Many organizations such as the Institute of Medicine, the World Health Organization and the National Consensus Project for Quality Palliative Care have identified the need for equitable access to palliative and end-of-life care (Ferrell, Coyle, & Paice, 2015). However, in many rural areas of the world, including rural Wyoming, patients at end-of-life are cared for in acute care settings where nurses have not received specialized training and education on evidence based end-of-life care. The aim for this DNP project was to assess rural registered nurses' perceptions of competencies important in end-of-life nursing practice (Coyne & White, 2011). A 32-item survey developed by White and Coyne (2011) was adapted for use in a rural critical access hospital to determine content priorities and educational needs of generalist nurses in a rural setting, regarding providing palliative and end-of-life care. A purposive sample of 16 nurses in a rural critical access hospital in Wheatland, WY, who care for patients at end-of-life, completed the survey. Only one-third of the nurses surveyed reported receiving any type of end-of-life care education in the prior two years. Similar to findings from the study completed in 2011 in an urban area, symptom management, talking to patients and families about death and dying, and pain control were the highest ranking core competencies. Nurses who did report receiving education in end-of-life care still felt inadequately prepared to talk to patients and families about dying, and this needs assessment identified that educational gaps are evident regarding provision of end-of-life nursing care in rural settings. The information gleaned from this survey will be used to design an educational program to disseminate evidence based practice guidelines regarding providing quality end-of-life care using ELNEC (End-of-Life Nursing Education Consortium) modules based on the findings of the needs assessment survey

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The purpose of this study was, first, to further our understanding of the experience of dying in a long-term care (LTC) facility from the perspective of family members and second, to identify the relationships between the various factors which may influence satisfaction with end-of-life care. Using a sequential mixed methods design, a convenience sample of 87 family members completed a survey interview using a modified version of the Toolkit of Instruments to Measure End-of-life Care (TIME) Nursing Home Version in the first phase of the study. Findings from the parametric and non-parametric analyses indicated that family satisfaction with end-of-life care was best predicted by contact and communication with nursing staff, feeling that care provided at the end of life met expectations, staff providing consistent care, feeling that the health care aide listened to their concerns about care and that respondents felt they had received enough emotional support. Being transferred to hospital in the last month of life, dying in a place other than the LTC facility, and respondent age and employment status were all associated with significant mean differences in satisfaction scores. In the second phase, three focus groups were conducted to further explore areas of satisfaction and dissatisfaction with end-of-life care. Focus groups provided confirmation of the findings of the first phase of the study and were instrumental in developing a list of ten recommendations for improvements in end-of-life care delivery. Recommendations for future research are made based on the study results.

Emergency departments (EDs) are often thought of solely as places where life-saving interventions occur. However, EDs are also places where dying patients receive end of life care. Though research examining expert nurse behaviours in care of the dying has been conducted in a variety of care settings, little is known about this topic as it relates to care of the dying adult in the ED. A descriptive exploratory study was conducted with registered nurse experts (n = 6) in two urban EDs in Western Canada. Five expert nurse behaviours deemed essential in care of the dying adult patient in the ED were identified: 1) providing comfort; 2) honouring the personhood of the patient; 3) responding to the family; 4) responding after the death of the patient; and 5) responding to colleagues. These findings contribute to the empirical evidence concerning expert nursing care of the dying.

This study explores and examines the roles of caregivers within rest home facilities in New Zealand; and specifically, how they unpack and deal with managing the tensions associated with end of life (EOL) care. It adopted a qualitative perspective to enable an exploration of how the experiences of caregivers help guide their practice and understanding of their roles in relation to EOL care. A grounded theory framework was utilised in order to explore how caregivers make meaning and find value in the roles they perform within rest home facilities. This study offers insights into some of the tensions that caregivers face in a working environment where life and death occur simultaneously. It was apparent that caregivers are aware of the many social taboos they must negotiate in order to conduct their work. It was also apparent that they understood that others might perceive their work as dirty but that this did not prevent them from finding job satisfaction and create meaning in their work. Instead, they created meaning by using the conceptual tool the imagination of care. This involved utilising their imagination and past experiences to enable EOL care which represented the dying rites of individual residents but also fitted within their ethic of care.

The purpose of this study was, first, to further our understanding of the experience of dying in a long-term care (LTC) facility from the perspective of family members and second, to identify the relationships between the various factors which may influence satisfaction with end-of-life care. Using a sequential mixed methods design, a convenience sample of 87 family members completed a survey interview using a modified version of the Toolkit of Instruments to Measure End-of-life Care (TIME) Nursing Home Version in the first phase of the study. Findings from the parametric and non-parametric analyses indicated that family satisfaction with end-of-life care was best predicted by contact and communication with nursing staff, feeling that care provided at the end of life met expectations, staff providing consistent care, feeling that the health care aide listened to their concerns about care and that respondents felt they had received enough emotional support. Being transferred to hospital in the last month of life, dying in a place other than the LTC facility, and respondent age and employment status were all associated with significant mean differences in satisfaction scores. In the second phase, three focus groups were conducted to further explore areas of satisfaction and dissatisfaction with end-of-life care. Focus groups provided confirmation of the findings of the first phase of the study and were instrumental in developing a list of ten recommendations for improvements in end-of-life care delivery. Recommendations for future research are made based on the study results.

Emergency departments (EDs) are often thought of solely as places where life-saving interventions occur. However, EDs are also places where dying patients receive end of life care. Though research examining expert nurse behaviours in care of the dying has been conducted in a variety of care settings, little is known about this topic as it relates to care of the dying adult in the ED. A descriptive exploratory study was conducted with registered nurse experts (n = 6) in two urban EDs in Western Canada. Five expert nurse behaviours deemed essential in care of the dying adult patient in the ED were identified: 1) providing comfort; 2) honouring the personhood of the patient; 3) responding to the family; 4) responding after the death of the patient; and 5) responding to colleagues. These findings contribute to the empirical evidence concerning expert nursing care of the dying.

The purpose of this study was, first, to further our understanding of the experience of dying in a long-term care (LTC) facility from the perspective of family members and second, to identify the relationships between the various factors which may influence satisfaction with end-of-life care. Using a sequential mixed methods design, a convenience sample of 87 family members completed a survey interview using a modified version of the Toolkit of Instruments to Measure End-of-life Care (TIME) Nursing Home Version in the first phase of the study. Findings from the parametric and non-parametric analyses indicated that family satisfaction with end-of-life care was best predicted by contact and communication with nursing staff, feeling that care provided at the end of life met expectations, staff providing consistent care, feeling that the health care aide listened to their concerns about care and that respondents felt they had received enough emotional support. Being transferred to hospital in the last month of life, dying in a place other than the LTC facility, and respondent age and employment status were all associated with significant mean differences in satisfaction scores. In the second phase, three focus groups were conducted to further explore areas of satisfaction and dissatisfaction with end-of-life care. Focus groups provided confirmation of the findings of the first phase of the study and were instrumental in developing a list of ten recommendations for improvements in end-of-life care delivery. Recommendations for future research are made based on the study results. / October 2007

As the population of the United States continues to age, providing this ever-growing group of individuals with end of life care is becoming an increasingly important issue. Quality end of life care begins with understanding the distinct needs and desires of each individual, and the best way to ensure that their wishes are followed is through the completion of advance directives. Although many Americans understand the importance of completing advance directives, the most vulnerable members of our society, the homeless, are often not given the opportunity to document their end of life wishes. In addition to dealing with the demands of everyday life on the street, homeless individuals are often disconnected from the healthcare system, and therefore they frequently miss out on the opportunity to partake in advance care planning. As this population ages, their end of life care is becoming ever more important. Studies have shown that homeless individuals are willing and able to fill out advance directives when they are given the opportunity, but in today’s busy healthcare system medical providers often do not have the time to assist each of their patients with completing an advance directive. Fortunately, nursing and medical students have proven that they can successfully assist homeless individuals in filling out advance directives, although the success of physician assistant students in providing this intervention has yet to be studied. This thesis will propose a new educational intervention designed to teach physician assistant students about advance care planning as well as giving them the opportunity to assist homeless individuals in completing advance directives. The curriculum will provide an innovative way of fulfilling educational standards set forth by the Accreditation Review Commission on Education for the Physician Assistant, and it can be adapted for physician assistant programs throughout the nation. As a result, physician assistant students will graduate with the confidence and skills necessary to provide advance care planning to all of their patients.

Introduction: In 2010, of the 129 million visits to the emergency department (ED), 240,000 resulted in the patient dying or being pronounced dead on arrival. This number is likely to continue to increase as a significant portion of the American population ages and seeks care in the ED. Though care in the ED is focused on saving lives, death cannot always be prevented. Consequently, nurses face many barriers to providing quality end-of-life (EOL) care in the ED when death occurs. The purpose of this study was to identify suggestions emergency nurses have to improve EOL care specifically in rural ED's. Methods: A 57-item questionnaire was sent to 52 rural hospitals in the Intermountain West and Alaska. One of the 57 questions asked nurses to identify the one aspect of EOL care they would change for dying patients in the ED. Each qualitative response was individually reviewed by a research team and then coded into a theme. Results: Four major themes and three minor themes were identified. The major themes were providing greater privacy during EOL care for patients and family members, increasing availability of support services, additional staffing, and improved staff and community education. Discussion: Providing adequate privacy for patients and family members is a major barrier to providing EOL care in the ED. This is largely due to poor department design, especially in rural ED's where space is limited. Lack of support services such as religious leaders, social workers, and additional staffing are also barriers to providing quality EOL care in rural ED's. Consequently, rural nurses are commonly pulled away from EOL care to perform ancillary duties because additional support personnel are lacking. Conclusion: Providing EOL care in the ED is an extremely challenging and demanding task. It is especially difficult in rural ED's where staffing and resources are limited. Consequently, it is imperative that supportive behaviors are acknowledged and barriers are identified to improve EOL care provided to patients and family members in rural ED's. Due to the current lack of research in rural EOL care, further research is justified regarding this topic.