PEACEFUL END OF LIFE

by Cornelia M. Ruland and Shirley

M. Moore
Presented by Jennifer Totten, Angela
Baird, and Amy Howard
Group 3
Nursing 324
 Letter to organization:
Dear Hospice organization,

We would like to introduce ourselves today as advocators for the Peaceful End of Life Theory.
Through our practice and research of theory we hope that your nursing organization will
adopt this theory to your everyday nursing practice of terminally ill patients as we have. This
theory can be used in all settings of Hospice care, where ever the patient or family chooses.
This includes their home, nursing home , hospital, and inpatient hospice care facility. We will
introduce you to the founders of the theory and give just a little background of their nursing
career. So get comfortable and let us show you what we feel is the up and coming theory for
your practice. This theory that will make you more knowledgeable about the complex care for
the dying patient and how you can make it the best experience for the patient, significant
other, and family during their peaceful end of life.

Angela, Amy and Jennifer.

The terminally ill patient has a illness that within 6
months or less are expected to die. The
terminally ill patient no longer wishes to have
procedures done on them in the hope of a cure.
He/she has accepted the fact of their death and is
preparing to die with the best experience for
them, their significant other and family.
With terminal patients the doctor does not
focus on them, so it is up to the nurses to
show knowledge about the dying process and
symptom management. The nurse needs to
know the complexity of taking care of a
terminally ill patient and how they can
contribute to a peaceful end of life.
 Theorists
• Cornelia M. Ruland
Received her PhD in nursing from Case Western
Reserve University, Cleveland, Ohio in 1998.
Currently she is the Director of the Center for
shared Decision Making and Nursing
Research at Rikshospitalet University hospital
in Oslo, Norway and holds an appointment as
adjunct faculty at the Department of
Biomedical Informatics at Columbia
University in New York. Ruland has been the
major investigator in many research projects
and had won awards for her work (Tomey &
Alligood p.775).
• Shirley M Moore
Received her master’s degree in Psychiatric and
Mental Health nursing (1990) and her PhD in
Nursing Science (1993) at Case Western Reserve
University, Cleveland, Ohio. She has taught
nursing theory and science to all levels of
nursing students. Moore also conducts research
and theory development in the recovery of
cardiac events and has assisted in development
and publication in several theories
(Tomey & Alligood p.775).
 The Peaceful End of Life theory was developed
from the standard of care of peaceful end of life.
The standard of care was developed by a
experienced group of nurses in Norway. This was
on a gastroenterological unit where half of the
patients were diagnosed with cancer and dealing
with terminal illness was on a daily basis (Ruland
and Moore 1998).
These nurses all had 5 or more years experience
with terminally ill patients and had attended
seminars and other post graduate education
on this group of patients (Ruland and Moore
1998).
They identified a need for clinical guidance in
taking care of these patients and giving them
quality care. This resulted in the development
of the theory for the Peaceful End of Life by
Ruland and Moore (Ruland and Moore 1998).
 The focus was not on dying in itself but on
peaceful and meaningful living during the final
days that remained for the patients,
significant others, and family members. It also
reflected the complexity that is involved with
taking care of the terminally ill patient and the
need to have knowledge on pain relief and
symptom
management (Ruland and Moore 1998).
 He/she needs to have a caring attitude,
awareness, sensitivity and compassion for the
terminally ill patient (Ruland and Moore
1998).
 This model started while Ruland was a
student in one of Moore’s classes. Ruland
helped develop a standard of practice for end
of life to provide a structured framework
where there had previously been none.
Ruland with the help of Moore then
developed the Peaceful End of Life Theory
from this standard of practice (Tomey &
Alligood 2006, pp. 775-8).
The major concepts that this theory
is based on are:

1) Being free of pain

2) Experiencing comfort
3) Experiencing dignity and respect
4) Being at peace
5) Being close to your significant
others
 Free of pain
Not being in pain is defined within this theory as
not having the experience of pain(Ruland &
Moore 1998).

Pain further is described as an unpleasant,

sensory, and emotional experience associated
with actual and potential tissue damage or
described in terms of such damage (Ruland &
Moore 1998).
 Comfort
The experience of comfort for this theory
was defined as the relief from
discomfort, the state of ease and
peaceful contentment, and whatever
makes life easy or pleasurable (Ruland
and Moore 1998).
 Experiencing dignity and respect
The experience of dignity was defined as being respected
and valued as a human being, having the value of
worth (Ruland and Moore 1998).

This includes, being acknowledged and respected as an

equal and not being exposed to anything that violates
the patient’s integrity and values (Ruland and Moore
1998).
 Being at peace
The definition for being at peace for this theory
involves the feeling of calmness, harmony, and
contentment (Ruland and Moore 1998).

To be free of anxiety, fear, and worry.

 Closeness to significant others

Closeness of significant others for this theory is the

feeling of connectedness to other human beings
who care (Ruland and Moore 1998).
 Peaceful End of Life
Experience of Experience of Closeness to Significant
Not being in pain Being at Peace
Comfort Dignity/Respect Others/Persons Who Care

Monitoring and Preventing, Including patient

Providing Facilitating
Administering pain Monitoring and and Significant
Emotional Participation of
relief Relieving Physical Others in Decision
Support Significant Others in
Discomfort Making Patient Care
Applying
Pharmacological and Monitoring and
Facilitating Rest, Treating Patient
Non-pharmacological Meeting Attending to
Relaxation and with Dignity,
Interventions Patient’s Needs Significant Others
Contentment Empathy and
for Anti-anxiety Grief, Worries and
Respect
Medications Questions
Being Attentive to
Inspiring Trust Attending to
Patient’s
Expressed Needs, Significant Others
Providing
Wishes and Grief, Worries and
Patient/Significa
Preferences Questions
nt Others With
Guidance in
Practical Issues Facilitating
Providing Opportunities for
Physical Family Closeness
(Ruland and Moore 1998 p.174) Assistance of
Another Caring
Person, if
Desired
 Reduction of outcome criteria from the standard to outcome
indicators of the proposed theory
Standard Theory
The patient is not having pain Not being in pain

The patient does not experience nausea Experience of comfort

The patient does not experience thirst
The patient does experience optimal comfort
The patient and significant others experience a pleasant environment

The patient and significant others participate in decision making regarding

the patient’s care Experience of dignity/respect
The patient and significant others experience being treated with dignity
and respect as human beings

The patient and significant others maintain hope and meaningfulness

The patient and significant others get assistance in clarifying practical and
economical issues related to the patient’s coming to an end of life Being at peace
The patient does not die alone
The patient is at peace

Significant others:
Are taking part in caring for the patient as they wish
Can say farewell wit the patient in compliance with their beliefs, cultural
rites, and wishes Closeness to significant others/persons who care
Are informed about different funeral procedures and possibilities
 Outcome Criteria of the Standard of Peaceful End of
Life
The patient:
• Is not having pain
• Does not experience nausea
• Does not experience thirst
• Experience optimal comfort
• Is at peace
• Does not die alone
The patient and significant other(s):
• Have confidence that they are receiving the best possible care
• Maintain hope and meaningfulness
• Participation in decision making regarding the patient’s care
• Experience being treated with dignity and respect as a human being
• Get assistance in clarifying practical and economical issues related to the
• Patient’s coming to an end of life
• Experience a pleasant environment
Significant others:
• Are taking part in caring for the patient as hey wish
• Can say farewell with the patient in compliance with their beliefs, cultural rites, and wishes
• Are informed about different funeral procedures and possibilities
• Are offered a follow-up visit after patient’s death

Ruland, Cornelia M., RN, PhD and Shirley M. More, RN,PhD, (1998) Theory Construction Based on Standards of Care: A Proposed Theory of the Peaceful End
of Life . Nursing outlook, 46, 169-75.
 In this theory the focus is not only on
the patient but on the significant others.
You are monitoring and caring for the
needs of the patient: pain, comfort,
dignity/respect, peace, and their
closeness to significant others.
You are providing guidance for the
significant other, answering questions
and offering support.
This theory could be accommodating to
any care setting or with in a patients
home. No matter where the patient
resides at, the focus on care is not to be
on cure, but instead on treating the
patient toward the goals of the five
concepts: no pain, comfort, dignity and
respect, peace, and closeness with
significant others
As the nurse, your goal will be to listen
to the patient and significant others or
to look for signs of complications with
pain, comfort, dignity and respect,
peace, and closeness with significant
others.
 As the nurse, you will need to be
prepared to provide
pharmacological and non-
pharmacological treatments. You
will need to be comfortable in
helping with the significant others,
as well as the patient, cope with the
disease and the disease process.
As nurses you will be educating the
patient and significant others on the
disease and disease process, on
what to expect as time goes on.
Remember, as you do this, keep in
mind to provide the patient and
significant others with dignity and
respect.
 As the patient declines the patient may
not be able to verbalize pain, discomfort,
anxiety, restlessness, or other
complications that need addressing.
You, the nurse, will need to be familiar
with these signs and symptoms, and
what interventions
to complete. At this point, it will be your
job to assess for problems and become
the patients advocate toward treating
these problems.
 Education will be prepared for you
and shared with you to assist you in
your comfort and confidence level
with this Peaceful end of life theory,
included, but not limited to:
Signs and symptoms Treatments
• Pain
• Discomfort
• Nausea • Pharmacological
• Incontinence
• Fear
• Confusion • Non-pharmacological
• Embarrassment
• Humiliation
• Anxiety
• Restlessness
• Withdrawn
• Depression
• Loneliness
 This model provides a framework that
reminds nurses of the important aspects
of care during the end of life. It reminds
nurses to not only treat the patient but
also the significant others. It calls for
thorough assessments of the alert
patient as well as the patient that no
longer is alert, and to assess the need
for medication or non-medication
interventions.
 A limitation that this model has is the
fact that it does not address cultural
differences toward end of life care. For
example, some cultures may feel that
the end of life is a very private time only
allowing specific people to share time
with their loved one, others have the
whole family (all adults or all ages) in the
room. Certain cultures may also rely on
home remedies or have rituals they may
wish to perform.
“Weakness of the theory include needing
more research to back up the theory, as
well as the usefulness of the theory in
influencing nursing research, education,
and practice. Empirical support for all the
relationships needs to be validated”
(Nursing theory 2007, p. 11).
 Nursing Education:
Currently there are no publications that report the use of
this theory for education.
This theory can be applied to a master’s prepared nurse
because it is important that the master’s prepared
nurse educate he/she on this theory and end of life
issues. This will help to educate his/her students to
understand end of life issues. Also when ever the
opportunity allows, give the patient, significant other,
and family the best experience possible and a peaceful
end of life (Tomey & Alligood 2006).
 Strengths of Theory:
Can be used in everyday patient
care.
New and original, based on
standards of care and can be
directed towards patient clinical
practice.
 Developed for the terminally ill who expect death
and can prepare for it.
With the development of the theory nurses are able
to treat patients, significant others, and family
with dignity, respect, and empathy.
Guides nurses in choosing interventions to decrease
suffering and make the last stages of life a
meaningful experience for the patients,
significant other and family.
All nursing interventions and outcomes can be
measured (Ruland and Moore 1998).
Your mouth and eyes are dry, breathing is difficult and it is
making you nervous, and pain is present throughout your
body. Even though you can hear your family members in the
room you feel very alone. Unable to move or speak it is
impossible to make your needs known or to ask for help and
comfort. Then you hear a knock and a familiar voice, the
voice of your nurse. She swabs your mouth, puts eye drops
in your eyes, and a pill and some drops under your tongue
which instantly start to dissolve. Even though you cannot
answer she talks to you and comforts you, then you hear
her tell your family to do the same. Soon someone is
holding your hand, the anxiety and pain are melting away,
and you are able to rest comfortably.
 References:
Case Western Reserve University. Frances Payne Bolten School of Nursing, picture of Shirley M. Moore
taken from http://www.fpb.case.edu, slide 5.

Columbia University. Picture of Cornelia Ruland taken from http://www.dbmi.columbia.edu, slide 5.

http://office.microsoft.com, picture slide 10.

http://www.naturespassage.com, picture slide 7

.
http://www.evergreenhospicecare.com, picture slide 18.

Nursing Theory Peaceful End of Life-Cornelia Ruland and Shirley Moore. Nursing 5330 Theories and
Therapies Texas Tech University Health Sciences Center School of Nursing, Submitted to: Yondell
Masten, October 17, 2007.

Ruland, Cornelia M. RN, PhD & Moore, Shirley, M. RN, PhD. Theory Construction Based on Standards of
Care: A Proposed Theory of the Peaceful End of Life. Nursing Outlook, 1998, 46 (4), p.169-75.

Tomey, Ann Mariner & Alligood, Martha Raile (2006). Middle range theories: Peaceful end of life theory.
Nursing Theorists and Their Work, (pp.775-781). Missouri: Mosby.