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electronic health record, end of life, hospice, nursing care plans, palliative care



  1. Lunney, Margaret PhD, RN
  2. Caffrey, Patricia M. MS, RN
  3. Umbro, Sally MS, RN


Standardized nursing languages should be used in end-of-life care for ease of transition to the electronic health record and to be able to benchmark best practices through aggregation of nursing care elements such as human response diagnoses, patient outcomes, and nursing interventions. The most comprehensive of the languages approved by the American Nurses Association are the research-based classifications of NANDA-International (NANDA-I), the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC). This was a qualitative study using participant action research methods to identify the NANDA-I diagnoses, NOC outcomes, and NIC interventions that staff nurses identified as relevant for end-of-life care in a hospital unit that is totally devoted to end-of-life care in collaboration with patients and families. The results are that 24 NANDA-I diagnoses were selected as relevant for typical patients, each with one or more outcomes and two to 12 interventions. A majority of diagnoses were in the coping/stress tolerance domain (n = 6) and in the safety/protection domain (n = 5). The intervention of feeding was identified as mainly used for comfort with spiritual and cultural aspects. In contrast to other types of care, feeding is not related to maintenance or improvement of nutrition. The selected standardized nursing language terms will be used for nursing care plans and in the front screens of this hospital's electronic health record.