Bakgrund: Palliativ vård går ut på att främja patientens autonomi, förbättra livskvaliteten och lindra lidandet för patienten och hens anhöriga ända fram till livets slutskede. Den palliativa vården bygger på de fyra hörnstenarna: symtomlindring, närståendestöd, teamarbete och kommunikation. Sjuksköterskans omvårdnad utgår från dessa hörnstenar där patienten och dess anhöriga ska ses som en helhet utifrån fysiska, psykiska, sociala och existentiella behov.  Syfte: Syftet är att beskriva sjuksköterskans upplevelse av att vårda patienter i livets slutskede. Metod:Litteraturöversikten är baserad på åtta vetenskapliga kvalitativa artiklar tagna från databasen CINAHL Complete och som analyserats utifrån Fribergs analysmetod. I denna litteraturöversikt användes Benners teori som teoretisk utgångspunkt.   Resultat:Sjuksköterskans upplevelser och erfarenheter inom palliativ vård presenterades i denna litteraturöversikt i fyra huvudteman: Mötet med döden och döende patienter, Sjuksköterskans upplevelser av eget lidande att vårda döende patienter, Sjuksköterskans behov av stöd och relationsskapande. Diskussion: I litteraturöversiktens diskussion har resultatet diskuterats i tre huvudteman: erfarenhetens betydelse, kollegialt stöd och närhet och distans. Detta utifrån Benners teori, som talar om sjuksköterskans utveckling från novis till expert. / Background: The essence of palliative care is to promote patients autonomy, improve the life quality, and relieve suffering of the patient and their family until life’s finiteness. Palliative care consists of four cornerstones: symptom relief, relative support, teamwork, and communication. These cornerstones set the foundation for nursing care where patients and their families are seen as an entirety in terms of the physical, physiological, social, and existential needs. Aim: The aim of this literature review is to describe nurse´s experience of caring for patients in the end of life. Method: The literature review is based on eight qualitative studies taken from the CINAHL Complete database and was analyzed using Friberg’s analysis method. In this literature review Banner’s theory was used as the theoretical starting point. Results: Nurse´s experience within palliative care was described in four main themes: facing death and dying patients, nurse´s experience of own suffering from caring for dying patients, nurse´s need for support, and creating a relationship. Discussion: During the discussion of the results in this literature review three main themes emerged: importance of experience, collegiate support, and closeness and distance. Benners theory was used that describes nurse´s progress from novice to expert.

Bakgrund: Sjuksköterskan har många olika arbetsuppgifter och att vårda döende patienter, är något som en del sjuksköterskor kommer att träffa på någon gång under sin karriär. Att vårda döende patienter påverkar sjuksköterskan, särskilt de som inte har varit med om detta tidigare. Syfte: Syftet med denna studie var att sammanställa tidigare kvalitativa empiriska studier om hur sjuksköterskan upplever och hanterar mötet med döende patienter. Metod: En litteraturstudie utfördes med tio kvalitativa empiriska intervjustudier som beskriver sjuksköterskans perspektiv på att vårda döende patienter. Datan insamlades genom databaserna CINAHL och PubMed och de relevanta artiklarna granskades av en mall från statens beredning för medicinsk utvärdering (SBU). De valda artiklarna till resultatet analyserades genom datakategorisering. Resultat: Fyra teman identifierades; Att känna emotionell stress, Att använda copingstrategier, Existentiella tankar hos sjuksköterskan och En önskan att vara expert. Under temat “Att använda copingstrategier”, uppkom fyra subteman; Att ha någon att prata med, Att skydda sig själv, att kunna koppla av och Att ha en andlig tro. Konklusion: Sjuksköterskan upplever att arbetet med att vårda döende patienter är påfrestande. De känner sig stressade i mötet med dessa patienter och det kunde ibland leda till utbrändhet. Detta var mer frekvent hos oerfarna sjuksköterskor. Därför har många sjuksköterskor nyttjat olika copingstrategier, som; stöd från familj, kollegor och vänner, andlig tro, gränssättning och genom att sjuksköterskan utvecklade sina kompetenser inom vård av döende patienter. Detta minskade risken för emotionell stress. / Background: Caring for patients in the final stage of life, is something that some nurses will encounter at some time during their career. This has certain effects on nurses who have not previously been involved in this type of situation. Aim: The purpose of this study is to compile previous qualitative empirical studies on how the nurse experience and manage the meeting with dying patients. Methods: A litterature review was conducted with ten qualitative emperical interviews that described the nurse´s perspective of caring for patients in the final stages of life. The data was collected through the databases: CINAHL and PubMed. The relevant articles were reviewed by Swedish agency for health technology assessment and assessment of social services. The selected articles were analysed by data categorization. Results: Four themes were identified; To feel compassion fatigue, Taking on coping strategies, Existential thoughts of the nurse & Wishing on becoming an expert. Under the theme of “Taking on coping strategies”, four subthemes emerged; To have someone to talk to, To be able to protect yourselves, To be able to relax and To having spiritual beliefs. Conclusion: Nurses experience that caring for patients in the final stage is stressful and could sometimes lead to burnout. This was more common with inexperienced nurses. Therefore, many nurses used coping strategies, such as; support from family, colleagues and friends, spiritual beliefs, boundaries and developing nurses skills in care of the final stage of life. This reduced the risk of developing compassion fatigue.

Background: End-of-life palliative care is provided to individuals who have a progressive and incurable disease or injury. The meaning of palliative care is to promote quality of life and to alleviate the relief of patients but also those close to them. Previous research shows that patients in palliative care have a limited everyday life and that they become more dependent on nurses, which in turn leads to reduced autonomy. There was also a lack of communication among nurses and relatives. Method: Systematic literature study with a descriptive summary, 13 care science articles were analysed, all of which have a qualitative approach. Aim: The aim of the thesis is to describe nurses' experiences of caring for patients at the end of life. Results: The analysis revealed two themes; experiences of challenges in care and experiences of being present in care. The first theme included three subthemes; to understand the importance of communication, to experience a lack of knowledge and experience and to be affected emotionally, which was about the communication difficulty and challenges those nurses encountered. The second theme in turn included two subthemes; to experience the care as rewarding and meaningful and to promote good relationships in the care, which were about how nurses were personally affected in the care of patients at the end of life and in the treatment of relatives. Conclusion: The nurse experienced gratitude in caring for the patient at the end of life. The nurse experienced the care as rewarding and satisfying when they promoted good relationships with the patient and relatives. However, the nurse experienced challenges in care due to lack of knowledge and experience. This led to the nurse experiencing an obstacle to meeting the patient's needs.

Sammanfattning Bakgrund: Vård i livets slutskede är krävande för såväl familj som sjuksköterskor, men många sjuksköterskor erfar trots det att de får någonting tillbaka av att vårda de döende. Cancersjukdomar är vanligt och både överlevnaden och prognosen skiftar mycket beroende på vilken typ av cancer en person blir diagnostiserad med. Det är därmed viktigt att sjuksköterskor har kunskap och förståelse om grundläggande palliativ vård samt vård i livets slutskede för att kunna erbjuda den bästa vården för såväl patient som dennes anhöriga. Syfte: Syftet var att beskriva sjuksköterskors erfarenheter i vårdandet av patienter med cancer i livets slutskede på sjukhus. Metod: Examenarbetet utgick enligt en systematisk litteraturstudie med beskrivande syntes. Resultat: Utifrån 11 artiklar analys framkom två tema: Etiska utmaningar i vårdandet och sjuksköterskans utveckling. Dessa innefattar fem subteman som beskriver sjuksköterskors erfarenheter att vårda i livets slutskede. Slutsatser: Det framkom att sjuksköterskor blir utmanade av känslomässig involvering med patienter, tidsbrist, mängden information sjuksköterskor bör ge sina patienter samt att kunna vara i ett existentiellt samtal. Sjuksköterskorna erfor att de har utvecklats mycket av att vårda patienter i livets slutskede, både personligt och professionellt. Däremot erfor sjuksköterskorna också att de saknade kunskap i att ge vård i livets slutskede. / Background: To give care in the end of life is a demanding process for both family members and nurses, but the nurses experiences that in spite this, they gain a lot in return to care for the dying. Cancer is common and the survival and prognosis differs depending on what type of cancer a person is diagnosed with. It is therefore important for the nurse to have knowledge and understanding in basic palliative care and end-of-life care to be able to offer the very best care for both the patient and their family. Aim: This study describes the experiences that nurses have in the care of patients with cancer in end-of-life care in a hospital. Methods: A systematic literature study with descriptive synthesis was used. Results: After 11 articles were analyzed two themes emerged: Ethical challenges in caring and nurses’ development. These include five subthemes that describes the nurses experience in end-of-life care. Conclusions: Results showed that nurses were challenged by the emotional involvements with their patients, the lack of time, how much information to give their patients and how to be in existential conversations with their patients. The nurses experienced that they developed a lot by caring for patients in the end of life. However, the nurses experienced that they lacked knowledge in providing end-of-life care

Despite hospice and palliative care services being available for patients at the end-of-life, it remains an easily accessible health care service which has been mostly underutilized and/or misunderstood. For this project, the practice problem was underutilization of hospice and palliative care services. A systematic review of the literature which focused on under usage of end-of-life care was conducted. MEDLINE, CINAHL, and ProQuest Nursing and Allied Source databases were searched (2005 to 2017). Studies that evaluated interventions for increasing hospice and palliative care services were selected. Conceptual variables included studies that addressed the under usage of end-of-life care. Kolcoba's comfort theory, Parse's theory of human becoming and Chochinov's dignity model was included to identify the issue, gather the data, and help transfer researched data into practice. The tools applied for analysis and synthesis were the appraisal of guidelines research and evaluation and the grading of recommendations, assessment, development and evaluation. The under usage of hospice and palliative care according to this systematic review, has resulted in (a)suffering negative effects on patients at the end of life, who do not receive adequate palliative or comfort care, (b) additional distress for families dealing with grief and denial, and (c) may result in unneeded acute care, adding significantly to the cost of care. This doctoral project formed a cogent set of recommendations consisting of, communication guidance and community education for a local hospice agency and the community. The contribution of positive social change in this community was through education and knowledge to bridge the gap into practice and improve end-of-life care in the community.

Most nurses receive limited formal education regarding end-of-life (EOL) care, which affects their ability to meet dying patients' needs. Guided by Bandura's social learning theory, this explanatory correlational study examined the relationships between critical care nurses' personal and professional characteristics and their perceived knowledge and self-efficacy when providing EOL care at an academic medical center. Convenience sampling was used to recruit participants from the eligible adult, pediatric, and neonatal critical care nurses for this study. The 67 participants completed the End-of-Life Professional Caregiver Survey (EPCS) to assess EOL care knowledge and self-confidence. Total EPCS scores revealed only moderate levels of EOL knowledge and self-confidence. The Fisher's exact test indicated that higher EPCS scores were significantly associated with nurses' age and completion of advance directive. A 3-day workshop was designed to address deficits related to EPCS scores and advance directive completion, while educating younger nurses to gain confidence in their EOL discussions. Additional research is recommended to distinguish between nurses' actual knowledge and perceived knowledge about EOL care, the long-term effects of EOL care education on the quality of patient care, nurses' levels of moral distress and burnout, and nurses' communication skills with patients and other health care providers. The result of this research promotes positive social change through EOL education to improve the confidence of nurses working with dying patients and their families, as well as to understand the challenges of communicating difficult decisions regarding EOL care.

Avoidable hospitalizations of hospice patients cost Medicare $3 billion a year. When hospice nurses are able to identify early signs and symptoms of acute illness and provide appropriate interventions to prevent such admissions, 20-60% of the hospitalizations are preventable. The practice problem addressed in this quality improvement doctor of nursing project was the 30% hospital admission rate of hospice patients as evidenced by chart review, admission data, and revocation data. The first purpose of the project was to identify evidence-based nursing care paths in the literature for the top 5 medical diagnoses related to avoidable hospital admissions. The second purpose was to develop an educational curriculum to educate the staff on the care paths with a pretest/posttest to assess knowledge gained from the education. Rosswurm and Larrabee's conceptual model was used to frame the project. Three content experts evaluated the curriculum plan using a 4 item dichotomous rating of 1 (not met) and 2 (met). An average score of 2 revealed that the curriculum content met the course objectives. Content experts validated each of the 16 pretest/posttest items using a Likert scale ranging from 1 (not relevant) to 4 (highly relevant). The content validation index score was .94, indicating that the pretest/posttest reflected the course objectives and content. Recommendations were made for structuring the pretest/posttest. The project promotes social change by assessing, intervening, and treating patients in the outpatient hospice setting to prevent avoidable hospitalizations, thus promoting patient well-being and fiscal responsibility of healthcare dollars.

Background: Advance directives allow patients to put in writing the type of health care they want if they are unable to make decisions due to their medical condition. Purpose: The purpose of this study was to determine if there were differences in senior nursing students’ knowledge, attitudes, and confidence based on when the information is positioned in the curriculum. Theoretical: Social cognitive learning theory and Zimmerman’s self-regulation model provided the theoretical framework. Methods: This study reflected a non-experimental, exploratory design, with a convenience sample of senior nursing students from 2 different nursing programs in central Illinois. One program offers advance directive education in the first year and the other program offers the information in the second year. A total of 131 students participated in the study that used subscales of the Knowledge, Attitudinal, Experiential Survey on Advance Directives. Results: The group that received the information the second year rated themselves as having more confidence with advance directives. However, both groups scored low in the area of knowledge of advance directives, the Patient Self-Determination Act, and Illinois law. Students who reported higher knowledge levels had higher attitudes about end-of-life care. There was no difference in attitudes between the two groups. Conclusion: The results of this study highlight the need to review nursing curricula specifically relating to end-of-life care content and its placement in the curriculum.

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Disgust is a part of medical education. Whether in the anatomy lab, the operating room, or the hospital wards, medical school is often the first time that future doctors see human suffering manifested in bodies that elicit embarrassment, disgust and fear. Over the course of training, seeing such bodies goes from exceptional to commonplace as doctors learn to witness and empathize with suffering without becoming overwhelmed by it. In this thesis, I examine students’ first encounters with abject bodies in the anatomy lab, their later encounters with such bodies in their clinical years, and the educational programming shapes students’ gaze towards these bodies as they develop from laypeople into professionals. I argue that while medical humanities curricula implemented into gross anatomy help students manage challenging personal feelings elicited by the corpse, taboos and silences during the clinical years prevent students from thinking deeply about how patients experience having bodies that elicit disgust. The dearth of reflection on feelings of disgust during clinical training leaves doctors in training ill-equipped to promote and maintain patient dignity during medical care, particularly at the end of life. / Urban Bioethics