishing I could do more to support my patient’s daughter,

but I feel that we made the appropriate decisions for the limited time we had with her.

While issues surrounding end-of-life are difficult and convoluted, I value the ability of

nurses to offer themselves in the midst of this. I believe that the relationships nurses form with

patients and families are as critical to overall well-being as the other interventions we perform. I

believe that only through offering of self and honest conversations, nurses can truly provide

excellent patient care.


CLINICAL EXEMPLAR 5

References

American Nurses Association. (2012). Nursing care and do not resuscitate (DNR) and allow

natural death (AND) decisions. Retrieved from http://www.nursingworld.org/dnrposition

Gillespie, M. & Peterson, B. (2009). Helping novice nurses make effective clinical decision: the

situated clinical decision-making framework. Nursing Education Perspectives, 30(3),

164-170.

Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Vancouver, WA: Pearson.

Pacini, C.M. (2006). Writing Exemplars. Nurse Action Days. Retrieved from

https://www.ucdmc.ucdavis.edu/cppn/documents/bridges_to_excellence/Writing_Exempl

ars.pdf