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1. Concerns for Health Promotion
This section of the paper is entitled Health promotion and disease prevention
and will discuss these aspects in relation to the hospice nursing vulnerability
group in Finland and America. It will reflect upon (1) the vulnerability groups
perspective of health promotion and disease prevention; (2) policies related to
health promotion and disease prevention and the vulnerability group in both
countries, and (3) the concerns regarding health promotion and disease
prevention for nurses working with the vulnerability group.

According to the World Health Organization, health promotion is the process
of enabling people to increase control over, and to improve, their health
(2014). However, the application of this definition to the Finnish and American
hospice nursing vulnerability group discussed in this paper is limited. This is
because, as the authors identified earlier in the paper, the service users in this
vulnerability group experience progressive end-stage illnesses which cannot
be halted, therefore no health promotion intervention could enable them to
gain control over or improve their health. For the purpose of disambiguation,
hospice nursing aims to meet the physical, mental, social, spiritual and
existential needs and support the relatives of patients with short life
expectancy due to progressive incurable disease (Ministry of Social Affairs
and Health, 2010).

Instead, health promotion for this vulnerability group focuses on the
attainment of physical, mental and social well-being (WHO, 1986).
Interestingly however, it is important to note that the concept of well-being too
must be adapted, in order to make it applicable to discussion about health
promotion and the hospice nursing vulnerability group. This is because
general consensus defines physical, mental and social well-being as the
presence of positive emotions and moods (e.g., contentment, happiness), the
absence of negative emotions (e.g., depression, anxiety), satisfaction with life,
fulfillment [!,] positive functioning [! and] physical well-being (e.g., feeling
very healthy and full of energy) (Centers for Disease Control and Prevention,
2013), and it is not entirely realistic to expect these behaviors from hospice
patients and their families. Undoubtedly, some patients and families display
greater capacities for coping with terminal illness than others (Ashton, 2008).
It is accepted that impending death can affect physical well-being, e.g.
insomnia and changes in appetite; alter mental well-being by generating
negative emotions like anger, anxiety and sorrow and may impair normal
social functioning, e.g. withdrawing from others, feeling vulnerable and finding
it difficult to perform simple everyday tasks and (Ashton, 2008).

Taking this into account, it is reasonable to determine that achieving physical,
mental and social well-being for these patients centers on being able to
satisfy needs, and to change or cope (WHO, 1986) and that the hospice
nursing vulnerability groups perception of health promotion is that it should
focus upon attaining these goals.

The Canadian Ministry of Health and Long-Term Care defines disease
prevention as prevention strategies that reduce the risk of disease, identify
risk factors, or detect disease in its early, most treatable stages (2006). This
definition is applicable and particularly significant to the hospice nursing
vulnerability group because their physical fragility is a risk factor for the
acquisition of co-morbidities. For example, members of the client group with
terminal cancers who undergo radiotherapy or chemotherapy can experience
temporary or prolonged immunosuppression, which is a risk factor for
acquiring infection. Based upon this, it would be reasonable to suggest that
the vulnerability groups perspective of disease prevention would be a slight
adaptation of the Ministry of Health and Long-Term Cares, i.e. prevention
strategies which reduce the risk of further disease or co-morbidity.

Unlike in the United States where hospice nursing is a well-established
specialism, hospice nursing admittedly has some way to go to achieve this
status in Finland. It was described by Vainio (1990) as being in its infancy in
1990 and more recent data from the Economist Intelligence Unit (2010)
highlights that there is still progress to be made - Finland ranks 28th in the
world for the quality of end-of-life care provision. This made it very challenging
to uncover governmental policies related to palliative care.

However, a Current Care Guideline for palliative (symptomatic) care of
(imminently) dying patients does stipulate that hospice nursing care should be
made available to all Finnish patients with terminal and end-stage diseases
at all health care levels (Current Care Guidelines, 2012). Health care
services in Finland are provided by municipalities, private health care
providers or employers - occupational health services (European Observatory
on Health Systems and Policies, 2012). But whilst there is evidence that the
Finnish hospice nursing vulnerability group is entitled to health promotion
services at municipal and private health care system level, there is no
evidence of health promotion procedures for this vulnerability group at an
occupational level. This is because occupational health care is only available
for Finnish residents in employment and the groups diseased state may
exclude them from this employment; suggesting that health promotion
services in Finland are only available to Finnish hospice nursing patients at all
health care levels, if they are employed. Nonetheless, when the vulnerability
groups access to health promotion services is assessed at a more basic level
i.e. primary, secondary and tertiary care level, the evidence that this Current
Care Guideline is being implemented is comprehensive.

In line with the Primary Health Care Act (1972) municipalities fund health
centers to provide primary health care for its residents (WHO, 2008) and since
the 1990s general practitioners have been responsible for health promotion -
encouraging physical, mental and social well-being by meeting patients
needs and supporting them to cope with their diagnoses of incurable illness -
at the Health Centre of Kangasala and the Health Centre of Virrat in Tampere
(Lammi et al., 2000). In these real life examples, health promotion is achieved
at primary care level through the alleviation of physical and psychosocial
symptoms (Lammi et al., 2000). Although the data about primary health care
provision for the hospice nursing vulnerability group in health centers was
published in 2000, its validity is re-affirmed by evidence that palliative care on
health center wards persists (Ministry of Social Affairs and Health, 2010).

There is evidence of health promotion for the vulnerability group at secondary
care level too: information about the palliative unit at Tampere University
Hospital on the Pirkanmaa Hospital District website (2013) describes the
hospice nursing provided by the hospital as active care to reduce various
symptoms of the disease, although there is no emphasis placed on
psychosocial symptoms or support for families. In tertiary care services like
the Acorn Home hospice in Helsinki, nursing staff with specialized palliative
care knowledge satisfy patients needs and wishes and support patients and
their families to cope by alleviating the physical and psychosocial symptoms
of the illness; helping them to see death a normal end-point; providing grief
support and supporting families during the illness and after the death of their
loved one (Acorn Home, no date).

An area of concern for nurses caring for the hospice nursing vulnerability
group in Finland which relates to both disease prevention and health
promotion, is the lack of palliative care education for health professionals
working with this vulnerability group. Hospice nurses need to be
knowledgeable about the risk factors and determinants of health associated
with terminal disease if they are to prevent further disease from occurring. But
there is insufficient focus on palliative care education at both an
undergraduate and postgraduate level (Lynch et al., 2010), meaning that
nurses are not sufficiently knowledgeable about the needs that must be
addressed to achieve the physical, mental and social well-being of this client
group. This has implications for nurses working with pediatric palliative care
patients too since terminally ill children wish to stay at home as much as
possible (Ministry of Social Affairs and Health, 2010) and parents are only
willing to allow their child to be cared for at home if they feel sufficiently
supported by knowledgeable nursing staff (Laakarilehti, 2010).

A further area of concern for nurses caring for this client group related to
health promotion and disease prevention is linked to the central aspect of
palliative care pain relief. Opioid analgesics are commonly administered for
the alleviation of the pain symptoms associated with terminal illness (Current
Care Guidelines, 2012) but can cause opioid induced constipation (British
National Formulary, 2014). Since the discomfort caused by constipation would
undermine the therapeutic effect of opioids and nursing interventions such as
suppositories, enemas or manual evacuation would be too distressing for this
physically vulnerable client group, it would be the role of the nurse to
administer a laxative alongside the opioid analgesia, thus preventing
constipation from occurring.

There are many areas of concern for health promotion regarding hospice
nursing in the United States. The process of dying is very emotional and
causes stress on the hospice patient and their family. It is important for the
nurse to be knowledgeable about the patients illness and the dying process.
The nurse is responsible for educating the patient and the family on this
crucial information. High costs of hospice care are another area of concern to
hospice patients and their families. The nurse needs to be sensitive to these
concerns and involve the patient and their family in all aspects of care
(Dobrina, Palese, & Tenze, 2014).

In caring for the patient through the emotional process of dying, the nurse
should understand that suffering is a multidimensional experience related to
physical symptoms, psychological distress, existential concerns, and social-
relational worries. The physical, psychological, social, and spiritual needs of
patients and their families must be considered by the nurse in hospice care.
These needs must be met in order to promote health within the hospice care
setting. The nurse is responsible for understanding the illness and dying
processes that the hospice patient experiences. The nurse should
communicate this knowledge to the patient and their family. The patient relies
on the nurse to educate and provide quality care for them based off
knowledge of the disease process (Dobrina, Palese, & Tenze, 2014).

The top nursing priority in hospice care is to establish a therapeutic
relationship with not only the patient, but the patients family as well,
facilitating an environment conducive to the best quality of care possible at the
end-of-life. The nurse should always take a non-judgmental approach and
provide individualized care for each patient and family. It is important to
consistently assess and reevaluate the patient and familys wants and needs
throughout the dying process (Dobrina, Palese, & Tenze, 2014).

When forming a therapeutic relationship, the nurse must create a comfortable
environment for the patient and their family to discuss the illness and dying
process. This can be extremely emotional and the nurse should be prepared
to answer questions about what the family can expect throughout the end-of-
life process. Empathetic communication is a necessary asset in this process.
It is important for the nurse, patient, and family to feel comfortable in this
relationship, sharing values, fears, and meaning regarding life and death.
Compassionate nurses in hospice care can help families achieve optimal
comfort and function during the death of a loved one and can empower the
patient to have a sense of peace and maintain aspects of autonomy through
the progression of their illness (Dobrina, Palese, & Tenze, 2014). This
therapeutic relationship helps to promote the mental and emotional health of
the dying patient and their loved ones.

The hospice nurse has an important role in reframing the patient and familys
views of illness. The family must transition from hoping for a cure to a realistic
idea of prognosis and treatment focusing on palliative care and comfort
measures when caring for the patient. With this understanding, the family
gains the ability to cope with life-threatening illness while maintaining the
patients quality of life (Dobrina, Palese, & Tenze, 2014).

Finances are a major concern in hospice care. Hospice can be quite
expensive and may be a burden on the dying patient and their family. With the
current economic instability, there is an increasing number of people that dont
have insurance or available money for necessary end-of-life care. In the
United States, there are both governmental and non-governmental resources
to help aid the family in paying for hospice costs. With the hospice patient
population rising, the need for hospice care and support is at an all-time high
(M. Blackwell, personal communication, September 24, 2014). It is important
for hospice patients to have a means to pay for their palliative care.

2. Plan for Rehabilitation
The population receiving hospice care is different than most vulnerable
population groups. Rehabilitation usually determines making something better
and returning to former or normal function. The term rehabilitation is looked at
from a different perspective with hospice because the patients receiving care
are in the process of dying. The illnesses and conditions the patients are
suffering from are terminal and there is no returning to normal function. The
vulnerable population is mainly older adults, but can encompass any age
group with terminal, chronic illness. The nurses providing the care are working
towards comfort. The patient is near the end of life and may need emotional
or psychosocial support as well as physical care and comfort.

The process of palliative care takes the place of rehabilitation with hospice
care. In the United States, palliative care usually means comfort care for the
dying. Palliative care is defined as, interdisciplinary team-based care that is
focused on the relief of suffering for clients with serious illness. It attempts to
achieve the best possible quality of life not only for clients but also for their
families (Harkness & DeMarco, 2012). This care emphasizes acceptance of
illness while improving quality of life until death. The hospice movement
began in the United States in the 1970s. Since then, over 7 million patients
and families have received end-of-life care at home, as well as in nursing
homes or hospitals through hospice programs. Today, the number of patients
and families utilizing hospice or end-of-life care has increased substantially. In
2008, about 38.5% of the people who were dying received hospice services
(Harkness & DeMarco, 2012). In other words, a little less than half the dying
population received comfort care and had an increased quality of life up until

Hospice is usually classified as support to dying patients with an expected
prognosis of less than six months. Two different doctors must determine that
an ill patient has six months or less to live. The patient and family then must
agree to receive and provide comfort care as opposed to aggressive medical
interventions. However, it is hard to accurately predict how long a patient will
end up living, especially with a specific chronic disease. The hospice program
is supported by Medicare and the program was added by Congress in the
1980s. Even now, the program is still evolving. Many hospice programs are
extending palliative care well before the last six months of life for patients
dying from chronic illnesses. To provide all around care, hospice generally
focuses on the whole patient. By caring for the body, mind, and spirit, the
nurse assists the patient through the end of life (Harkness & DeMarco, 2012).

A multidisciplinary team is needed with hospice care. Typically, a nurse,
physician, therapist, pharmacist, social worker, pastoral counselor, and the
family all work together to provide care. The nurses main role is to act as a
patient advocate and manage pain while controlling symptoms (Harkness &
DeMarco, 2012). The nurse should also assess the patient and familys
coping mechanisms. The nurse can refer the family to other helpful outside
resources and make sure the patients wishes are closely followed. Even
though the patient is going through a difficult time and may have fears
associated with dying, the nurse experiences stress as well. It is difficult to
provide comfort care for a patient who is suffering. The nurse forms a working
relationship with the patient and may become emotional when that patient
eventually dies. That process over and over, or even simultaneously, is
draining mentally, emotionally and physically on a nurse. The multidisciplinary
team then comes together to provide adequate end-of-life care.

Throughout the world, hospice care ultimately has the same focus. Palliative
care, or comfort care, is provided in similar ways to relieve and guide the
dying patient. Hospice care is currently at different stages around the world.
The type of care develops and responds to various needs for each part of the
world. However, limited access to palliative care is one of the major issues.

The World Health Organization estimates that about 24 million older adults
require palliative care at the end of life and about 66% of those adults are
over 60 years of age. With the growing need of hospice care, 42% of
countries still have no identified hospice and palliative care programs, and
80% of adults globally lack adequate access to medication for moderate to
severe pain. This explains that millions of older adults are dying in
unnecessary pain and distress, especially in the developing world. The
Worldwide Palliative Care Alliance (WPCA) urges for the improvement of
palliative care for older adults and to meet the needs of the worlds aging
population (World hospice, 2014). Integrating palliative care into community
and national health systems around the world can help start the trend for
better access to care during the dying process.

3. Government and Non-government Organizations
According to the National Hospice and Palliative Care Organization (NHPCO)
in the United States, in 2012, an estimated 1.5 to 1.6 million patients received
services from hospice. This estimate includes patients who died while
receiving hospice care, patients who received care in 2011 and who
continued to receive care in 2012, and patients who left hospice care alive in
2012 (Facts and figures, 2013). In 2012, hospice care cost the United States
government nearly 14 billion dollars. This amount is expected to increase
steadily with the baby boomer population, or individuals born between the
years 1946 and 1964, turning sixty-five and older. Although end-of-life care
can be a major financial burden on both the individual and the family,
Medicare hospice benefits cover costs for over 80% percent of patients (Facts
and figures, 2013).

The United States government defines Medicare as, a federal health
insurance program for people who are 65 or older, certain young people with
disabilities, and people with End-Stage Renal Disease (Medicare, 2014).
Medicare was created in 1965 by President Lyndon B. Johnson as a social
reform known as The Great Society, which strived to eliminate poverty and
racial injustice within the United States. In 1982, congress passed the
Medicare Hospice Benefit, which offers patients and families multiple services
including pain and symptom management, emotional and spiritual support,
and both medication and medical supplies. Medicare insurance is funded
nationally by the government, which is supported and paid for by taxpayers of
the United States. All United States taxpayers pay 1.45% of earnings and
employers pay another 1.45% to the Social Security Administration, which
then funds Medicare (Medicare, 2014). Most individuals 65 years or older who
are permanent residents of the United States are eligible for Medicare

The next biggest source for hospice funding is non-governmental, private
insurance coverage. For United States citizens, private insurance is the main
source of health coverage. If an individual is not covered, or only partially
covered by a governmentally funded program, a private insurance plan will
need to be obtained. In 2012, 7.6% of patients receiving hospice care were
covered by private insurance plans. For individuals needing hospice care that
cannot afford private insurance and are unable to receive governmentally
funded Medicare coverage, some uncompensated, or charity care is

Many non-governmental associations within the United States have also been
created in order to support and drive research related to end-of-life and
hospice care. One of these organizations is the Hospice Foundation of
America (HFA). HFA provides leadership in the development and application
of hospice and its philosophy of care with the goal of enhancing the U.S.
healthcare system and the role of hospice in it (HFA, 2014). The National
Hospice and Palliative Care Organization (NHPCO) is the largest nonprofit
organization committed to improving hospice care and enhance the quality of
life for individuals during this time. Serving as an advocate for the terminally
ill, the NHPCO provides educational programs and resources, conducts
research, and monitors Congressional and regulatory activities. This
organization also works closely with other organizations that share a passion
for improvement and advancement in hospice care. An example of this is
Caring Connections. Caring Connections was created by the NHPCO and
provides free resources to help clients and families make difficult decisions
about hospice care (NHPCO, 2014).

Physicians, nurses, and medical professionals within the United States can
also promote and work towards an advancement in hospice and end-of-life
care on both national and local boards. The American Board of Hospice and
Palliative Medicine (ABHPM) advances hospice care by developing standards
for practice and quality care for clients and families. Within Missouri and the
Midwest, the Missouri Hospice and Palliative Care Association (MHPCA) is a
state wide, non-for-profit organization with the mission to support and
strengthen coordinated care for the terminally ill Missourians and their families
through the advancement of hospice and palliative care (NHPCO, 2014).

With life expectancy consistently increasing, and the older population
projected to increase from 40.4 million in 2010 to 55 million in 2020, hospice
care is essential (Mauk, 2014). The government and non-government
organizations all play a major role in addressing community health concerns
within the US. In order to meet the increasing demand for hospice care,
performance and quality must somehow be measured in order to make
improvements and continue to grow. NHPCO provides hospice patients and
their family evaluations to identify components of quality care, discover what
areas of care are effective, and target specific areas for improvement. In
2012, the overall rating of the Family Evaluation of Hospice Care (FEHC), or
percentage of individuals rating the quality of hospice care excellent, was
73.5% overall with a global measure of hospice quality at 85.8% (NHPCO,
2012). In order to continue to meet the appropriate demand in the near future,
these organizations must continue to grow with funding, volunteerism, and
health professionals steadily increasing. The United States and its hospice
organizations must plan appropriately by allotting enough money and
resources to provide quality care as the field continues to grow.

In Finland adequate social, health and medical services (Taperi et al., 2009,
p. 39) are guaranteed by public authorities as stated in the Constitution. The
resident Finnish population has the right to suitable health services
irrespective of the ability to pay and residence place. One of the main long-
term goals for healthcare policies in Finland is the equal distribution of
services and costs, as well as to promote, improve and maintain the
populations physical and mental well being (Anttonen et al., 2011).
The Finnish healthcare system is very similar to those in other Nordic
countries. It offers universal coverage for a broad variety of health services,
which are manly provided publicly and are funded mostly through general
taxation (Taperi et al., 2009). This system, however, is also very
decentralized; in fact, local municipalities (which are 348, p. 37) organize and
provide primary healthcare services for their residents, receiving funding for
this through taxation and state subsidies. Furthermore, alongside this public
municipal healthcare system, the Finnish population receives partial
reimbursement for private healthcare services through the statutory National
Health Insurance scheme, which falls under the Parliaments authority and is
run by the Social Insurance Institution, covering also some family and housing
benefits, rehabilitation, basic unemployment security and students aids.
Private sickness insurance is uncommon in Finland: in 2005 only 5% (p. 42)
of the adult population had purchased a private healthcare insurance scheme.
To conclude, looking at the classification of the healthcare patterns around the
world as described by PNHP (2010), the Finnish healthcare system is a
mixture of the Beveridge model and the National Health Insurance Model, as
it manages and provides services at the governmental level and through tax
payments, combined with a governmentally-run insurance scheme.

The Finnish Ministry of Social Affairs and Health claims (2013) that health
among the Finnish population has gained better quality in the 21
century; life
expectancy has augmented incessantly, by around 25 years in less than a
century. Life expectancy is 76 years for men and 82 years for women. In
2012, Finlands population was approximately 5.4 million. Ageing is the factor
the mostly changed in the demographic structure. The over-65s represented
13.5% of the population in 1990; data indicate an increase to 17.5% in 2010.
In Finland, approximately 50,000 people die every year (Anttonen et al.,
2011), mainly due to malignancies, cardiovascular conditions, accidents and
violence. Nearly 27,000 people develop cancer yearly; around 60% are cured,
whereas almost 10,000 die of it. Juha Hnninen, palliative care specialist,
argues hat cancer is the main condition seen in end-of-life care in Finland
(Salonen, 2008), although patients with any other type of terminal illnesses
can be referred to hospice care.
The Cancer Society of Finland was established in 1936; it is one of Finland's
largest public health organizations, comprising 17 registered member
organizations, 12 of which are regional cancer societies, and 5 are nation-
wide patient organizations. Connected to the Cancer Society of Finland are
also the Finnish Cancer Foundation, the Finnish Cancer Registry and the
Finnish Foundation for Cancer Research. Donations, bequests and
fundraising represent the main funding sources for the Cancer Society of
Finland, together with fees for services of the laboratory and outpatient clinics,
membership fees and funds of the Finnish Slot Machine Association. Main
fields of activity of the Cancer Society of Finland include health promotion,
public information, patient support and rehabilitation, advocacy, fundraising,
cancer screenings as well as maintenance of clinics, laboratories and

Finnish palliative care services are not funded directly by the government, as
the Finland Country Report, Atlas 2007 states (EAPC Taskforce, 2014);
hospices are society-based and funded by the communities (p. 59). The
Finland Report 2008 (EAPC Taskforce, 2014) clarifies that the two hospices in
Finland founded in 1980s, Pirkanmaa Hospice in Tampere - the first hospice
for Finland and the whole Scandinavia, and Terhokoti Hospice in Helsinki, are
funded by private foundations and cancer societies (Cancer Society of
Finland, 2012). Salonen (2008) adds that the same applies for the other two
Finnish hospices, Karinakoti in Turku and Koivikko in Hmeenlinna. Patients,
however, pay as much as in public hospitals (around 18USD) as the
municipality pays the fees.

Over the years Finland has been working hard on terminal care, aiming at
making it more systematic and uniform through the whole country (Ministry of
Social Affairs and Health, 2010). In fact, the recommendations on terminal
care published in 2010 were supported for the first time by legislation, which
meant Parliament focused on pain relief and end-of-life care as a basic right
and choice for each individual.
The European Association for Palliative Care (EAPC, 2014) presents a list of
the EU countries where Palliative Care has acquired the status of medical
specialty; Finland was certified in 2007. In fact, in the Atlas of Palliative Care
in Europe 2013, Centeno et al. (2013) trace Finlands milestones in palliative
medicine: in 2007 the first 2-year long program began as a medical specialty,
and in 2008 the first national guidelines on end-of-life care were produced,
recently updated in 2012. The 2007 version of the Atlas (EAPC Taskforce,
2014) reported that it was difficult to estimate Finlands palliative care
workforce capacity, as well as the number of nurses working in palliative care,
since they were a mixture of hospices, palliative care units, home care teams,
and health care units. The 2013 Atlas version, instead, depicts a clear picture
of the 23 palliative care services in Finland as of 2012, with 4 inpatients
hospices, 12 home palliative care support teams.

4. Health Services available to vulnerability group
With hospice care within the United States defined as the caring, not curing
treatment for patients at the end of life many health services are available for
both clients and their families during this time. Hospice care is considered the
model for quality compassionate care for people facing life-limiting illness
(NHPCO, 2012). This form of care utilizes an interdisciplinary team made of
up multiple health professionals including nurses, volunteers, physicians,
spiritual counselors, social workers, home health aides, and therapists to
name a few. Although most hospice clients are older adults, hospice care is
not limited to older adults and does not discriminate based on terminal illness,
age, religion, race, or any other factors.

Among its major responsibilities, the interdisciplinary hospice team manages
the patients pain and symptoms, assists the patient with the emotional,
psychosocial, and spiritual aspects of dying, provides needed drugs, medical
supplies, and equipment, instructs the family on how to care for the patient,
delivers special services like speech and physical therapy as needed, and
makes short-term inpatient care available when pain or symptoms become
too difficult to treat at home or the caregiver needs respite; it also provides
bereavement care and counseling to surviving friends and family (NHPCO,

Hospice care provides services both in the home and on an inpatient basis. If
the client has access to care and hospice coverage, he or she will receive
routine home visits at the place where he or she lives. If necessary during
periods of crisis, or to keep the patient at home for comfort issues, the client
may receive continuous home care provided by licensed nursing
professionals on a constant basis. Within the scope of hospice care, general
inpatient care is also included. General inpatient care is often provided related
to pain control and management of symptoms that are unable to be managed
in the home. Finally, hospice care offers inpatient respite care for caregivers
on a short-term basis. This aspect is necessary to prevent caregiver strain
related to the constant supervision needed by clients in hospice care.
Included in hospice care is the care for not only the individual but the family as
well. This type of care encompasses both the emotional and spiritual needs
tailored and individualized to each client and family. Health professionals must
advocate on behalf of the client and respect the wishes of the client through
culturally competent, quality care (NHPCO, 2012).

In Finland, hospital districts and health centers are responsible for the
implementation of hospice care. Palliative care is carried out most commonly
at health centers or wards. For instance, one of the 4 hospices in Finland,
Terhokoti Hospice in Helsinki, provides palliative care to approximately 350
patients and their relatives every year (Anttonen, 2011). The services are
available through the hospice-based homecare, the hospice day care unit,
and the 17-bed hospice ward. The Finnish recommendations for terminal care
(Ministry of Social Affairs and Health, 2010) highlight that people should be
able to decide where to be provided end-of-life care, whether at home, at a
health center or hospital ward, or in a hospice, or also at a nursing home.
If the person wishes to be treated at home, the family attends to his/her basic
needs, such as eating and personal hygiene, but can always request the
assistance of specialized home care teams; staff from municipal or private
home nursing care services are in charge of medical treatments; the patient is
still supposed to visit the hospital on a weekly basis for updates on symptoms
monitoring and general checkups. Palliative care is otherwise provided in
hospitals, health centers or hospices when symptoms management requires
stricter intervention and/or the patients need cannot be met comfortably at
home (Cancer Society of Finland, 2009b).

The doctor attending the patient is responsible for deciding to start palliative
care (Cancer Society of Finland, 2009a), and makes therefore a referral to
this service. Initially, an assessment is performed of the patients life
expectancy, based on type of disease, changes in functional capacity,
symptoms and general status. The key aspect is that patient should be as
comfortable and dignified as possible and symptoms are under control; this is
also achieved by offering pleasant and safe environments, and supporting
relatives and friends. Support to the family is also crucial, especially from the
psychological point of view. Family members are allowed to visit the patient at
anytime they wish; they also have the option to stay with their beloved at the
palliative facilities. If palliative care patients have special spiritual needs, such
as reading the Bible, singing hymns or praying, they are offered the
opportunity to do so. The family is constantly updated about the patients
condition. Support continues after their beloved has died.
Palliative care is centered on written care plans, which are arranged together
with the patients, if applicable, and the family members (Ministry of Social
Affairs and Health, 2010). The key professional is the attending physician who
is responsible for any decision around care; a multiprofessional team works to
provide palliative care guided by evidence-based medicine and nursing
practice; the nursing staff consists of qualified nurses, practical nurses and
volunteers (Anttonen et al., 2011). The whole team works in cooperation to
provide good continuity of care, based on honesty, transparency, and a caring
environment both to the patient and the family.

5. Nursing Theories
The World Health Organization (2005) has strongly recommended that expert
palliative care be integrated in all levels of health care, given that it is needed
worldwide as an urgent humanitarian necessity for people affected by cancer
and other chronic incurable conditions. The overall goal of hospice nursing is
to provide comfort, care and support services to people who are terminally ill.
Hospice care helps them live the time they have remaining to the fullest extent
possible, while keeping them comfortable (Harkness & DeMarco, 2012).
Among various nursing theories, some help draw parallels between nursing
practice and hospice care; this is the case of Kocalbas Theory of Comfort and
Paterson and Zderads Humanistic Nursing Theory.

The comfort theory by Katharine Kolcaba stands out and applies directly to
the principles of hospice nursing; it builds upon Florence Nightingales theory
and recognizes that comfort is essential for patients (George, 2011).
Kolcabas theory breaks down comfort into three types: relief, ease, and
transcendence. Relief is defined as the experience of a patient who has had
a specific comfort need met. Ease is defined as a state of calm or
contentment. This type of comfort is more focused on the environment and
psychological state of the patient. Finally, transcendence is defined as a state
in which one rises above problems or pain. Transcendence comfort is
explained when a patient is able to rise above challenges that may occur in
care (George, p.13 ).

Kolcaba identifies four contexts of the human experience of comfort. These
contexts include physical comfort, psychospiritual comfort, environmental
comfort, and sociocultural comfort. The most obvious comfort needed and
expressed by hospice patients is physical comfort. This form of comfort
usually includes prescription medications to ease the pain of the patient in
order to make them as comfortable as possible in their last few months of life.
Psychospiritual comfort includes everything that gives life meaning for an
individual. This entails self-esteem, self-concept, sexuality, and ones
relationship to a higher order or being. Environmental comfort pertains to
external surroundings, conditions, and influences on ones health.
Sociocultural comfort involves interpersonal, familial, and societal
relationships. This also encompasses finances, education, and support
(George, 2011).

All of these contexts work together to promote the health of the hospice
patient. If the patient is comfortable physically, they are more likely to be
mentally and emotionally well. The nurse also must work to provide comfort
on the psychospiritual level to aid in mental and emotional well-being. This
helps the patient find a sense of peace and acceptance with ones life before
passing on. A healthy environment that is conducive to the patient helps to
provide a different sense of comfort. Finally, sociocultural comfort allows for
the patient to feel supported by loved ones and be free from worries such as
finances during their end stage of life.

The role of the hospice nurse according to this theory is to assess the
patients comfort needs and create a nursing care plan to meet those needs
based on all these contexts of comfort. As the patients illness progresses, it is
important for the nurse to adapt to changes and intervene as needed. As the
comfort theory explains, comfort is the most important factor in palliative or
end of life care, which is the sole focus of hospice nursing (George, 2011).

Paterson and Zderads Humanistic Nursing Theory (HNT) also integrates well
to hospice nursing as it emphasizes the humanity and uniqueness of every
human being, especially of their physical, psychological, social, spiritual and
cultural needs. Therefore, in tune with WHO definition of holistic health, the
patient is seen as a whole person, not just as an illness. As Wu & Volker
(2012) state, hospice nursing is centered on humanistic care since it values
the uniqueness of individuals and enhances patients autonomy; therefore,
HNT represents a suitable framework for nurses to respond to those
individuals who are at the end of their lives.

The first main concept of HNT is individual humanity and uniqueness
(Paterson & Zderad, 2007, p. 4): each person has a particular lens through
which they look at the world around them and give meanings and sense to
what happens to them, others and the wider environment (Wu & Volker,
2012). This applies to hospice care, where every patient responds to and
copes with their end of life very individually, most often on the basis of their
own experiences of life, as the hospice volunteers statements in Part 1
(Perspectives of Health) demonstrate. Related to this, HNT highlights
existentialism key idea that man is his choices, his history, his possibilities,
his present and future, what he has become and what he has not become
(Paterson & Zderad, 2007, p. 16); this is true for both patients and nurses, it is
a process of self-reflection that gives shapes and interpretation to events in
life, and can be easily applied to hospice nursing care and the end-of-life time.
If this process is effective, an empathetic and supportive relation develops
with the dying patient, and comfort, dignity and quality of life are provided in a
way specific to each individual patient. Paterson & Zderad (2007) emphasize
in fact that not only is well-being important in palliative care, but also the
more-being (p. 12), since nurses are concerned with helping the individual
become more as humanly possible (p. 12) within the limits of every patients

Humanism as presented by Paterson and Zderad stresses caring and
empathy, and the (self)awareness that each individual, both the patient and
the nursing professional bring their own viewpoint into the nurse-patient
relationship (Wu & Volker, 2012); therefore, the role of hospice nurses is to
enhance holism, dignity and quality of life, and to continuously advocate for
hospice patients and families best interest. HNT can represent a common
language through which planning care, portraying interventions and
collaborating within the interdisciplinary hospice team to cope with the
challenges of the end-of-life journey.

Primary, secondary, and tertiary prevention are important in promoting
emotional health in the hospice patient. While these levels of prevention
usually apply to preventing an illness, hospice nursing is all about the end-of-
life processes and illness prevention is not an option. Incorporating Kolcabas
comfort theory, as well as Paterson & Zderads Humanistic Nursing Theory,
caring for the patient on a palliative level while maintaining their physical,
emotional and psychological health is most important in hospice nursing.
Primary prevention for the hospice patient includes education on mental and
emotional health. The patient needs to understand the process of their
disease and the emotional effects that dying can have on an individual and
their family. The nurse should have a strong knowledge base about the
patients illness, the emotional factors involved in the end-of-life stages, and
deep awareness of individual emotional responses to the moment of ending
life. On the secondary prevention level, the nurse should frequently screen the
patient and their family mentally and emotionally and make sure they are
stable and have effective coping skills. These screenings can help the nurse
to detect early signs of emotional and mental instability, and achieve the
more-being as the HNT suggests. Hospice nursing focuses mainly on tertiary
prevention as nurses care for patients on a palliative level. This form of health
promotion may involve pharmaceutical interventions to make the patient as
comfortable as possible, but still includes counseling and treatment related to
the emotional and mental well-being of the patient and family (George, 2011).
These levels of prevention implemented by the nurse work with both
Katharine Kolcabas Comfort Theory and the Humanistic Nursing Theory, to
promote the individual uniqueness, their mental and emotional health, and
provide palliative care for the end-of-life patient and their family.

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