Under normal circumstances, nursing, especially as it relates to the theory and practice of palliative care, is a demanding profession that requires not only information, knowledge, and skills, but also emotional and cultural competence in working with a diverse population of patients, each of whom has unique medical care needs. Because nurses are charged with the responsibility of “protect[ing], promot[ing], and optim[izing] health and abilities, prevent[ing]… illness and injury, alleviat[ing]… suffering through the diagnosis and treatment of human response, and advocat[ing] in the care of [patients],” one may get the impression that the duties of the profession are fulfilled primarily through hands-on action (American Nurses Association, 2003, p. 7).

With the above definition in mind, as several noted palliative care scholars are quick to remind us, the active treatment of patients does not always occur through the introduction of measures of physical prevention or intervention. On the contrary, in certain circumstances, the best and most active work a nurse will perform for a patient will involve listening and providing little or no physical treatment at all (Burt, 1997). Palliative care nurses are skilled at making this critical distinction between hands-on activity and what may, to the outsider, seem to be passivity. The palliative care nurse knows, however, that the key nursing functions in providing care to patients in the final stages of life are offering comfort and support (Billings, 2000). While this responsibility of palliative care nurses may sound easy, the fact of the matter is that palliative care is highly demanding and requires several special skills that must work in union with one another (Vachon, 1995). As the class notes, citing Twycross (2001) indicated, the challenge of this branch of nursing is “learning to be with patients rather than doing things for them” (n.p.).

In this exploration of issues related to nursing and palliative care theory and practice, the writer examines the theory and practice of palliative care nursing by applying theoretical constructs to a specific clinical situation that have been experienced. The situation will be presented and then analyzed through the lens of seminal and recent palliative care theory, and the conclusion will convey the lessons that have been learned as the result of this experience. Furthermore, how one might anticipate particular situations related to this field situation and best respond through this improved understanding of theory will influence future practice in the field as well as provide a firm framework for professionally addressing many important aspects of palliative care.

Clinical Situation

Although many patients requiring palliative care are advanced in age, it is not uncommon for nurses to be called upon to provide palliative care for patients who are young and who are suffering from chronic or terminal illnesses. These can be some of the most difficult patients to treat, as nurses may struggle with feelings that go beyond the normal daily emotional challenges of providing palliative care. In the situation analyzed here, the writer was confronted with a task  that was still more challenging: providing palliative care to an eight year old girl whose parents identified themselves as Christian Scientists and who had, because of their religious beliefs, rejected treatment for an illness that had a relatively high probability of success had medical interventions been introduced earlier. Most states protect parents’ rights to make medical decisions—even in life-threatening situations—based on their religious beliefs.

Relevance of Clinical Situation: Personal and Professional Perspectives

The clinical situation described here has been relevant both to my personal and my professional development as a nurse because it challenged me—and continues to do so—to learn how to be culturally competent, even when my own religious and professional beliefs direct me to feel differently from a patient and his or her family and support system. I take seriously the profession’s charge to provide patients with every opportunity to achieve the best quality of life that is possible for them given their medical condition, and in this case, I struggled mightily to provide professional and courteous care in the face of a situation that I considered to be so unnecessary and even morally wrong. I ultimately had to learn how to provide palliative care to a child who I believed could have been saved had her parents permitted medical intervention.

Discussion and Analysis of Theory and Related Issues

The research and theoretical literature on the subject of palliative care acknowledges that this type of nursing presents specific clinical and psychological challenges for medical professionals (Rancour, 2000; Sharp & Oldham, 2004). First, palliative care is intense, but it is not, generally speaking, a fast-paced, hands-on type of nursing to which general practice and other specialty nurses are accustomed. Palliative care demands a shift in both paradigm and practice (Doyle, Hanks, & MacDonald, 1998; Rancour, 2000; Vachon, 1995). Rather than using instruments to perform physical procedures intended to stabilize a patient and improve his or her health, functioning, and well-being, palliative care tends to rely more on one’s emotional, psychological, and social awareness and skills, which are deployed in the service of making patients and the people who comprise their support system feel as comfortable and as prepared as possible for the pending death of the patient (Vachon, 1995). Such a shift in thought and practice may precipitate stress for the nurse who is either new to palliative care or who feels uncomfortable confronting death (Doyle et al., 1998). The nurse who is practicing palliative care for the first time is introduced to a number of challenges to the extent that he or she is called upon to examine his or her belief systems, not only about quality of life, the practice of nursing, and the nurse-patient relationship, but also about life and death in general.

For these reasons, Vachon (1995) contends that the palliative care nurse must demonstrate a “hardy personality” in fulfilling the specific tasks that are expected of him or her. According to Vachon (1995), a nurse with a hardy personality demonstrates specific character and personality traits in addition to general nursing knowledge and skills. First, the nurse with a hardy personality exhibits a clear and profound commitment to the profession in general, and to palliative care in particular (Vachon, 1995). Such commitment is expressed through the nurse’s actions, which reflect the belief that life is precious until its very end, and that quality of life is always possible and is the objective of competent care. Second, the hardy personality is marked by the individual’s intense and persistent curiosity about oneself, one’s circumstances and the situations in which one finds himself or herself, and about others (Vachon, 1995). Related to the characteristic of curiosity is the notion that the hardy personality views difficult situations and people as challenges rather than threats, and responds to them from this perspective (Vachon, 1995). Perhaps because of this approach to what many people consider problems, hardy nurses tend to experience the feeling of being control, not in the sense of dominating other people, but in the sense of being empowered (Vachon, 1995). Next, the hardy nurse knows that his or her work is meaningful, and her or she derives profound satisfaction from knowing that work helps other people (Vachon, 1995). Finally, the hardy personality knows that change is inevitable, and for this reason, is always prepared for the dynamic nature of life (Vachon, 1995). One can see, then, how these traits serve the palliative care nurse well. In the face of difficult situations that are constantly changing, the hardy palliative care nurse is likely to be able to retain a sense of efficacy and stability for himself or herself, as well as to create that feeling for the patient and his or her family and support system.

The nurse who is interested in providing palliative care to medically fragile patients approaching the end of life would certainly do well to cultivate the kinds of characteristics that Vachon (1995) identified; furthermore, it is obvious that such a set of traits would serve the individual well in any sector of nursing, as well as in his or her personal life. In addition, though, theorists explain that the palliative care nurse must demonstrate specific skills and competencies that are particularly necessary for end-of-life patients (Rancour, 2000). Rancour (2000), for instance, wrote about the Buckman Protocol, which is a framework that can be used to plan for, discuss, and respond to difficult conversations with patients. The acronym for the protocol is SPIKES, which stands for Setting, Perception, Invitation, Knowledge, Explorations; and Summary and Strategies. Each of these tasks will be explained below and the writer will indicate how he used each of these stages in working with the patient and family described in the case situation.