The Importance of End-of Life Care: Nurse Education

Abstract

Recently, there has been neglect of the traditional focus upon comforting patients who are at the end of their lives. In addition, there has been inadequate staff for palliative care, limited knowledge of palliative medicine, and a lack of knowledge in medical practitioners about the preferences of elderly adults who are receiving end-of-life care. The scope of palliative medicine has not been exploited fully in the current hospital environment and there is a need to expand the scope. One way of doing this is by ensuring that the current working staff are enlightened and equipped to deal with the palliative issues they encounter now and then.

There has been an exploitation of palliative care in nursing homes, but the scope needs to be extended to home care centers for the sick in a wider perspective. There exists a demand for palliative care for patients in the face of a shortage of nurses in nursing homes. Topics that need to be featured in palliative care programs include making nurses aware of the demand for palliative care among patients, increasing the efficiency of palliative care, organizing nurses so they can establish common principles of palliative care, and consideration of patients’ preferences.

Introduction

Nature of the Problem

The traditional role of comforting terminally ill patients as they face their final days has been recently neglected by modern foci in medicine despite the advance of the latter in biomedical research and the ability to treat long-term illnesses. In addition, there is no palliative medicine specialist in the United States. There is, therefore, the need to increase focus in the field of palliative medicine in terms of increasing specialists, conducting research, and boosting interest in the field among current practitioners.

Palliative and hospice care has emerged as an important field in today’s society in the face of inefficiency in the healthcare system, aging of the population, and shortage of healthcare practitioners, among other factors. End-of-life care is necessary to increase patients’ quality of life as well as to ease the transition into death. Caring for the elderly at home has also become an interest in the field of geriatric health care. The latter may involve components of end-of-life care. There is a necessity to equip registered nurses, licensed practical nurses, and certified nursing assistant staff with end-of-life care skills to improve the practice.

Purpose of the Study

The current study seeks to analyze the field of palliative and hospice care in current medical settings and how much interest has been given to the field. The research will explore the components of end-of-life care such as modifiable and non-modifiable elements, as well as necessary interventions.

The study seeks to establish ways through which palliative and hospice care can be improved by enlightening the importance of it among current medical practitioners, including registered nurses, licensed practical nurses, and certified nursing assistants. This research will explore the various issues to be covered in programs that focus on enlightening medical practitioners in improving palliative care. There is a need for medical practitioners to have a common focus on the basic principles of end-of-life care as well as understand that various clinical care demands exist among patients. While some patients may require highly specialized care, others may not need, or desire, it.

Significance of the Study

This palliative and hospice care study shall establish the existing situation in the field as it relates to the focus on the current medical setup and the capability of registered nurses, licensed nurses, and certified nursing assistants to handle end-of-life patients. Knowledge of the current competence of medical practitioners in the field of palliative and hospice care would help improve the situation by seeking to establish ways in which competence can be enhanced.

Application of research-based methods and palliative care literature for training staff in palliative care would enhance the effectiveness, competence, and skills of practitioners. The health care industry needs to focus on improving pain management and other components of palliative care. The community would benefit from such a study in that the number of people treated through improved palliative and hospice care will increase; hence, suffering and deaths will decrease.

Awareness of the demand for palliative care would help healthcare institutions to increase their focus on these services to serve their customers more efficiently. In addition, management of staff and enhancement of their skills as they relate to palliative care boosts institutions’ capability to serve their customers well; for example, offering more complete healthcare services reduces costs incurred as a result of employing specialists because such an approach focuses on equipping a current staff.

Research Question

What are the appropriate topics to apply in fostering education among medical practitioners? What is the current status of palliative care in medical practice?

Review of the Literature

Chronicle

Studies have proved that many Americans do not have access to end-of-life care. It was revealed in a study that 40% of patients aged 80 and above experienced severe pain during their last three days of life (Vig, 2002; p. 1541). The recommendations issued by the Institute of Medicine on addressing the deficiencies identified at the end of life include strengthening the knowledge base for end-of-life (Vig, 2002; p. 1541).

Nursing homes in the United States have been termed as increasingly becoming places of death given the increasing number, frailty, and age of terminally ill individuals residing there (Weitzen et al., 2003; Holtzman et al., 1996; as cited in Renée et al., 2005, p. 1651). These numbers include patients transferred there from hospitals during their final days. In contrast to the beginning of the twentieth century, when most people died at home, a quarter of the deaths in the United States now occur in nursing homes (Renée et al., 2005, p. 1651).

Recently, more people have been able to postpone, if not avoid, admission to nursing homes thanks to options that are increasingly becoming available. Considerable physician presence at nursing homes has been the expectation of families and residents owing to their perception that such places are healthcare institutions. Concerns have been raised about the insufficiency of staff for good care, pain treatment, and appropriate assessment of end-of-life care in nursing homes (Teno et al., 2004; Harrington et al., 2001; cited in Renée et al., 2005, p. 1651).

Many problems such as

  1. dissatisfaction of residents and their family members with nursing homes,
  2. poor communication and decision-making,
  3. inadequate symptom management,
  4. high rates of hospitalization, and
  5. mistaken patient diagnosis have been linked to inadequate physician presence in nursing homes (Hanson et al., 1997; Mehr1 et al., 2003, Hanson et al., 2002; as cited in Renée et al., 2005, p. 1651).

Different Principles

In 1996, a group involving medical specialties, subspecialties in internal medicine (including the American Medical Association), and 13 surgical specialties agreed to work within their respective societies to develop clinical methods, tools, and guidelines to meet agreed-upon needs regarding the access and quality of clinical care at the end of (Cassel & Foley, 1999) life. The aforementioned group came up with a set of principles for end-of-life care that was organized into 11 core principles, which were then issued to representatives to take to their societies for consideration and implementation.

The core principles included the need to promote clinical and evidence-based research on providing care at the end of life, provide access to palliative care and hospice care, offer continuity of care if the patient desires so (by his/her primary care and specialist providers), and the provision of therapy realistically expected to improve end-of-life care as well as assess and manage psychological, social, and spiritual/religious issues according to Cassel & Foley, (1999). Other principles agreed upon included

  1. respecting the right of the patient to refuse treatment,
  2. discontinuing some treatments when appropriate while remaining considerate of the family’s and patient’s preferences,
  3. having sensitivity towards and respect for patients’ and families’ wishes, and
  4. respecting the dignity of caregivers and patients.

The adoption of the principles was carried out by some societies such as the American Medical Association (AMA); who, in their submission expressed that they would expect eight elements of care to be observed by physicians, health care institutions, and the community as patients in the end-of-life phase sought peace and dignity (Cassel & Foley, 1999). The Academy of Psychosomatic Medicine (APM), for its part, focused on several issues, including attention to psychiatric complications of terminal illness, by conducting related research through young investigators who were trained in this area. The research was expanded through collaboration with private foundations and governmental funding agencies (Cassel & Foley, 1999).

Preferences

The importance of patients having an active role in determining the quality of end-of-life care has been discussed. Preferences of patients may help the health professionals to understand them and develop patient-centered care plans (Vig et al., 2002). Terminally ill adults and older adults are the two distinct populations that face end-of-life issues and that have higher mortality rates than other populations. There has been a belief among investigators that caregivers and healthcare providers may not accurately interpret the dying experience of others (Higginson et al., 1996; as cited in Vig et al., 2002, p. 1542). For example, older adults’ preferences for end-of-life interventions like resuscitation are not understood adequately among healthcare providers or the patients’ families (Uhlmann et al., 1988; Seckler et al., 1991; as cited in Vig et al, 2002, p. 1542).

It has been found in one study that end-of-life treatment preferences among older adults were influenced more by the anticipated outcome of serious illness than the medical interventions employed to sustain life (Rosenfeld et al., 2000; as cited in Vig et al, 2002, p. 1542). According to Vig et al. (2002), the latter research failed to address the views of older adults about good and bad deaths, the associations between current values and preferences for the end-of-life, and the reasons for the preferences.

Nursing homes must understand the expectations of the patient residents and their families regarding the need to have adequate staff on-site as well as maintain high standards, such as staff that are highly qualified to provide palliative care. The latter can be ensured by training existing staff. This is because specialists in palliative care are scarce and may be expensive to employ to meet demand, and/or existing specialists in the institutions may not serve patients’ needs satisfactorily.

Pain management is an important aspect of palliative care and nurses must learn practical skills for reducing pain in patients to reduce their suffering. Institutions must also be informed that such practices may be covered by the law; and, therefore, that they need to know the practical strategies to implement so that it will not be difficult for healthcare practitioners to offer palliative care to their patients. Such practices include the use of certain drugs and procedures of pain management, as well as an emphasis on the ethics, as well as the legal, implications involved in the management of palliative care, and ensuring that nurses understand the foregoing.

The efficiency of Hospice and Palliative Care practitioners is also an important aspect of end-of-life care; therefore, the organization of services and facilities must provide support for end-of-life care. Equipping of the aforementioned practitioners to enhance end-of-life care includes the provision of education and other skills to make them aware of what end-of-life care means, the importance and necessity of end-of-life care, how to achieve end-of-life care, and to enable them to handle end-of-life patients through practical experience.

Of the 2.5 million people who die in the United States yearly, many of those who die at ages above 65 do so from complications of neurobiological disorders like Parkinson’s, Alzheimer’s, or stroke, and the need for improvement in the care provided by those responsible to care for the dying has been necessitated by the wide range of clinical disorders (Cassel & Kathleen, 1999). These practitioners are exposed to these types of patients from time to time.

Establishing a common focus and basic principles that underlie the roles and responsibilities of medical practitioners in end-of-life care is necessary because different specialties may see different aspects regarding the care of dying patients (Cassel & Kathleen, 1999). Differences exist among the patients as relates to the type of or the extent of clinical needs (Institute of Medicine, 1997; cited in Cassel & Kathleen, 1999). While some patients may require highly specific specialty care, others may not.

Methodology

The research undertaken in this study will be a developmental research methodology that focuses on prior research. In this study, past research on palliative and hospice care has been analyzed and the former status of palliative care established through consideration of past research articles.

It has been established from past research that the demand for palliative care exists because patients in need of end-of-life care continue to flock to hospitals and because those who choose home care and other options are also in need of end-of-life care. The literature establishes that there is a shortage of practitioners who are specialized in or focused upon providing end-of-life due to the existing demand for palliative care. Hence, it is the conceptualization of the researcher that medical institutions can solve the existing problem by training current staff on palliative care. This will boost the number of staff who can provide palliative care.

It has been established in this paper that, although the demand for specialized palliative care is high, medical practitioners do not understand older adults’ preferences regarding end-of-life care. Indeed, the literature has not yet explored this subject. To train staff, there is a need for an educational program that deals with a range of topics and will seek to create knowledge and awareness of the subject matter. The topics to be featured include the need for palliative care, the demand among patients for the same, and practical skills for meeting the needs of the patients, such as inquiring into and investigating their preferences and those of their families before developing plans for palliative care.

Other topics include the need to organize the working staff to agree on the common or basic principles of palliative care. Nurses must be aware that they are each empowered to solve patients’ needs or enlist his/her colleagues to help provide patients with palliative care since they will interact with such patients now and then in their careers. Staff must be committed to assisting without terminating care to patients unless the patients are willing to do so. Other topics include increasing nurses’ efficiency in providing palliative care to save lives and the particular illnesses that may pose the greatest danger to patients, such as cancer.

Procedures

The research undertaken in this study will be a developmental research methodology that focuses on prior research. In this study, past research on palliative and hospice care has been analyzed and the former status of palliative care established through consideration of past research articles.

Assumptions

One of the assumptions in the above methodology is that the literature considered discusses the current situation or covers the current status of palliative care. This may be somewhat true because evidence of the shortage of nurses and problems with inefficiency in healthcare systems have lately been reported. It is also true that several Americans, for example, do not have health insurance and, therefore, such problems as obtaining end-of-life pain management would be expected.

Another assumption is that the literature considered covers individuals in most or all locations. Of course, there are differences in terms of the availability of palliative care, even within countries like the United States. For instance, individual states may adopt various measures in healthcare that may have quickened or slowed down the focus on palliative care. Other differences exist in the implementation of strategies to take care of patients and focus on palliative care among different hospitals. Another assumption is that there is agreement among the studies that have focused on palliative care. Of course, differences of opinion on the efficiency, methods, and how to achieve palliative care may exist concerning theory and practice.

Limitations

Various limitations to this research are evident; for instance, analysis of data could have presented a more accurate assessment of the state of palliative care. Data-driven evidence may have communicated the message more strongly. Research in this case dealt with limited literature on palliative care, and expansion of this theory would have been important. Although the literature brings out the diversity amongst healthcare institutions as pertains to the implementation of palliative care to some extent, consideration of more case studies would have been more influential.

Expectations

Anticipated Benefits

The anticipated benefits expected from this educational endeavor will be educating healthcare professionals in the area of Hospice and Palliative Care. It is the aim of this practicum to broaden the knowledge base of healthcare professionals in the field of Hospice and Palliative Care. It is the expectation that Registered Nurses, Licensed Practical Nurse, and Certified Nursing Assistance among other professionals will be educated on how to improve end-of-life care.

The literature developed in this program will equip nurses, healthcare professionals, and the institutions involved with actual, practical skills to be able to venture into the field of palliative care by raising concern about the demand for the service. This literature would help institutions manage their personnel more effectively and even equip them with the necessary skills that are required to fully assist patients in need of palliative care. The program will also educate medical professionals on the need to establish patient-based palliative care plans by making sure that their expectations and choices are the basis for such plans. A focus on training existing staff would enable institutions to benefit by utilizing them in providing palliative care services to offer a complete range of care for their patients.

Assumptions

The literature applied in this research varies in time, and we assume that it is the most recent. Changes would, however, be expected in the development of a focus on palliative care. The emphasis on the implementation of the methods discussed to improve care is done on the assumption that they will be useful where they have not been implemented and that they will give the desired results. Normally, local conditions would demand some adjustment to the techniques to be used in improving palliative care. Thirdly, we assume that the problem of palliative care is being experienced uniformly across all states and institutions, which may or may not be the case.

Implications

Different hospitals and healthcare institutions may have different ways of ensuring that palliative care is a component of their day-to-day activities, depending on existing local conditions that may not have been exhausted in this research. Such local conditions differ from one country to another, one state to another, etc.; therefore, a uniform curriculum may not work.

The implications of the current research include the consideration of a small number of studies. The use of more cases would have shed more light on the implementation of the core principles of palliative care and helped to explore more options that the program could have focused on. The program would, therefore, be more persuasive literature if more case studies of hospitals or healthcare institutions had been considered. The assumption that the literature considered is current is not correct and, therefore, may undermine more research on the topic because this research presents only partial practical reality on the subject matter.

References

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Ersek, M., & Wilson, S.A. (2003). The challenges and opportunities in providing end-of-life care in nursing homes. J Palliat Med 6, 45–57.

Farber, S.J., Egnew, T.R., Herman-Bertsch, J.L. et al. (2003). Issues in end-of-life care: Patient, caregiver, and clinician perceptions. J Palliat Med 6,19–31.

Higginson, I., Wade, A., & McCarthy, M. (1990). Palliative care: Views of patients and their families. BMJ 301, 277–281.

Hanson, L.C., Danis, M., & Garrett, J. (1997). What is wrong with end-of-life life care? Opinions of bereaved family members. J Am Geriatr Soc 45, 1339–1344.

Hanson, L.C., Henderson, M., & Manon, M. (2002). As individual as death itself: A focus group study of terminal care in nursing homes. J PalliatMed 5, 117–25.

Holtzman, J. & Lurie, N. (1996). Causes of increasing mortality in a nursing home population. J Am Geriatr Soc 44, 258–264.

Mehr D.R., van der Steen, J.T., Kruse, R.L. et al. (2003). Lower respiratory infections in nursing home residents with dementia: A tale of two countries. Gerontologist 43, 85–93.

Shield, R. R., Wetle, T., Teno, J., Miller, C.S., and Welch, L. (2005). Physicians “Missing in Action”: Family Perspectives on Physician and Staffing Problems in End-of-Life Care in the Nursing Home. The American Geriatrics Society 53(10).

Shuster, J.L., Jr., Breitbart, W., & Chochinov, H.M. (1999). “Psychiatric Aspects of Excellent End-of-Life Care,” Ad Hoc Committee on End-of-Life Care, Academy of Psychosomatic Medicine. Psychosomatics 40(1), 1–4.

Rosenfeld, K.E., Wenger, N.S., & Kagawa-Singer, M. (2000). End-of-life decision making: A qualitative study of elderly individuals. J PalliatMed 15, 620–625.

Seckler, A.B., Meier, D.E, Mulvihill, M. et al. (1991). Substituted judgment: How accurate are proxy predictions? Ann Intern Med 115, 92–98.

Uhlmann, R.F., Pearlman, R.A., & Cain, K.C. (1988). Physicians’ and spouses’ predictions of elderly patients’ resuscitation preferences. J Gerontol 43, M115–M121.

Vig, K.E., Davenport, A.N., & Pearlman, R. (2002). Good Deaths, Bad Deaths, and Preferences for the End of Life: A Qualitative Study of Geriatric Outpatients. The American Geriatrics Society 50(9), 1541–1548. Web.

Weitzen, S., Teno, J.M., Fennell, M. et al. (2003). Factors associated with the site of death: A national study of where people die. Med Care 41, 323–335.

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