Transcript Slide 1

Presented by Angela Baird and Jennifer
Totten
This presentation in on the
use of the Peaceful End of
Life (EOL) Theory within
evidence based practice.
This theory is new and
continues to need further
research to refine and
improve it, but we will show
how this theory has been
used within nursing research.
We will do this by presenting
two research studies that
utilized the theory as the
framework to conduct the
research.
The Peaceful End of Life (EOL)
theory was developed by Cornelia
M. Ruland and Shirley M. Moore. It
was one of the first to be developed
using standards of practice and was
written by a team of experienced
nurses on a gastroenterological floor
where many patients were
diagnosed with cancer . It is
primarily based on the Donabedians
model of structure, process, and
outcomes (Tomey & Alligood).
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 EOL by Ruland
and Moore (Ruland and Moore 1998).
The Peaceful EOL theory is
structured around the family setting
and includes the terminally ill
patient and significant others that
receive care from healthcare
professionals. The process if defined
by nursing interventions that
promote positive patient/family
outcomes. These outcomes are
being free from pain, experiencing
comfort, having dignity and respect,
being at peace and being close to
significant others and those who
care (Tomey & Alligood 2006).
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).
The reasons for choosing this
theory for us was based on
our current positions within
nursing practice. We
currently have positions that
benefit from the
understanding and use of
this theory. With researching
this theory we now have
guidance and a resource to
help care for patients and
their families and give them
the best experience for a
peaceful end of life.
Practice areas/topics that have
been studied using this theoretical
framework/theorist work.
•Critical Care units-Nurses are vital
to end of life care and Critical Care
nurses encounter death and dying
every day. They provide patients
and their families with end of life
care and many feel responsible to
provide them with the care that
leads to a peaceful end of life
(Kirchoff & Beckstrand 2000).
•Gastroenterological
care unit-The
Peaceful EOL 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).
•In
one review article the Peaceful EOL
theory was referred to the
development of practice standard as a
foundation for developing theory (Liehr
& Smith1999).
•In a second review by Baggs & Schmidt
2000 they discuss potential usefulness
of the Peaceful EOL theory as a tool to
improve end of life decision making for
the critically ill adults.
The next slides will discuss and show
the research findings of research
articles utilizing the Peaceful EOL
theory as the framework
Critical Care Nurses’ Perceptions of End-OfLife Care
Written by Lynn Anne Orser
August 2007
“The object of the study was to measure
and describe critical care nurses’
perceptions of the intensity and frequency
of the occurrence of obstacles and
supportive behaviors that affect the
provision of end-of-life care in critical care
units” (Orser p.34).
The study was done by surveying those who
had attended a local meeting of a local
chapter of American Association of Critical
Care Nurses. There was a total of 89
members who attended the meeting and
those who were eligible was asked to take
a survey packet and fill out prior to leaving
the meeting. The survey took 20 minutes to
complete and was a questionnaire by the
name National Survey of Critical Care
Nurses Regarding End-of-Life Care. The
questionnaire included a list of obstacles
and facilitators to end-of-life care. The
participates were asked to respond to these
questions by answering with a 0-5 response.
57 usable surveys were included in the
study for a response rate of 71.29% (Orser
2008).
Results of the study identified top
obstacles of behaviors that nurses have
no control over which were related to
physicians and families. Supportive
behaviors were identified as those that
nurses had control over such as
providing support to the patient and
family (Orser 2007).
Top rated obstacles :
•Frequent call by family and friends of the
critically ill patient. Nurses find these call
frustrating as they remove them from the
patients bedside and they are unable to
provide care during these times.
•Family members who do not understand
the meaning of live-saving measures.
•Communication among the family, patient
and healthcare team. These could include
physicians who are evasive and avoid
conversations with the family and
physicians who are overly optimistic (Orser
2007).
Supportive behaviors:
•Providing support to the dying patient and
family.
•Supporting the family after the death of the
patient.
•Providing a peaceful, dignified bedside scene
and allowing the family adequate time to be
alone with the patient after death.
•Allowing the family to be close to the dying
patient.
•Teaching the family how to act around the
dying patient.
•Having all physicians agree on the direction
of the care of the dying patient (Orser 2007).
Limitations of the Critical Care nurse
study include:
•Low response rate of those eligible to
participate in the study which leads to
a limit of the generalization of findings.
•Biases from the nurses participating
due to them attending a professional
meeting and the investigator being a
member of the local nursing
organization.
•Attendees may have answered the
questionnaire to please the
investigator.
• Sample of nurses was not large enough
to allow correlation of study results
based on variations of demographic
data (Orser 2007).
Another limitation to the Critical Care
Nurse study is that there was nothing
documented that took into account the
different cultures and religions that
encompass patients and nurses giving
them appropriate end-of-life care
depending on what their particular
religion or culture was.
Another study was performed to
identify end of life care in intensive
care units. Information was obtained by
interviewing nurses in four focus groups
from various hospitals. All of the
participants were registered nurses
who had two to twenty-two years of
experience working in the ICU and all
had previous nursing experience in
other areas of nursing.
The tools used were an ICU Nursing
Questionnaire that addressed demographics
such as years of experience in the field,
age, sex, and experience with death, and a
Focus Group for ICU Nurses Guide which
addressed specific issues relating to end of
life care, the challenges they have had in
this area, and areas needing improvement
(Kirchhoff, Psuhler, Walker, Hutton, Cole &
Clemmer 2008).
The results of the research showed that
the nurses involved described good end
of life care that closely followed the
Peaceful End of Life Theory concepts
proposed by Ruland and Moore. It
identified main barriers to this care
including difficulty identifying when to
transition from curative to palliative
care, communication between patients,
their families and their physicians as
well as mixed messages between
various physicians, and lack of
resources such as social services and
chaplain.
Limitations of the research included
different breadth of responses from
different nurses, some have very little
input while other had a lot to add, and
the study only including nurses instead
of a whole team approach with
physicians, social workers, and input
from families or patients (who might
have received some end of life care but
survived) (Kirchhoff, Psuhler, Walker,
Hutton, Cole & Clemmer 2008).
Findings from the studies show that
end-of-life care can be improved and
are:
•Improving staffing patterns
•Improving communication between
family and healthcare team
•Educating family on interventions and
treatments used in critical care units
•Initiation of palliative care early in the
ICU setting.
•Supporting the nurse who participated
in the emotional experience of
providing end-of-life care (Orser 2007).
Within the research studies the
Peaceful EOL theory is a framework
to the studies by supporting the
obstacles and supportive behaviors.
The questionnaire itself had many
questions related to the outcomes
of the theory and many of the
obstacles and supportive behaviors
identified were also based on the
five outcomes of the Peaceful EOL
theory. These outcomes include, no
pain, experiencing comfort, dignity
and respect, the patient being at
peace and the patient experiencing
closeness to significant others
With the major amount of information to
be processed by nurses in any given day at
work, theories serve as a reference for
nurses to understand and organize their
patient care. It also provides for a useful
means of reasoning, critical thinking, and
decision making in nursing practice. It gives
the very reason why we do what we do and
how we take care of patients. Since
starting this class a lot of the theories are
utilized in nursing practice without even
knowing it. It has been an exciting journey
to see all of these theories and where they
fit into our nursing practice.
Baggs, J.G. & Schmitt, M.H. (2000). End of life decisions in adult
intensive care: current research base 158 and directions for the
future. Nursing Outlook, 48(4), 158-164.
Kirchhoff, K.T., Psuhler, V., Walker, L., Hutton, A., Cole, B. &
Clemmer, T. (2008). Intensive care nurses experience with end of
life care. American Association of Critical Care. Retrieved April
12, 2009 fromhttp://classic.aacn.org.
Liehr, P. & Smith, M.J. (1999). Middle range theory: spinning
research and practice to create knowledge for the new
millennium. ANS Advances in Nursing Science, 21(4), 81-91.
Orser, L. (2007). Critical care nurses’ perceptions of end-of-life
care. Pp. 1-108.
Ruland, C.& Moore, S. (1998).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, A. & Alligood, M.(2006). Middle range theories: Peaceful end
of life theory. Nursing Theorists and Their Work, (pp.775-781).
Missouri: Mosby.