Peaceful Death

Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Nursing Care

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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.

16. 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).

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).


1 International Council of Nurses. (1997). Basic Principles of Nursing Care. Washington, DC: American Nurses Publishing.


Robert Wood Johnson Foundation End-of-Life-Care Roundtable
November 11 -12, 1997
ANA Hotel
Washington, DC

Inge Corless, PhD
MGH Institute of Health Profession
Graduate Program in Nursing
Boston, MA

Cecilia Eagen (Sister Cecilia), PhD
Director, Hospice Education
Madonna University
Livonia, MI

Betty Ferrell, PhD
Associate Research Scientist
City of Hope National Medical Center
Duarte, CA

Barbara Given, PhD
College of Nursing
Michigan State University
East Lansing, MI

Ed Halloran, PhD
School of Nursing
University of North Carolina - Chapel Hill
Chapel Hill, NC

Bernard "Bud" Hammes, PhD
Director, Medical Humanities
Gundersen Lutheran Medical Center
La Crosse, WI

Susan McMillan, PhD
American Cancer Society Professor of Oncology Nursing
College of Nursing
University of South Florida
Tampa, FL

Paula Nelson-Marten, PhD
University of Colorado Health Sciences Center
School of Nursing
Denver, CO

Kathleen Puntillo, DNSc
Associate Professor
School of Nursing
University of California - San Francisco
San Francisco, CA

Cindy Rushton, DNSc
School of Nursing
Johns Hopkins University
Baltimore, MD

Sarah Shannon, PhD
Dept. of Biobehavioral Nursing and Health Systems
University of Washington
Seattle, WA

Deborah Sherman, PhD, ANP, CS
Assistant Professor
Division of Nursing
New York University
New York City, NY

Denice Sheehan, MSN, CRNH
Coordinator of Palliative Care
Breen School of Nursing
Ursuline College
Pepper Pike, OH

Barbara Stewart, PhD
Lienhard School of Nursing
Pace University
Pleasantville, NY

Diana Wilkie, PhD
Associate Professor & American Cancer Society Professor of Oncology Nursing
Dept. of Biobehavioral Nursing and Health Systems
University of Washington
Seattle, WA

The Robert Wood Johnson Foundation Staff:

Rosemary Gibson
Program Director
The Robert Wood Johnson Foundation
Princeton, NJ

American Association of Colleges of Nursing Staff:
1 Dupont Circle, NW, Suite 530
Washington, DC 20036

Anne Rhome
Director, Member Education

Martha Mihaly
Special Projects Manager

Joan Stanley
Director of Education Policy


Mary Peterson
Director of Development
College of Nursing
Montana State University
Bozeman, MT

(February 1998)

Related AACN Documents

AACN Chosen by The Robert Wood Johnson Foundation to Coordinate National Effort to Improve End-of-Life Nursing Care
(News Release - March 3, 2000)