Traditionally, nursing has been the nexus of care for patients with chronic and advanced disease. However, near the end-of-life, goals of nursing care change from life-prolongation to the provision of palliation and healing other than physical. While in the disease-focused model of care, there may be little emphasis on the individuality of the patient and the relationship between nurse and patient. In palliative care, an individual relationship with the patient and family, together with specialized knowledge and nursing skills, are of the essence.
Because of the ongoing and familiar interaction between nurse, patient and family, there is often a shift in the balance of decision-making at the end of life from physician to nurse. A nurse trained in palliative care can be instrumental in guiding the physician and redirecting care toward providing comfort. In effect, the palliative care team nurse acts as a patient advocate. He/she may also be responsible for communicating care plan goals and interventions as well as monitoring
and evaluating care provided by other team members.
As the core of the interdisciplinary team, the nurse must evaluate the needs of the patient, family and physician and intervene appropriately. Successful intervention requires:
- Assessment skills
- Expertise in comprehensive care planning and goal
- Collaboration and communications savvy
- Teaching ability
- Knowledge regarding symptom control
- Understanding of bioethics
- Comfort in discussing spiritual issues
To provide quality palliative and end-of-life care, the team nurse uses three guiding principles: autonomy/choice, advocacy and acceptance to best meet the goal of supporting an individualized dying experience. He/she also must recognize that a change in the patient's physical, functional, interpersonal or spiritual well-being affects the status of all dimensions of well-being. Consequently, the interdisciplinary team care nurse works to prevent and/or minimize suffering, thus allowing patient and family to attend to other dimensions of well-being, spirituality and life closure.
The interdisciplinary palliative care team nurse also may become involved in patient and family education concerning topics such as personal care, administration of medications, use of equipment, catheter care, nutrition, skin care, nutrition and assistance with activities of daily living. He/she also may educate the family about changes to expect, stages of disease and interventions to decrease suffering, physical as well as psychosocial and spiritual.
Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. New York: Oxford University Press, 2001.
Matzo ML, Sherman DW. Palliative Care Nursing: Quality Care to the End of Life. New York: Springer Publishing Company, 2001.
Competencies Necessary for Nurses to Provide High-Quality Care to Patients
and Families During the Transition at the End of Life
In 1997, the International Council of Nurses mandated that nurses have primary responsibility for ensuring that individuals at the end-of-life experience a peaceful death. (International Council of Nurses. Basic Principles of Nursing Care. Washington, DC: American Nurses Publishing, 1997)
Educational preparation for end-of-life care has been inconsistent at best, and sometimes neglected within nursing curricula, health care ethicists and palliative care experts. The American Association of Colleges of Nursing, supported by The Robert Wood Johnson Foundation, convened a roundtable of expert nurses and other healthcare professionals to develop the End-of-Life Competency Statements listed below.
1. Recognize dynamic changes in population demographics, healthcare 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 healthcare 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 healthcare delivery system.
15. Apply knowledge gained from palliative care research to end-of-life education and care.
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