September 28, 2017

By: Mary Janette Sendin, MSN, CNS, CCNS, PCCN

Patient advocacy: Sooner better than later

This patient could be us, our family, or other people we love. Vulnerable, scared, helpless. Do we listen to our patients? How can we support them and their families while they are under our care? The bottom line answer is patient advocacy.

According to the Merriam-Webster dictionary, advocate used as noun is defined as one who pleads the cause of another, one who defends or maintains a cause or proposal, one who supports or promotes the interests of a cause or group. Advocacy used as a verb is defined as the act or process of supporting a cause or proposal.

All nurses are patient advocates but the clinical nurse specialist (CNS) advocates at an advanced practice level. According to the American Association of Critical-Care Nurses (AACN) Scope and Standards for Acute Care Clinical Nurse Specialist (CNS) Practice, CNSs are influential in enabling an organizational culture of caring. They work with patients and families to establish an environment where caring is supreme. They also work to create an environment for patients and families where patient advocacy is one of the groundwork in achieving optimal outcomes for patients, families, and the organization.

Here is an example of patient advocacy by a CNS.

First, some background information. Atrial fibrillation (AF) can be debilitating and devastating. To some patients it can be frustrating and scary. The risk of having a stroke causes much anxiety and depression. Some patients suddenly feel that their lives go on hold and they clamor for answers of how they can feel well and safe again.

Patients who are at a high risk for stroke are placed on oral anticoagulation therapy. While stroke prevention is important, being on oral anticoagulant (OAC) places them at risk for bleeding. Some patients can be considered for the WATCHMAN Left Atrial Appendage Closure (LAAC) device implant procedure. This is an alternative to OAC therapy for non-valvular AF patients who are at a high risk for stroke but with history of major bleeding while on OACs or a career or lifestyle that increases their risk for bleeding secondary to trauma.

A 77-year-old male patient, diagnosed with paroxysmal AF with a stroke risk score of 9.8%, required the need to be on a long-term OAC therapy for stroke prevention. He was placed on warfarin but developed a hemorrhagic stroke while on the medication. He was therefore taken off OAC, and the risk for stroke extremely worried this patient.

The patient said, “After having a stroke and recovering from it, I am thankful for this second chance. I want to live longer to spend more time with my family, mainly to witness special milestones and celebrations in my grandchildren’s lives. I feel apprehensive of having another stroke and being incapacitated.” He expressed the desire to have the WATCHMAN procedure as soon as possible. He was willing to cancel several planned family trips except for the high school graduation of a grandson (from out of state) who had almost died when he was an infant. This milestone was significant and much anticipated. Because of the patient’s past experience of bleeding complications while on OAC, he preferred to be near his doctors post-implant for closer monitoring while on short-term OAC therapy, which is required after the procedure.

A date had been set, but was then moved to 5 weeks later due to financial concerns. Because of the high stroke risk and not being on OAC therapy, along with the planned important family event, clinical and service outcomes were concerns. Collaboration among our team of physicians and leaders was conducted incorporating clinical leadership and patient advocacy and applying this to the CNS three spheres of influence—patient and family/nurse and nursing care/system. As a result the procedure was scheduled sooner. The patient received the WATCHMAN device with no complications. He and his wife were able to attend their grandson’s graduation. It has been over 6 months post procedure. The patient is now off OAC therapy and is able to continue with his daily life without the fear of bleeding complications associated with long-term OAC therapy.

The patient said, “I am glad to have had the procedure done and I am grateful for team who made the difference.” As a CNS, I was instrumental in advocating for both processes and patient outcomes associated with a novel treatment for AF.

Mary Janette Sendin is a clinical nurse specialist for cardiology and atrial fibrillation patient care coordinator at Orlando Health-Orlando Regional Medical Center in Florida.

 

Selected references

Bell L. (ed.) AACN Scope and Standards for Acute Care Clinical Nurse Specialist Practice. 2014. Aliso Viegjo, CA: American Association of Critical Care Nurses.

Holmes DS, Jr., Doshi SK, Kar S, et al. Left atrial appendage closure as an alternative to Warfarin for stroke prevention in atrial fibrillation: A patient -level-meta-analysis. J Am Coll Cardiol. 2015;2614-2623.

Panaich S, Holmes DR, Jr. Left atrial appendage occlusion. 2017. acc.org/latest-in-cardiology/articles/2017/01/31/13/08/left-atrial-appendage-occlusion

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