RESOURCES FOR STAFF:

Bulletin boards with a designated section for EOL and Palliative care topics are excellent resources for quick, on the run educational snippets. Articles should change every 2-3 weeks or monthly so that staff can have ongoing learning opportunities. Both staff and faculty should contribute articles as they find relevant material in their own professional reading. Additionally, seek articles from Ethics Committee members, pastoral care, case managers, and local Hospice agencies used by the case managers for referrals. Sources of pertinent articles can include journals targeting professional nursing practice in the following arenas" general medical / surgical nursing, hospice and palliative nursing, oncology, critical care, and emergency care. The Last Acts E-newsletter published by Last Acts (http://www.lastacts.org), a national coalition dedicated to improving care and caring near the end of life will also be a current and reliable resource for information. Local groups working to further EOL initiatives should also be sources of unique information on trends, and cutting edge legal efforts.

Guest speakers at staff meetings; possible CE offerings of 2-4 hours with entire topic being EOL are also venues for providing practical and relevant information to staff. Professional death educators willingly take advantage of such invitations to expand knowledge and skills in this arena. The Association for Death Education and Counseling (ADEC) keeps a roster of members and guest speakers who may be approached about being presenters at meetings. Faculty from local nursing programs who also teach EOL content will also be open to coming as guests to both staff meetings, as well as local professional organizations of nursing specialties. These educators can offer expanded ideas on topics and resources in the community for additional enhancement to staff learning.

Special topics might be arranged for unique situations such as perinatal or neonatal death. Leaders of support groups for infant loss can be resources. Additionally, the excellent input that parents who have experienced the pain of a miscarriage or stillbirth can significantly increase staff awareness of nursing roles and facilitative methods of support.

In-service educational offerings could also review legal implications of Advance Directives: Directive to Physicians, Families and Surrogates, Medical Power of Attorney, and Out of Hospital DNR's. Staff from pastoral care or case management who assist families to deal with these legal documents can be excellent resources on the details and differences of these forms. Having accurate facts will allow nurses to feel more comfortable initiating and managing conversations and offer them effective alternative personnel to refer a family to when needed.

The Ethics Committee can offer insights into dilemma resolution and their role in mediation or decision making. The chair of the ethics committee or the hospital legal staff can provide clear guidance on these roles and responsibilities.

Role Play communication scenarios can promote increased confidence for the nurses. Topics for these include encounters with the angry patient, managing denial manifestations, addressing fears of dying, and answering questions from patients and families regarding EOL dilemmas and decisions. Help in development of these role plays can come from local nursing faculty who do teach this content, chaplains and social workers affiliated with local Hospice agencies. Use situations encountered on the unit as the basis for as many of the scenarios as possible since they carry the validation of 'real life' with them.

Pediatric units might explore the perspective of issues related to dying children who are remaining in school classrooms for longer periods of time after terminal diagnoses are made. School nurses are excellent resources on the problems and limits facing school districts and campus personnel in these situations. Sharing information about many topics can facilitate admissions and referrals while enlarging the understanding of pediatric care for both the staff and school nurses. Germane topics that might lend themselves to discussion include: general situations associated with parents' reactions to impending death of a child, denial manifestations of parents and family members, communication techniques that can be effective with other children in the class and school, assessment criteria that school nurses, and by extension teachers, can be aware of so that appropriate notification of school officials can be implemented, and effects of Out of Hospital DNR's on classroom dynamics.

The importance of keeping experienced staff informed on current trends in EOL care cannot be underemphasized. Attendance at workshops should be promoted and the use of agency continuing education departments to facilitate ongoing education should be a priority for nursing administration. Many options can be employed to keep costs down and interest up on EOL issues and options with just a little creative effort on the part of nursing leadership in each agency. The rewards personally and institutionally are well worth the effort.

STUDENT NURSES:

Enhanced understanding of EOL issues and care techniques can easily be integrated into the clinical learning experiences by nursing educators who view end of life care as a standard of practice. Students can be shown that care elements associated with death and dying need not be limited to the last 24 hours of a person's life, but can be integral to decisions and care early in diagnosis and treatment of many disease processes. The following suggestions are only a few ways that clinical conferences can be used to expand student awareness and skills beyond the theoretical content received in the traditional classroom.

CLINICAL DISCUSSIONS:
Faculty can include EOL information within clinical discussions during Pre and Post conferences. Other clinical focus topics for the week can have EOL info incorporated easily into any discussion:
Cultural differences in end-of-life philosophies, care needs, grief responses, and management of the deceased after death are only a few of the topics that can bring a multicultural awareness into the nursing care administered by students.
Nutrition foci can include topics such as anorexia in the dying process, the ethical administration of artificial nutrition and hydration, and care of patients with dysphasia near the end of life.
Pain management is a very important topic today, and EOL issues about increasing levels of analgesia vs. concerns regarding side effects can and should be examined. Guest speakers from Hospice can shed tremendous light on this topic.
Medication administration in general, and the effects of the dying process on absorption and distribution of medications warrants review and examination, especially for students early in their nursing clinicals. This topic can reinforce anatomy and physiology while reflecting the physiological changes that occur in the dying process. Risks and contraindications to medications administration should be illuminated and emphasized. A focus on patient safety and the importance of assessment can reinforce quality nursing care.
Critical Thinking exercises can be effectively used in discussions about modifications of routine care when the patient is actively dying. Bathing and turning schedules can be evaluated for the desired outcomes as the treatment goals change with the progressive dying process. Students, particularly early in their education, easily focus on the tasks. Such discussions and exercises will help them advance in their recognition of the broad scope of nursing care that can be rendered based on individual patient situations and data.
Nursing diagnoses infrequently used with many of the patients students could be assigned to can be reviewed and clarified. Topics to look at with these Nursing Diagnoses would include the definition of the diagnostic label, possible etiologies that might be common in different disease processes, essential characteristics of the Nursing Diagnosis statement found during assessment activities that would confirm the applicability of the diagnosis and etiology, along with realistic goals and interventions for such patients. Students benefit from faculty elaboration in the area of proper identification and use of specific nursing diagnoses. Such discussions will enhance assessment skills, and promote critical thinking within the application of the nursing process.
Discussions about manifestations of grief and appropriate nursing actions will contribute to students' skills and ease with such situations. These grief reactions are occurring even with losses that do not include death, such as losses of body parts, general health deterioration, and sense of identity with changing lifestyles make valuable topics for discussions within clinical conferences.

Death will be encountered in every avenue in which nurses are found. Nurses must be prepared to extend care and caring to persons and families who face sudden and unexpected deaths, untimely deaths of children and young persons, as well as the inevitable death of elderly and infirm. Without additional opportunities to explore and resolve issues surrounding the care of the dying and bereaved, we will deprive nurses of key tools and talents they deserve to be using. It is up to those of us already active in nursing and nursing education to pursue such opportunities and solicit support for expanded education in the context of end-of-life issues.

References:

American Association of Colleges of Nursing, Washington, DC. Position Paper on "Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Nursing Care."

ELNEC Project, American Association of Colleges of Nursing, City of Hope, and the Robert Wood Johnson Foundation. Washington, DC.

Ferrell, Betty Rolling and Coyle, Nessa. Textbook of Palliative Nursing. New York: Oxford University Press, 2001.

Fleming D.A. Cultural sensitivity in end-of-life discussions. Mo Med. 2003 Jan-Feb.;100 (1): 69-75.

Jezewski, MA, Meeker, MA, Schrader, M. Voices of oncology nurses: What is needed to assist patients with advance directives. Cancer Nurs. 2003 Apr;26(2):105-12.

Wakefield, A. Nurses' responses to death and dying: a need for relentless self-care. Int J Palliat Nurs. 2000 May: 6(5): 245-51.