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Background In
recognition of the universal need for humane end of life care, the American Association
of Colleges of Nursing, supported by the Robert Wood Johnson Foundation, convened
a roundtable of expert nurses and other health care professionals to stimulate
scholarly discourse and initiate change on this important reality. This is in
accord with the International Council of Nurses' 1997 mandate that nurses have
a unique and primary responsibility for ensuring that individuals at the end of
life experience a peaceful death.1 The
United States is facing the realities of an aging population, a recognition of
the limits and inappropriate use of technological resources, and concerns about
the capabilities of health care providers. Additionally, the increase in demand
for assisted suicide and apprehensions of the public about suffering and expenses
associated with dying that may be prolonged unnecessarily by technology contribute
to a renewed interest in humane end-of-life care. Increased awareness of the success
of hospice as an alternative model of care has served as a catalyst for integrating
palliative care into traditional models of care delivery. Precepts
underlying hospice care are essential principles for all end-of-life care. Such
precepts include the assumptions that individuals live until the moment of death;
that care until death may be offered by a variety of professionals; and that such
care is coordinated, sensitive to diversity, offered around the clock, and gives
attention to the physical, psychological, social, and spiritual concerns of the
patient and the patient's family. These precepts provide guidance to the development
of the educational preparation of nurses. However, educational preparation for
end-of-life care has been inconsistent at best, and sometimes neglected within
nursing curricula. This document is intended to address these deficiencies. Given
the likelihood that care will be given by a variety of health care professionals,
it is essential that such preparation be interdisciplinary in its approach to
preparing students for the end-of-life practice in which they will engage. The
roundtable's group of health care ethicists and palliative care experts developed
the End-of-Life Competency Statements presented here, which every undergraduate
nursing student should attain. Finally,
the group made recommendations concerning the content areas where these competencies
could be addressed. Competencies
Necessary for Nurses to Provide High-Quality Care to Patients and Families During
the Transition at the End of Life 1.
Recognize dynamic changes in population demographics, health care economics, and
service delivery that necessitate improved professional preparation for end-of-life
care.
2. Promote the provision of comfort care
to the dying as an active, desirable, and important skill, and an integral component
of nursing care.
3. Communicate effectively
and compassionately with the patient, family, and health care team members about
end-of-life issues.
4. Recognize one's own attitudes,
feelings, values, and expectations about death and the individual, cultural, and
spiritual diversity existing in these beliefs and customs.
5. Demonstrate
respect for the patient's views and wishes during end-of-life care. 6.
Collaborate with interdisciplinary team members while implementing
the nursing role in end-of-life care. 7. Use
scientifically based standardized tools to assess symptoms (e.g., pain, dyspnea
[breathlessness] constipation, anxiety, fatigue, nausea/vomiting, and altered
cognition) experienced by patients at the end of life. 8.
Use data from symptom assessment to plan and intervene in
symptom management using state-of-the-art traditional and complementary approaches. 9.
Evaluate the impact of traditional, complementary, and technological
therapies on patient- centered outcomes. 10. Assess
and treat multiple dimensions, including physical, psychological, social and spiritual
needs, to improve quality at the end of life. 11. Assist
the patient, family, colleagues, and one's self to cope with suffering, grief,
loss, and bereavement in end-of-life care. 12. Apply
legal and ethical principles in the analysis of complex issues in end-of-life
care, recognizing the influence of personal values, professional codes, and patient
preferences. 13. Identify barriers
and facilitators to patients' and caregivers' effective use of resources. 14.
Demonstrate skill at implementing a plan for improved end-of-life
care within a dynamic and complex health care delivery system. 15.
Apply knowledge gained from palliative care research to end-of-life
education and care.
The
purpose of the competency statements is to assist nurse educators in incorporating
end-of-life content into nursing curricula. This document is developed with the
understanding that few schools of nursing would offer a discrete course in end-of-life
care. Thus, this document offers an approach to incorporating end-of-life content
throughout the currently existing curriculum. Content
Areas Where Competencies Can Be Taught
Nursing schools use a variety of
approaches to organize curriculum. There are common content areas, even though
the particular courses may have different titles at different schools. Below are
content areas, or courses, where various aspects of end-of-life care can logically
be included. Health Assessment
In a course on health assessment, students should be taught to use standardized
assessment tools for common problems experienced at the end of life. Such tools
might include visual analogue or numeric rating scales to quantify pain or dyspnea.
Since analysis of a symptom always includes assessment of intensity, this would
be an appropriate opportunity to discuss the value of rating scales for initial
and on-going assessment (competency #7). For
inclusion in the health assessment course, the roundtable participants also strongly
advocate content on common symptoms experienced at the end of life, appropriateness
of various physiological measures for evaluating comfort in the dying person,
and the indicators of approaching death (competency #7). Pharmacology
The introduction of appropriate pharmacologic management of symptoms, with
a focus on palliative care, is an important part of the curriculum. Included in
this content should be use of equianalgesic tables and discussion of the negative
impact of myths and misconceptions surrounding use of analgesics. Assessment and
management of side effects of analgesics, such as constipation and nausea, should
be addressed (competency # 8). Psychiatric-Mental
Health
Coursework that addresses psych-mental health and communication
issues provides multiple opportunities to discuss end of life issues, for example:
- communication
with the patient and family (competency #3);
- eliciting
patient's and family's wishes for end-of-life care (competency #4);
- recognition
of the student's own attitudes, feelings, and expectations about death (competency
#5);
- preparing the patient's family
for decline in emotional and cognitive status (competency #10); and
- assisting
the patient, family, and colleagues to cope with suffering, grief and loss, and
crisis in the family (competency # 11).
Nursing
Management Courses
Nursing management courses usually include pathophysiology
of disease and use of the nursing process to assist patients in the management
of problems associated with disease. Within these nursing management courses,
faculty can incorporate specific learning objectives related to management of
end-of-life illness, such as: - provision
of comfort care to the dying as an active, desirable, and important service (competency
#2);
- collaboration with interdisciplinary
team members while implementing the nursing role in end-of-life care (competency
#6);
- assessment and management of
symptoms that occur near the end of life in persons with end-stage cardiac, pulmonary,
and renal disease, cancer, dementia, immuno-suppression, and other conditions
that may lead to death (competencies #7 and #8);
- evaluation
of the impact of nursing interventions on patient outcomes (competency #9); and
- implementation of end-of-life care
with appropriate use of technology as desired by patients and their families (competency
#8).
Faculty teaching these courses
should integrate this content into their specific courses, as appropriate. For
example, if the course takes a body-systems approach, the faculty member could
talk about expected symptoms in each system near the end of life. Ethical/Legal
Content
Coursework that assists nursing students in identifying
and assessing their own attitudes towards death, as well as teaching respect for
others' attitudes and values, should be an integral part of the nursing curriculum
(competency #4). Faculty covering
ethical-legal content might include content on: - relevant
state and federal laws regarding informed consent, advance directives, portable
(community based) do-not-resuscitate orders, etc. (competency #12);
- common
legal myths and professional misperceptions regarding end-of-life care (competency
#12); and
- differences between laws,
institutional policies, personal values, family values, and professional values
and ethics (competency #12)
Cultural
Issues Content
Increasingly, nursing education includes content
about culture. Faculty who teach this content should incorporate cultural influences
on attitudes and beliefs about death and dying in the cultures represented in
the surrounding community (competency #5). Nursing
Research
Courses that address nursing research should include examples
of research done in palliative care settings and in settings where death is a
frequent outcome. For example, a number of nursing studies have been published
in the areas of symptom assessment and management, family member bereavement,
and quality of life in palliative care settings (competency #15). Professional
Issues/Health Care Settings
A discussion of hospice as a type of
health care model should be included in the curriculum. Professional issues surrounding
providing care in the home, the role of the family caregiver, and the role of
the nurse in supporting the family caregiver should also be addressed in addition
to the professional issues surrounding provision of palliative care within traditional
acute and clinic settings (competencies #1, #10, #11). References
1 International
Council of Nurses. (1997). Basic Principles of Nursing Care. Washington,
DC: American Nurses Publishing. | 
