The Ethos of Palliative Nursing
By Mark Lazenby and Michael Anthony Moore
This is an edited extract from the full chapter ‘The Ethos of Palliative Nursing’ from the Oxford Textbook of Palliative Nursing, Fifth Edition (OUP, 2019).
Palliative nursing has an ethos, a moral character that builds meaning in the context of serious illness and death and dying. This moral character is defined by the qualities of a caring relationship – including trustworthiness, moral imagination, attending to the beauty of patients’ humanity, creating a moral space for patients to flourish, and being present with them.
Trustworthiness cuts close to the heart of the ethos of palliative care nursing. Year after year, the public has rated nurses as members of the most trusted of professions1. Speculation on the potential reasons for the public’s trust is possible, but the most obvious answer is that nurses are, in fact, trustworthy. The contemporary bio-ethicist Onora O’Neill has convincingly argued that trustworthiness has three components: competence, reliability, and honesty2.
Often, not having straightforward answers to medical and spiritual issues overwhelms those in palliative nursing. All nurses have had patients who, before they die, have one last desire that seems impossible to achieve. These situations demand imaginative thinking. The eighteenth-century philosopher, Immanuel Kant, believed that imagination takes an individual back to “first principles”, meaning that imagination brings one back to what matters most and what is most fundamental3.
Beauty is another quality of a caring relationship: seeing the beauty of patients’ humanity. The first way to honor patients’ beauty is to listen to them. Not only is listening the process of relationships, according to the contemporary moral psychologist Carol Gilligan, but listening is the only way a provider can discover who patients are and what matters to them as they face serious illness4. Amid the injury of serious illness, listening to patients is actively restorative; listening restores their humanity in face of the injury of serious illness. While actively listening, the nurse ceases to be the nurse, the healthcare provider, rather, the nurse becomes a person listening to another person, listening to the other’s joys and sorrows, reminiscences and regrets, hopes and fears. When actively listening, nurses treat their patients not as patients but as people who, though sick and dying, are alive.
One quality of a caring relationship is to create the space, in the context of the impersonal medical industrial complex, in which patients can still be themselves; of course, this is not simple5. By being trustworthy with their patients, by imagining what needs to be done to fulfil patients’ goals, by being faithful to who patients are, and by active listening, nurses open up the space for patients to be who they are— undefined by serious illness. This is part of the reason to become a palliative nurse: to treat patients as the people they are, to provide them the space to be who they are, even as serious illness imperils or takes their lives. For many palliative nurses, it is what sustains them: those moments when they see a smile shine through, the expression of hope, and the stories of a beautiful life.
To be trustworthy with patients, to offer imaginative responses, to listen to stories, to create the space for patients to be themselves in the clinic or their home, nurses must be present. Being present is another quality of a caring relationship. Presence, in the context of palliative nursing, is not nurses adopting a power pose by which to assert themselves and their desires upon patients and families. Presence is, rather, being with patients and families not as cases but as people. When in the presence of other people, nurses respect patients’ capacity to make their own decisions and to be in relationships6.
Mark Lazenby, PhD, APRN, FAAN, is Associate Professor of Nursing at Yale School of Nursing and Associate Professor of Religion and Health at Yale University Divinity School.
Michael Anthony Moore, BA, RN, Yale University School of Nursing.
Oxford Textbook of Palliative Nursing, Fifth Edition, edited by Betty Rolling Ferrell and Judith A. Paice.
1 Norman J. Americans Rate Healthcare Providers High on Honesty, Ethics. Gallup News Web site. 2016; http://news.gallup.com/poll/200057/americans-rate-healthcare-providers-high-honesty-ethics.aspx. Accessed December 7, 2017.
2 O’Neill O. A Question of Trust: The BBC Reith Lectures 2002. Cambridge: Cambridge University Press; 2002.
3 Kant I. Fundamental Principles of the Metaphysics of Morals. New York: Liberal Arts Press; 1949.
4 Gilligan C, Eddy J. Listening as a path to psychological discovery: an introduction to the Listening Guide. Perspect Med Educ. 2017;6(2):76–81. doi: 10.1007/s40037-017-0335-3.
5 Butler J. Notes Toward a Performative Theory of Assembly. Cambridge, MA: Harvard University Press; 2015
6 Farley MA. Compassionate Respect: A Feminist Approach to Medical Ethics and Other Questions. Mahwah, NJ: Paulist Press; 2002.
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