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Nurses spend more time with patients and their families who are facing the end of life than any other member of the healthcare team. 1 As members of the largest healthcare profession, nurses have long advocated for attention to quality of life. Achieving quality of life, especially at the end of life, is contingent upon competent, "state of the art" professional nursing care. Nursing pioneers in palliative care, Florence Wald, Cicely Saunders (also a physician) and Jeanne Quint Benoliel, have emphasized that those in need of care at the end of life merit "the most competent, expert, evidence-based care provided in a way that embodies compassion, respect for dignity, and an appreciation for the whole person and the family."2(p xiii-xv) In 1962, registered nurse Harriet Goetz published an approach to care for the dying that focused on open communication with the patient and family and symptom management techniques such as atropine for secretions and environmental adjustments (such as making the room pleasant, soft lighting, and so on), to provide comfort. 3 The work of these nurse leaders forged the way towards the current standard practice for comprehensive and compassionate care at the end of life.


Competency-based nursing practice at the end of life includes expert assessment skills, critical thinking, comprehensive pain and symptom management, and the acquisition of knowledge, attitudes, and skills in areas related to the phases of wellness and illness at the end of life. Ferrell emphasized that the management of a "single physical symptom, such as dyspnea, requires expert knowledge of physiology, numerous pharmacological treatments, non-drug interventions and psychological support to ease the distress of patient and family experiencing this symptom."2(p xiii-xv) End-stage illness usually presents with not only one, but multiple and often complex symptoms that affect the body, mind, and spirit in tangential means, driving the professional nurse to employ highly trained skills and provide holistic care that is consistent with the goals of the patient and family. Individualized professional nursing care at this time of life has never been so critical to maximize autonomy, dignity, healing, and comfort.


When faced with a serious illness, people turn to their nurse or nurse practitioner for education, support, and guidance. Nurses are intimately involved in all aspects of end-of-life care. Professional nurses face end-of-life situations whether they work in hospitals, homes, long-term care facilities, clinics, universities and schools, industry, or prisons. They are the primary team members who coordinate, assess, direct, and evaluate patient care needs that arise during the illness experience. With their knowledge about the physical, psychosocial, and spiritual dimensions of life-limiting and terminal illness, nurses are central in assuring the comfort, autonomy, and healing of patients and families.


The professional nurse is also a key player in moving the healthcare team towards a recognition of end-of-life care situations and the comfort care and psychological support that are required. 4 Professional nursing at the end of life is grounded in keeping the positive traditions of past practices while shaping care for the future that will meet the evolving needs of the sick and dying. The professional nurse establishes and supports the methods and means to assure these outcomes are met.



It is the position of HPNA Board of Directors that professional nursing care is critical to achieving the patients', families', and communities' goals of care at the end of life. Support of hospice and palliative care research and education is necessary to ensure that care is evidence-based, effective, and appropriate.



Critical thinking-process of utilizing cognitive skills to analyze, apply standards, discriminate, seek information/data, reason logically, predict and transform knowledge. Critical thinkers exhibit habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. 5


End-of-life care-nursing care for people who are experiencing life-limiting progressive illness(es). 6


Evidence-based practice-practice that is based on research, clinical expertise, and patient preferences that guide decisions about the healthcare of individual patients. Evidence-based nursing de-emphasizes ritual, isolated, and unsystematic clinical experience, ungrounded opinions, and traditions as a basis for nursing practice. It stresses the use of research findings, quality improvement data (as appropriate), other operational and evaluation data, the consensus of recognized experts, and affirmed experience to substantiate practice. 7




1. Ferrell BR, Grant M, Virani R. Strengthening nursing education to improve end-of-life care. Nurs Outlook. 1999; 47:252-256 [Context Link]


2. Ferrell BR. Forward. In: Matzo M, Sherman D, eds. Palliative Care Nursing:Quality Care to the End of Life. New York: Springer; 2001:xiii-xv. [Context Link]


3. Poleto M. Hospice care: underutilized and misunderstood. In: Dochterman J, Grace HY, eds. Current Issues in Nursing. St. Louis: Mosby; 2001:175-181. [Context Link]


4. Zinc M, Titus L. Ethical issues and resource for nurses across the continuum. In: Dochterman J, Grace HY, eds. Current Issues in Nursing. St. Louis: Mosby; 2001:568-575. [Context Link]


5. Rubenfeld M, Scheffer B. Critical thinking: what is it and how do we teach it? In: Dochterman J, Grace HY, eds. Current Issues in Nursing. St. Louis: Mosby; 2001:125-132. [Context Link]


6. Hospice and Palliative Nurses Association. Definition of End of Life Care. Pittsburgh, Pa: Author; 2003. [Context Link]


7. Goode C, Krugman M. Evidence-based practice: a tool for clinical and managerial decision making. In: Dochterman J, Grace HY, eds. Current Issues in Nursing. St. Louis: Mosby; 2001:60-68. [Context Link]