Decision Making in Advanced Clinical Area


During my work as a dialysis nurse in the past, I came across a difficult situation. I was the charge nurse for the dialysis unit on weekends that was operated by five staff nurses. One day while all 12 dialysis patients were receiving their dialysis treatment, the technician came and said he needed to check the water treatment room. After a few minutes, all 12 dialysis machines went off indicating high temperatures of the dialysate. To enhance the safety of the 12 patients given that there was no doctors present, by preventing blood hemolysis and hyperthermia or shock, I decided to terminate the dialysis treatment by instructing the nurses to disconnect the patients from the machines.

Dialysis encompasses the process of according the artificial replacement of the kidney functions that have been lost in people suffering from renal failure. In this case, it replaces the kidney functions through ultrafiltration or removal of excess fluid and diffusion or removal of waste from the bloodstream (Kitamura and Saito, 2001). The two types of dialysis encompass hemodialysis and peritoneal dialysis.

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The most commonly utilized method is hemodialysis in which the patient’s blood is pumped through the dialysis machine to enhance the diffusion of wastes and ultrafiltration of excess water into the dialysate as well as the diffusion of essential minerals from the dialysate into the blood before the blood can be pumped back into the body (Ayoub and Finlayson, 2004). Maintaining the right dialysate temperature is essential during dialysis, as warmer dialysate can culminate into hemolysis and hyperthermia (Fortner et al 1970). This is the basis on which the decision to terminate the dialysis for the twelve patients was made, intending to enhance their safety.

Critical Thinking in Clinical Decision Making

The validity of the above decision can be enhanced based on critical thinking in nursing. Alfaro-Lefevre (1999) affirms that critical thinking encompasses the intellectual and disciplined practice of applying skilful reasoning before acting. In nursing, critical thinking as applied to clinical decision making encompasses the capability to think systematically and logically, while at the same time being open to question and reflecting on the reasoning process, to ensure quality care and safe nursing practice (Higgs and Jones, 2000).

It includes proficient use of reasoning, adhering to scholarly standards, as well as competency in the use of thinking abilities and skills in secure clinical decision-making and perfect clinical judgments (Alaszewski et al, 2000). Critical thinkers in the nursing profession endeavour to be accurate, logically complete, clear, fair, concise and significant in listening, writing, reading and their actions (Benner, 1995). In this case, their reasoning power is based on the eight elements of thought that aid them in figuring the answers to difficult questions and critically analyzing their thinking to ensure that it meets intellectual thought standards.

According to Alfaro-Lefevre (1999), these elements include the question, issue, concern or problem that the thinker attempts to comprehend, the goal or purpose of thinking, the world view, points of view or frame of reference held on the problem or issue, the positive assumptions on which the issue is held, the central principles, ideas, theories and concepts used when reasoning about the problem at hand, the information, data and evidence utilized in supporting the claims made based on the issue, the reasoning, inferences, lines and interpretations that culminate into the conclusions made on the matter as well as the consequences and implications of the position held about the matter.

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From the above explanation, the decision made was based on critical thinking and reasoning as it can be analyzed using the eight elements of reasoning (Alfaro-Lefevre, 1999). As per the first element, the issue being comprehended encompasses the best course of action to be taken to prevent hemolysis and hyperthermia, after the rising of the dialysate temperature.

As per the second element, the reason why attempts were being made to figure out the issue stated above was the enhancement of the patients’ safety given the absence of doctors during the weekend, to ensure that the patients were not subjected to further medical complications, in addition to their present problem of renal failure (Burns and Bulman, 2000).

As per the third element, the point of view and frame of reference held on the issue encompasses the fact that terminating the dialysis treatment was the best option in preventing hemolysis and hyperthermia, given the limited scope that the nurses had on dialysis during the absence of trained doctors (Higgs and Jones, 2000. As per the fourth element, the positive assumption on which the above decision was based included the fact that stopping the dialysis treatment was more beneficial to the patients, rather than continuing the process. This is because this would prevent the occurrence of additional medical complications for the patients.

Essentially, this treatment encompassed only one of the three dialysis treatments that the patients have to undergo in a week; hence forgoing it was more beneficial than going through with it. This is because continuing with it would subject the patients to hyperthermia and hemolysis that would in turn require additional treatment, on top of what they were receiving for renal failure (Kitamura and Saito, 2001).

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As per the fifth element, the principles, theories, concepts and ideas that were utilized when reasoning about the issue at hand included the principle that the dialysate temperature should not rise above the normal temperature of the patient, the right dialysate temperatures can only be ascertained by the patient’s doctor in regards to the level of his or her renal failure condition, a dialysis nurse should never alter the functioning of the dialysis machine without the supervision of a qualified doctor, the patient’s health and safety are paramount in all cases and prevention are better than cure. As per the sixth element, Frank-Stromborg and Olsen (1997) make certain that clinical research should be conducted utilizing various instruments. The use of these instruments should be analyzed through concept analysis, reflection as well the literature available on such instruments.

Many medicine, nursing and renal journals have been written on dialysis. Evidence extracted from the information and data provided from such ascertains that a cooler and lower dialysate temperature is essential for the reduction of various complications related to dialysis treatment. Misra (2005) determines that the dialysate temperatures should be limited to ensure its effectiveness and proper functioning. Ayoub and Finlayson (2004) establish that cooler temperatures of the dialysate ascertain the positive perception that patients have towards haemodialysis. Essentially, data extracted from previous dialysis treatments shows that higher temperatures of the dialysate, culminate in various medical conditions that can lead to death (Fortner et al 1970).

As per the seventh element, inferences, interpretations, lines and reasoning extracted from the various journals and research on dialysis has led to the conclusion that the decision made was the best given the conditions at that time (Charles, et al, 1997). From the inferences, it can be ascertained that an increase in the dialysate temperature that cannot be remedied through a change in the dialysate or reduction of the temperature should be remedied by the discontinuing of the dialysis treatment. This is not only beneficial to the patient, but it also reduces the number of lawsuits the hospital or the dialysis nurse can face based on patient neglect.

As per the last element, the negative consequences of terminating the treatment were overridden by the negative consequences of continuing the treatment, while seeking additional help from the absent doctors. The negative consequences of continuing the treatment encompassed the development of such complications as hemolysis and hyperthermia (Fortner et al 1970).

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These could culminate in the eventual death of the patients or increased need for additional treatment to cure such conditions, while the patient continues to undergo dialysis treatment (Kitamura and Saito, 2001). Such additional treatment could translate to more renal complications as well as costs for the patients.

Due to this, the hospital might face a lawsuit from the patient or his or her legal agent, since such conditions could have been avoided in the first place, where the patient is not neglected by the medical practitioners according to him or her with primary care. Data obtained from the DOPPS (Dialysis Outcomes and Practice Patterns Study) shows that missing one treatment every month is linked to a 30% higher mortality risk as well as a 13% higher hospitalization risk. Such percentages are lower as compared to the higher 60% higher mortality risk associated with continuing dialysis treatment with higher dialysate temperatures.

Decision-making for Advanced Clinical Practice Using Clinical Decision Making Models

Clinical decision making encompasses a complex process involving an interaction between pre-existing pathological conditions and knowledge, experimental learning, nursing care as well as unequivocal patient information (Cooksey, 1996). In this case, it is the process utilized by a nurse in making judgments on management issues and the care they accord to patients daily (Jones and Beck, 1996). The three clinical decision-making models utilized to enhance the process include intuitive-humanist, hypothesis-based and evidence-based models.

The hypothesis-based or information processing model utilizes a hypothetico-deductive approach that uses decision trees to numerically analyze the potential outcomes of the decision made (Bonner, 2001). In this case, a numerical value is assigned to each possible outcome in the decision tree and an assessment of the probability of arriving at an outcome is carried out. As per the results of Hammond (1996) findings, many nurses were faced with considerable difficulties when utilizing this model, due to the amount of caution required when producing hypotheses. For this reason, the limited scope of the situation at hand negated the complete use of the model, in the decision-making process.

Though the entire model was not utilized, a part of it was utilized. Hedberg and Larsson (2003) assert that nurses possess the ability to think ahead of situations, to enable the formulation and adoption of preventive strategies to anticipated circumstances.

As per Easen and Wilcockson (1996), this is linked to the hypothetico-deductive model. In making the decision, I used my ability to think ahead of the situation to formulate the preventive strategy of terminating the dialysis treatment, in face of the anticipated circumstances of acquiring such additional medical conditions as hemolysis and hyperthermia by the patients. A positive anticipated circumstance, in this case, was the prevention of the medical conditions that would complicate the rental conditions of the twelve patients. Under the Intuitive-Humanist model, the relationship between nursing experience and intuition as well as the effect it has on clinical decision making is studied (Benner, 1995, Buckingham and Adams, 2000, Burns and Bulman, 2000).

Cioffi (1997) defines intuition as the process of perceiving relationships, possibilities and meanings through insight. In this case, it is the process of acting based on sudden awareness of knowledge that has been extracted from previous experiences, which can be deemed difficult and complex to articulate. Dane and Pratt (2007) assert that intuition is highly utilized in making complex decisions within short time horizons that pressure the decision-maker. Accordingly, it is affirmed that intuition is nonconscious, engages the making of holistic associations that recognizes various structures and patterns, is fast and culminates in affectively charged judgments (Cooksey, 1996, Dane and Pratt, 2007, Wilcockson, 1996).

For this reason, the circumstances surrounding the case at hand called for the making of a fast decision that could only be made under the intuitive-humanist model. The decision was made based on the nonconscious processing of the information on the varying temperatures of the dialysate (Lamond and Thompson, 2000, Thompson and Dowding, 2002). Essentially, the decision was based on the holistic association of the recognition and awareness of the consequences linked to higher dialysate temperatures in dialysis treatment.

Due to the cognitive feelings linked to the enhancement of the quality of care according to the patients, the decision can be said to have been made due to effectively charged judgments. The above factors coupled with the fast nature in which the decisions were made ascertains the fact that the decision was made based on the intuitive-humanist model that has been highly acceptable in clinical decision making (Hall, 2002, Thompson and Dowding, 2002 ).

The evidence-based model focuses on the use of specific applications and research in the promotion of evidence used in clinical decision making, to reduce inappropriate and unwanted practice variations (Dixon et al 1997, Denisco and Barker, 2013, Hammond, 1996, Sackett et al 1997). In this case, the results of research studies are utilized in enhancing the outcomes of the clinical decision-making process. Evidence is extracted from clinical epidemiology, under which the medical practitioners keep up with changes in medical technology by obtaining relevant medical information’s in their fields, from the new information provided by various journals (Sackett et al 1997).

Before making any clinical decision, the clinician should be aware of the evidence that supports his or her decision as well as the considerable strength of that evidence (Higgs and Jones, 2000). The appropriate interpretation of the evidence to be used in the clinical decision-making process relies on the interpretation of various clinical observations as well as a clear understanding of pathophysiology. Inherently, the evidence-based model is based on the integration of external clinical evidence extracted from systematic clinical research into individual clinical experience. Individual clinical experience encompasses the experience that each clinician acquires from the clinical practice and experience (Dixon et al 1997).

This asserts that the decision above was made using the evidence-based model of clinical decision making. This is because as a dialysis nurse, I had acquired considerable individual clinical experience from the dialysis clinical practice and experience. In addition, I always replenished my knowledge in different dialysis matters by carrying out considerable research on the topic from the internet as well as newly published journals, covering the topic. This accorded me with the required external clinical evidence, which when coupled with my individual clinical experience, would accord me with the requirements for making a clinical decision based on the evidence-based model of clinical decision making (Cooksey, 1996).

Most external clinical evidence contained in dialysis journals ascertains the fact that cooler dialysate temperatures are recommended for successful dialysis treatment, as compared to the higher dialysate temperatures. Essentially, my individual clinical experience evidences the fact that preventive measures are more recommendable, as compared to treatment measures. In this case, preventing the occurrence of such clinical complications as hemolysis and hyperthermia was more recommended, as compared to treating such conditions that could have been prevented in the first case (Thompson and Dowding, 2002, Moskowitz et al, 1998).

Criticism and Justification of the Decision Made

Misra (2005), under the monitoring of the dialysate circuit, asserts that the temperature monitor encompasses a heat sensor utilized in monitoring the dialysate temperature, as it is positioned near the dialyzer. In this case, it should contain a short feedback loop situated in the heater element, to enhance quick dialysate temperature adjustment. 35 to 42 degrees centigrade encompasses the most highly recommended dialysate temperatures.

To prevent the Hypotensive episodes that can occur during dialysis treatment, colder dialysate temperatures are recommended. An alarm of the monitor automatically diverts the dialysate into the drain (Misra, 2005). This indicates that instead of terminating the dialysis treatment for the 12 patients, the monitor should have been utilized to trigger the alarm so that the high-temperature dialysate could be diverted to the drain. This would have enhanced the continuation of the treatment without any further hitches.

Additionally, to prevent the reheating of the new dialysate, I should have engaged in a considerable discussion with the technician, to find out the course of action he had taken in the water treatment room. This is because his action might have culminated in the increase in the dialysate temperature. In the water treatment, machines are utilized to heat the incoming water into body temperature.

The technician might have tampered with the machines culminating in the heating of the dialysate instead of the water, culminating into the higher dialysate temperatures (Misra, 2005). Finding out the activities carried out in the water treatment area would enhance the pre-setting of the machines to ensure that further heating of the dialysate is prevented. This establishes that other options were available and they should have been implemented before deciding to terminate the dialysis treatment. According to the facts propounded by Ayoub and Finlayson (2004), each dialysis machine is preset per the patient’s condition.

Presetting such machines after they have been tampered with requires considerable consultations with the doctor that preset the machine. This means that I would have had to consult with the doctors that preset the machines for the patients, before making any changes. This course of action would have taken a long time, within which the patients would have been exposed to hemolysis and hyperthermia. According to the Renal Physicians Association (2010), withdrawal from dialysis treatment should be informed by such recommendations as shared decision making, informed consent or refusal, estimating prognosis, conflict resolution and advance directives.

The decision to withdraw patients from the dialysis treatment should only be based on a shared decision making, under which the patient and the physician should agree on the decision to be made. In cases where the patient lacks sound decision-making capacity, a legal agent should be involved in the decision-making process. Under, Informed consent or refusal, the patient is provided with considerable information about a diagnosis, prognosis as well as available treatment options. From this, he is allowed to consent or refuse the withdrawal from the treatment (Renal Physicians Association, 2010).

Underestimating prognosis, a discussion of the effects of the withdrawal on the patient’s quality of life or life expectancy should be formulated between the patient and the doctor, before the decision for withdrawal is made (Renal Physicians Association, 2010). Essentially, any conflicts that should arise between the physician and the patient should be resolved before the withdrawal decision should be done. Following such recommendations requires length consultations between the clinician and the patient or the patient’s legal agent in cases where the patient lacks sound decision-making capacity.

The problem at hand was characterized by the limited time available for taking a recommended action. Hedberg and Larsson (2003) affirmed that the nurse possesses the ability to think ahead of situations. This leads to the formulation of preventive strategies that can enhance the quality of care according to patients. Additionally, as asserted by Dane and Pratt (2007), intuition is highly utilized in making a complex decision within short time horizons that pressure the decision-maker.

These assertions justify the decision made based on the hypothesis-based and intuitive-humanist models of clinical decision making. Inherently, the decision is justified based on the fact that research establishes the need for speedy decision making, in cases where the dialysate temperature can culminate in additional complications for the renal patient during the dialysis treatment. Kitamura and Saito (2001) ascertain that exposing a renal patient to a dialysate of 40 degrees centigrade for less than 15 minutes might not culminate into hemolysis or hyperthermia, but increasing the duration in which the patient is exposed can culminate to the two adverse conditions.

Fortner et al (1970) assert that exposing patients to highly heated dialysate at temperatures of above 46 degrees centigrade can culminate in death during dialysis. This is because red blood cells can only tolerate temperatures up to 46 degrees centigrade and temperatures above this lead to hemolysis that not only depends on the temperature but also the duration in which the red blood cells were exposed to the overheated dialysate.

A major criticism of the decision made based on the above facts would be that the decision was made very fast without the consideration of other options. This is because at the time the decision was made, the patients had not been exposed to very high dialysate temperatures for a lengthy period. In this case, they could not immediately develop hyperthermia and hemolysis (Fortner et al, 1970).

This can be countered by the fact that in the case at hand, the dialysate temperatures were considerably increasing with time and the limiting conditions brought about by the fact that it was during the weekend, could not ascertain the duration of time that would be taken to correct the problem. For this reason, deciding to terminate the dialysis treatment was the most viable and effective option. This would prevent the heating of the dialysate to temperatures above 46 degrees centigrade would lead to hemolysis and hyperthermia. Hyperthermia and hemolysis have been identified as the main causes of acute renal failure.

In this case, continuing with the dialysis treatment could have culminated in acute renal failure for the 12 patients, after the development of hyperthermia and hemolysis. Additionally, Kitamura and Saito (2001) affirm that quick response during dialysis is efficient and effective in preventing the elevation of the renal conditions affecting the patients. This point is overemphasized in the provision of quality care to patients because care should be accorded to improve the condition from which the patient is suffering, rather than make the condition worse than it was before the administration of care and treatment.

In conclusion, though the decision made can be criticized in various ways, the various factors that justify ascertaining that it was the best decision could be made given the various limiting factors. Essentially, the decision was viable because it was made using the three critical decision-making models of intuitive-humanist, hypothesis-based and evidence-based models.


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