The nurse's role in end-of-life care in nursing homes

¶ … Role as a Nurse/Life Helper in a Long-Term Care Facility

Nursing in a long-term care facility would be the prescription for burnout and depression for many people. And yet, it is an essential activity in the current society. There are ways to approach the profession, however, that help explain its purpose and also allow the nurse to place his or her activities into a context at once useful and conceptual. There are traditions from almost every philosophy and religion that point to the same things; the value of service, humility, compassion, and transcendence all arising out of the desire to do good works (nursing) and the will to create the skills necessary to do those works.

A knowledge of some of these is essential to place the activities of nursing into a scheme that will give the best result possible for all concerned, the nurse, the patient, the patient's family and friends, the community, the region, the state, the nation and the universe, ultimately. Once the precepts regarding the nature of nursing, the nature of service, the nature of compassion and the nature of transcendence are brought together, it is not necessary to prescribe specific acts that will cause value; the specific acts will arise naturally from the interplay of intelligence, knowledge, humility and a desire to serve.

Choosing the profession of nursing

If one has chosen one's profession properly, one will believe that it is two things, the best possible profession on a personal level, and a profession of essential benefit to at least one other person. By choosing nursing, one has joined the ranks of society's caregivers, which seems to be an essential function, more so when society is in a state of upheaval which anyone who ever reads a newspaper knows ours is now and has been for many years.

Nurses seem to enjoy the enviable position of being regarded as still worthy of the public trust. (Hegevary, 2002) At the same time, of course, there are all the news stories but nursing shortages and how that condition makes true nursing care almost impossible in some respects in some areas. With early discharges from hospitals, some people are even asking whether nurses are all that necessary, despite the regard we are apparently held in. But fortunately, the work of Linda Aiken and others has shown clearly that patients have better outcomes when there is good nursing care. (Hegevary, 2002)

There is more research being done on the specifics of how good nursing care matters. But perhaps it would be better to link nursing care to the rest of society's needs, and also to link it to various world views from the major religions, to see how very much nursing matters to a world in upheaval, and how very much it is at the foundation of community, the interconnectedness that even physicists are now finding exists between all things -- people, animals, plants, the sky, music, tenderness, dancing (of people or molecules), feelings, concepts

As a nurse in a long-term care facility, I find that I encounter everything a person can feel, want, do, hope for, suffer from or despair of. In the middle of all that, it is sometimes difficult to overcome one's own reactions and carry on, giving the care that changes outcomes. Granted, sometimes the outcome will not be changed; people die. In that case, it seems to me, it is all the more essential to give good nursing care because, at least on this plane of existence, that is all the person has. To fail to do that would be a failure of immoral magnitude under those circumstances. So, nursing in a long-term care facility requires a good hands-on technique, good knowledge of the art and science of nursing. But it also requires something more: it requires a knowledge of how it all fits into the universe. To achieve that understanding, it is necessary to look at how many of the world's religions and philosophies view the underlying concept to everything a nurse does: the meaning of life.

Relationship: a popular concept revisited regarding nursing care

In nursing, there has been an assumption that the relationship of nurse to patient is first to establish trust, then to perform the care giving work, and ultimately terminate the relationship. This works, nominally, in the long-term care arena because the relationship will be terminated. But in long-term care, despite its finality, the relationship is often, and should be, more organic and dynamic. While trust needs to be established very quickly in most nursing relationships, (Patusky, 2003) in long-term care there is more time. While this doesn't mean trust should not be attended to immediately, it does mean that the relationship has a dynamic, and levels of trust may increase incrementally.

Moreover, while in most situations, people will trust others with one or another aspect of their lives, in a long-term care setting, the patient will come to trust the nurse for just about everything in his or her life, from medication to a loving touch on the hand, to running interference with meddling relatives and more. In this sense, then, the nurse is a servant of many communities -- patients, medical personnel, family, and often even bureaucracies involved in patient care, from insurance to government office.

In addition to easing anxiety and enabling patients to secure necessary elements for survival and companionship, "interpersonal relatedness influences brain development and neurotransmitter and hormonal regulation (Seigel, 2001)" (Patusky, 2003), meaning that the nurse has a very real means of making the quality of life for his or her patients better than it might otherwise be.

While all this puts an extra burden on the long-term care nurse, the situation also affords the long-term care nurse something other nurses almost never get: time to create and built all the relationships that will result in a better life for the patient. Moreover, recent studies have found that nurses consider vulnerability of patients to be an essential foundation of their ability to connect with patients in a meaningful way. (Patusky, 2003) That this is inherent in the long-term care situation gives nurses unique opportunities to make a difference in their patients' lives and the lives of their families and communities, but also makes it imperative that the nurse approach these vulnerabilities from a position of thoughtful, and elevated, moral ideals.

Comfort as the goal

Creating comfort -- whether through administration of medications, developing rapport or any other nursing skill -- has long been considered a core value of the profession. "Comfort is a dimension or component of dynamic processes, experiences, and concepts such as quality of life, hope, control, decision making, and reconciliation (Arruda, Larson, & Meleis, 1992; Cameron, 1993; Larson, 1987). Pain control is used often as a proxy for 'comfort,' and pain is used often to describe discomfort." (Siefert, 2002) Before continuing a discussion of the value of nursing in a long-term care setting to community, and to a nurse's responsibilities within that setting, it important to note that in the long-term care setting, comfort may often include pain control that goes far beyond 'discomfort' relief and to what one might describe as the quality of mercy. And still, at times, all one can do is not enough. And then it is important for the nurse to know that all that can be done has to be enough, and that as long as his or her professional responsibilities have been tended well, then the result -- whether temporarily less than optimal for the patient -- contributes to the improvement of the state of the world in general. But it all begins with applying the nursing process responsibly.

Regarding a philosophy of service; first things first

Applying the nursing process" is a term that is often used in studies of nursing and in nursing texts. But here, it can be applied in a much more far-reaching way, to mean applying the principles of nursing and its process to creating something of value to individuals and community. It would take a nursing textbook to explain to people how the processes of nursing are to be performed, but it takes only an interest and inquiry into the philosophies behind nursing -- behind all 'interventions' into the lives of others -- to demonstrate the value of those processes to the community, but which I mean the local community, the state, region, nation and ultimately, in fact, to global peace.

Care giving is basic for global peace; in my view, it is the polar opposite of hatred and war.

None of this by itself will convince others to enter nursing and help solve the shortage. But it might. In any case, it may help others to understand the place of nursing in the major scheme of things -- not simply as a valued and respectable/respected profession -- and that alone might conceivably change the world. I propose this on the basis of the old 'butterfly' story; that when a butterfly flaps its wings in Argentina, it might create a tsunami in Japan. All things are connected.

With that basis, a look at some of the approaches one might take to proving nursing as a world-changing, life-enhancing profession are in order. This is particularly true regarding long-term care. Why? Because with nursing in a hospital or clinic setting, there is the expectation that the patients will recover and leave to go home, or not recover and die, or possibly recover only enough to enter a long-term care facility.

While there are recoveries in long-term care facilities, it is much more likely that a patient who enters such a facility will, as the metaphysicians say, make his or her transition. Because of this, caring for this population is frightful for many, but yet it is essential. Because of the potential 'burn out' nature of the work, it is even more essential to base it on one or another strong and workable religious or philosophical principles.

The democratic society and long-term care nursing

One writer for History Today noted that "Democratic education is always part socialisation in democratic norms like tolerance and reciprocity and part lesson in scepticism and subversion. It means learning to live with uncertainty...." (Barber, 1994) There is a great deal of uncertainty in long-term care nursing, despite the relatively predictable outcome. At this point in the patient's life, nursing is much more an art than a science, knowing when to do what and why, and sometimes being less sure than with a more robust patient what the outcome will be. The same article says that the demeanor of a democratic citizenry should be humble rather than full of hubris, social rather than solipsistic. In this respect, long-term care nursing is exactly democratic in its foundation. It is impossible, in fact, to bring an inflated sense of self to the work and do anything at all for the patients. It is impossible to be self-involved, rather than socially oriented, and help one bit.

That same commentator, however, warned against considering democracy -- and I would argue long-term care nursing -- to be merely a thought process. "To think aright about politics, we must act aright, and to act aright calls for better citizens rather than better philosophers." (Barber, 1994) In nursing, this translates to a need to keep our skills at their optimal values and to use them, and not just to philosophize about how valuable nursing is to the world as we know it.

Religious points-of-view that point in the same

The Americans with Disabilities Act (ADA) made it incumbent upon the entire society to be more accepting of and helpful to those whose abilities were not the same as the average American's. While one cannot completely mandate values, such as compassion and the like, it seems to have gone some distance toward that goal, a fact perhaps reflected in the many articles written about the ramifications of the ADA.

Old-time religion point-of-view

But one could go back a lot farther to find compelling reasons to behave with compassion, compelling reasons that a profession founded on care giving is an essential function for any civilized society. Some of these were included in a recent article in the William and Mary Law Review, and they came from the Old Testament, a work that was part philosophy, part setting out of legalistic demands. The article cites Leviticus 19:14: "Thou shalt not curse the deaf, nor put a stumbling-block before the blind...but thou shalt fear thy God." (Quoted by Soifer, 2003) That is a powerful command to care for those who are physically dis-abled. The next passage says, "Ye shall do no unrighteousness in judgment; thou shalt not respect the person of the poor, nor favor the person of the mighty; but in righteousness shalt thou judge thy neighbor." (Quoted by Soifer, 2003)

As a nurse, I take this to mean that the same care and comfort is to be given to all people, regardless of their 'station in life.' In fact, because this is the last stop on the train for the vast majority of the patients, it is necessary to treat each one as royalty. If one is going to believe in a transition to another world, then it is incumbent on those 'running the train' to see that all passengers have a safe, comfy seat and refreshments to make their transition a pleasant one. If one doesn't believe there is another world, then it is incumbent upon one to see that their last experience is a comfy and pleasurable one, insofar as that is possible given their physical condition and that state of medical arts.

An article in First Things: A Monthly Journal of Religion and Public Life suggests that faith and reason are supportive of each other, and continues to propose there are cogent reasons based in Christianity for working as nurses do in the context of the ultimate meaning of life. "Christian philosophers should shape arguments in a way that provides common ground with those of other religions and all 'who have at heart the renewal of humanity'." (Neuhaus, 1998) Certainly, this is at the heart of nursing. St. Bonaventure, regarded as "the great master of thought and spirituality," (Neuhaus, 1998) recognized that it was useless to acquire knowledge without using it in service of someone or something, to research things without experiencing wonder, to be careful but not joyous, to learn without loving, or to use intelligence without humility. All of this leads to the conclusion that it is necessary to accept responsibility for using knowledge and gifts in service of some greater good.

Islam and the meaning of life and work

An Islamic scholar recently pointed out the main features of a good and democratic government as one in which, whatever the situation of the peopled, they have high hopes for the future. (Bajunid, 2004)This is truncated by the situation in a long-term care facility; most have a hope only for a fairly pain free existence with some of their favorite joys -- time with family and so on. The same scholar noted that in a democracy, it is necessary for the leaders to: