ANA OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector.

Find Out More...

Letter to the Editor

  • A critical element of preparing competent nursing students, not mentioned in "Crisis in Competency: A Defining Moment in Nursing Education", is the need to eliminate barriers to recruiting and retaining nurse educators still engaging in clinical practice.

  • Continue Reading...
    View all Letters...

Teaching Patient-Centered Care During the Silver Hour

m Bookmark and Share

Marilyn Smith-Stoner, PhD, RN, CHPN


Teaching students and clinicians about end-of-life care is an important part of healthcare. Utilizing the framework of the Silver Hour is one method of illustrating the urgent, intense comfort needs required by patients and families throughout the imminently dying process, wherever the patient may be receiving services. When death is imminent, it is extremely important to provide patient- and family-centered care as the waning moments of life transition to the first moments of death. A variety of instructional methods can be used can be used to teach students to provide multidimensional, patient-centered care at the end of life. The author begins by describing the basic concept of patient-centered care and by discussing the importance of teaching students about this level of care. Next she describes the concept of the Silver Hour, along with a discussion of how the Silver Hour relates to nursing education. She also notes the importance of both role modeling in providing patient-centered care and of drawing upon the five ways of knowing to strengthen the teaching of students about care during the Silver Hour.

Citation: Smith-Stoner, M., (May 31, 2011) "Teaching Patient-Centered Care During the Silver Hour" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 6.

DOI: 10.3912/OJIN.Vol16No02Man06

Key words: active learning, end of life care, end of life communication, healthcare continuum, imminent death, interdisciplinary care, mindful communication, patient-centered care, patient-centered death, peaceful death, Silver Hour, transformative education, ways of knowing

The Silver Hour (Smith-Stoner, 2009a) marks the last moments of a patient's life and the first moments of death. The antecedent events leading to the moment of death vary widely. Fetal demise, sudden cardiac death in the home, heart failure in the long term care facility, and end-stage cancer at home are different pathologically. Yet persons experiencing these events share many common attributes: the patients, who are more than their cause of death, have both integrated relationships with the people who love them and also a need for coordinated, evidenced-based, patient-centered care.

There are three stages in the Silver Hour Model: dying, death, and dead. Each stage is differentiated by the context, patient care goals, and regulatory restrictions. The Silver Hour is illustrated in the Figure. The focus of this article is on presenting the most essential and transformative approaches to educating students and clinicians about patient-centered, end of life care using the Silver Hour Model.

Patient-centered care (PCC) has been defined by Mead and Bower (2000) as a multidimensional concept which includes the following five dimensions: the biopsychosocial, patient-as-person, sharing power and responsibility, therapeutic alliance, and doctor-as-person. In the last dimension, doctor-as-person, is transformed to clinician-as-person, since end of life care requires multidisciplinary care including (but not limited to) physicians, nurses, respiratory therapists, social workers, counselors, volunteers, and other support staff.

In this article, the concept of the Silver Hour, as a framework for providing patient- and family-centered, end of life care will be presented with a focus on educational strategies to promote quality end of life care. I will begin by describing the basic concept of patient-centered care along with the five dimensions of patient-centered care and by discussing the importance of teaching students about this level of care. Next I will describe the concept of the Silver Hour, along with a discussion of how the Silver Hour relates to nursing education. I will conclude by noting the importance both of role modeling in providing patient-centered care and of drawing upon the five ways of knowing to strengthen the teaching of students about care during the Silver Hour.

Patient-Centered Care

At the heart of PCC is a commitment to provide the best care, in the most skillful and compassionate way, based on patient preferences and best practices. Well before, and since, the Institute of Medicine's (2001) Crossing the Quality Chasms: A New Health Care System for the 21st Century was published, patient-centered care (PCC) has been an important part of the clinical and educational dialogue. Providing patient- and family-centered care means clinicians and healthcare organizations, following relevant laws and regulations, work together to develop a plan that has been mutually agreed upon by the patient. Often these decisions are negotiated and mutually agreed upon not only by the patient and members of the healthcare team but also by members of the patient’s family. At the heart of PCC is a commitment to provide the best care, in the most skillful and compassionate way, based on patient preferences and best practices. When the patient is not able to speak, surrogates speak for the patient. Mead and Bower's (2000) presentation of the five dimensions of PCC (mentioned above) provides a foundation for the development of policies and procedures that view the patient holistically, as a person who has both the responsibility for and the interest in participating in decision making related to care decisions. The patient and healthcare providers establish a therapeutic alliance that will facilitate these decisions.

However, when the end of life comes, particularly when it is sudden, the patient's wishes may not be known. Patient surrogates and healthcare providers may be in conflict with each other and within their professional groups. This conflict requires that physicians and nurses act for the patient first and secondly for the family. Patient-centered care models do not provide a clear path to reconcile the conflicts associated with end of life decisions in often rapidly changing circumstances. Requests for futile treatment (Downar et al., 2011), cultural differences (Hasnain, Connell, Menon, & Tranmer, 2011) and the realization that death must be faced (Fine, 2010) bring a wide variety of emotions from relief to rejection on the part of patients, families, and healthcare providers. The practice of patient-centered care is essential during these often stressful last days (hours) of life.

The patient's desire to be informed of treatments and prognosis and the desire to be involved in the plan of care is at the heart of multiple models of PCC (Balik, Conway, Zipperer, & Watson, 2011; Hurtado, Swift, & Corrigan, 2001). However, information about difficult topics is challenging for the clinician to ‘share’ and challenging for the patient/family to ‘hear.’ Although not all patients want to participate in their plan of care (Murphy, 2011), ongoing communication with family does have beneficial effects even in critical care areas (Radwin, Ananian, Cabral, Keeley, & Currier, 2011). The practice of patient-centered care is essential during these often stressful last days (hours) of life.

Importance of Teaching Students about Patient-Centered Care

Teaching students how to participate in discussions about end of life care is an important part of their education. PCC requires students and clinicians to understand that the relationship between the clinician and the patient and family is influenced directly and indirectly by environmental factors. Skilled communication at the time of death includes easily understood descriptions of events, time for the patient and family to ask questions, and time for the nurse to listen. For patients who have sustained a trauma, communication may be focused on deciding between life-sustaining treatment and termination of treatment, immediately followed by decisions related to organ and tissue donation. Shared decision making is essential during this period. End of life care and communication that is patient centered may need to be accomplished in a short time frame of minutes to a few hours. Because the dying period can go so quickly, we need to educate healthcare workers and students in the unique needs of patients who are imminently dying. Throughout the following discussion regarding teaching students about the Silver Hour, Mead and Bowers’ (2000) five dimensions of PCC, namely the biopsychosocial, patient-as-person, sharing power and responsibility, therapeutic alliance, and doctor-as-person dimensions, will be highlighted to show the integration of the two concepts in nursing education.

The Silver Hour

The concept of the Silver Hour provides a flexible model by which to measure quality in end of life care in conjunction with the agency mission, regulations, and community needs. In the same way that a resuscitation team works in earnest to provide medications, therapies, and many other interventions, clinicians work within the Silver Hour paradigm to provide expert, urgent, comfort care. During this period the nursing staff may also be called on to mediate conflicts within the family or the healthcare team. Utilizing the model may help healthcare organizations develop policies and procedures to support the patient and family during difficult procedures, such as the policy of family presence during cardio-pulmonary resuscitation (Emergency Nurses Association, 2009).

The Silver Hour model focuses exclusively on the care given between the time that death is first recognized as an imminent possibility and until the patient leaves the site of death for burial. The five dimensions of PCC as described by Mead and Bowers (2000) will be identified in the discussion below and are summarized in Table 1 as applied to end of life care. One important assumption of the Silver Hour is that the patient and family are the focus of care from admission through the removal of the patient’s body from the healthcare agency, home, or other location of death. The Silver Hour includes three phases, namely dying, death, and dead. Each phase requires unique skills and care goals which will be discussed below.

Education for the Silver Hour

A variety of nursing curriculum standards guide educators in providing integral, transformational, educational activities that focus on the experience of the patient and family.

The goal of patient-centered care during the dying phase is to ensure that the patient and family realize that death is imminent and provide opportunities for the family to have as much contact with the patient as possible... The National Consensus Project Guidelines outlines eight domains of end of life care. Although the Silver Hour is primarily focused on Domain #1 (Structure and Processes of Care) and Domain #7 (Care of the Imminently Dying Patient), the Silver Hour concept includes ideas related to all domains (National Consensus Project, 2009). The success in educating over 4,000 nursing educators (academic and clinical) through the End-of- Life Nursing Education Consortium (Malloy, Paice, Virani, Ferrell, & Bednash, 2008) highlights the benefits of focusing on standardizing educational content on selected types of end of life care. Other guidelines, such as the National Consensus Project Guidelines (2009) and the Hastings Center Guidelines on End of Life Care (2010), also assist educators in teaching end of life care.

Helping students begin to understand the challenges in identifying patient and family end of life preferences can be accomplished by assigning students to complete their own advance directive. Suggesting students discuss their own end of life wishes with families brings home to students how difficult it can be to conceive of their own death and to describe what care they may or may not want at some unknown time in the distant future. Active learning strategies for each of the three phases of the Silver Hour, dying, death, and dead, that work equally well for both practicing clinicians and nursing students, as well as the concept of the geriatric orphan are described below.


The recognition of imminent death begins the dying phase or first part of the Silver Hour. The events that lead to the end of life can be spontaneous as in a trauma or as a result of a prolonged disease. The goal of patient-centered care during the dying phase is to ensure that the patient and family realize that death is imminent and provide opportunities for the family to have as much contact with the patient as possible (focusing on the shared decision making and responsibility dimension of PCC). This is important as the last moments of life, especially for patients who have sustained a trauma, are often intense. Healthcare workers may be working diligently to save a life, while simultaneously recognizing that death is likely. The transition between life-saving care and comfort-care measures may be difficult to establish.


The second phase of the Silver Hour is the declaration of death. The declaration of death can occur over seconds or hours. A patient can be considered brain dead, but not released for burial until organs are procured, or an autopsy or other medical procedure is completed. Seeing the patient dead for the first time can be an emotionally charged experience for the family; it requires vigilance on the part of the staff toward family members (reflecting the clinician as person dimension of PCC). Clinicians must be available for support. The focus of care at the time of death is to follow the patient's wishes about death rituals and help the family to say good-bye.

As a first step in mastering this dimension, students can share their own cultural expressions related to death. Brookfield and Preskill (2005) have described two strategies that I have found to be very effective in my teaching. The Circle of Objects strategy involves students bringing to class an object related to end of life care that any member of their cultural group would instantly recognize as representing their cultural group. This strategy can be used online as well as in the traditional classroom. Students are divided into small discussion groups with 4-6 students in a group. Each student presents their object, describing specifically what the object is, how it is used, and its significance to the family as related to death rituals. The same thing is done online, as students photograph the item and post the photograph online. If students are not able to bring the object to class, they are allowed to bring a photo of the item. Typically items are religious items, ancestor photographs, jewelry, or special books.

Students then discuss the significance of their object both to their culture and themselves. When students are placed in groups that are dissimilar to begin with, for example, students from different countries, they are engaged and eager to understand the death-related items and customs from other countries. It can be challenging, however, to help students appreciate the differences within a given culture, especially if the cultural group is not one with which they are familiar. Students are guided to explore how symbols denote cultural similarities and differences within any cultural group. For example, in a group comprised of students from different countries, participants may share a common religion that is practiced differently in different geographical areas. When students are in groups with members that share many traits, such as a common religion, they are surprised to learn that mourning rituals, such as the color of clothing worn during mourning or the length of time the family mourns a death, differ from area to area.

A second activity described by Brookfield and Preskill (2005) is the sentence completion activity. The instructor starts the discussion using the following sentence: "The most crucial need a patient and family has when a ventilator is being withdrawn is...." Students then complete the sentence and the instructor leads a discussion on care related to the withdrawal of life support. I have found that both in formal student ratings of instruction and when students are asked to recall the most memorable learning activity in class during the term, they identify these two activities as the most memorable. Through both classroom observations and student ratings for teaching effectiveness, these two learning activities are rated as some of the most memorable of the term.


The third phase begins when the patient is declared dead and the body is released for transport to the next service provider. Once the patient is pronounced dead and released for burial, the family begins the transition to remembering the patient as an ‘ancestor.’ During this phase, death discharge procedures focus on maintaining the intensity of care given prior to death – but at this point giving the care to the family. For example, the family should be given written discharge instructions, which include the names of people who can answer questions about the patient's death and that of the physician or clinician who pronounced the patient dead. Other patient-centered approaches include a healthcare worker walking the family to their car(s) (thus demonstrating the therapeutic alliance dimension of PCC). A thought provoking assignment for helping students understand the need for information and support after the death of a loved one is to ask them to create an information page that gives the most important information a family may ask the day after a death.

Many healthcare agencies have developed a support team to help families navigate the post-mortem procedures and legal responsibilities (University of Michigan, 2011), thus recognizing that the entire interdisciplinary team has a role in providing end of life care. Social workers play an especially important role in providing postmortem support. Teaching students about the postmortem experience can be done by asking students to call, during class time, someone who has experienced leaving a hospital after the death of a loved one. Explanations are given early in the term about the use of cell phones for spontaneous interviews during class. Students are asked to tell friends and family about the potential for calls and secure permission to be contacted for this and other in-class interview activities. Students are impressed that many family members want to tell their story about the (lack of) care received after the death of a loved one. Such activities help students understand the variety of experiences family members report after the death of a loved one.

Geriatric Orphans

There is in our society an emerging, vulnerable population, called ‘geriatric orphans’. There is in our society an emerging, vulnerable population, called ‘geriatric orphans’ (Meis, 2009). These people may not have any family to support them through the dying process. Clinicians become the surrogate family for these geriatric orphans. The ‘No One Dies Alone’ campaign started by Sandra Clarke in 1986 (Shiller & Clarke, 2008) is an example of patient-centered support that can be given to geriatric orphans. Staff members or volunteers attend to and are present as a loving witness to the death of these patients, becoming a member of their extended (surrogate) family. Students also can be assigned the task of sitting with dying patients who do not have visitors, during which time they provide typical clinical care based on the course objectives but are directed to remain in the room, using their presence and nursing skill to care for the patient. As much as possible, students minimize the time spent on non-patient care activities, such as documentation or completing class-related care plans. Instead they are directed to focus exclusively on the comfort of the patient. They may play music, read, or talk to the patient. It is important to debrief this learning experience during a post-conference session.

Role Modeling Patient-Centered Care

Patient-centered education begins with student-centered courses... In order to teach a concept effectively, the educator must model the behavior. Patient-centered education begins with student-centered courses, programs, and universities. For example, role modeling student-centered education may include the same commitment to connecting students and families as patient-centered care does to connecting patients and families. Policies and procedures that allow students to bring children into the classroom in emergency situations can provide faculty and students with the opportunity to talk about how organizations, such as healthcare organizations and colleges, can support family-centered services.

Role modeling end of life care, especially the communication techniques that enhance end of life care, can also be practiced in the simulation laboratory. The many variations of end of life situations can be practiced in the nursing skills lab with simulators and standardized actors. Broadcasting simulations using digital, downloadable learning content allows maximum convenience for student learning (Smith-Stoner, 2009b). Digital sources of end of life instructional material are readily available online (Wink & Smith-Stoner, 2011). Using the best practices of simulation, students can debrief their experiences with their faculty and reflect on their own learning needs (Leighton & Dubas, 2009; Parker & Myrick, 2010; Sperlazza & Cangelosi, 2009).

Ways of Knowing

The transformative education that helps students appreciate the beauty, complexity, challenges, and grief associated with death can involve Carper’s (1998) four ‘ways of knowing,’ as well as Chinn and Kraemer’s (2010) emancipatory way of knowing (Table 2). Organizational policies and procedures outline the minimum, the floor of nursing care, if you will. In contrast patient-centered care is the ceiling, expanding the historical ‘that is the way we have always done it’ to include ‘this is what this patient needs now.’ This expansion is a fundamental part of nursing education. Listening to students, responding to their needs, and assisting them with the intense emotions that often accompany end of life care are critical to socializing them to become caring and competent professionals. Ways of knowing are some of the methods used by students to ‘make sense’ of information (Berragan, 1998). Five ways of knowing commonly discussed in the nursing literature include the personal, aesthetic, legal-ethical, empirical (Carper, 2998), and emancipatory (Chinn & Kraemer, 2010) ways of knowing. Examples of each of these five ways of knowing about PCC at the end of life are presented below.

Organizational policies and procedures outline the minimum, the floor of nursing care, if you will. In contrast patient-centered care is the ceiling... At each level of education, relationship skills are central to fostering a ‘personal’ approach to care. Hunter (2008) found that storytelling was one successful way of helping students integrate their understanding of the art and science of nursing and begin to see themselves personally as a caring nurse. Working with other students when preparing for group projects, and establishing relationships with clinicians and faculty by asking thoughtful questions enhance students’ personal knowing. Patients and their families benefit by students’ ability to integrate patient/family preferences into the standardized, evidenced-based care provided.

The value of including ‘aesthetically oriented’activities has been reported in the literature (Kontos, Mitchell, Mistry, & Ballon, 2010; Wikstömmub, 2003). Death and dying are common themes in aesthetics, including art and literature. Using music to help students explore their feelings about death and dying is always received positively (Levitin, 2009). Conor Oberst wrote his classic song, "I don't want to die in the hospital," for an older friend who was dying. The following lines of this song, Can you make a sound to distract the nurse?; Before I take a ride in that long black hearse, provide students with a patient narrative describing the intersection of the nursing role and the patient's point of view. A discussion of how this patient's intention to leave the hospital, essentially against medical advice, provides an innovative way to engage students in a discussion about patient preferences for their place of death.

What Oberst's song is to music, the classic film Wit is to movies. This movie describes English Professor Vivian Bearing's journey from her cancer diagnosis to her death. Written by Margaret Edson, who had worked as a unit secretary on an oncology unit, this movie brings students directly into the experience of living and dying. Wit is widely available via DVD, cable television, and web-streaming services. All five dimensions of patient-centered care are demonstrated throughout the movie. The dimension of shared responsibility for decision making and clinician as person are eloquently demonstrated in Chapter 13, titled “Popsicle.”

Students and clinicians alike are challenged to understand the ‘ethical and legal’ issues related to death and dying. Some of the most evocative topics related to death and dying have included discussions of the Louisiana physician, Anna Pou, and two nurses, Lori Budo and Cheri Landry, who were charged with homicide (euthanasia) after several very ill patients died following hurricane Katrina. The nurses were given immunity for testifying; Dr. Pou was investigated but never indicted by the grand jury (Cable News Network, 2010). Students express their evolving understanding of the intersection between professional standards, laws, and ethical principles when this case study is discussed in class.

‘Empirical’ knowing is the heart of nursing science. Students explore evidenced-based practice throughout their nursing education. Historically patients were not told they were dying, and some cultures today still do not consider disclosure of a terminal condition as acceptable. However, when students investigate how ideas have changed about what it means to be patient centered, especially when the issue of disclosure of a terminal condition is considered, the complexity of conducting research with patients and families during the end of life becomes clear. Since communication is such an important part of patient-centered care, strategies for teaching about the disclosure of sudden death, such as the GRIEV_ING death notification protocol (Hobgood, Tamayo-Sarver, Hollar, & Sawning, 2009), along with evidence-based techniques of pain and symptom management are seen as the backbone of nursing education.

‘Emancipatory’ knowing (Kagan, Smith, Cowling, & Chinn, 2010) focuses on the ability to notice social injustices, investigate the causes of these injustices, and identify changes necessary to correct the structures of injustice and oppression. Literature provides many patient and family stories addressing power inequalities in the patient-family-clinician therapeutic relationship. The book, The mercy papers: A memoir, by Robin Rumm tells the story of her mother's hospice care at home. Romm describes her experience with a hospice nurse who suggested she tell her mother that she (Romm) will be okay when her mother dies. Robin responds that she cannot tell her mother she will be okay after her death; she does not want her to die. The nurse tries to comfort her with a discussion of an afterlife, which is not a part of Romm's world view. Romm became increasingly alienated and resistant to the hospice team suggestions. Romm's memoir is an ongoing narrative of the power struggles between the daughter and the hospice team. Many sections of the short book (194 pages) describe the ongoing power and control challenges between Romm and the hospice team; students have many questions about these exchanges. Inviting a hospice social worker to class to discuss family-centered care is a valuable learning experience.

Another excellent learning activity to bring out issues related to existential crises for students is to view the 2009 movie, The Invention of Lying. In this fictitious world no one knows how to lie. As one character reaches the end of her life, she tells her son she is afraid to die, stating “…an eternity of nothingness.…I am afraid.” Her son responds with a beautiful description of life after death: an existence not previously described in their rational world. Prior to that exchange, there had been no lying in this world. Students may find viewing some, or all, of the movie as very helpful in starting a conversation about caring for patients who do not believe in a god and/or an afterlife, by discussing what constitutes an appropriate intervention for these patients and/or family members.


...students benefit from learning experiences that role model the integrating of patient needs with organizational policies, procedures, and regulations relevant to each circumstance. Educators have made much progress in developing patient-centered, end of life educational experiences through their own individual efforts and through building on the work of professional organizations. In order to ensure the continued development of patient-centered, end of life care, additional emphasis on personalizing evidenced-based care through utilization of the five dimensions of person-centered care is needed. Encouraging students to find their own voice in decision making can assist them in helping patients to find their voices.

Using the Silver Hour as guide for teaching students to plan care through the three phases of dying, death, and dead provides a holistic approach to end of life care across the healthcare continuum. Providing expert clinical care within a therapeutic environment and attending to the needs of the family is the essence of the Silver Hour model. Whatever antecedent event brings a patient into the healthcare system, students benefit from learning experiences that role model the integrating of patient needs with organizational policies, procedures, and regulations relevant to each circumstance. As healthcare reform progresses, students will better understand how nursing roles are changing as nurses become collaborators with their patients and families from birth to death.


Marilyn Smith-Stoner, PhD, RN, CHPN
(Email contact updated 12.05.16 per author request)

Dr. Smith-Stoner is an Associate Professor at California State University, San Bernardino where she teaches the beginning medical-surgical course, research, and nursing theory to undergraduate students. At the graduate level she teaches nursing theory and courses on educational assessment, evaluation, and technology. Dr. Smith-Stoner has worked in end of life care as a clinician and a manager since 1992. She has studied end of life care in China, Sweden, Brazil, The Gambia, and Norway. The Silver Hour (see is a concept she has developed through her international travels and her research on end of life preferences for diverse populations, including Atheists, Tibetan Buddhists, and Wiccans. Because patients are at their most vulnerable when they are dying, the focus of her current activities revolves around ensuring that clinicians know how to provide effective, individualized spiritual, as well as physical, care. Dr. Smith-Stoner received her BSN and her MSN from California State University, Dominguez Hills. She received her doctorate in transformative education from the California Institute of Integral Studies (San Francisco) in 2000.


Balik, B., Conway, J., Zipperer, L., & Watson, J. (2011). Achieving an exceptional patient and family experience of inpatient hospital care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2011 Retrieved May 1, 2011 from

Berragan, L. (1998). Nursing practice draws upon several different ways of knowing. Journal of Clinical Nursing, 7(3), 209-217.

Brookfield, S. & Preskill, S. (2005). Discussion as a way of teaching: Tools and techniques for the democratic classroom. San Francisco, CA: Jossey-Bass.

Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23.

Chinn, P. & Kramer, M. (2010). Integrated theory & knowledge development in nursing, St. Louis: Mosby.

Cable News Network (CNN). (2010, September 9). Release Katrina hospital death file, Louisiana judge says. Retrieved from:

Downar, J., Luk, T., Sibbald, R., Santini, T., Mikhael, J., Berman, H., & Hawryluck, L. (2011). Why do patients agree to a “Do Not Resuscitate” or “Full Code” order? Perspectives of medical inpatients. Journal of General Internal Medicine, 1-6: Doi: 10.1007/s11606-010-1616-2.

Edson, M. (writer) (2001). [Movie] Wit. HBO Films.

Emergency Nurses Association (2009). Family presence during invasive procedures and resuscitation in the emergency department.Retrieved from:

Fine, R. L. (2010). Keeping the patient at the center of patient- and family-centered care. Pain and Symptom Management, 40(4), 621-625.

Gervais, R., & Robinson, M. (directors) (2009). [Movie] The invention of lying. Warner Bros.

Hasnain, M., Connell, K. K., Menon, U. & Trammer, P. A. (2011). Patient-centered care for Muslim Women: Provider and patient perspectives, Journal of Woman's Health, 20(1), 73-83. DOI: 10.1089/jwh.2010.2197.

Hastings center guidelines on end of life care. (2010). Accessed April 5, 2011 from:

Hobgood, C. Tamayo-Sarver, J., Hollar, D,. & Sawning, S. (2009). Delivering the news with compassion: The GRIEV_ING death notification protocol. Teaching and Learning in Medicine, 21(3), 207-19.

Hunter, L. (2008). Stories as integrated patterns of knowing in nursing education. International Journal of Nursing Education Scholarship, 5(1), 1-13. Doi: 10.2202/1548-923X.1630

Hurtado, M., Swift, E., & Corrigan, J. (eds) (2001). Envisioning the national health care quality report. Washington, DC: National Academy Press.

Hamilton, C. A. (2010). The simulation imperative of end-of-life education. Clinical Simulation in Nursing, 6(4), e131-e138. doi:10.1016/j.ecns.2009.08.002

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Author.

Kagan, P. N., Smith, M. C., Cowling III, W., & Chinn, P. L. (2010). A nursing manifesto: An emancipatory call for knowledge development, conscience, and praxis. Nursing Philosophy, 11(1), 67-84. doi:10.1111/j.1466-769X.2009.00422.x

Kontos, P., Mitchell, G., Mistry, B., & Ballon, B. (2010). Using drama to improve person-centred dementia care. International Journal of Older People Nursing, 5(2), 159-168. doi:10.1111/j.1748-3743.2010.00221.x

Leighton, K., & Dubas, J. (2009). Simulated death: an innovative approach to teaching end-of-life care. Clinical Simulation in Nursing, 5(6), e223-30.

Levitin, D. (2009). The world in six songs. New York: Plume.

Malloy, P., Paice, J., Virani, R., Ferrell, B., & Bednash, G. (2008). End-of-life nursing education consortium: 5 years of educating graduate nursing faculty in excellent palliative care. Journal of Professional Nursing, 24(6), 352-357.

Mead, N., & Bower, P. (2000). Patient-centredness: A conceptual framework and review of the empirical literature. Social Science Medicine, 51(7):1087-110.

Meis, M. (2009). Geriatric orphans: A study of severe isolation in an elderly population. Saarbrücken, Germany: VDM Verlag.

Murphy, J. (2011). Information systems & technology. Patient as center of the health care universe: a closer look at patient-centered care. Nursing Economic$, 29(1), 35-37.

National Consensus Project. (2009). Clinical practice guidelines for quality patient care (2nd). Accessed April 5, 2011 from:

Oberst, C. (2008). I don't want to die in the hospital. On Conor Oberst. Location: Durham, North Carolina. Merge Records.

Parker, B., & Myrick, F. (2010). Transformative learning as a context for human patient simulation. Journal of Nursing Education, 49(6), 326.

Radwin, L. E., Ananian, L., Cabral, H. J., Keeley, A., & Currier, P. F. (2011). Effects of a patient/family-centered practice change on the quality and cost of intensive care: research protocol. Journal of Advanced Nursing, 67, 215–224. doi: 10.1111/j.1365-2648.2010.05448.x

Rumm, R. (2009). The mercy papers. New York, NY: Scribner.

Shiller, J., & Clarke, S. (2008). Creating moments of grace: From Nightingale to 'No One Dies Alone'. Retrieved April 30, 2011 from

Schouten, B. C., & Meeuwesen, L. (2006). Cultural differences in medical communication: A review of the literature, Patient Education and Counseling, (64), 1-3, 21-34.

Silver Hour. (2010). Website educating students about patient-centered end-of-life care. Retrieved January 3, 2010, from

Smith-Stoner, M. (2009a). Using high-fidelity simulation to educate nursing students about end-of-life care. Nursing Education Perspectives, 30(2), 115-120.

Smith-Stoner, M. (2009b). Web-based broadcast of simulations: expanding access to learning. Nurse Educator, 34(6), 266-270.

Sperlazza, E., & Cangelosi, P. (2009). The power of pretend: using simulation to teach end-of-life care. Nurse Educator, 34(6), 276-280.

University of Michigan, Department of Social Work. Office of decent affairs. Retrieved from:

Wikstömmu, B. (2003). A memory of an aesthetic experience transferred to clinical practice Education for Health, (16)1, 40–50.

Wink, D. & Smith-Stoner, M. (2011, in press). Teaching with Technology: Free Web Resources for Teaching and Learning. Nurse Educator.

Figure. Silver Hour Changing Focus of Care

Table 1. Patient-Centered Care in Silver Hour Interventions





Biopsychosocial perspective - going beyond the illness to address other issues holistically

Offering additional support, e.g. a comfort cart, and obtaining additional support staff

Acknowledging the extent of the patient's condition prior to death

Addressing family issues, such as obtaining coverage for medical costs, burial finances, or other concerns

Patient as a person - knowing the patient beyond the illness

Referring to patient by name

Sharing stories of patient

Encouraging family participation/observation in care

Leaving the face uncovered, continuing to refer to patient by name

Offering context for the death – “everything was done,” <name> is   peaceful, "I know   <name> felt your   presence"

Sharing power and responsibility - mutual participation in decision making

Seeking to understand the patient and family wishes regarding life- sustaining treatment or withdrawal

Mediating conflicts promptly in a positive manner

Coordinating death-  related rituals

Devising a mutually agreed upon place and time to say good-bye

Adapting policies and procedures to meet family needs

Allowing time with patient after death

Therapeutic alliance:  empathetic, positive  regard and perception of care givers as caring

Listening to concerns

Helping patient/family understand treatments and organizational procedures

Assuring environment of care is quiet and respectful

Participating in meaningful rituals with patient and family

Providing evidenced-based approach to death notification

Coordinating care with additional professionals, such as coroners, law enforcement, and organ procurement organizations

Offering mementos, locks of hair, medical supplies used by patient, and photographs

Walking family to the car after death

Doctor/(clinician) as a person: being treated as an individual with warmth and sufficient information

Focusing person-specific information on status changes

Completing death notification with opportunities for questions

Sharing of patient's story

Giving name and contact phone number to family in case there are questions later


Table 2. Ways of Knowing for Teaching Patient-Centered Care in End of Life

Ways of Knowing




(Patient as a person dimension)

Understanding how the experience of dying is for oneself and for others


Patients Like Me


“I Don’t Want to Die in the Hospital,” by Conor Oberst

“If I Die Young,” by The Band Perry

“Wake Me Up When September Ends,” by Green Day

Active learning strategies:

Cell phone interviews during class asking about the experience of caring for someone who is dying

Lewis Blackman Story

Television shows:

The Big C (Showtime)


(Doctor/clinicians as person dimension)

Understanding how happiness, fear, grief, and transformation from life to death are experienced by caregivers, patients, and family


Create a map of spiritual life journey

Create a digital story of someone who has died

Visit a museum to experience and analyze the representation of pain, grief, and loss in art of all kinds.


The Leisure Seeker: A novel (2009).


(Biopsychosocial dimension)

Highlighting the procedures for obtaining genetic and reproductive specimens from dying patients, advance care planning, and organ donation, among other issues.

Supporting patient decision making regarding advance directives

Demonstrating understanding of State Nurse Practice Act - standards of competency: care planning, nursing diagnosis

Explaining the scope of the national guidelines for end-of-life care


Surgeon General Family History

Advance directive forms:


Advance directives (by state)


Wit, Chapter 13, Popsicle

California Nurse Practice Act

Nursing Diagnosis related to end-of-life care 2010-2011


All Nurse Practice Acts

National Hospice and Palliative Care Organization

National Consensus Project


(Biopsychosocial dimension)

Evaluating the quality of end-of-life care.

Using Home Care Compare


Quality of Dying Index


Home Care Compare


(sharing power and responsibility dimension)

Using the Nursing Manifesto

Students creating their own manifesto, including the nursing care of people who are dying

Describing the unique end-of-life care needs for vulnerable populations.

Conducting a literature and other search for discussion on the “death panel” misinformation


Nursing manifesto


Kathy Mattea: “Where Have You Been?”


International Observatory on End-of-Life Care

International Association for Hospice and Palliative Care

Palin's Death Panel

Doctor's Urged to have end of life conversation

© 2011 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2011

Related Articles