End-of-Life Education for Nurses

Betty Ferrell, PhD, RN, FAAN

Disclosures

Topics in Advanced Practice Nursing eJournal. 2007;7(2) 

The Critical Need for End-Of-Life Education

Of the 2.4 million deaths in the United States each year, approximately 44% occur in hospitals, 25% in nursing homes, and 25% at home. Nurses spend more time at the bedside caring for patients at the end-of-life (EOL) than any other professional group, so it is vital that they receive up-to-date education in palliative care. Comprehensive training should ideally include information and resources for effective coordination of EOL care across all settings and disease transitions, and include the psychosocial and spiritual needs of patients and families.

End-of-Life Nursing Education Consortium (ELNEC)

Initiated in 2001, the End-of-Life Nursing Education Consortium (ELNEC) is a national education initiative to improve end-of-life care in the United States. ELNEC uses a "train-the-trainer" model to prepare nursing school faculty, continuing education providers, staff development educators, and other nurses to return to their institutions and facilities and conduct ELNEC training sessions that teach the essential components of EOL care to nursing students and practicing nurses. ELNEC training courses are designed for nurses in all healthcare settings, whether they work in the intensive care unit, neonatal unit, nursing home, or oncology unit. The current ELNEC course schedule is available at the American Association of Colleges of Nursing Web site.

To date, more than 3750 nurses representing all 50 states have received ELNEC training and have shared the ELNEC curriculum in many settings. ELNEC trainers host seminars, incorporate ELNEC content into nursing curricula, conduct regional training sessions to expand ELNEC's reach into underserved communities, present ELNEC at national and international conferences, and improve the quality of EOL nursing care in other innovative ways.

The ELNEC project is administered by the American Association of Colleges of Nursing (AACN) and the City of Hope National Medical Center in Duarte, California. The ELNEC curriculum was developed by nationally recognized palliative care experts with extensive input from an advisory board and reviewers. It is revised regularly based on participant recommendations and new advances in the field, and is modified for each distinct audience. The curriculum focuses on core areas in end-of-life care reflecting AACN's 1998 publication Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Nursing Care. Participants receive a syllabus, textbooks, and a wealth of resources to support teaching the ELNEC content to other groups. ELNEC now offers 4 comprehensive train-the-trainer courses.

ELNEC courses. ELNEC-Super Core expands the original core curriculum to include separate 'tracks' for those in undergraduate or graduate teaching positions, oncology, acute care, or hospice settings. The first ELNEC Super-Core training program is scheduled for October 2007. This curriculum addresses palliative and EOL care for clinical nurses in all roles (including advanced practice and nursing administration) in hospital, outpatient, clinic, and home settings. Additionally, ELNEC training is valuable for disciplines other than nursing, such as social workers, case managers, and spiritual care providers. ELNEC-core content is divided into 9 modules:

  1. Nursing Care at the End of Life

  2. Pain Assessment & Management

  3. Symptom Management

  4. Ethical/Legal Issues

  5. Cultural Considerations in End-of-Life Care

  6. Communication

  7. Loss, Grief, Bereavement

  8. Achieving Quality Care at the End of Life

  9. Preparation for and Care at the Time of Death

ELNEC-Pediatric Palliative Care (PPC). A pediatric-specific course, ELNEC-PPC was developed by 20 pediatric palliative care experts and piloted in 2003. To date, 460 nurses, representing 45 states plus the District of Columbia, have completed ELNEC-PPC. The next course will be held in August 2007.

ELNEC-Critical Care. This course was developed for nurses in intensive care, coronary care, burn units, dialysis units, emergency departments, and other critical care areas. The course debuted in November 2006, and a second ELNEC-Critical Care course offered in 2007 to California nurses was funded by the Archstone Foundation. To date, 250 critical care nurses from 31 states, the District of Columbia, and Canada have attended this course. The next ELNEC Critical Care course will be held in November 2007.

ELNEC-Geriatrics. The California HealthCare Foundation funded the development of the ELNEC-Geriatric curriculum and a pilot course held in February, 2007 in Long Beach, California. This curriculum addresses the unique EOL needs in long-term care, skilled nursing, and hospices that serve these facilities. The curriculum also includes teaching strategies for educating unlicensed personnel in geriatric settings. The next ELNEC-Geriatric course is scheduled for September 2007.

The following case study is an example of the clinical scenarios used in the ELNEC program to expand learning by applying the principles of EOL care and family support to actual patient situations. Discussion questions are offered following the case study.

Jennie M., aged 79, was admitted to the medical intensive care unit (MICU) from a long-term care facility. Jennie had a history of advanced-stage Alzheimer's disease and had been a nursing home resident for 4 years. She was now in septic shock secondary to a urinary tract infection and had osteomyelitis from a stage IV sacral decubitus. Upon admission, and before her family's arrival at the hospital, Jennie was treated aggressively with intubation, mechanical ventilation, vasopressors, and fluid resuscitation.

Jennie had created an advance directive many years ago that named her daughter Mary as her advocate (healthcare proxy). Jennie's directive indicated "no surgery, antibiotics, dialysis, mechanical ventilator, or tube feeding." While these wishes were known by the nursing home, they had not been communicated to hospital staff.

When Mary arrived at the MICU she acknowledged her mother's wishes, but was clearly upset to see her mother in such a debilitated condition. The MICU team understood the gravity of the patient's condition and the appropriateness of shifting treatment goals from 'aggressive' to 'comfort-focused.' Mary stated, "I just need more time."

What would you (or your healthcare team) do in this situation to provide the best care for Jennie M.? How can you best fulfill the requests of both Jennie M. and her daughter Mary?

Many ELNEC trainers have had opportunities to travel internationally and provide this education to nurses and other healthcare providers throughout the world. ELNEC trainers and faculty have traveled to 6 of the 7 continents, representing 45 countries. Many trainers have provided ELNEC courses, while others have gone as consultants to work with educators, health administrators, and community leaders to improve care of the dying in their countries.

For more information about the ELNEC project, go to the ELNEC conference Web site or contact Pam Malloy at 202-463-6930, ext. 238 or by email at pmalloy@aacn.nche.edu .

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