Palliative And End-of-Life Care - CASN

Palliative and End-of-Life CareEntry-to-Practice Competencies and Indicators for Registered NursesCanadian Association of Schools of NursingAssociation canadienne des écoles de sciences infirmières

Canadian Association of Schools of NursingAssociation canadienne des écoles de sciences infirmièresACKNOWLEDGEMENTSThe Canadian Association of Schools of Nursing (CASN) gratefully acknowledges the expertise, time and contributions of all those whoengaged in the development of these national competencies and indicators. Production of this document has been made possible through afinancial contribution from Health Canada.Palliative and End-of-Life Care Advisory CommitteeBrenda Jacono (Chair), MScN, RNSchool of Professional Studies, Department of Nursing,Cape Breton UniversityCynthia Baker, PhD, RNCanadian Association of Schools of Nursing -Executive DirectorDarcee R. Bidgood, MSN, RN, CHPCN(C)Canadian Hospice Palliative Care Nurses GroupMaryse Bouvette, BScN, MEd, RN, CON(C), CHPCN(C)Palliative Care Program, Bruyère Continuing CareBeryl Cable-Williams, BScN, MN, PhD, RNTrent/Fleming School of Nursing, Trent UniversityFlorence Flynn, MSW, RSWCanadian Association of Social Workers Health Interest CommitteeHeather Jewers, MN, CHPCN(C)School of Nursing, St. Francis Xavier UniversityEvelyn Kennedy, PhD(c), RNCanadian Association of Schools of Nursing Board of DirectorsMireille Lavoie, PhD, RNFaculté des sciences infirmières, Université Laval, Centre derecherche du CHUQ – Hôtel-Dieu de QuébecS. Lawrence Librach, MD, CCFP, FCFPAssociation of Faculties of Medicine of Canada, Head, Divisionof Palliative Care, Dept. of Family & Community Medicine, andSun Life Financial Chair in Bioethics and Director Joint Centre forBioethics, University of TorontoMitzi G. Mitchell, BScN, BA, MHSc, MN,Faculty of Health, School of Nursing, York UniversityDNSc, PhD(c), RN, GNC(C)Holly R. L. Richardson, BScN, MA, PhD(c), RNSchool of Nursing, Dalhousie UniversityChristine Rieck Buckley, MScA, RNCanadian Nurses AssociationSharon Specht, BA, BSN, RN, CHPCN(C)Canadian Hospice Palliative Care Nurses GroupMary Strain, BScN StudentCanadian Nursing Students’ AssociationLynne E. Young, PhD, RNSchool of Nursing, University of VictoriaPalliative and End-of-Life Care Competencies and Indicators Working GroupLynne E. Young (Chair), PhD, RNSchool of Nursing, University of VictoriaDarcee R. Bidgood, MSN, RN, CHPCN(C)Canadian Hospice Palliative Care Nurses GroupMaryse Bouvette, BScN, MEd, RN, CON(C), CHPCN(C)Palliative Care Program, Bruyère Continuing CareBrenda Jacono, MScN, RNSchool of Professional Studies, Department of Nursing,Cape Breton UniversityHeather Jewers, MN, CHPCN(C)School of Nursing, St. Francis Xavier UniversityChristine Rieck Buckley, MScA, RNCanadian Nurses AssociationCopyright Canadian Association of Schools of Nursing, 2011

PreambleAn Advisory Committee of the CanadianAssociation of Schools of Nursing (CASN)on Palliative and End-of-life Care (PEOLC)developed national, consensus basedcompetencies and indicators to facilitategreater integration of this area of nursingin undergraduate curricula in Canada. Thecommittee selected the conceptualizationof palliative and end-of-life care used in theCanadian Strategy on Palliative and End-of-LifeCare to guide this work. The competencies andindicators were developed through a multistep,iterative, process of literature syntheses andnational stakeholder consultations.Many different terms refer to care given at theend-of-life such as hospice care, end-of-lifecare, and palliative care. Moreover, there is alack of agreement on what period constitutesend-of-life. In the Canadian Strategy onPalliative and End-of-Life Care, the termsare used together to describe care aimed atimproving the quality of living and dying forthose facing life threatening illness (HealthCanada, 2007). Palliative and end-of-life careincludes both caregiver and bereavementsupport, and involves the “combination ofactive and compassionate therapies intendedto comfort and support individuals andfamilies who are living with, or dying from,a progressive life-threatening illness, or arebereaved”(Canadian Hospice Palliative CareAssociation (CHPCA) Nursing StandardsCommittee, 2002, p. 5). It is “appropriate forany patient and/or family living with, or at riskof developing, a life-threatening illness due toany diagnosis, with any prognosis, regardlessof age, and at any time they have unmetexpectations and/or needs, and are preparedto accept care” (Ferris et al., 2002, p. 17).Palliative and end-of-life care also incorporatesthe community services that provide care topatients and their family at the end of their life(Palliative Care Australia, 2009).For this project, competency is defined as acomplex know-how based on combining andmobilizing knowledge, skills, attitudes, andexternal resources to apply appropriately tospecific types of situations (Tardif, 2006).PEOLC indicators are the specific outcomebehaviours that reflect the integration of agiven competency (Matzo & Sherman, 2001).In nursing education settings, the PEOLCcompetencies may provide direction to curriculadevelopment; indicators may be used bynurse educators and students as a guide forassessing the development and integration of acompetency.The following list of indicators for eachPEOLC competency is not intended to beexhaustive. Moreover, as there is no one-toone correspondence between indicators andcompetencies, some indicators may be relevantfor more than one competency.

Competencies and Indicators1. Uses requisite relational skills to support decision making and negotiatemodes of palliative and end-of-life care on an ongoing basis.

1.1.1.2.1.3.1.4.1.5.Discusses the benefits and burdensof the usual palliative and end-of-life(PEOL) treatment options to assist thepatient and family members in meetingtheir goals of care, and documents theinformation provided.1.6.Provides the opportunity for the patientapproaching end-of-life to conduct a lifereview.1.7.Reviews, and clarifies the patientand family members’ understandingof palliative and end-of-life careinformation presented by other careproviders, and documents this.1.8.Facilitates conversations that supportend-of-life decision making such ashealth care directives, living wills andtending to personal affairs.1.9.Conserves patient and family dignity byfacilitating expression of their feelings,needs, hopes, joys, and concerns inplanning for palliative and end-of lifecare.Communicates and documents decisionsmade by the patient and family membersregarding their goals for palliative andend-of-life care.1.10.Invites, facilitates, negotiates andrespects the involvement of the patientand family members and other teammembers in discussions about the planof palliative and end-of-life care.Identifies and documents the need forreferral to support palliative and endof-life decision making and providesnecessary follow-up to ensure timelyreferral.1.11.Creates a safe environment to buildpatient and family members’ trust andfacilitate palliative and end-of-lifedecision making.Provides information and assuranceto the patient and family membersregarding comfort measures during thelast days/hours of living, and documentsthe information provided.Communicates respectfully,empathetically and compassionatelywith the PEOL patient and familymembers.

2. Demonstrates knowledge of grief and bereavement to support others from across-cultural perspective.

2.1.Accurately assesses and documentsthe patient’s and family members’needs related to loss, grief andbereavement.2.6.Demonstrates understanding of thecommon, normal manifestations ofgrief (emotional, physical, cognitive,behavioural).2.2.Identifies individuals experiencing,or at high risk for experiencing, acomplicated and/or disenfranchisedgrief reaction, and discusses,documents and makes appropriatereferrals.2.7.Demonstrates understanding ofindividual, social, cultural, andspiritual variables that affect grief.2.8.Provides guidance, support, andreferrals to bereaved family membersand documents such practice actions.2.9.Listens, affirms, and respondsempathetically and compassionatelyto the patient and family membersworking through the tasks of grief andbereavement.2.10.Develops the capacity to be in thepresence of patient and familymembers’ suffering.2.3.2.4.2.5.Uses insights gained from personalexperiences of loss, bereavement andgrief to provide supportive care toothers.Identifies situations when personalbeliefs, attitudes and values result inlimitations in the ability to be presentfor the patient and family membersexperiencing loss, grief, and/orbereavement.Demonstrates understanding of grieftheories and their application toPEOLC.

3. Demonstrates knowledge and skill in holistic, family-centered nursing careof persons at end-of-life who are experiencing pain and other symptoms.

3.1.3.2.3.3.3.4.Identifies gaps in knowledge, skills,and abilities as a first step in acquiringnew knowledge, skills, and abilities forPEOLC.Demonstrates understanding of theconcept of ‘total pain’ when caringfor PEOL patients and their familymembers, total pain being inclusive ofphysical, emotional, spiritual, practical,psychological, and social elements.Applies principles of pain and othersymptom management when caring forPEOL patients.Utilizes best practice assessment toolsfor baseline and ongoing assessmentof pain, including word descriptors,body maps, precipitating andalleviating factors, and documents painassessments.3.5.Utilizes and documents evidenceinformed pharmacological approachesto alleviate pain, including intendedeffects, doses and routes of medication,and common side-effects.3.6.Utilizes and documents evidenceinformed non-pharmacologicalapproaches to pain, including anypotential adverse effects.3.7.Assesses and documents common nonpain symptoms at end-of-life.3.8.Understands causes of common nonpain symptoms at end-of-life.3.9.Implements and documents evidenceinformed pharmacological and nonpharmacological approaches for nonpain symptoms at end-of-life.3.10. Discusses, teaches, assists PEOL patientand family members in managing painand other symptoms including therecognition of areas requiring furtherassessment, and documents this.3.11. Evaluates and documents all outcomesof pain and symptom managementinterventions throughout the course ofthe patient’s illness experience against abaseline assessment using comparativeevaluations.3.12. Practices person-centered PEOLC thatincorporates the unique contributionsof the particular family and communitymembers in routine care giving whilealso demonstrating general knowledgeof pain and symptom management in thePEOL population.3.13. Demonstrates the capacity to be presentwith pain and suffering.3.14. Effectively collaborates with the interprofessional team in the management ofpain and other PEOL symptoms.

4. Recognizes and responds to the unique end-of-life needs of various populations, such as elders, children, multicultural populations, those with cognitive impairment, language barriers, those in rural and remote areas, thosewith chronic diseases, mental illness and addictions, and marginalized populations.

4.1. Recognizes and responds to the unique needs or backgrounds of patients ofvarying ethnicities, nationalities, cultures, genders, ages and abilities that mayaffect their experience of palliative and end-of-life care.4.2. Identifies who the family is for the PEOL patient, and responds to familymembers’ unique needs and experiences.4.3. Adapts communication, assessment and information sharing to the unique needsof the PEOL patient and family members to facilitate informed decision-making,and consults with/refers to appropriate supports such as translated documentsand interpreters.4.4. Considers and incorporates the determinants of health when formulating a planof care for PEOL patients and families with unique needs.