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CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 705

more standardized in the form of theory, competen- and relieving physical discomfort) and the peace pro-
cies, and curricular guidelines. Ruland and Moore cess criterion (monitoring and meeting patient’s
(1998) are an example of an early end-of-life theory as needs for antianxiety medication). Nonpharmaco-
attention to hospice and palliative care has developed. logical interventions (e.g., music, humor, relaxation)
Ruland and Moore (1998) were cited by Kirchoff and that serve to distract a dying patient are useful for
colleagues (2000) when End of Life was a featured the relief of pain, anxiety, and general physical
topic of a CE (continuing education) offering for discomfort. Future studies are suggested to explore
critical care nurses in their online journal. linkages of the Peaceful End-of-Life Theory to other
middle-range theories such as one for acute pain
Research based on practice guidelines (Good and Moore,
The Peaceful End-of-Life Theory has gained interna- 1996), pain management (Good, 1998), and unpleas-
tional recognition as containing key components of a ant symptoms (Lenz, Pugh, Milligan, et al., 1997;
peaceful death. Kongsuwan and colleagues created a Lenz, Suppe, Gift, et al., 1995).
conceptual model (Kongsuwan & Touhy, 2009) and
conducted qualitative (Kongsuwan & Locsin, 2009) Critique
and quantitative research (Kongsuwan, Keller, Touhy
et al., 2010) on peaceful death in adult patients in Clarity
Thailand. Ruland and Moore’s (1998) Peaceful End- All elements of the theory are stated clearly, including
of-Life Theory served as a comparison model for the setting, assumptions, concepts, and relational
Kongsuwan and colleagues’ work and was cited as statements. These concepts vary considerably in their
possessing qualities essential for a peaceful death that level of abstraction, from more concrete (pain and
have been identified in many cultures. comfort) to more abstract (dignity).
In Quebec, an ethnographic study was conducted
to identify key components of a good death for rural Simplicity
residents, and the authors identified The Peaceful Despite uncomplicated terms and clear expression of
End-of-Life Theory as important to developing an ideas, the theory has been described as one of a
understanding of the concept of a good death (Wilkie, higher-level middle-range theories (Higgins & Moore,
Johnson, Mack, et al., 2010). 2000), primarily because of the level of abstraction
of the outcome criteria and the multidimensional
complexity expressed in its relational statements.
Further Development
Ruland and Moore acknowledge the need for contin- Generality
ued refinement and development of the theory. There The Peaceful End-of-Life Theory has specific bound-
are a number of potential ideas to advance its devel- aries related to time, setting, and patient population.
opment, and testing the theory is in the planning It was developed for use with terminally ill adults and
stage; for example, testing the relationships among their families who are receiving care in an acute care
the five major concepts is a possibility. Another idea setting. The concept of peaceful end of life came from
is merging some of the process criteria from the three a Norwegian context and may not be appropriate for
concepts of pain, comfort, and peace to explore out- all cultures; however it has been noted for practice by
comes related to physical-psychological symptom nurses in other cultures. Its concepts and relation-
management. Concept analysis or mapping could be ships resonate with many nurses, and it comprehen-
used to determine if the process criteria associated sively addresses the multidimensional aspects of
with the three concepts are different or sufficiently end-of-life care. For example, the outcome indicators
alike to allow merging. For the concept of pain, two associated with the five concepts address the techni-
process criteria (monitoring and administering pain cal aspect of care (providing both pharmacological
relief and applying pharmacological and nonpharma- and nonpharmacological interventions for the relief
cological interventions) are closely related to the of symptoms), communication (decision making),
comfort process criterion (preventing, monitoring, the psychological aspect (emotional support), and