PERSONAL EXPERIENCES, INSIGHTS, AND REFLECTIONS

The emergency room is a dynamic work environment and looking back at the resuscitation cases I handled before, only a handful made it to the ICU or Medical Ward. Most of them died on the ER bed after we exhausted all our efforts to revive them. It was a secondary hospital and we were understaffed. We barely had the chance to communicate with the relatives after they have witnessed their relative coding. We were handling several cases and as much as we would like to spend some time to comfort them in their grief, our time is considerably limited.

I could recall some relatives screaming, crying, asking us to do all our best to save their loved one. If I could only go back in time and somehow have better knowledge with this theory I could have asked our nursing management to better facilitate trauma and death cases. Losing someone you love is tough and assisting relatives in the care of their dying loved one could somehow ease the pain. We could have assigned a senior or trained volunteer nurse to stay with the relative or counsel them. Nurses and doctors engaged in the code may do less after the resuscitation because of exhaustion or they have to assist other patients.
Discovering the concepts that the Peaceful EOL entail, I will try to revisit my old facility and chat with our nursing manager and check if we can incorporate some steps that will help patients achieve a peaceful death not only during ER or urgent cases but also in other departments as well.

-Michael Lagarde

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Long Term Care and Respite Care here in Bermuda, just like other Western countries, are really a big thing, I used to think that families do leave their elders in a nursing home because they just seem not to have time or don't want to care for them but after getting insights from my aunt and friends who are working in a nursing home, it widened my eyes that this is their sign of love for their loved ones. They are confident with the expertise of the medical profession, including doctors, by entrusting  their elders in "home-like environment" afterall, its never free and also cost a lot of dollars. 
Most of our admitted cases in the Emergency Room are critically ill and mostly elders. If a patient is known to be a terminal case, we have a special unit called Agape house where they spent their remaining days and I strongly advocate that terminally ill should be separated from the others as their immune system is very sensitive and they usually need appropriate attention. Not all hospitals in the world do this.
Part of our admission criteria is giving our patient, their next of kin or family, to decide whether they are for code or no code. The doctors are discussing this to all admitted patients and as nurses we are their to reinforce what they have decided and be supportive to whatever decision they made. 
Many people still think that palliative care is just the waiting time of death. However, in nursing homes and in Agape house, I can see that they facilitate, fun, tours, bingo games and still give their medications. 
To dig more deeper understanding of EOL theory, we can fully impact the lives of our terminal and elder population and this gives us helpful tips and best practices we can adapt. Let me share you a close exaple of how are elders being taken good care and trying to achieve an Eden Alternative as they call it here. 
Resource: http://www.edenalt.org

-Christopher John Fernandez

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Of all the areas of nursing practice, I consider oncology nursing as the most difficult area. It is not only physically and mentally taxing but also emotionally draining. In 2001, I have had the chance to work in the oncology department of Ziekenhuis Gooi-Noord in The Netherlands. The hospitals there do not allow the presence of a carer beside the patient. Visitors were only allowed during visiting hours unlike in the Philippines, where patients have a “bantay” to attend to all their needs. Part of my uniform then was a beeper, so that I could be signaled by the patients wherever I was. The patients would bell for varying reasons, from pain or just to get something from their bags. So in that aspect alone, I realized that I have to be everything for the patients.

Given the gravity of end of life palliative care, it is very useful to follow a nursing theory as guide. At that time I have not yet heard about the Peaceful End Of Life nursing theory of Ruland and Moore. Although it was also around that time that the theory was created in Norway. Luckily, the dutch nurses guided me in the framework of care which is consistent to the relatively new middle range nursing theory by Ruland and Moore. I appreciated the organized well coordinated approach to care that we rendered to the patient/family. In EOL cases, it is very important to establish first a clear understanding of the plan of management and care between the patient, family, doctors and head nurse. This decision will be the basis of the individualized plan of care. As part of the nursing team, I remember how detailed our planning and discussions were, taking into consideration the patient’s wishes.

The Peaceful End of Life Nursing Theory of Ruland and Moore proposes that by easing fears and anxiety, both real and or perceived for the patient and family, nurses can create a more peaceful end of life, rather than simply completing the task at hand in the day to day care of the patient.

Peaceful End Of Life Scenario
• Mrs. Janssen 75y/o widow admitted for Stage IV Colon cancer.
• She is in and out of consciousness, but most of the time asleep.
• Unable to eat, drink and speak.
• Grimaces quite often.
• Expressed to the family that she wants no life prolonging procedures
• Pain medication given via morphine pump.
• Render comfort measures
• Encourage the family to spend time with the patient and participate in patient care.
• Encourage the family to continue talking to the patient in a soft voice. Explaining that even in coma, their loved one can still hear them. Encourage the family to reassure Mrs. Janssen that they will stay nearby. And to hold Mrs. Janssen’s hand or stroke her hair.
• Nurses answer any questions and provide emotional support.
• Facilitate a vigil/continuous visiting hours as requested by family; offer coffee or tea.
• Facilitate spiritual (priest or pastor) support as needed.
• Mrs. Janssen receives comfortable, pain- free end of life care compatible to her wishes.
The outcome of the peaceful end of life theory can be evaluated by the family through an existing instrument like comfort questionnaire developed by Kolcaba in 2003.
The Peaceful End of Life Nursing theory helps advance the practice of nursing because it offers basic guidelines and principles . In the field of education, as continuing education for critical care nurses, oncology nurses, and caregivers. And as a basis for further research for the improvement of nursing administration, hospital policies, and budget allocations.
The Peaceful End Of Life concept of comfort was based on Katherine Kolcaba’s Comfort Theory’s definition of comfort. Comfort is the state that is experienced by recipients of comfort measures. It is the immediate holistic experience of having needs met in four contexts of experience (physical, psycho spiritual, social and environmental). Comfort measures are defined as nursing interventions designed to address specific comfort needs of recipient, including physiological, social, financial, psychological, spiritual, environmental and physical interventions. It is in this concept that the Peaceful End Of Life theory relates to the Comfort theory. Both theories are similar on the issues of comfort measures but have different nursing outcomes. In Comfort theory the nurse performs comforting actions for a patient to increase comfort level with expected positive outcome while in the Peaceful End of Life theory the nurse helps the patient/family achieve a peaceful death.

“The systematic accumulation of knowledge is essential to progress in any
profession . . . however theory and practice must be constantly interactive.
Theory without practice is empty and practice without theory is blind.”
( Cross, 1981 , p. 110).

-Maria Elena Feliciano

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As a nurse, we are gifted for being compassionate and has the power of giving our patient a touch that no other profession can do what we are doing. Doctors apprised the possible risks and benefits of the operation and procedure , but when patient deteriorated, the end of life theory applies. The patient being a whole complete individual needs to received the basic human needs like feeding and the medications needed. Here in the Philippines , the family has a very strong ties. The family seeks guidance regarding the decisions to make and or even confront the health team of what happen to the patient. As a nurse, we refer this to the chaplain or pastor for spiritual healing. Families are gathered for family conference . I was once a patient and had a near death experienced. After that incident , I had difficulty handling patients who went on CP arrest. I realized that dying is not simply what it is but on how we can contribute to the peaceful and meaningful living of an individual .
-Ana Liza Huet