PEACEFUL END OF LIFE (PEOL) THEORY: IN A NUTSHELL

The Peaceful End-of-Life Theory is a relatively young, mid-range nursing theory developed by Cornelia M. Ruland and Shirley M. Moore published in 1998. Its nursing goal is to enhance the quality of life and to achieve a peaceful end-of-life on a terminally-ill patient and relates nursing interventions and outcomes specific to this patient group.

I.          Major Concepts and Definitions

The theory is based on the standard of the peaceful end of life for terminally ill patients. Standard development concentrates on serene and meaningful quality of life in the time that remained patients and their significant others. This standard consists of sixteen outcome criteria (Table 1):

Table 1. Outcome Criteria of the Standard of Peaceful End of Life

The patient: Is not having pain Does not experience nausea Does not experience thirst Experiences optimal comfort Is at peace Does not die alone The patient and significant other(s): Have confidence that they are receiving the best possible care Maintain hope and meaningfulness Participate in decision making regarding patient’s care Experience being treated with dignity and respect as a human being Get assistance in clarifying practical and economical issues related to the patient’s coming to an end of life Experience a pleasant environment Significant others: ·         Are taking part in caring for the patient as they wish ·         Can say farewell with the patient in compliance with their beliefs, cultural rites, and wishes ·         Are informed about different funeral procedures and possibilities ·         Are offered a follow-up visit after the patient’s death

It can be discerned that the outcome criteria in the standard were concrete; thus, similar concepts were reduced into summary concepts (Table 2):

Table 2. Reduction of outcome criteria from the standard to outcome indicators
Standard	Theory
The patient is not having pain.	Not being in pain
The patient does not experience nausea. The patient does not experience thirst. The patient does experience optimal comfort. The patient and significant others experience a pleasant environment.	Experience of comfort
The patient and significant others participate in decision making regarding the patient’s care. The patient and significant others experience being treated with dignity and respect as human beings.	Experience of dignity/respect
The patient and significant others maintain hope and meaningfulness. The patient and significant others get assistance in clarifying practical and economical issues related to the patient’s coming to an end of life. The patient does not die alone. The patient is at peace.	Being at peace
Significant others: Are taking part in caring for the patient as they wish Can say farewell with the patient in compliance with their beliefs, cultural rites, and wishes Are informed about different funeral procedures and possibilities	Closeness to significant others/persons who care

Five outcome indicators were derived from the sixteen standard outcome criteria that represent the key concepts in the theory:

A.            Not Being in Pain

This concept is defined as not having the experience of pain (Ruland & Moore, 1998). This is the central part of many patients’ end-of-life experience. Pain is considered an unpleasant sensory or emotional experience associated with actual or potential tissue damage (Alligood, 2014).

B.            Experience of Comfort

The experience of comfort is defined as relief from discomfort, the state of ease and peaceful contentment, and whatever makes life easy or pleasurable (Ruland & Moore, 1998).

C.            Experience of Dignity and Respect

Each terminally ill patient is “respected and valued as a human being”. This concept incorporates the idea of personal worth, as expressed by the ethical principle of autonomy or respect for persons, which states that individuals should be treated as autonomous agents, and persons with diminished autonomy are entitled to protection (Alligood, 2014).

D.            Being at Peace

Being at peace involves the feeling of calmness, harmony, and contentment (Ruland & Moore, 1998). According to Aaron & Cooksey, the patient is free of anxiety and fear, and possess feelings of calmness and peace.

E.            Closeness to Significant Others

A connection, physical or emotional, to the caring individuals important to and involved in patient care (Aaron & Cooksey, 2013).

II.          Major Assumptions

Nursing, Person, Health and Environment

                                                                                                          

Two assumptions of Ruland and Moore’s theory are identified as follows:

A.            According to Ruland & Moore, the person’s approach to end-of-life is a highly personal experience. The occurrences and feelings of end-of-life experience are personal and individualized

B.            Nursing care is crucial for creating a peaceful end-of-life experience. Nurses assess and interpret cues that reflect the person's end-of-life experience and intervene appropriately to attain and maintain a peaceful experience, even when the dying person cannot communicate verbally (Alligood, 2014).

The following are two additional, implicit assumptions:

A.            Family a term that includes all significant others, is an important part of end-of-life care.

B.            The goal of end-of-life care is care is to maximize treatment. The best possible care will be provided through the judicious use of technology and comfort measures, in order to enhance quality of life and achieve a peaceful death (Alligood, 2014).

III.           Theoretical Assertions and Propositions

According to Ruland & Moore, six relational statements were identified as theoretical assertions for theory as follows:

A.            Monitoring and administering pain relief and applying pharmacological or non-pharmacological interventions contribute to the patient’s experiences of not being in pain.

B.            Preventing, monitoring and relieving physical discomfort, facilitating rest, relaxation and contentment, and preventing complications contribute to the patient’s experience of comfort.

C.            Including the patient and significant others in decision making regarding patient care, treating the patient with dignity, empathy and respect, and being attentive to the patient’s expressed needs, wishes, and preference contribute to the patient’s experience of dignity and respect.

D.            Providing emotional support, monitoring and meeting the patient’s expressed needs for anti anxiety medications, inspiring trust, providing the patient and significant others with guidance in practical issue, and providing physical preference of another caring person if desired contribute to the patient’s experience of being at peace.

E.            Facilitating participation of significant others’ grief, worries, and questions, and facilitating opportunities for family closeness contribute to the patient’s experience of closeness to significant others or person who care.

F.            The patient’s experience of not being in pain, comfort, dignity and respect, being at peace, closeness to significant others or person who contribute to peaceful end of life.

The five concepts comprised of outcome indicators are measurable in both qualitative and quantitative methodologies, while visualizing the direction of relationships (Figure 36-1):

FIGURE 36-1 Relationships among the concepts of the Peaceful End-of-Life Theory. From Ruland, C. M., & Moore, S. (1998]. Theory construction based on standards of care: A proposed theory of the peaceful end of life. Nursing Outlook, (46) 4, 174.

Reference:

Ruland, C.M., Moore, S. (1998). Theory Construction Based on Standards of Care: A Proposed Theory of the Peaceful End of Life. Nursing Outlook 1998 (46) 4: 169-175.

Alligood, M.R., (2014). Nursing Theorists and their Works (8^th ed.). USA: Mosby Elsevier.

Aaron, J.C. & Cooksey, C. (2013). Peaceful End-of-life Theory: A Mid-Range Nursing Theory [Video file]. Retrieved from https://www.youtube.com/watch?v=82016bO8Ku4