I have been a nurse manager in major cities such as San Antonio, Austin and New York City. However, this is my first management experience in a small rural setting and I have found that the nursing shortage has an entirely different impact out here in the country. More...

A new graduate has been working on a cardiac unit for a few weeks, and on this day is assigned to a patient with advanced CHF and Diabetes. The patient asks the graduate to answer some questions he and his wife have about Advance Directives and treatment options as his CHF worsens. He makes clear that he understands that his physical health is rapidly deteriorating and that death could come suddenly. He has heard terms such as "Palliative Care" and "Hospice" and wants to know more. The graduate seeks out her preceptor, and shares her frustration over the vague information she has about Advance Directives, ethical and legal parameters for treatment decisions, and her fears about working with a patient who expresses his awareness of his own dying process. You are the preceptor. What do you do and why?
What would you do if this situation involved a student nurse?

End of Life (EOL) issues encompass diverse subjects, dilemmas, and nursing care needs. However, today's practicing nurses may have received limited or even outdated information on such topics while in school, and usually take limited, if any, advantage of CE options about death, dying, grief, and end of life decisions. Concurrently, in most nursing education programs, students get less than 5 hours of classroom content and discussion on these topics. Studies have repeatedly shown even experienced nurses feel uncomfortable when teaching about such topics is warranted. The result is that nurses today are deferring these conversations to pastoral care and to social workers / case managers. Nurses in general feel ill equipped to accurately discuss Advance Directives and treatment options or to even offer effective support to dying patients and their families. Statements such as "I don't know what to say." Or "I'm afraid I'll make them feel bad." are given as reasons for avoiding conversations and failing to follow up on overt conversation clues from patients they care for. The ability to individualize care for those persons near death is also difficult, and many times routines continue to be followed even when treatment goals should have changed from cure to care. Information regarding specific needs of the dying patient must be introduced and integrated into the ongoing education of all nurses without regard to specific areas of practice. Dying and death are inseparable from living and life. Every patient and their family needs nursing care that includes accurate and appropriate actions no matter where they are in the living and dying process.

Nurses remain the primary link to resources for patients and their families. Patient teaching traditionally has and continues to hold a significant priority in nursing care for all patients. Patients trust and listen to nurses, and many feel more at ease about taking time to ask questions and discuss situations with nurses than with physicians. Professional nurses recognize the effectiveness of 'therapeutic listening skills,' yet they are reluctant to participate in conversations on topics related to death and dying, often leading to avoidance and failure to adequately meet a patient's needs. But, burnout and methods of preventing burnout for nurses who care for large number of dying patients, are also concerns that warrant attention and prevention by educators and supervisors.

What needs to be done to change this? How can nursing educators in schools of nursing and in health care facilities help students and practicing nurses expand their knowledge and, more importantly, feel more comfortable with these topics and conversations? Several avenues are open if a willingness to pursue them is present. The American Association of Colleges of Nursing (AACN) published, in 1997, a list of "Competencies Necessary for Nurses to Provide High-Quality Care to Patients and Families During the Transition at the End of Life." This document provides a blueprint for nursing regarding the standards and educational outcomes needed today for care of the dying, and can be obtained online at: http://www.aacn.nche.edu/Publications/deathfin.htm . Additionally, a comprehensive national education program designed to improve end-of-life care by nurses is currently being offered around the nation and has been offered regularly since February 2000. This program is entitled the End-of-Life Nursing Education Consortium (ELNEC) Project. It is jointly sponsored by the AACN and the City of Hope National Medical Center. The consortium offering provides nursing educators from both schools of nursing as well as continuing education arenas the opportunity to obtain current information and a vast array of teaching resources. Additional information can be obtained at the ELNEC website: http://www.aacn.nche.edu/elnec/

This is a 2 part series on end-of-life issues