Cornelia M. Ruland received her Ph.D. in nursing from Case Western Reserve University, Cleveland, Ohio, in 1998. She is now the Director of the Center for Shared Decision Making and Nursing Research at Rikshospitalet University Hospital in Oslo, Norway. She also holds an appointment as adjunct faculty at the Department of Biomedical Informatics, Columbia University, in New York. Ruland has established an extensive research program on improving shared decision making and patient-provider partnerships in health care, and the development, implementation, and evaluation of information systems to support it. Her focus is on aspects of and tools for shared decision making in clinically challenging situations: (1) when patients are confronted with difficult treatment or screening decisions for which they need help to understand the potential benefits and harms of alternative options and to elicit their values and preferences, and (2) preference-adjusted management of chronic or serious long-term illness over time. Ruland has been the primary investigator on a number of research projects and has received several awards for her work.

THEORETICAL SOURCES

The Peaceful End of Life (EOL) Theory is informed by a number of theoretical frameworks (Ruland & Moore, 1998). It is based primarily on Donabedian’s model of structure, process, and outcomes, which in part was developed from general system theory. The influence of general system theory is pervasive in other types of nursing theory, from conceptual models to middle and microrange theories—an indicator of its usefulness in explaining the complexity of health care interactions and organizations. In the EOL theory, the structure-setting is the family system (terminally ill patient and all significant others) that is receiving care from professionals on an acute care hospital unit, and process is defined as those actions (nursing interventions) designed to promote the positive outcomes of the following: (1) being free from pain, (2) experiencing comfort, (3) experiencing dignity and respect, (4) being at peace, and (5) experiencing a closeness to significant others and those who care.

A second theoretical underpinning is preference theory (Brandt, 1979), which has been used by philosophers to explain and define quality of life (Sandoe, 1999), a concept that is significant in EOL research and practice. In preference theory, the good life is defined as getting what one wants, an approach that seems particularly appropriate in EOL care. It can be applied to both sentient persons and incapacitated persons who have previously provided documentation related to EOL decision making. Quality of life, therefore, is defined and evaluated as a manifestation of satisfaction through empirical assessment of such outcomes as symptom relief and satisfaction with interpersonal relationships. Incorporating patient preferences into health care decisions is considered both appropriate (Ruland & Bakken, 2001; Ruland, Kresevic, & Lorensen, 1997) and necessary for successful processes and outcomes (Ruland & Moore, 2001).

This theory was derived in a doctoral theory course in which Ruland was a student and Moore was the faculty. Middle range theories were just emerging, and there were few good definitions or examples. The class was challenged to think about the future use and development of middle range theory for nursing science and practice. The students discussed knowledge sources from which they could derive middle range theory, such as empirical knowledge, clinical practice knowledge, and synthesized knowledge. Each student was asked to derive a middle range theory from a knowledge source of choice. Ruland had just completed a major project to develop a clinical practice standard for peaceful EOL with a group of cancer nurses in Norway. The standard was synthesized into the theory of peaceful EOL by Ruland and later was refined with Moore’s assistance. This is an example of middle range theory developed by doctoral nursing students as they study knowledge development methods. This theory is also an example of early middle range theory development using a standard of practice as a source.

USE OF EMPIRICAL EVIDENCE

The theory of peaceful EOL is based on empirical evidence from both direct experience of expert nurses and a thorough review of the literature addressing several components of the theory. The group of expert practitioners who developed the standard of care for peaceful EOL had at least 5 years of clinical experience caring for terminally ill patients. The standard of care consisted of best practices based on research-derived evidence in the areas of pain management, comfort, nutrition, and relaxation. This prescriptive theory comprises several proposed relational statements for which more empirical evidence is needed as well. Importantly, explicit hypotheses can be derived easily from these relational statements to be tested for their usefulness. It should be noted that the authors of the standard of care and the theory attempted to incorporate clearly described, observable concepts and relationships that expressed the notion of caring.

Because the theory of peaceful EOL was derived from standards of care written by a team of expert nurses who were addressing a practice problem, the metaparadigm concepts were inherent in the nursing phenomena addressed, the complex and holistic care required to support peaceful EOL.

Two assumptions of Ruland and Moore’s (1998) theory are identified as follows:

Two additional assumptions are implicit:

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