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CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 707

approach could be used to investigate patient and
family perceptions of their opportunities for and sat- breathing, even though her mother has a Do Not
isfaction with family closeness, decision making, or Resuscitate (DNR) order.
both. Also with attention to linkages, a number of The physician has ordered home hospice care.
existing instruments could be considered to measure The daughter greets the social worker and nurse at
outcome indicators associated with the five concepts the door and insists the word hospice is not men-
(see Figure 36–1) such as perception of symptoms tioned to her mother, as it would “kill” her. During
with the Memorial Symptom Assessment Scale the hospice admission, it became clear that Becky
(Portenoy, Thaler, Kornblith, et al., 1994) or the Gen- understands she is dying and sees how much her
eral Comfort Questionnaire (Kolcaba, 2003). children are grieving over the thought of losing
another parent. After several weeks on the hospice
program, Becky continues to report discomfort,
high pain levels, shortness of breath, and difficulty
CASE STUDY
in communicating with her children about her
Becky is a 66-year-old woman who was diag- wishes. She is not ready to say good-bye to her
nosed with stage IV congestive heart failure children or grandchildren and is afraid to die.
(CHF). She is recently widowed (approximately Despite prescribed medication and team-focused
6 months ago) and the mother of four devoted care (social worker, nurse, nursing assistant, and
young adult children and the grandmother of clergy), Becky continues to rate her pain level at
two. Her youngest daughter (Sue) lives with her severe (8 to 10) and talks about her suffering, fear of
mother and is a student at a local University. Sue death, and concern over what will happen to her
has taken leave from the University to care for family when she is gone. During a team meeting, it
her mother. Becky has completed her advance was decided to ask Becky to describe three different
directives, and is adamant that she not receive kinds of pain (physical, emotional, and spiritual).
extraordinary measures to sustain her life. This Becky had a physical pain rating of 3 to 4, and both
has been a difficult issue for her children, as they emotional and spiritual pains were rated as severe
cannot fathom the loss of another parent. Sue is (8 to 10). The adult children continue to ask about
the durable power of attorney (DPOA) and states treatments that are more aggressive; however, they
she will call 911 in the event her mother stops also state that they do not like to see her suffer.

CRITICAL THINKING ACTIVITIES
The end of life is filled with complex physiological, to suffering (e.g., emotional, spiritual, and psy-
psychological, spiritual, and family relationship chological) in a case from your clinical practice?
problems that affect the patient’s comfort and ability In the case of Becky?
to achieve peaceful end of life. In addition, unre- 2. Use the concepts of “closeness to significant others”
solved issues in family relationships can lead to and “experience of dignity and respect” from the
complicated grieving for family members before Peaceful End-of-Life Theory to assist you in devel-
and after the death. Suffering outside of physical oping a nursing practice strategy to address the
discomfort is not readily understood, but the relief relationship issues for Becky and her family.
of suffering is a fundamental goal of end-of-life care 3. With the professional ethical standards for nursing
and is necessary to achieve comfort and a peaceful practice (such as ANA), evaluate the correspon-
end of life. dence with the “experience of dignity and respect”
1. Explore the Peaceful End-of-Life Theory in in this theory. Discuss the similarity, difference,
relation to your practice. How does it assist relevance, significance, scope, usefulness, and
you in identifying and addressing issues related adequacy.