ARTICLES

PEACEFUL END OF LIFE THEORY FOR OLDER

PATIENTS IN NURSING PRACTICE
By
MEHTAB QUTBUDDIN JAFFER
MScN (Student Year II), BScN, Aga Khan University, School of Nursing and Midwifery.

ABSTRACT
Providing appropriate end-of-life care has become a primary concern of nurses. In today's world, it is important for
nurses to strengthen their knowledge regarding end-of-life especially for elder people. The purpose of this article is to
study the theoretical underpinning, concepts, metaparadigms and definitions of the peaceful end-of-life framework
proposed by Cornelia Ruland & Shirley Moore in 1998. Proposed theory was reviewed in depth to identify the concepts
emerging from end-of-life care. Ruland & Moore have defined five major outcome standards that contribute to a
peaceful EOL for terminally ill patients. (1). being free from pain, (2) experiencing comfort (3), experiencing dignity and
respect, (4) being at peace and (5) experiencing a closeness to significant others or other caring person. This theory
contributes the rich body of knowledge for nurses the need to provide end-of-life care. It provides insights and can
contribute to increase knowledge about nursing interventions that provides peaceful end of life to the terminal ill
patients.
Keywords: End-of-Life Care, Terminal Ill Patients, Nursing Interventions.

INTRODUCTION end-of- life care.

Since past years, the development of middle range Aim of the Paper
theories has been increased. Recognition of these theories The aim of this paper is to discuss the use of Ruland and
in the nursing field provides knowledge and has been Moore: Peaceful end of life (EOL) from middle range theory
stimulated to address issues related to clinical nursing for the care of older patient.
practice (Ruland & Moore, 1998). Middle range theories
Background of the Theorist
are applied and can be tested in clinical situations. These
Cornelia M. Ruland, received Ph.D in nursing degree from
theories offers framework which provide guidance for
Western Reserve University, Ohio, in 1998. She has been
nursing interventions. Several Middle range theories
primary investigator of number of research projects, having
(Maternal role attainment, uncertainty in illness, self-
extensive experience on various research programs in
transcendence theory, theory of chronic sorrow, theory of
improving patient-provider partnership in health care
comfort, theory of caring and peaceful end of life theory)
(Tomey & Alligood, 2010). Also, Shirley M. Moore, received
have emerged in the literature and can increasingly
her Ph.D in nursing science in 1993. She has gained
applied and tested at various clinical settings (Tomey &
experience in teaching nursing theory and nursing science
Alligood, 2010). These theories provides specific framework
subjects to nursing students. She conducts various research
which provide guidance to the nursing interventions in daily
programs at graduate and undergraduate level studies.
day clinical practice guidelines. Nurses emphasize
This theory was derived during the doctoral theory course in
physical interventions as an integral part of their clinical
which Moore was the faculty and Ruland was the student.
process; however majority of the nurses did not feel
Ruland was able to successfully complete the project and
comfortable discussing end of life care with the patients
developed standard clinical guidelines for the peaceful
(Murrish, 2010). So, in order to provide appropriate end-of-
EOL (Tomey & Alligood, 2010).
life care, it is important to study the literature addressing

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Theoretical Underpinning at EOL experience are personal, are based on

The End of Life (EOL) theory is based primarily on the classic individualized patients and secondly nursing reflection on
work of Donabedian's Model, which consists of standards dying patient interventions. The goal of EOL care in not to
includes structure, process, and outcomes. In this theory, optimize care in terms of technological or over treatment
structure is the family and terminally ill patient that are rather the primary goal is to provide best possible comfort
receiving care from health care professionals, process measures in order to achieve quality of life and peaceful
defined as those nursing action which are intended to death (Patricia in Alligood & Tomey, 2010 p. 756-757).
endorse the positive patient care which results in positive Ruland & Moore theory was straight forward and clearly
outcomes in clinical settings. There are several middle progressed. It was widely practiced over community
range theories that address the aspects of EOL care, development as a means to improve EOL decision-
however none of the nursing theories exists which provides making for critically ill adults, integrated into nursing courses
framework that consist of all the aspects that are necessary and for research purpose (Patricia in Alligood & Tomey,
for the terminally ill patients. The need for this theory was 2010 p.757). The concept of hospice and palliative derives
identified when there were no formal clinical guidelines. from Ruland & Moore's.
“The lack of clearly defined directions for terminally ill Major Concepts and Definitions
patients, serves as barrier for provision of quality nursing This theory on EOL was proposed from direct experience of
care (Ruland & Moore, 1998, p.3)”. nurses who had 5 years of clinical experience and
The development of this theory resulted in initiation of new thorough literature review. This theory attempted to clearly
standards for the patient about peaceful EOL. Ruland & described, observable concepts that express the idea of
Moore (1998) cited “The main focus for the development caring (Patricia in Alligood & Tomey, 2010, p. 756). Ruland &
was not dying itself; but contribution to peaceful and Moore (1998) defined five outcome standards that
meaningful living that remained for the patients and their contribute to a peaceful EOL for terminally ill patients. (1).
significant others (p.171)”.In nursing homes; many patients being free from pain, (2) experiencing comfort (3),
are in EOL stage, facing problems of all dimensions and experiencing dignity and respect, (4) being at peace and
need comfort care. They have several discomfort feelings (5) experiencing a closeness to significant others or other
(nausea, thirst, elimination problem and other bodily caring person (p.174). The conceptual definition of
related problems which they were unable to verbalize and outcomes standards were thoroughly and well defined in
ventilated (Ruland & Moore, 1998).These concepts were the several literatures. To visualize the relationship between
not entertained. At that point of time, they need physical, five standards of EOL care for terminally ill patients, see
social as well as psychological care. Figure 1.
This theory provides a new dimension that will enhance and Firstly, being free from pain means not having any sort of
provide best possible nursing care for the terminally ill pain. Pain is unpleasant, sensory experience which is
patients. Another very important point is that the terminally associated with any actual or potential tissue damage
ill patients are not able to communicate their pains, (Patricia in Alligood & Tomey, 2010, p. 780). Almost in many
distress, and sorrows to the nurse who are involving in their literatures, pain has been well defined including its
care. Therefore, it is important for nurses to make patient assessment, management and treatments.
rest of the life in meaningful manner. Secondly, experience of Comfort was defined as “Relief
Metaparadigm Concepts from discomfort, the state of ease and peaceful
Ruland and Moore (1998) addressed metaparadigm contentment and whatever makes life easy or pleasurable
concepts to provide holistic peaceful EOL. These were (Ruland & Moore 1998, p.172)”. In nursing homes, most of
nursing, person, environment and health. They have the patients were sick, bedridden and terminally ill. They
identified two assumptions in this theory. Firstly, the feelings were in the state of discomfort and it could be due to many

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reasons (e.g. nausea, thirst and elimination problem). by providing physical assistance if desired.
Ruland & Moore (1998) described few actions that help Finally, experiencing the closeness by providing the feeling
patients experience comfort. It includes providing of connectedness to other significant persons. It can also
comfortable bed position, preventing from bed sore, using be achieved by facilitating opportunities to meet and
therapeutic touch, offer comfortable activities like music, share with their close family members.
massage, physical activity, mouth care, foot care and eye
The application of these theories provides guidance that
care (Ruland & Moore, 1998, p.173).These theorists very
lead to positive interventions. The rationale for selecting
nicely identified three criteria to facilitate patient comfort:
these theories was that it was relatively simple, logical in
(1) Preventing, monitoring and relieving physical
nature, generalized, understandable and facilitates nurses
discomfort, (2) facilitating relaxation and (3) preventing
to improve their clinical practice. It explains about quality of
complications (Patricia in Alligood & Tomey, 2010 (Figure 1).
life and delivers significant concept in EOL in research and
Thirdly, experience of dignity/respect is another third very practices both. This is the best approach to deal with EOL
important indicator for terminally ill patients. Every human patients.
being liked to be respected and valued. For a terminally ill
Summarization
patient, it is important that they should be include in
Caring is the essence of nursing and disciplinary
decision making, treat them with dignity, empathy and
foundation core of profession (Watson 1985/2008,
respect.
p.17). In nursing profession, we are always talking about
Fourthly, being at peace involves the sense of serenity,
caring concepts, to care people around us, helping
calmness, harmony and contentment. It is suggested that
trusting relationships and to have peaceful death for
patient should be free from all sort of worries, anxieties, and
our patients who are terminally ill and so on. However, in
fear. This can only be done by providing emotional support,
reality somehow we miss all those concepts of caring.
by meeting the needs for antianxiety, by inspiring trust, and
We would love to work on fancy and attractive projects

PEACEFUL END OF LIFE

EXPERIENCE OF EXPERIENCE OF CLOSENESS TO SIGNIFICANT

NOT BEING PAIN BEING AT PEACE
COMFORT DIGNITY / RESPECT OTHERS/ WHO CARE

Preventing, Facilitating
Monitoring and Including patient and
monitoring and Providing emotional participation of
administering pain significant others in
relieving physical support significant others in
relief decision making
discomfort patient care

Applying Monitoring and Attending to

Facilitating rest, Treating patient with
pharmacological and meeting patient’s significant others
relaxation and dignity, empathy and
non-pharmacological needs for anti- grief, worries and
contentment respect
interventions anxiety medications questions

Being attentive to Inspiring trust Facilitating

patient’s expressed opportunities for
needs, wishes and Providing family closeness
preferences patient/significant
others with guidance
in practical issues

Providing physical
assistance of another
caring person, if
desired

Figure 1. Ruland, C. M., & Moore, S. M. (1998). Theory construction based on standards of care:
A proposed theory of the peaceful end of life. Nursing Outlook, 46(4), 174

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but the essence of 'real nursing' is lost some where in References

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The development of this theory is very significant because it Theorists and their work. (7th Ed.).St. Louis: Mosby, Inc.
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suffering and help patient lives a meaningful experience. care/decision pamphlet in the ICU. Published Thesis
All those patients who are terminally ill are going through the dissertation of Masters of Science in Nursing. Retrieved from
terrible feeling of fear and worry. At that point of time, nurses csuchico-dspace.calstate.edu/.../11%2015%202010%
plays key role in providing compassionate care at this 20Jennifer%20...
stage. The development of this theory provides a unique
[3]. Ruland, C.M., & Moore, S. (1998). Theory Construction
way to care for terminally ill patient and can contribute
based on Standard of care: A proposed theory of peaceful
towards effective nursing interventions. With the application
End of Life. Nursing Outlook, 46, 169-175.
of this theory, nurse will able to identify the ways to prevent
[4]. Ruland, C.M., Kresevic, D., & Lorensen, M. (1997).
patients from unnecessary suffering and to maintain dignity
Including patient preferences in nurses' assessment of
and respect.
older patients. Journal of Clinical Nursing, 6(6), 495-504.

ABOUT THE AUTHOR

Mehtab Qutbuddin Jaffer is presently a student of Masters in Science in Nursing (MScN) at the Aga Khan University School of Nursing
and Midwifery. She has completed her diploma in nursing in 2001 and Bachelors of Science in Nursing (BScN) in 2007 for the same
university. She has worked on a various positions and capacities in the field of nursing including in-patient and out-patient services.
She started and gained her clinical experience by working in section of emergency medicine department of the Aga Khan
University, hospital at variety of nurse roles of registered nurse, critical care nurse, senior critical care nurse, and clinical nurse
instructor. She has also the opportunity to work at the earthquake disaster at northern part of Pakistan in 2005. She also serving as a
volunteer staff nurse at the nursing homes of terminally ill patient at our community settings. In 2007, She has received “Best Critical
Care Nurse Award” as an outstanding achievement from the Aga Khan University hospital.

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