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CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 703

MAJOR CONCEPTS & DEFINITIONS can be derived from these relational statements to be
tested their usefulness. The authors of the standard
Not Being in Pain of care and authors of the theory attempted to incor-
Being free of the suffering or symptom distress is the porate clearly described, observable concepts and
central part of many patients’ end-of-life experience. relationships that expressed the notion of caring.
Pain is considered an unpleasant sensory or emo-
tional experience associated with actual or potential Major Assumptions
tissue damage (Lenz, Suppe, Gift, et al., 1995; Pain
terms, 1979). Nursing, Person, Health and Environment
As in other middle-range theories the focus of the
Experience of Comfort theory of peaceful end of life does not address each
Comfort is defined inclusively, using Kolcaba and metaparadigm concept. The theory was derived from
Kolcaba’s (1991) work as “relief from discomfort, standards of care written by a team of expert nurses
the state of ease and peaceful contentment, and who were addressing a practice problem, therefore,
whatever makes life easy or pleasurable” (Ruland the metaparadigm concepts explicitly addressed were
& Moore, 1998, p. 172). nursing and person. The theory addresses the nursing
phenomena of complex, holistic care to support per-
Experience of Dignity and Respect sons’ peaceful end of life.
Each terminally ill patient is “respected and valued Two assumptions of Ruland and Moore’s (1998)
as a human being” (Ruland & Moore, 1998, p. 172). theory are identified as follows:
This concept incorporates the idea of personal 1. The occurrences and feelings at the end-of-life
worth, as expressed by the ethical principle of experience are personal and individualized.
autonomy or respect for persons, which states that 2. Nursing care is crucial for creating a peaceful end-
individuals should be treated as autonomous of-life experience. Nurses assess and interpret cues
agents, and persons with diminished autonomy are that reflect the person’s end-of-life experience and
entitled to protection (United States, 1978). intervene appropriately to attain or maintain a
peaceful experience, even when the dying person
Being at Peace cannot communicate verbally.
Peace is a “feeling of calmness, harmony, and con- Two additional assumptions are implicit:
tentment, (free of) anxiety, restlessness, worries, 1. Family, a term that includes all significant others,
and fear” (Ruland & Moore, 1998, p. 172). A is an important part of end-of-life care.
peaceful state includes physical, psychological, and 2. The goal of end-of-life care is not to optimize care,
spiritual dimensions. in the sense that it must be the best, most techno-
logically advanced treatment, a type of care that
Closeness to Significant Others frequently results in overtreatment. Rather, the
Closeness is “the feeling of connectedness to other goal in end-of-life care is to maximize treatment,
human beings who care” (Ruland & Moore, 1998, that is, the best possible care will be provided
p. 172). It involves a physical or emotional near- through the judicious use of technology and com-
ness that is expressed through warm, intimate fort measures, in order to enhance quality of life
relationships. and achieve a peaceful death.

terminally ill patients. The standard of care consisted Theoretical Assertions
of best practices based on research-derived evidence Six explicit relational statements were identified
in the areas of pain management, comfort, nutrition, (Ruland and Moore, 1998) as theoretical assertions
and relaxation. This prescriptive theory comprises for the theory, as follows:
several proposed relational statements for which 1. Monitoring and administering pain relief and
more empirical evidence is needed. Explicit hypotheses applying pharmacologic and nonpharmacologic