1. Ann Leemhuis is clinical nurse III, adult medical-surgical intensive care unit, University of California San Francisco Medical Center, San Francisco, California. Yuriko Shichishima is a clinical nurse II and a clinical nurse educator, Department of Community Health Systems, School of Nursing, University of California San Francisco Medical Center. Kathleen Puntillo is professor emeritus, Department of Physiological Nursing, University of California San Francisco School of Nursing