1. 6 June 9, 2014 the kansas city nursingnews
in brief Touched by the
angel of death
By Joshua M. Felts, BS, BSN, RN
Special to Kansas City Nursing News
I couldn’t help it; my eyes were replete with
tears. The lacrimation rolled over my pores like
torrents of water rolling over bedrock. I couldn’t
help it. My tears were uncontrollable, instinctu-
al and atavistic. Over the years, I’ve befriended
death; I’m a nurse. I understand death, mortal-
ity, and the nature of humanity. Yet, I couldn’t,
can’t, cognitively digest the death of a child.
In lieu of writing this arti-
cle at home, I instead chose to
write it outside the pediatric
ICU of a hospital. I wanted a
taste of death, something raw
and repugnantly more dis-
tasteful than that to which I’m
normally accustomed. While
in the waiting room, I could
feel death’s presence. Instead
of blessing an adult with his
eternal dictate, a child was in his crosshairs.
The family wept, the mother fell to her knees,
crying uncontrollably. The father, a social au-
tomaton, tried to act as a stalwart and comfort
his wife and his bereaved family members, all
the while torn from the inside out. I don’t know
the specifics, what caused their child to perish,
but it was an experience inadequately commu-
nicated by words.
The nurses, who tepidly entered the madness,
felt grief, yet remained stone cold in appearance.
After all, it would be unprofessional and too hu-
man to confirm their humanity. They were, like
most professionals, professing their inhumanity
for the sake of professional progress.
I’m not a pediatric nurse — I can’t handle it.
I admit, a child’s death makes me weak in the
knees. As a nurse, we’re thrown into mortali-
ty. We are, in a way, the brokers of death. We’re
the middlemen, the professionals who help the
weak, yet whom ultimately assist them to the
shore of the river Styx.
Albeit, we may be the concierge of death, we
don’t always have to embrace the role. When
a child is in insurmountable pain and staring
down the barrel of death’s dark revolver, we
can’t prevent the fact that they are death’s can-
non fodder. However, we can act as a bridge be-
tween this world and the next, alleviating pain
by comforting the dying child and the bereaved.
And while the angel of death may hover nearby,
wings outstretched and ready to embrace the
soon-to-pass, I cannot help but wish desperately
to clip his black wings and create an impasse. I
don’t have the answers, and I don’t know why
children are taken from this earth all too soon,
but I do know the answer is beyond human.
Joshua M. Felts, BS, BSN, RN, practices nursing
and writing in the Kansas City area.
This story originally appeared in www.mightynurse.com.
Joshua M. Felts,
BS, BSN , RN
While recent federal legislation
and changes to the U.S. Medicare
program have expanded opportu-
nities for certified registered nurse
anesthetists (CRNAs) to provide
care to more patients and receive
reimbursement for their services,
many states still restrict their scope
of practice and limit their pay. A
special section in the current issue
of Clinical Scholars Review, the
journal of advanced practice nurs-
ing published by Columbia Nurs-
ing, explores how the Affordable
Care Act (ACA) empowers CRNAs
to help make anesthesia services
more accessible to patients, while
also highlighting laws in New York
and other states that may impede
the expanded access to care envi-
sioned by ACA.
The broad goals of the ACA are to
extend health insurance to millions
of uninsured Americans and to im-
prove the accessibility, quality, and
cost-effectiveness of care. With re-
spect to anesthesia and pain man-
agement, the ACA takes some steps
in the right direction, but still falls
short of fully achieving these goals,
argues Janice Izlar, CNRA, DNAP,
MS ’06, immediate past president of
the American Association of Nurse
Anesthetists, in her essay in the
journal, “Health Care Challenges
to the Certified Registered Nurse
Anesthetist as an Advanced Prac-
tice Registered Nurse.”
Starting in January 2014, the
ACA put a stop to health plans’
practice of excluding qualified
licensed health-care providers,
such as CRNAs, from insurance
networks solely on the basis of
their licensure. But the ACA
left untouched a Medicare reim-
bursement policy that lets states
opt out of regulations permitting
CRNAs to administer anesthesia
without physician supervision.
In many states, including New
York, this has pitted anesthesiol-
ogists against CRNAs in legisla-
tive fights over scope of practice.
“Health-care facilities should
have the flexibility to choose
practice arrangements that best
meet their needs without endur-
ing a political battle that has
nothing to do with patient safety
and could limit access to care,”
Izlar says. “Unfortunately, the
ACA doesn’t address this issue.”
Another federal policy that lim-
its opportunities of CRNAs has to
do with funding for clinical edu-
cation, Izlar says. While Medicare
pays hospitals extra money for
training medical residents, no such
funds are provided for advanced
practice nurses to do clinical rota-
tions. Here, the ACA offers a glim-
mer of hope, ushering in a $200 mil-
lion federal pilot project to provide
funding for graduate nurse educa-
tion at five institutions around the
country. “For hospitals right now,
it’s much more beneficial to train
anesthesiologists because they get
the graduate education funding,”
Izlar says. “While this has put all
advanced practice nurses at a dis-
advantage, it has been a particular
hardship for CRNAs.”
In her essay, “The Tipping Point
in Health Care: Using the Full Scope
of Practice of Certified Registered
Nurse Anesthetists as Advanced
Practice Registered Nurses,” Mari-
beth Leigh Massie, CRNA, PhD, MS
’98, a program director for the Uni-
versity of New England Nurse Anes-
thesia Program, argues that models
of care delivery need to change to
achieve the high-quality, cost-ef-
fective anesthesia care envisioned
by the ACA. Instead of the current
vertical integration, with physicians
positioned at the top, we need to look
at organizing anesthesia services in
a more horizontal, collaborative re-
porting structure, Massie says. “We
currently have this arcane model of
medical direction that even anes-
thesiologists have found unsustain-
able,” she argues. “A collaborative
team or CRNA-only model would
improve access to care by using all
providers at their highest level while
decreasing the costly and duplica-
tive requirements of the medical di-
rection model.”
In New York State, however, this
model of care may not be possible.
Laura Ardizzone ’10 DNP, ’04 MS,
chief nurse anesthetist at Memo-
rial Sloan Kettering Cancer Cen-
ter in New York City, explores the
roadblocks created by state laws in
her essay, “Navigating the Uncer-
tainty That Lies Ahead: Certified
Registered Nurse Anesthetists and
the Patient Protection and Afford-
able Care Act.” In New York, for
example, the state doesn’t recog-
nize advanced practice nursing
licenses, making it impossible for
CRNAs to receive payment from
the state-administered Medicaid
program. This barrier to practice
at the state level is an unnecessary
roadblock to providing care to pa-
tients newly insured under the
ACA, Ardizzone argues.
“As more people gain coverage
under ACA, there are going to be
a lot more people needing surgery
and needing anesthesia,” Ardizzone
says. “Instead of just saying we need
to spend taxpayer dollars to educate
another 6,000 medical residents in
anesthesia, why can’t we use the
CRNAs we have already trained
and start letting them practice to the
fullest scope of their potential.”
By Source: Columbia University School of Nursing
Clinical review shines spotlight on certified registered nurse anesthetists
Submitted photo
Many states restrict the scope of practice and limit pay of nurse anesthetists. An article in the
current issue of Clinical Scholars Review looks at how the Affordable Care Act empowers CRNAs.