PEACEFUL END OF LIFEby Cornelia M. Ruland and Shirley M. Moore

Presented by Jennifer Totten, Angela Baird, and Amy Howard

Group 3Nursing 324

Letter to organization:Dear Hospice organization,

We would like to introduce ourselves today as advocators for the Peaceful End of Life Theory. Through our practice and research of theory we hope that your nursing organization will adopt this theory to your everyday nursing practice of terminally ill patients as we have. This theory can be used in all settings of Hospice care, where ever the patient or family chooses. This includes their home, nursing home , hospital, and inpatient hospice care facility. We will introduce you to the founders of the theory and give just a little background of their nursing career. So get comfortable and let us show you what we feel is the up and coming theory for your practice. This theory that will make you more knowledgeable about the complex care for the dying patient and how you can make it the best experience for the patient, significant other, and family during their peaceful end of life.

Angela, Amy and Jennifer.

The terminally ill patient has a illness that within 6 months or less are expected to die. The

terminally ill patient no longer wishes to have procedures done on them in the hope of a cure. He/she has accepted the fact of their death and is preparing to die with the best experience for them, their significant other

and family.

With terminal patients the doctor does not focus on them, so it is up to the nurses to

show knowledge about the dying process and symptom management. The nurse needs to

know the complexity of taking care of a terminally ill patient and how they can

contribute to a peaceful end of life.

Theorists

• Cornelia M. Ruland

Received her PhD in nursing from Case Western Reserve University, Cleveland, Ohio in 1998.

Currently she is the Director of the Center for shared Decision Making and Nursing Research

at Rikshospitalet University hospital in Oslo, Norway and holds an appointment as adjunct

faculty at the Department of Biomedical Informatics at Columbia University in New

York. Ruland has been the major investigator in many research projects and had won

awards for her work (Tomey & Alligood p.775).

• Shirley M Moore

Received her master’s degree in Psychiatric and Mental Health nursing (1990) and her PhD in

Nursing Science (1993) at Case Western Reserve University, Cleveland, Ohio. She has taught

nursing theory and science to all levels of nursing students. Moore also conducts research and

theory development in the recovery of cardiac events and has assisted in development and

publication in several theories (Tomey & Alligood p.775).

The Peaceful End of Life theory was developed from the standard of care of peaceful end of

life. The standard of care was developed by a experienced group of nurses in Norway. This was on a gastroenterological unit where half of the patients were diagnosed with cancer and dealing with terminal illness was on a

daily basis (Ruland and Moore 1998).

These nurses all had 5 or more years experience with terminally ill patients and had attended seminars and other post graduate education on this group of patients (Ruland and Moore

1998).

They identified a need for clinical guidance in taking care of these patients and giving them quality care. This resulted in the development

of the theory for the Peaceful End of Life by Ruland and Moore (Ruland and Moore 1998).

The focus was not on dying in itself but on peaceful and meaningful living during the final days that remained for the patients, significant others, and family members. It also reflected

the complexity that is involved with taking care of the terminally ill patient and the need

to have knowledge on pain relief and symptom

management (Ruland and Moore 1998).

He/she needs to have a caring attitude, awareness, sensitivity and compassion for the

terminally ill patient (Ruland and Moore 1998).

This model started while Ruland was a student in one of Moore’s classes. Ruland

helped develop a standard of practice for end of life to provide a structured framework where there had previously been none.

Ruland with the help of Moore then developed the Peaceful End of Life Theory

from this standard of practice (Tomey & Alligood 2006, pp. 775-8).

The major concepts that this theory is based on are:

1) Being free of pain2) Experiencing comfort

3) Experiencing dignity and respect4) Being at peace

5) Being close to your significant others

Free of pain

Not being in pain is defined within this theory as not having the experience of pain(Ruland &

Moore 1998).

Pain further is described as an unpleasant, sensory, and emotional experience associated

with actual and potential tissue damage or described in terms of such damage (Ruland &

Moore 1998).

Comfort

The experience of comfort for this theory was defined as the relief from

discomfort, the state of ease and peaceful contentment, and whatever

makes life easy or pleasurable (Ruland and Moore 1998).

Experiencing dignity and respectThe experience of dignity was defined as being

respected and valued as a human being, having the value of worth (Ruland and Moore 1998).

This includes, being acknowledged and respected as an equal and not being exposed to anything that

violates the patient’s integrity and values (Ruland and Moore 1998).

Being at peace

The definition for being at peace for this theory involves the feeling of calmness, harmony, and

contentment (Ruland and Moore 1998).

To be free of anxiety, fear, and worry.

Closeness to significant others

Closeness of significant others for this theory is the feeling of connectedness to other human beings who care (Ruland and Moore 1998).

Peaceful End of Life

(Ruland and Moore 1998 p.174)

Not being in pain Experience of Comfort

Experience of Dignity/Respect Being at Peace Closeness to Significant

Others/Persons Who Care

Monitoring and Administering pain

relief

Applying Pharmacological and Non-pharmacological

Interventions

Preventing, Monitoring and

Relieving Physical Discomfort

Facilitating Rest, Relaxation and Contentment

Including patient and Significant

Others in Decision Making

Treating Patient with Dignity, Empathy and

Respect

Being Attentive to Patient’s

Expressed Needs, Wishes and Preferences

Providing Emotional Support

Monitoring and Meeting

Patient’s Needs for Anti-anxiety

Medications

Inspiring Trust

Providing Patient/Significant Others With

Guidance in Practical Issues

Providing Physical

Assistance of Another Caring

Person, if Desired

Facilitating Participation of

Significant Others in Patient Care

Attending to Significant Others Grief, Worries and

Questions

Attending to Significant Others Grief, Worries and

Questions

Facilitating Opportunities for Family Closeness

Reduction of outcome criteria from the standard to outcome indicators of the proposed theory

StandardThe patient is not having pain

The patient does not experience nauseaThe patient does not experience thirstThe patient does experience optimal comfortThe patient and significant others experience a pleasant

environment

The patient and significant others participate in decision making regarding the patient’s care

The patient and significant others experience being treated with dignity and respect as human beings

The patient and significant others maintain hope and meaningfulness

The patient and significant others get assistance in clarifying practical and economical issues related to the patient’s coming to an end of life

The patient does not die aloneThe patient is at peace

Significant others:Are taking part in caring for the patient as they wishCan say farewell wit the patient in compliance with their

beliefs, cultural rites, and wishesAre informed about different funeral procedures and

possibilities

TheoryNot being in pain

Experience of comfort

Experience of dignity/respect

Being at peace

Closeness to significant others/persons who care

Outcome Criteria of the Standard of Peaceful End of Life

The patient:• Is not having pain• Does not experience nausea• Does not experience thirst• Experience optimal comfort • Is at peace• Does not die alone

The patient and significant other(s):• Have confidence that they are receiving the best possible care• Maintain hope and meaningfulness• Participation in decision making regarding the patient’s care• Experience being treated with dignity and respect as a human being• Get assistance in clarifying practical and economical issues related to the • Patient’s coming to an end of life• Experience a pleasant environment

Significant others:• Are taking part in caring for the patient as hey wish• Can say farewell with the patient in compliance with their beliefs, cultural rites, and wishes• Are informed about different funeral procedures and possibilities• Are offered a follow-up visit after patient’s death

Ruland, Cornelia M., RN, PhD and Shirley M. More, RN,PhD, (1998) Theory Construction Based on Standards of Care: A Proposed Theory of the Peaceful End of Life . Nursing outlook, 46, 169-75.

In this theory the focus is not only on the patient but on the significant others.

You are monitoring and caring for the needs of the patient: pain, comfort,

dignity/respect, peace, and their closeness to significant others.

You are providing guidance for the significant other, answering questions

and offering support.

This theory could be accommodating to any care setting or with in a patients home. No matter where the patient

resides at, the focus on care is not to be on cure, but instead on treating the patient toward the goals of the five

concepts: no pain, comfort, dignity and respect, peace, and closeness with

significant others

As the nurse, your goal will be to listen to the patient and significant others or to look for signs of complications with

pain, comfort, dignity and respect, peace, and closeness with significant

others.

As the nurse, you will need to be prepared to provide pharmacological and non-pharmacological treatments. You will need to be comfortable in helping with the

significant others, as well as the patient, cope with the disease and the disease process.

As nurses you will be educating the patient and significant others on the disease and disease process, on what to expect as time goes on. Remember, as you do this, keep in mind to provide the patient and significant others with dignity and

respect.

As the patient declines the patient may not be able to verbalize pain,

discomfort, anxiety, restlessness, or other complications that need

addressing. You, the nurse, will need to be familiar with these signs and

symptoms, and what interventionsto complete. At this point, it will be your job to assess for problems and become the patients advocate toward treating

these problems.

Education will be prepared for you and shared with you to assist you in your comfort and confidence level with this Peaceful end of life theory,

included, but not limited to:

Signs and symptoms

• Pain• Discomfort• Nausea• Incontinence• Fear• Confusion• Embarrassment• Humiliation• Anxiety• Restlessness• Withdrawn• Depression• Loneliness

Treatments

• Pharmacological

• Non-pharmacological

This model provides a framework that reminds nurses of the important aspects of care during the end of life. It reminds nurses to not only treat the patient but also the significant others. It calls for thorough assessments of the alert patient as well as the patient that no longer is alert, and to

assess the need for medication or non-medication interventions.

A limitation that this model has is the fact that it does not address cultural

differences toward end of life care. For example, some cultures may feel that

the end of life is a very private time only allowing specific people to share time with their loved one, others have the

whole family (all adults or all ages) in the room. Certain cultures may also rely on home remedies or have rituals they may

wish to perform.

“Weakness of the theory include needing more research to back up the theory, as well as the usefulness of the theory in

influencing nursing research, education, and practice. Empirical support for all the

relationships needs to be validated” (Nursing theory 2007, p. 11).

Nursing Education:Currently there are no publications that report the use

of this theory for education.This theory can be applied to a master’s prepared nurse

because it is important that the master’s prepared nurse educate he/she on this theory and end of life issues. This will help to educate his/her students to understand end of life issues. Also when ever the

opportunity allows, give the patient, significant other, and family the best experience possible and a peaceful end of life (Tomey & Alligood 2006).

Strengths of Theory:Can be used in everyday patient

care.New and original, based on

standards of care and can be directed towards patient clinical

practice.

Developed for the terminally ill who expect death and can prepare for it.

With the development of the theory nurses are able to treat patients, significant others, and

family with dignity, respect, and empathy.Guides nurses in choosing interventions to

decrease suffering and make the last stages of life a meaningful experience for the patients,

significant other and family.All nursing interventions and outcomes can be

measured (Ruland and Moore 1998).

Your mouth and eyes are dry, breathing is difficult and it is making you nervous, and pain is present throughout your body. Even though you can hear your family members in the room you feel very alone. Unable to move or speak it is impossible to make your needs known or to ask for help and comfort. Then you hear a knock and a familiar voice, the voice of your nurse. She swabs your mouth, puts eye drops in your eyes, and a pill and some drops under your tongue which instantly start to dissolve. Even though you

cannot answer she talks to you and comforts you, then you hear her tell your family to do the same. Soon

someone is holding your hand, the anxiety and pain are melting away, and you are able to rest comfortably.

References:Case Western Reserve University. Frances Payne Bolten School of Nursing, picture of Shirley M. Moore

taken from http://www.fpb.case.edu, slide 5.

Columbia University. Picture of Cornelia Ruland taken from http://www.dbmi.columbia.edu, slide 5.

http://office.microsoft.com, picture slide 10.

http://www.naturespassage.com, picture slide 7.http://www.evergreenhospicecare.com, picture slide 18.

Nursing Theory Peaceful End of Life-Cornelia Ruland and Shirley Moore. Nursing 5330 Theories and Therapies Texas Tech University Health Sciences Center School of Nursing, Submitted to: Yondell Masten, October 17, 2007.

Ruland, Cornelia M. RN, PhD & Moore, Shirley, M. RN, PhD. Theory Construction Based on Standards of Care: A Proposed Theory of the Peaceful End of Life. Nursing Outlook, 1998, 46 (4), p.169-75.

Tomey, Ann Mariner & Alligood, Martha Raile (2006). Middle range theories: Peaceful end of life theory. Nursing Theorists and Their Work, (pp.775-781). Missouri: Mosby.