We are writing to challenge nurses in the field of home health to address the urgent need for improved end-of-life care. The care that nurses provide to patients at the end of life has received much recent attention. Numerous organizations have developed professional standards on end-of-life care for their members.1,2 While deficiencies in care at the end of life have many causes, insufficient training of nurses in this area is a major reason.3 Our research has identified major deficiencies in the end-of-life content of more than 50 nursing textbooks used in undergraduate nursing curriculum. The 50 textbooks spanned a wide range of nursing specialty areas such as: AIDS, health assessment, communication, community health, critical care, emergency, ethics/legal issues, fundamental and medical-surgical nursing, oncology, patient education, pediatrics, pharmacology, and psychiatric nursing. Overall, only 2% of content in nursing texts was related to any end-of-life-related topic with similar results reported from review of texts for medicine and pharmacy.4,5 Of the 50 textbooks reviewed, four (8%) were related to home health nursing. A total of 3108 pages reviewed from these four home health textbooks included 21.3 pages related to end-of-life care (only 0.7%). In the face of documented textbook deficiencies, we have undertaken an effort to encourage publishers, editors, and authors to improve their textbooks' end-of-life content, including chapters, cross-referencing, and indexing. As a follow-up to this effort, we have reviewed textbook revisions and new additions to assess changes made during the time of the first review (1998) to present.

We are pleased to report a very positive response. To date, the editors, authors, and publishers of the 50 nursing textbooks reviewed have responded that they have plans to expand or have already completed expansion of end-of-life content in their textbooks or future editions of their textbooks. The overall response of end-of-life content added to these books is approximately 40% of texts, with an additional 30% planning to expand content in their next editions. Recently, the Robert Wood Johnson Foundation honored the textbook publishers, editors, and authors who have been working to make these important changes. On February 21, 2001 at an awards ceremony at the Last Acts Project National Meeting, the researchers presented awards to 13 medical, nursing, and pharmaceutical editors, authors, and publishers. Eight of the 13 that were awarded were nursing texts.

Unfortunately, there is still much work to be done. Many best-selling textbooks have not yet responded to the suggestions of nursing specialty groups, the needs of readers, or the demands of patients and families to improve education of nurses about care of patients at the end of life. We will continue monitoring textbooks over the next several years, and the Robert Wood Johnson Foundation will continue to offer recognition to those publishers, editors, and authors who improve the end-of-life content in their books.

Positive strengths of community health nursing textbooks were goals of palliative care and a focus on ethical issues such as advanced directives, living wills, and do-not-resuscitate orders. Potential improvement for home health textbooks include: a chapter or section on end-of-life care related to community health; more content on pain and symptom management specific to end-of-life care; content on care of patients dying at home; and support for family caregivers. Another important area to include would be quality of life at the end of life. It is essential that current knowledge base for providing excellent palliative care is quickly disseminated into the bestselling nursing textbooks. We encourage the Journal of Hospice and Palliative Nursing to promote end-of-life content in this journal and to encourage editors, authors, and publishers of textbooks to also promote end-of-life content within the specialty of home health nursing.

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