Introduction

With the increase in legalization of marijuana for medical and recreational use birth centers are seeing an increase in infants born to mothers who have used marijuana during pregnancy, often times from dispensaries.  The potency of marijuana today compared with the 1970s or even 80s is much higher. The availability through dispensaries also makes it more accessible, controlled and considered, by some, ‘safer’ than street sold marijuana. This impact on the use of marijuana during pregnancy is being felt throughout the United States, especially, in states where marijuana sales are now legal. This rise in use prompted statements from the American Academy of Pediatrics (AAP), almost every state and health department, American College of Obstetrician and Gynecologists (ACOG), and AWHONN regarding use of marijuana during pregnancy, concerns for effect on the infant, and breastfeeding with marijuana use after birth. Currently there is a large quantity of evidence exploring the impact of marijuana use and birth outcomes.

Picot

In newborn infants (neonatal period defined as <28 days of age) (P), how does marijuana use during pregnancy (I) compared with no marijuana use during pregnancy (C) effect infant growth and development or NICU admission (O) after birth (T).

Discussion Board

The discussion board for MN504 showed a great interest in this subject with a varying amount of knowledge regarding marijuana use and birth outcomes. First, the original (P) in the PICOT is now newborns (<28 days) rather than the pregnant mom. Second the (O) was changed to be more specific. This focuses the review of EBP research.

Student, Raegan McCorkle, commented regarding the change in laws in California  and the effect on self-reported marijuana use rising from 4% in 2009 to 7% in 2016. The report also noted, that the positive toxicology screens in California are not grounds for a child abuse or neglect report according to one article (Goler et al., 2018). In Nevada, in my experience as the reporting nurse on a newborn infant, child protective services will not take a report for the infant until the infant tests positive on a urine screen. Follow up is with a hospital social worker in the hospital and a scheduled home visit with the family after discharge. For marijuana use only, without any other extenuating factors, children are not removed from the mother.

The discussion also included questions and research regarding breastfeeding while continuing marijuana use and whether a mom’s marijuana use impacts prenatal care. Both of these posts were interesting. Of note, in evaluating the mom’s marijuana use and whether she accesses prenatal care and the effect on the infant, the research needs to account for lack of prenatal care as a variable that impacts birth outcome separate and in conjunction with marijuana use.

Continuing breastfeeding after birth has multiple positive health, as well as cognitive and neuro development impacts for the infant (Dieterich et al., 2013). Evaluating the impact of breastfeeding with or without marijuana use prenatally or postnatally is challenging. First, in evaluating IQ in the infant exposed to marijuana use in utero, IQ, as well as, neuro and cognitive development need to be evaluated separately and in conjunction with the feeding source. Nutrition’s impact on growth needs to be accounted for separately and in conjunction with infants exposed to marijuana use in utero. In other words, exclusively artificial baby milk fed unaffected newborn infants compared with affected artificial baby milk fed newborn infants need to be compared in studies assessing long term impact of marijuana use during pregnancy. I would also add, that those infants exclusively or partially breastfed need to be included in this study to see what the risk benefit is when breastfeeding while continuing marijuana use vs the risk of feeding artificial baby milk. It may also be important to include pumped milk or donor milk fed infants in this assessment as well, since the positive impact of breastfeeding is not just the breastmilk (nutrition), but the interaction and action of feeding at the breast. Furthermore, Fransquet et al. (2017), found no significant impact to DRD4 from cannabis use during pregnancy, and the nominally significant impact reported is not altered with 8 weeks of breastfeeding postpartum.

Marijuana Use and Infant Outcome

There is a body of research that shows no impact on birth weight, nicu admission, or prematurity. Mark et al. (2016) found, “no differences in birth outcomes or utilization of prenatal care by marijuana exposure” (Mark et al., 2016, p. 105). More currently, research is being done specifically in states where marijuana is legal. Crume et al. (2018) found that with cannabis use any time during pregnancy there was a 50% increase in LBW, independent of tobacco use. Also noted was no increased risk of preterm or NICU admission. (Crume et al., 2018)

Marijuana use during pregnancy, in a systematic review, is not noted to be linked to differentials in neurodevelopmental outcomes up until 3 years of age (Zhang et al., 2017). An increased risk of addictive behaviors after the age 14 was not found in this systematic review either (Zhang et al., 2017). The effect of in utero exposure to marijuana as the child ages, in this study, is minimally lower IQ scores at age 6 and minimally impulsivity and hyperactivity at 10 years of age were noted (Zhang et al., 2017). This study does not account for how the child was fed as an infant and the impact of nutrition on these factors.

Fransquet et al. (2017), found the opposite in a meta-analysis of 24 studies. Results demonstrated cannabis exposed, “infants had a higher risk of anemia, decreased birth weight, and a greater chance of being placed in intensive care.” (Fransquet et al., 2017, p. 671).  These infants also showed deficits in verbal reasoning and short term memory as they aged if the mothers used cannabis daily in the first trimester as well as other long term detrimental effects (Fransquet et al., 2017).

Warshak et al., 2015, found an increase in SGA infants as well as nicu admissions. Of note in this study is that of the 361 marijuana users, 208 also used tobacco (58%). Prenatal care and no prenatal care rates in the marijuana users group were the same. Of note, when tobacco users were excluded and when tobacco users were included in the results, there was no change in the infant health outcome after birth. (Warshak et al., 2015).

Root Cause?

To get to the heart of marijuana use during pregnancy and infant health outcome at birth one must first evaluate for the effect on in utero development. In the study, by Franscquet et al. (2017), the effect epigenetically on infant DNA methylation of the dopamine receptor DRD4 is evaluated. THC is known to pass through to the placenta and can have an epigenetic impact on development, and therefore can negatively impact the fetus in utero. (Fransquet et al., 2017) The study focused on DRD4 methylation patterns because this gene is associated with substance use and addiction. This gene is also linked to infant birth outcomes including birth weight, behavior, and neurodevelopment (Fransquet et al., 2017). The study allotted for tobacco smoking as well since this is already known to impact infant peripheral DNA methylation.  Also well known is the, “dose-dependent relationship between cigarette smoking and birth weight reduction” (Sherwood et al., 1999, p. 488).  The results showed no significant impact to DRD4 from cannabis use during pregnancy (Fransquet et al., 2017). The researchers in acknowledging that they did not find the root cause, recommended to continue research and evaluate for marijuana’s impact on CNR1 in utero (Fransquet et al., 2017).

Conclusion

Further investigation is needed on how marijuana use during pregnancy impacts utero growth which impacts birth outcomes. More research is also needed on whether or not continued marijuana use while breastfeeding exacerbates the impact of the already present marijuana use in utero, has no effect, or may be protective for the infant. Furthermore, in reviewing the research there is evidence that the use of marijuana may reduce the immune response in the infant. This is also of concern as it may have a great impact on infant mortality rates long term as well as long term health of children (Zummbrun et al., 2014).

References

• American Academy of Pediatrics. (2017). Medical risks of marijuana. Itasca, IL: Author. Retrieved from https://eds-b-ebscohost-com.libauth.purdueglobal.edu/eds/detail?sid=2f324e24-bc18-441e-96ae-9585963d6f42@pdc-v-sessmgr05&vid=0&format=EB&rid=5#AN=1840885&db=nlebk
• Crume, T. L., Juhl, A. L., Brooks-Russell, A., Hall, K. E., Wymore, E., & Borgelt, L. M. (2018). Cannabis use during the perinatal period ina state with legalized recreational and medical marijuana: The association between maternal characteristics, breastfeeding patterns, and neonatal outcomes. The Journal of Pediatrics, 197, 90–96. http://dx.doi.org/10.1016/j.jpeds.2018.02.005
• Dieterich, C. M., Felice, J. P., O’Sullivan, E., & Rasmussen, K. M. (2013). Breastfeeding and health outcomes for the mother-infant dyad. Pediatric Clinics of North America, 60(1), 31–48. Retrieved from https://www.sciencedirect.com/science/article/pii/S0031395512001575?via%3Dihub
• Fransquet, P. D., Hutchinson, D., Olsson, C. A., Allsop, S., Elliott, E. J., Burns, L., … Ryan, J. (2017). Cannabis use by women during pregnancy does not influence infant DNA methylation of the dopamine receptor DRD4. The American Journal of Drug and Alcohol Abuse, 43, 671–677. http://dx.doi.org/10.1080/00952990.2017.1314488
• Goler, N., Conway, A., & Young-Wolff, K. C. (2018). Data are needed on the potential adverse effects of marijuana use in pregnancy. Annals of Internal Medicine, 169(7), 492–493. Retrieved from https://eds-a-ebscohost-com.libauth.purdueglobal.edu/eds/pdfviewer/pdfviewer?vid=1&sid=cd8c4f1b-0efd-4db8-a40a-058f49e9bc5c%40sessionmgr4006
• Mark, K., Desai, A., & Terplan, M. (2016). Marijuana use and pregnancy: Prevalence, associated characteristics, and birth outcomes. Archives of Women’s Mental Health, 19, 105–111. http://dx.doi.org/10.1007/s00737-015-0529-9
• Melnyk, B. M., & Fineout- Overholt, E. (2019). Evidence-based practice in nursing and healthcare (4th ed.). Philadelphia, PA: Wolters Kluwer.
• Sherwood, R. A., Keating, J., Kavvadia, V., Greenough, A., & Peters, T. J. (1999). Substance misuse in early pregnancy and relationship to fetal outcome. European Journal of Pediatrics, 158, 488–492. Retrieved from https://eds-a-ebscohost-com.libauth.purdueglobal.edu/eds/pdfviewer/pdfviewer?vid=8&sid=3e0586b4-f1ef-4666-9016-cf587be1ab33%40sdc-v-sessmgr01
• Warshak, C. R., Regan, J., Moore, B., Magner, K., Kritzer, S., & Van Hook, J. (2015). Association between marijuana use and adverse obstetrical and neonatal outcomes. Journal of Perinatology, 35, 991–995. Retrieved from https://search-proquest-com.libauth.purdueglobal.edu/docview/1735653696/fulltextPDF/47BFF86B6A1643EAPQ/2?accountid=34544
• Zhang, A., Marshall, R., Kelsberg, G., & Safranek, S. (2017). What effects if any does marijuana use during pregnancy have on the fetus or child? The Journal of Family Practice, 66(7), 462–466. Retrieved from https://eds-b-ebscohost-com.libauth.purdueglobal.edu/eds/pdfviewer/pdfviewer?vid=3&sid=e476370d-d87d-4426-a8b5-1f79f7c48374%40pdc-v-sessmgr01
• Zumbrun, E. E., Sido, J. M., Nagarkatti, P. S., & Nagarkatti, M. (2015). Epigenetic regulation of immunological alterations following prenatal exposure to marijuana cannabinoids and its long term consequences in offspring. Journal of Neuroimmune Pharmacology: The Official Journal of the Society on Neuroimmune Pharmacology, 10, 245–254. http://dx.doi.org/10.1007/s11481-015-9586-0

Introduction

The environment has a significant impact on human health. In terms of global disease burden, air pollution accounts for more than one-third of deaths from lung cancer, stroke, and chronic respiratory disease, and nearly one-quarter of deaths from ischemic heart disease. The combined effects of indoor and outdoor air pollution have resulted in about 7 million deaths from air pollution annually (Ferrero et al., 2017; WHO, 2015). Pregnant women are one of the vulnerable and susceptible groups, against health-threatening factors such as toxic compounds present in polluted air. Considering the health of pregnant women who are exposed to toxic pollutants in the air, it is important because in addition to the health of the mother, the health of her fetus is also under threat (Mannucci and Franchini, 2017). According to the results of some studies, pregnant women in industrial areas due to exposure to toxic pollutants were prone to preterm delivery and consequently increased risk of fetal injury, low birth weight and intrauterine growth restriction (Phatrabuddha et al., 2013; Ritz and Wilhelm, 2008; van den Hooven et al., 2011).

The petrochemical industries, as one of the sources of air pollution, play an important role in the production and release of toxic pollutants, including BTEX to the environment, and have adverse effects on public health, especially pregnant women living in the vicinity of these industries. Benzene, toluene, ethylbenzene and xylene (BTEX) are a group of  Volatile Organic Compounds (VOCs) (Tsangari et al., 2017),  that due to their adverse effect on human health are classified as hazardous air pollutants (Rafiee et al., 2018). International Agency for Research on Cancer (IARC), classified benzene as a human carcinogen (group 1) and ethylbenzene as a possible carcinogen (group 2) ((IARC), 2000). The source of BTEX emissions may be outdoor activities including traffic congestion and industrial processes (Bailey and Eggleston, 1993; Bauri et al., 2015; Truc and Kim Oanh, 2007), and also indoor sources such as smoking, chemicals used in the structure of furniture and interior decoration, color, and glue (Hazrati et al., 2015; Singh et al., 1992). Therfore, people living in polluted areas and close to industrial areas are more likely to be exposed to BTEX and consequently these population face a greater risk from exposure to these chemicals (Crebelli et al., 2001; Sutic et al., 2016).

The effects of exposure to BTEX compounds on human health can also be categorized as short-term effects including nausea, headache and dizziness, eyes and skin irritation, throat and nose irritation, and asthma exacerbation (Blount et al., 2006; Mohammadyan et al., 2016; Rafiee et al., 2019; Zhou et al., 2011), or in the form of long-term effects including leukemia and congenital birth defect, impact on central neural system (CNS), as well as adverse effects on the respiratory system (Rafiee et al., 2019; Sekhar and Subramaniyam, 2014). Evaluation of biological evidence showed that benzene had an adverse effect on intrauterine growth during pregnancy or in another study indicated the possible role of benzene in adverse effects at birth (Chen et al., 2000; Khan., 2007). In addition to the above-mentioned effects, overall, toxic air pollutants induce oxidative stress in the lung, causing chronic respiratory tract and ultimately systemic inflammation, which increase the levels of immune factors (cytokines) in the circulatory system and can, in severe cases, cause inflammation of the brain (Block and Calderón-Garcidueñas, 2009; Guxens et al., 2012). Cytokines are soluble hormone-like proteins that affect the activity, differentiation, proliferation and survival of immune cells and regulate the activity of other cytokines by increasing (pro-inflammatory cytokines) or decreasing (anti-inflammatory cytokines) (de Oliveira et al., 2011; Dinarello, 2007; Tayal and Kalra, 2008).

Some cytokines, including, interleukin-6 (IL-6) and Tumor necrosis factor-a (TNF-α), play key roles in acute inflammatory interactions. Interleukin-6, an anti-inflammatory cytokine with  multiple functions is produced by macrophages, monocytes, and T cells. These cytokines play an important role in regulating immune reaction and inflammatory responses (El-Khier et al., 2013; Ma et al., 2017). Tumor necrosis factor-a (TNF-α) is produced by the monocytes and is one of the most important proinflammatory cytokines that contribute to increased bronchial excitability or airway remodeling in asthmatic patients (Akdis et al., 2011), promotes tumor growth and migration (Esquivel-Velázquez et al., 2015), and or in the development of liver inflammation (Tuncer et al., 2003). In general, proinflammatory cytokines such as TNF-α, after binding to target cells, induce protein tyrosine phosphorylation and ultimately inhibit the activity, proliferation, or differentiation of different cells during immune responses (de Oliveira et al., 2011; Dinarello, 2007). Nowadays, the use of Human Biological Monitoring (HBM), as a viable and reliable approach to assess human exposure to chemicals and measure their metabolites, using biomarkers in human specimens, and also, as an important tool for environmental protection and policy-making of human health is considered (Sciences, 2005; WHO, 2015). The use of urine samples and serum samples, respectively, for the measurement of BTEX compounds and immune factors has been used in the current study.  Since pregnancy is a vital period for the mother and fetus has been associated with a number of physiological changes in pregnant women, therefore, these changes can affect the toxicity of chemicals into the body. Considering the importance of maternal and fetal health during pregnancy as an indicator of health development assessment in a community, this study aimed to exposure assessment of pregnant women living in the vicinity of petrochemicals to BTEX compounds and evaluation of its possible impact on immune factors, IL-6 and TNF-α were assessed. The results of this study can be used as a useful information tool for health organizations to adopt management policies and strategies.

2. Materials and method

2.1. Study design and participants

This study was designed to exposure assessment of pregnant women living in the vicinity of petrochemicals to BTEX compounds and evaluation of its possible impact on immune factors, IL-6 and TNF-α. The present study was conducted from August to October 2019. All participants in this study lived in their current place of residence for more than 10 years. The study population consisted of 200 pregnant women who were divided into case (n = 110) and control (n = 90) groups. The demographic data and medical records of the participants in this study are shown in Table 1. According to Figure 1, the distance between the case group and the control group from the petrochemical company was 2 and 30 km, respectively. For a comprehensive assessment of changes in serum concentration of immune factors, subjects were randomly selected from each trimester including first trimester (n = 10), second trimester (n = 15) and third trimester (n=5). Blood and urine samples were obtained from pregnant women for a period of 2 weeks. The implementation protocol for this cross-sectional study, Urine and Blood samples collected from pregnant women referred to Chavar comprehensive health center (Iran, Ilam) was approved by the Ethics Committee of the Shiraz University of Medical Science (Number), and written informed consent was obtained from all pregnant women included in the present study.

2.2. Clinical and labratoary data

2.2.1. Biomonitoring protocol of urinary BTEX

Sample collection, storage and preparation

Urine samples were obtained from pregnant women who referred to Chavar comprehensive health center (Iran, Ilam). Urine samples were collected in a special encoded container, and stored at 4°C in the freezer until sent to the laboratory. Once every two days, the collected samples were sent to the laboratory in a cold box containing dry ice to analyze BTEX compounds. All glassware used in this study was sterilized prior to the extraction process of BTEX compounds. To prevent contamination of glass containers, they were first sterilized by ultrasonic process and then immersed in 20% nitric acid solution for 24 hours. Finally, they were washed with distilled water and incubated at 180°C for 5 hours.

Sample preparation and headspace solid-phase micro extract

In order to prepare the urine samples for quantitative analysis, 2 ml of each urine sample was transferred to 4 ml glass vials containing 1 mg sodium chloride. To reduce the urine foaming, a small amount of 0.3 – 0.4 µl of antifoam (Antifoam C, Restek, USA) was injected into each vial. Using a micro-syringe, 1 µl of methanolic solutions of benzene-d6, toluene-d8, m-xylene-d10, and naphthalene-d10 was added to each vial as internal standard. Immediately to seal the vials, a magnetic crimp cap with a a silicone-PTFE septa product from Sigma Aldrich was used. To create a uniform solution, samples were shaken and then stored at -20°C. Headspace Solid-PhaseMicro-Extraction (HS-SPME) was performed for analysis of non-metabolite BTEX compounds in urine samples. Prior to any extraction operation, the vials were incubated at a controlled temperature of 37°C for 20 min at a stirring rate of 750 rpm. The analytics were extracted using a PDMS 75 μm fiber for 5 min and then by insertion of the fiber into the chromatographic injection port, thermal desorption for 3 min was done.

In order to separate the analytics, by Gas Chromatograph (GC, Agilent 7890N, Agilent Co.), Helium gas at a purity of 99.999% and mass flow rate of 1 ml/min through a DB-5MS analytical capillary column (30 m length, 0.25 mm diameter and 0.25 μm film thickness) for separation of the analytics by The GC device was used. Finally, mass spectrometry (MS, Agilent 5975C, Agilent Co.) was used to detect and quantify the constituents of BTEX.

All of the BTEX reference materials and solutions from Sigma Aldrich (Austria) were purchased, in the range of purities from 99% to 99.8%. In parallel to each urine sample, a blank sample containing distilled water was prepared for each participant using the same materials and solutions according to the same protocol described for urine. Blank samples were analyzed similar to urine samples and if BTEX is present, the BTEX concentration is subtracted from the values ​​in the urine samples. In the present study, the detection limit (LOD), quantitative limit (LOQ) and matrix effects were used to control the method used. The LOD and LOQ related to the BTEX compounds are shown in Table 2. The limit of detection (LOD) of the assay for each BTEX compound was calculated according to the following formula: LOD = (3Sy-a)/b, where “Sy” is the standard error associated with each BTEX compound, “a” and “b” are intercept and slope, respectively.

2.2.2. Determination of IL-6 and TNF-α in serum

The blood samples were withdrawn from pregnant women within 2 weeks under complete aseptic conditions had been collected in a Vacationer (Gel & Clot Activator, AB MEDICAL Co., Ltd, South Korea). Approximate 3 mL blood samples were obtained from each participant. After each sampling, the samples were immediately sent to the laboratory for serum preparation and separation. Then, for serum preparation, the samples were centrifuged at room temperature at 3500 rpm for 15 min and immediately stored at -80°C for measuring Interleukin-6 and TNF-α. The Serum concentrations of Interleukin-6 and TNF-α were carried out by using the Enzyme-Linked Immunosorbent Assay (ELISA) according to the manufacturer’s instructions, kit supplied by Biosource International (CA, USA). The concentrations of measured cytokines were expressed in units of pg/mL. In order to, IL-6 assay, a human IL-6 high-sensitivity ELISA kit (sensitivity: <0.16 pg/mL) with the minimum detectable level < 1 pg/mL and subsequently for TNF-α assay, a human TNF-α high-sensitivity ELISA kit (sensitivity: <0.5 pg/mL) with the minimum detectable level 0.09 pg/mL were used. Finally, the absorbance of the samples was measured at a wavelength of 450 nm by ELISA reader. Due to increased levels of IL-6, under inflammatory and infectious conditions (Buttaro et al., 2010; Honda et al., 1990) and In order to investigate the relationship between Immune factors and the effects of exposure to BTEX compounds, women with chronic inflammatory diseases such as rheumatoid arthritis (12 patients), Granulomatous mastitis (2 patients), Type 2 Diabetes Mellitus (6 patient), Periodic fever (1 patient), Reproductive system infections (16 patient), Inflammatory bowel diseases, (13 patient) and women taking antibiotics within one week (30 people) were excluded from the study.

Statistical analysis

Statistical Package for the Social Science (SPSS) software, version 22.0 software (IBM Co., USA) was used for analysis. Descriptive analysis of the results were performed using frequency, percentage, mean and standard deviation. Prior to any statistical tests, the normality of the data was evaluated first by Skewness and Kurtosis and then by Kolmogorov-Smirnov test. All data obtained in this study did not have a normal distribution (P < 0.05). Due to the lack of data normality, the Kruskal-Wallis test was used to compare the difference between the concentrations of BTEX compounds measured in urine samples of pregnant women. Then, Spearman correlation coefficient analysis was used to investigate the relationship between the concentration of cytokines measured in blood samples and the concentration of different BTEX compounds in urine samples. The optimal cut-off value of the cytokines was estimated using Receiver Operating Characteristics (ROC) analysis. Area under the curve (AUC), calculated as sensitivity and specificity. The Area Under the Curve (AUC) was calculated to determine sensitivity and specificity.

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The American professional organization that represents the nursing field in the emergency department was founded in 1970, known as the Emergency Nurses Association (ENA). The purpose of the organization is to lead the future of emergency nursing through education, research, innovation, advocacy and leadership. According to the ENA, their mission is to “advocate for patient safety and excellence in emergency nursing practice”(2019a, para. 1). According to the ENA (2019a), they envision themselves as being great advocates for safe practice and care along with being a worldwide resource for emergency nurses (ENA, 2019a). ENA members are well trained in all aspect of emergency care to ensure the delivery of safe, evidence-based practice, and high-quality care for all patients.

ENA has a five years strategic plan called the 2020 vision that guides their organization. It is comprised of five strong pillars: knowledge, advocacy, quality and safety, community, and infrastructure. Each one carries a vision statement and goal of the ENA’s highest value on their members. They acknowledge their members for contributing to the best patient care and nursing profession. For the community, the ENA is known as the premier and authority membership organization for the emergency nursing community. Their goal is to support emergency nursing colleagues across the nation and to work on outreach programs for students to learn about emergency nursing care as well as empowering emergency nurses from varied practices setting by expanding their education and advocacy agenda and resources. The ENA encourages new ideas and knowledge of nurses by funding their research and collaboration. They define the standards for quality and safety through evidence-based safe practice, task-oriented and safe care. The organization also participates in legislative and regulatory issues impacting community to promote patient safety and excellent care. The ENA invests and utilizes their resources in people, technology, and facilities to support the development and delivery of their objectives, goals and advancement to their mission, vision, and values (ENA, 2019c).

There are 50 state councils and more than 174 local chapters in the ENA. State councils determine the structure, role, and decision-making at the state level. It’s chartered by the organization to implement its objectives, philosophy, and leadership. Local chapters’ plans and decisions are aligned with each of their State Councils. They are accountable for managing professional events directed by the State Council. Not all states have state council, therefore, many members’ first exposure to the ENA is offered through the local chapter. This is where their members can learn about what the ENA can offer. Each state and local chapter hold their meetings and activities on different dates, places, and time. All members have the chance to participate in both local and state events immediately upon joining the organization (ENA, 2019g).

The ENA leaders focus on managing affairs and working towards the goal of the organization. They determine policies and oversee rules and regulation that impact the decisions in business and financial matters. There are twelve members in ENA Board of Directors. The Board of Directors consists of seven different positions which include the President, President-Elect, Secretary, Treasurer, Immediate former President, Directors, and the Executive Director as a nonvoting advisory member (ENA, 2019g). The president of the ENA is Patricia Kunz Howard. Howard has been involved with the ENA at the national, state and local level since 1990 and became director of ENA in January 2015. She was recently elected as the President of this organization in January 2019 (ENA, 2019f).

The organization supports state council and chapter leaders in managing the local educational program, social events, as well as volunteer projects which help to improve the quality of healthcare in the community. In August 2019, the organization is hosting a geriatrics care webinar in Texas to increase knowledge regarding the disease process, elder abuse, and adaptation of care for the older adult population (ENA, 2019d). Members who are also associated with programs at the national level are making changes to the world. Since 2015, the ENA has partnered with Project Helping Hands, a nonprofit organization, to have its members travel to developing countries and provide sustainable healthcare and educational programs for everyone. It allows their members to make a difference in people’s lives not only in the hospital but also in rural areas (ENA, 2019b).

The ENA plays an essential role in healthcare related legislative and regulatory concerns that impact nurses in an emergency setting. The Public Policy Agenda for 2018/2019 identifies their top priorities in safety work environment, nursing education, timely and quality access to care, and injury prevention (ENA, 2019i). The organization’s government relations team in all 50 states focus on issues affecting both nurses and patients across the country. They continually seek opportunity for their members to be a part of the lawmaking process as well as guide them to advocate for themselves and their patients. The efforts of the ENA members are essential in advancing the principles of “Safe Practice, Safe Care” (ENA, 2019e, para. 3)

NewYork-Presbyterian Hudson Valley Hospital located in Peekskill New York, is known for providing high-quality access to health care for residents living in Westchester, Putnam, and Lower Dutchess Counties (NYP Hudson Valley Hospital, 2019a). The hospital’s Emergency Department have very low wait time and has highly trained medical staff. They are trained in all aspect of emergency care such as stroke and trauma care, and disaster preparedness. This practice has led to outstanding patient care outcomes (NYP Hudson Valley Hospital, 2019b). According to nurses in the hospital, the emergency department has more than 30 nurses who are active members of the ENA. Members of the New York region receive continuous seasonal conferences and events update through emails and letter mail, regarding structure changes and results of any kind (B. Mazzola, personal communication, July 3,2019).

The ENA plays a significant role in NewYork-Presbyterian Hudson Valley Hospital’s outstanding professionalism. The ENA published the Emergency Public Safety Guidelines. This guideline contains information and instructions for the care of children and injury prevention which is still being used today. The organization also advocates on nursing issues related to emergency care reform and emphasizes the role of nurses over the practice setting of the emergency department. It encourages people who are interested in emergency care to become knowledgeable about the health care process and get involved in health policy advocacy (ENA, 2019e). Just like every member of the ENA organization, nurses at Hudson Valley hospital have strong clinical skills that focus on quality improvement and commitment to providing the highest standards of care to all patients.

The ENA currently has more than 43,000 members committed to promoting care to the community. There are different types of membership, which include national member, international member, senior member, military member, international digital member, affiliate member, and student member (ENA, 2019h). It’s required that a member be a Registered Nurse residing inside or outside of the United States or its territories. The ENA ‘s membership is tailored to fit everyone’s career path. The cost of membership varies depending on the location and member’s qualification determined by the organization upon completion of the application. Voting members of the ENA have the right to vote, be elected for office, serve as the board of directors and committees, and attend all social functions. Nonvoting members can only attend some meetings and activities (ENA, 2019h).

References

• Emergency Nurses Association. (2019a). About Emergency Nurses Association. Retrieved from https://www.ena.org/about#mission
• Emergency Nurses Association. (2019b). ENA and project helping hands. Retrieved from https://www.ena.org/membership/get-involved/ena-and-project-helping-hands
• Emergency Nurses Association. (2019c). ENA has 2020 vision. Retrieved from https://www.ena.org/docs/default-source/default-document-library/enastrategicplan.pdf?sfvrsn=5c367de2_2
• Emergency Nurses Association. (2019d). Events. Retrieved from https://www.ena.org/event/2019/08/14/ena-events/older-adult-geriatric-care-a-special-population-webinar
• Emergency Nurses Association. (2019e). Government relations. Retrieved from https://www.ena.org/government-relations
• Emergency Nurses Association. (2019f). Patricia Kunz Howard, PhD, RN, CEN, CPEN, TCRN, NE-BC, FAEN, FAAN. Retrieved from https://www.ena.org/about/leadership-and-governance/ena-board-of-directors/patricia-kunz-howard-phd-rn-cen-cpen-ne-bc-tcrn-faen
• Emergency Nurses Association. (2019g). Leadership and governance. Retrieved from https://www.ena.org/about/leadership-and-governance
• Emergency Nurses Association. (2019h). Membership options. Retrieved from https://www.ena.org/membership/membership-options
• Emergency Nurses Association. (2019i). Public policy agenda 2018/2019. Retrieved from https://www.ena.org/government-relations/public-policy-agenda
• NewYork-Presbyterian Hudson Valley Hospital. (2019a). About us. Retrieved from https://www.nyp.org/hudsonvalley/about-us
• NewYork-Presbyterian Hudson Valley Hospital. (2019b). Emergency department. Retrieved from https://www.nyp.org/hudsonvalley/services/emergency-services

• 
  Natalia Perdomo
  

Introduction

Ethical dilemmas have been at the forefront in the healthcare industry. Nurses are constantly faced with situations in which difficult decisions must be made. It is crucial to determine at what point autonomy outweighs patient wellbeing.

Gather Data

The ethical situation presents a woman delivering a baby in a country hospital after suffering complications. These complications cause inadequate oxygen delivery to the baby. The baby is supported by nutrition and hydration and currently in an unresponsive state to verbal and tactile stimulus. The NICU staff and nurse have never experienced this situation in the past and are unaware of how to proceed. The parents are in a state of extreme grief while the staff feels overwhelmed and uncertain in regards to a solution. Information not presented in this case includes reassessment of Apgar score, gestational age, weight of infant or type of delivery as well as mother’s medical history.

Key Participants

The key participants in this dilemma include the parents, the NICU staff and the nurse who is primarily responsible for the mother’s care. When considering the mother’s perspective, it is crucial to understand the many factors that play into her thought process. She has been through a difficult labor and is stated to be weak and grieving. When asked to make a decision, she feels competent enough to make a valid decision. The father, who is also grieving, agrees with his wife, who is in a distressed state. Both parents are saddened by the condition of the infant and feel there is no choice other than to discontinue life support measures because they value quality of life and do not want their infant to endure suffering any longer.

The NICU staff, who pride themselves in valuing patient autonomy, want to be as supportive as possible and perform in the best interest of the patient. The nurse and staff agree that the mother does not have decision-making capacity at the time of the decision. The nurse demonstrates an ethical struggle, as she needs to fulfill her supportive role towards her patient. She feels that by not offering enough information, she cannot assist the parents in making the best decision or intervene due to her lack of knowledge.

Statement of Ethical Problem of Conflict

The ethical conflict rests on the nurse in this case. The conflict is whether she should support the decision of her patient to discontinue nutrition and hydration or whether she should seek out alternative options to convince her patient to reassess her decision.

Review of Literature

When dissecting a situation such as this one, it is critical to understand the key points in their entirety to determine the most effective approach. According to Conde-Agudelo and Romero (2012), an amniotic fluid embolism (AFE) is known as a rare and fatal obstetric condition associated with severe symptoms such as sudden cardiovascular collapse, respiratory distress, altered mental status and fetal distress. It is currently the second leading cause of maternal death in the U.S. and must receive prompt and aggressive treatment by a multidisciplinary team. The fetal distress caused by AFE results in hypoxia of the neonate, which in consequence may cause life threatening injuries and lifelong disability. Anju, Naijil, Paulose, Roshni and Shilpa (2012) state that hypoxia may cause multi organ failure and functional damage especially to the cardiovascular and central nervous systems. The authors also note that because hypoxia has the potential to induce neuronal death in vulnerable brain regions, impairment of cognitive function can be detected later in life.

In addition to the effects of the AFE, it is crucial to understand the hormonal process contributing to the emotional state in the postpartum period. After a woman gives birth, the levels of estrogen and progesterone decline rapidly. Harvard Medical School (2011) explains that due to the plummet of hormones immediately after birth, emotional instability may result as these reproductive hormones interact with neurotransmitter systems that affect mood and mental health. Expected post partum emotions, according to Turner (2012) include feelings of tiredness, anxiety, tearfulness, lack of energy and insomnia.

There are many laws that serve to protect the rights of the infant and child. The United Nations Declaration of the Rights of the Child (1959) states that the child “shall be entitled to grow and develop in health; to this end, special care and protection shall be provided both to him and to his mother, including adequate pre-natal and post-natal care.” Although care and protection of the infant is essential, there are always exceptions. In the court case Miller v. HCA (1990), a premature infant was born with multiple complications and a poor prognosis. The parents made it clear they wanted no measures taken to save the infant. However, the physicians intervened regardless and initiated life sustaining measures. These parents valued quality of life and disagreed with life sustaining measures due to likelihood of severe and permanent physical and mental impairments in the future. When their autonomy was not respected and the infant was kept alive, the parents became responsible for the life of a child with severe disabilities.

Aladangady and Rooy (2012) clarify that babies with poor prognosis should have treatment decisions made jointly by the health care team and infant’s family while considering the best interests of the baby and current clinical condition. Ethics committees in hospitals serve as resources to the providers as well as the patients and should be considered as they provide ethics education. However, Gaudine, Lamb, LeFort and Thorne (2011) assess barriers to requesting an ethics consult, which include consult worsening the situation, unhelpful consultations, solutions conflicting with good practice and working with unqualified ethics consultants.

Supporting Principles or Theories

Burkhardt & Nathaniel (2014) define autonomy as the “freedom to make choices about issues that affect one’s life, free from lies, restraint, or coercion” (p. 60). This principle respects each individual and highlights his or her uniqueness and value within a society. There are four basic elements that determine autonomy. The autonomous person must be respected, have the ability to determine explicit personal goals, have the capacity to decide on a plan and have freedom to autonomously act upon choices made. Children, fetuses and individuals with mental impairments are not considered autonomous; therefore, they are unable to make informed choices.

The principle of beneficence according to Burkhardt & Nathaniel (2014) requires that nurses act in ways that will benefit their patients by doing good. There are three major components within this principle, which include doing or promoting good, preventing harm and removing evil or harm. By striving to act in ways that are morally and legally correct, it allows the nurse to gain trust from her patients as well as from society.

Within the context of the situation, the two ethical principles presented oppose each other in regards to the ethical dilemma of the nurse. By supporting the decision to discontinue hydration and nutrition, the nurse is respecting the patient’s autonomy. The baby does not possess autonomy and therefore, cannot make decisions. The parents possess the right to make decisions as they see fit and the nurse must respect their freedom. The nurse abides by the principle of beneficence by choosing to seek out options to provide the best possible alternatives within her scope of practice. By doing this, she can educate the parents and give them an opportunity to make an educated decision, which may facilitate reassessment of the decision to prevent any further harm to the neonate.

Desired Outcome for All Participants

The desired outcome for the situation presented is for the country hospital’s NICU staff to work together and form a plan of care that is in the best interest of the neonate. The plan of care should be discussed with the parents and they should feel confident with their informed decision. Once the plan is discussed with the parents and they are in agreement, the NICU team will work together to implement the plan.

Options

The nurse may support her patient’s wishes to have life sustaining measures withdrawn in the infant. Within the mother’s current emotional state, this action may seem as the most reasonable but down the line, she may feel extreme guilt and regret. This decision may trigger moral distress amongst the nurse and NICU staff due to their lack of knowledge and guidance in the situation. However, by supporting the decision the nurse demonstrates respect for patient autonomy. If the infant is disconnected, the staff may speak to the parents about providing palliative care and donation of the infant’s viable organs.

The nurse may also choose to reassess both mother and baby for a week due to the mother’s initial lack of decision-making capacity. This option violates patient autonomy as the parents wish to disconnect hydration and nutrition. By keeping the baby in its current state, it may cause difficulties for the parents as they value quality of life and disagree with life sustaining measures. However, this option provides the nurse with an opportunity to intervene, consult specialists, research and learn about the mother’s condition and most effective implementation. By reassessing both patients for a week, it buys the infant some time to recuperate from birth trauma and allows the mother to reach optimum health in order to make a rational decision.

Another option that may be considered in this situation is to consult the hospital’s ethics committee. Since the nurse is unsure of whether to support parents or encourage them to reassess their decision, she may call in a third party to intervene. This option also goes against the patient’s wishes and may cause them to lose trust in the nurse, which may result in stress on the patient-nurse relationship. The patient and her husband may also refuse to speak to the ethics committee altogether. However, if the patient and her husband consider the option of speaking to an ethicist, it allows them to discuss their decision-making process and values with an unbiased party. By incorporating another person who was not initially involved in the situation, it will assist in relieving some distress the staff feels in regards to the dilemma.

Decision and Justification

The best decision in this case is for the nurse to reassess both the patient and infant for a week due to the mother’s initial lack of decision-making capacity. Although this choice goes against the autonomy of the mother, it is a decision that is made in the best interest of both the mother and the infant. Extra time allows the nurse to obtain research about AFEs and clinical manifestations to better aid her patient. As stated earlier, one of the main symptoms of an AFE is altered mental status, which may explain why such a rash decision was initially made. The nurse is aware of the altered mental status and must intervene due to the principle of beneficence. During this time, the nurse may consult with a neurologist to observe the mother’s neurologic status and monitor for any impairment. Furthermore, the nurse may consider consulting a neonatologist to determine possible treatment options and prognosis of the infant.

This option serves as the most effective over the others because it involves the most thought out process. The option to support her patient’s wishes and autonomy is not in the best interest of the mother or baby, as the nurse is aware of the mother’s lack of decisional making capacity. It is the nurse’s responsibility to do good within her scope of practice and seek out the best option for her patient; this option does not allow her to do so. Requesting an ethics consult would involve more staff in this very delicate situation and most likely negatively affect the nurse-patient relationship by further upsetting the patient and her husband.

Effectiveness of Decision

The decision that is chosen by the nurse is effective because it involves the implementation of a plan that is carried out by the staff, as well as other collaborative means such as neurology and neonatology. This decision provides the nurse with an opportunity to research options with the patient’s best interest in mind while providing the patient with the prospect of healing. Meanwhile, the infant may receive an appropriate evaluation to determine likelihood of survival. If after further assessment possession of decisional capacity is confirmed, along with confirmation of infant’s unchanged state, the parents may then restate their wishes to disconnect nutrition and hydration as they strongly value quality of life. At this point, the nurse may feel confident in her decision to support the patient’s autonomy as the appropriate measures were taken.

Conclusion

This scenario is one of many in which a nurse may be faced with a difficult decision. Assessment is the key component in determining whether or not autonomy outweighs patient wellbeing. Once a conclusion can be deferred, the nurse can then implement the most effective plan of care.

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