Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Palliative Care for Terminally Ill Individuals With Borderline Personality Disorder

Terry L. Terpstra, MSN, RN, AGPCNP-BC, ACHPN-BC; Shelley Williamson, MSN, RN, CHPN

Abstract

Individuals with borderline personality disorder (BPD) exhibit persistent patterns of instability in mood, impulse control, self-image, and interpersonal relationships. These issues complicate quality end-of-life care for this population and are of particular concern for hospice and palliative care nurses and health care providers. This article presents case studies of terminally ill individuals with BPD as a series of vignettes that present common clinical issues encountered by the palliative care team. Interventions suggested in the literature as well as approaches used by team members when working with terminally ill individuals with BPD are discussed. [Journal of Psychosocial Nursing and Mental Health Services, 57(9), 24–31.]

Abstract

Individuals with borderline personality disorder (BPD) exhibit persistent patterns of instability in mood, impulse control, self-image, and interpersonal relationships. These issues complicate quality end-of-life care for this population and are of particular concern for hospice and palliative care nurses and health care providers. This article presents case studies of terminally ill individuals with BPD as a series of vignettes that present common clinical issues encountered by the palliative care team. Interventions suggested in the literature as well as approaches used by team members when working with terminally ill individuals with BPD are discussed. [Journal of Psychosocial Nursing and Mental Health Services, 57(9), 24–31.]

Since 1990, the U.S. health care system has placed greater importance on the delivery of quality care to terminally ill individuals. Palliative care focuses primarily on anticipating, preventing, diagnosing, and treating symptoms that individuals with serious or life-threatening illnesses are experiencing. The goal of palliative care is to improve quality of life for these individuals and their families (Rome, Luminais, Bourgeois, & Blais, 2011). Hospice care also emphasizes the provision of comfort-focused care but is aimed primarily at individuals with terminal illnesses who are no longer seeking curative care and who have a prognosis predicted to be less than 6 months (Terpstra, Williamson, & Terpstra, 2014).

There is a need to build on what has been learned and to devise effective methods aimed at caring for specific populations, particularly those with serious and persistent mental illness. Terpstra and Terpstra (2012) reported an estimated 6% of adults older than age 18 have a serious and persistent mental illness. In 2016, approximately 1.43 million individuals received endof-life care provided by more than 4,400 hospice organizations nationwide (National Hospice & Palliative Care Organization, 2018). These numbers mean that in 2016, approximately 86,000 individuals with a serious and persistent mental illness were treated in hospice care, and these numbers can be expected to grow in the future.

The current authors are hospice and palliative care clinicians who have cared for terminally ill individuals with borderline personality disorder (BPD). The first author (T.L.T.) is an advanced practice nurse who is the primary provider on an inpatient palliative care unit, and the second author (S.W.) is the facility's palliative care coordinator, an RN who oversees all aspects of the hospice and palliative care program at the medical center and its associated outpatient clinics. In 2008, a large-scale community study of personality disorders in the United States found a lifetime prevalence of 5.9% (18 million people) for BPD, with no difference in the prevalence between men and women (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). The actual prevalence may even be higher. According to a study by Ruggero, Zimmerman, Chelminski, and Young (2010), more than 40% of individuals with BPD have been misdiagnosed previously with other disorders such as bipolar disorder and major depressive disorder. Individuals with BPD comprise 10% of psychiatric outpatients and 15% to 20% of psychiatric inpatients (SAMHSA, 2012). Consequently, hospice and palliative care providers are likely to see terminally ill individuals with BPD in clinical practice on a regular basis.

Psychological suffering is one of the most concerning issues that patients and families may experience at the end of life. Patients commonly feel a variety of emotions ranging from grief to anger or despair. Most patients can achieve acceptance and learn to cope with the dying process. For distressed terminally ill individuals with BPD, the emotional challenges of their illness can be daunting, and physical and psychiatric symptom control can be more problematic. When faced with a terminal illness, their defensive attempts to maintain stability can become increasingly rigid, counterproductive, and unreasonable (Hay & Passik, 2000). Nurses have described individuals diagnosed with BPD as being among the most challenging patients encountered in their practice (Bland & Rossen, 2005).

This article is the first in a series that discusses the care of individuals with serious and persistent mental illnesses who are also terminally ill. Caring for patients with psychiatric and personality disorders at the end of life is complex, given the nature of psychopathology and its impact on interactions between patients and their caregivers (Feely, Havyer, Lapid, & Swetz, 2013). This article explores interventions suggested in the literature that may be helpful when working with individuals who are terminally ill and diagnosed with BPD. These interventions are categorized into three broad themes: (a) Meet the Challenge and Build Rapport, (b) Be Flexible and Negotiate When Possible, and (c) Recognize Splitting Behavior and Set Boundaries. Case studies within each of these three types of interventions present challenging patient issues encountered by the palliative care team.

Meet the Challenge and Build Rapport

Case Study: Patient A

A 64-year-old man was admitted to the psychiatric unit with BPD and psychosis. He was homeless, was demonstrating bizarre and aggressive behavior in the community, and was unable to provide for his own care. He also had been diagnosed recently with adenocarcinoma of the stomach, multiple lytic bone lesions, and an adrenal mass. Masses in the chest and neck encased the left carotid and subclavian arteries. He had been evaluated by oncology and was given no further treatment options for his cancer.

Behaviorally, he had been challenging. He was belligerent with staff, demanding to leave, faking seizures leading to multiple medical emergency calls, and vacillating between accepting his advanced cancer diagnosis and demanding transfers to other hospitals to see specialists. He demonstrated extremes of emotion.

The palliative care team was consulted to establish end-of-life care goals and help manage his symptoms, which included pain in the chest and abdomen, shortness of breath, and anorexia. This patient was deemed to have medical capacity at the time of the consult. He had one brother who had remained in contact with him over the years and an elderly mother who lived in the vicinity. He named his brother as his surrogate decision maker.

BPD is a serious mental illness characterized by pervasive patterns of instability in four areas: mood, impulse control, self-image, and interpersonal relationships (National Institute of Mental Health, 2017; Salters-Pednault, 2019). Individuals with BPD exhibit intense and volatile feelings and moods, inappropriate intense anger, and difficulty controlling anger. Suicidal behavior, gestures, or threats are recurrent and may involve self-mutilation (Bland, Tudor, & McNeil Whitehouse, 2007). Impulsivity occurs in areas that are potentially self-destructive, such as spending, sexual promiscuity, substance use, and recklessness (Bland & Rossen, 2005).

Individuals with BPD often complain of feeling empty. They have severe difficulties in sustaining close interpersonal relationships with dramatic shifts from idealization to devaluation, and they take frantic efforts to avoid real or imagined abandonment. Although these individuals can be intensely seductive at times, they also alienate others because of their neediness, wildly shifting emotions, pronouncements of their own entitlement, or tendency toward provocation (Hay & Passik, 2000).

Social stigma has long been associated with mental illness. There is no psychiatric diagnosis more laden with stereotypes and stigma than BPD (Nehls, 2000). Markham and Trower (2003) gave mental health nurses a questionnaire that contained descriptions of challenging behaviors in which patients had a diagnosis of depression, schizophrenia, or BPD. Individuals with BPD elicited more negative responses from staff than patients with other diagnoses. In fact, the term “borderline” sometimes is used by staff in a derogatory way to describe difficult patients regardless of their diagnosis (Evans, 2007).

Numerous studies have examined attitudes of mental health professionals regarding BPD. In one large survey by Black et al. (2011) that included 706 mental health clinicians, approximately one half reported they preferred to avoid these patients. Among respondents, nurses had the lowest ratings on empathy toward individuals with BPD and were the least optimistic about treatment efficacy. However, interestingly, despite difficulties with these patients, caring attitudes, empathy, and optimism about treatment were higher among staff who had encountered a greater number of individuals with BPD in the past year.

For hospice and palliative care providers, a key challenge is establishing and maintaining a therapeutic alliance with patients. Knowledge of the disorder, anticipation of difficult behaviors, and preparation of the team for the dynamics and interactions that ensue are essential. Individuals with BPD will engage and challenge an entire community to get their needs met, and likewise, the response must be a community or team effort. Team members need to support one another and share their triumphs and their failures (Post, 2003).

When individuals with BPD who have severe psychiatric symptoms develop terminal illnesses, it is sometimes difficult for them to be admitted to an open or general medical or palliative care unit. Safety was of primary concern for Patient A and for the staff providing care. At first, the palliative care team chose to intervene in the psychiatric setting because stabilization of his mental illness was the priority. The team recognized that the initial approach to Patient A would set the tone for the entirety of the care experience.

Knowing that BPD is characterized by unstable, volatile interpersonal relationships and intense fears of abandonment, the team established an attitude of genuine respect for Patient A from the beginning. His intense emotional outbursts were met with a calm, composed, and emotionally neutral demeanor. Efforts were aimed at not engaging him in argument or debate (Feely et al., 2013). The palliative care team told Patient A that they would be back to see him twice weekly as the goal was to work toward symptom management and comfort. These visits were kept even though the team was met at first with skepticism and verbal outbursts. During the course of several weeks, the team members became familiar visitors, and a sense of rapport was established. Interventions aimed at alleviating pain and shortness of breath were effective, which built a foundation of trust.

Hill (2005) discussed five predictors of success in forming a therapeutic alliance with individuals with BPD. One of these is a supportive relationship with the family. Patient A strongly valued the opinion of his brother, the only family member with whom he had maintained a relationship over the years. With Patient A's permission, his brother was contacted to discuss his medical status, realistic care goals, symptom management, and prognosis.

Patient A's brother became a remarkable asset. He provided ongoing emotional support for Patient A, and he served as the voice of reason when medical decision making was necessary. He did not take Patient A's angry, critical, or demeaning remarks literally, and he was supportive of the hospice team. The brother had been the lifelong anchor in Patient A's tumultuous life and had an effective rapport with him. In turn, the hospice team provided grief and bereavement support and guidance for Patient A's brother.

Eventually, Patient A transitioned to the inpatient palliative care unit when he was psychiatrically stable and his physical condition had deteriorated to the point where elopement was not a concern. The team learned that Patient A had been a talented wood carver. He asked that one of his carvings be donated to the unit after his death so that he would be remembered. Selecting a display cabinet for his art work and a location for it on the unit helped give him a sense of legacy. He died peacefully with his brother at his side approximately 3 weeks after his admission to the unit.

Be Flexible and Negotiate When Possible

Case Study: Patient B

Patient B was a 59-year-old man with a history of BPD and depression who was referred to the inpatient hospice unit for functional decline, frequent falls, recurrent encephalopathy, and escalating opioid self-dosing related to his history of advanced liver cirrhosis with ascites. Recently, he had travelled out of state for liver transplantation evaluation at a large university medical center. The evaluation did not go well, and he had several complicated medical issues while he was at the medical center. He was encephalopathic for most of the stay, became belligerent, refused care, and demanded to leave. Ultimately, he was turned down for transplantation. He returned home, was living alone, and was unable to provide for his own care. He had refused community in-home hospice care but agreed to be admitted.

Individuals with BPD can be very dependent on services and demand elevated levels of care and attention. They adamantly fight for the right to determine their own actions. On the other hand, they also undermine attempts to help them and behave in self-destructive ways that interfere with care processes (Evans, 2007). Patient B was no exception. He was often critical of the care he received and complained that it was insufficient. He blamed the transplant center for not placing him on the transplant list even though he demanded to leave.

After admission to the hospice unit, he frequently refused medications to treat encephalopathy and manage as-cites. He demanded escalating doses of opioids and yet was often somnolent and at considerable risk for falls. Hay and Passik (2000) suggest that clinicians should begin by prioritizing the patient's agenda. Providing effective ways for Patient B to get his needs met could be valuable in reducing his sense of panic over perceived abandonment and bolster his sense of self control. Patient B prioritized his end-of-life care goals with the provider. First, he wanted to be steady on his feet enough to ambulate on the unit and visit the facility's therapeutic garden independently. He vehemently objected to the 1:1 sitter he had been assigned. Second, he strongly desired to visit his cabin on a lake one more time and go fishing with his brother. Finally, he wanted to be clear minded enough to talk with his daughter and grandchildren from whom he had been estranged.

McLafferty and Childers (2015) suggest that encounters begin with a tactful assessment and acknowledgement of the patient's distress and a focus on specific problems. In this case, the first discussion on how Patient B could reach his goal of independent ambulation focused on what role he could play toward gaining more mental clarity. He had been refusing medications including rifaximin and lactulose, both aimed at treating his encephalopathy.

Jones (2008) recommends reframing the goals of medications or treatments to fit the individual's needs. Accordingly, the provider explained how these medications were tied to improving his mental status. He balked and claimed that nurses were giving him too many medications and on their schedule, not his. He was given a list of medication pass times and asked to select times that worked for him. Lactulose doses were scheduled and available as needed so that if he refused at scheduled medication passes, he could take additional doses at other times. This medication often causes loose stools so that timing of administration is important. He was told to dose the lactulose sufficiently to achieve three to four stools daily. Patient B responded by keeping meticulous records of his medications and daily bowel movements, and sharing the record with the provider every day. He began taking his medications more routinely, and his encephalopathy abated.

With one success achieved, the provider tackled the issue of excessive opioid use next. Patient B described “all over” pain and had been using larger doses of opioids than were prescribed when living in the community. He was often somnolent, which led to unsteadiness of his gait and contributed to falls. Even when somnolent and difficult to rouse, he was angrily demanding more opioids. Self-destructive behaviors in individuals with BPD may be an effort at self-regulation of intense emotions (Bland & Rossen, 2005).

One of the biggest problems that individuals with BPD present to health care providers is their inability to communicate clearly what is bothering them. They may substitute the language of physical pain to describe both their physical and emotional suffering. Clinicians should use themselves as therapeutic agents, model genuine acceptance of the patient, and attempt to see the world through his/her eyes (Cassidy, 2000). At the same time, clinicians can work toward interventions on the plan of care that will encourage better ways of coping and then give these patients more attention for positive coping skills (Deluca, 2001; Post, 2003). The provider talked with Patient B about working toward the fishing trip goal. Because falls were a big concern, Patient B was told that he would need to be more alert and steady on his feet to leave the facility safely.

A judicious taper of opioid dosing to achieve more alertness and improve function was recommended. Of course, in the setting of hospice care, to suggest reduction in opioid dosing when Patient B was demanding the opposite required provider fortitude. Miller (2012) calls this fortitude a virtue that ensures firmness in difficulties and constancy in the pursuit of good. Staff were skeptical about it, and Patient B was angry.

Frank et al. (2017) conducted a systematic review of 67 original research studies about the effectiveness of strategies to reduce or discontinue long-term opioid therapy for chronic pain. They concluded that among those studies examining patient outcomes after dose reduction, there was weak evidence that pain, function, and quality of life actually improved. They recommended team-based approaches to support opioid tapering if it was to occur.

Other interdisciplinary team members became involved. Patient B was referred to physical therapy to improve his strength, balance, and stamina to the extent possible. He received massage therapy to help with muscle tension and stress, and a paracentesis was scheduled to alleviate ascites. The psychologist also worked with him on anxiety and grief. Patient B took some time to ponder all of this and threatened to leave the facility several times. However, after a few days, he told the provider that the “fish were calling,” and he worked with the team.

Over 1.5 months, his opioid dosing was reduced by 40%, and Patient B consistently attended physical therapy sessions. He had a large volume paracentesis, which provided relief for abdominal discomfort. He reported that his pain was being managed to his satisfaction. He was ambulating steadily with his walker and spending hours in the garden. He no longer needed a sitter.

A weekend pass to go fishing with his brother was issued. Upon return, he was in a more mellow state of mind and told staff that he had a memorable time with his family. He reconnected with his daughter and grandchildren as well and spent some time off campus with them. In the end, he was visiting the provider's office daily, sometimes just sitting in the office in silence for a while as he grew weaker. It was evident that therapeutic alliance had been achieved.

Recognize Splitting Behavior and Set Boundaries

Case Study: Patient C

Patient C was a 59-year-old woman who was admitted to the hospice unit from a local hospital. She had a long history of abdominal mesothelioma, and 2 years prior to admission, a biopsy of a lung mass was diagnosed as adenocarcinoma. She refused any treatment. More recently, she had complaints of headache, left-sided weakness, and recurrent falls. She then was found to have a large right frontal brain mass with vasogenic edema and midline shift. Once again, she refused all cancer-related treatment. She was placed on dexamethasone to control brain swelling and levetiracetam to manage seizures, and was referred to the hospice unit with a poor prognosis.

In addition, Patient C had a history of BPD and had required psychiatric hospitalization in the past. The hospice team was informed that during past mental health admissions, she had been challenging behaviorally. She was verbally abusive to staff and physically assaultive, and she often refused medications and care. She was homeless and had failed various attempts at placement related to her behavioral issues. She was single and had two children who were, until this time, peripherally involved. She had no other friends or family related to stormy relationships over time.

After admission to the hospice unit, Patient C told staff that she was pleased to have a lovely place to stay and that she would do her utmost to follow the rules and get along with everyone. However, within a few days, she was screaming obscenities and insults at the staff and throwing dirty linen at them. She told some staff that they were her favorites and others that they could do no right.

Patient C showed frequent disregard for unit rules. She plugged toilets, smoked cigarettes in her room, hoarded and hid food that spoiled, smoked off the unit at night after curfew, and turned the television on full volume in the middle of the night. She frequently refused medications and treatments. When approached by the hospice provider in her room for assessment or discussion, she would face the wall, refusing to acknowledge the provider's presence. Alternatively, she would storm into the provider's office suddenly and unexpectedly with complaints or issues at any time of the day.

Nordgren (2007) reported the symptoms of BPD are exacerbated by stress. These symptoms can alarm staff. One common symptom encountered is that of splitting. Splitting is a coping defense mechanism that individuals with BPD use to avoid being rejected or hurt. Splitting means that others are viewed as either good or bad. The patient's rigid approval of and cooperation with “good” caregivers and scorn for “bad” caregivers can lead different hospice team members to experience the patient differently. In addition, these alliances may shift rapidly with minimal justification. If splitting is not recognized, hospice team members may disagree about various aspects of the patient's care, such as validity of symptoms and need for medication. The team can descend into discord with resulting inadequate communication and inconsistent care. Team members may take sides either for or against the difficult patient (Hay & Passik, 2000).

Although most inpatient hospice clinicians are skilled in meeting the holistic needs of terminally ill patients, they are less equipped to manage the behavioral symptoms of BPD. A psychiatric consult–liaison, additional training, and support can help team members feel better prepared to work with these patients and alleviate negative responses to them (Bland et al., 2007). In this case, the palliative psychologist provided the education and support the team clinicians needed. The team learned about the complex etiology of BPD, common behavioral symptoms, and appropriate responses. The team learned splitting was not just a thing that happens but was a process that clinicians were responding to and experiencing with Patient C.

The psychologist worked with staff to examine their own reactions to the splitting behavior and to respond in a respectful and empathetic but consistent and neutral manner. Staff members who were on the front line, such as nursing assistants and housekeepers, were involved with treatment planning. They were encouraged to call on a colleague for substitution if they needed to regroup or to avoid feeling overwhelmed. Other interventions for splitting behaviors have been suggested in the literature. Feely et al. (2013) developed and modeled a script that staff could use to respond to behavioral disruptions. James and Cowman (2007) recommended the use of standard treatment protocols for BPD in inpatient and outpatient settings.

Setting boundaries for individuals with BPD is essential to minimize disruptive behaviors and staff burnout. Hill (2005) defined clinical boundaries as limits that protect the relationship between the nurse and the patient. Boundaries have several desired outcomes. First, boundaries keep the focus on the patient's needs and problems rather than allowing the patient to shift the focus back to staff or to other issues. Second, boundaries ensure that the relationship is goal-directed (i.e., peaceful death). Finally, boundaries confirm that the relationship is objective rather than subjective and that staff are not personalizing their reactions to difficult behaviors.

In this case, the team used several types of boundaries to curtail problematic conduct. One way to set limits is with contingency management; this involves spelling out “if X behavior happens, then Y consequence will occur.” The behaviors and consequences can be either positive or negative. Patient C was informed that her room was unkempt, smelled from spoiled food, and contained contraband such as hidden cigarettes. She was told that if contraband and spoiled food were found again, staff would intervene twice daily to remove these items and clean the room. When these items were found, twice-daily health and welfare checks were performed by a nursing staff member and the housekeeper. Two staff were present to prevent accusations of stealing. Patient C also was told that if she knocked on the provider's door and was asked to enter, then the provider would either meet with her at that time or make an appointment to see her later that day. If she barged in uninvited, she would be politely asked to leave.

Cigarette smoking also required limit setting. The team told Patient C that tobacco use risk assessments would be performed weekly. If she was noted to be unsafe with her smoking materials, then smoking privileges would be revoked. As she deteriorated functionally, this did happen, and a nicotine patch was prescribed. When her family visited, they escorted her to the smoking area at which time the nicotine patch was removed.

Patient C refused medications considered essential to manage her cancer-related symptoms. She complained of headaches related to her brain mass but refused oral steroids and pain medications. She had significant edema of her legs but refused diuretics. She adamantly refused any psychotropic medications. Nordgren (2007) described patients who are medically noncompliant as “help rejecting complainers” (p. 379) and labeled this behavior as noncollaborative. Yet, as symptoms mounted with disease progression, partnership toward the goal of a peaceful death was necessary.

There were ongoing efforts to educate Patient C about how various treatments could ameliorate uncomfortable symptoms, and compromise happened often. For example, Patient C refused to continue to take the oral steroid medication because she did not like the increased appetite or weight gain that she experienced. The provider explained that this drug had improved her left-sided weakness such that she was walking independently again, speaking more clearly, and achieving relief from headaches. She then agreed to take a lower dose, and the dose was adjusted as some steroid was better than none.

She also initially refused to take any oral opioid for ramping pain, but she agreed to subcutaneous morphine. Because pain relief was the goal, the provider went with what she would accept at first. Eventually, she agreed to the conversion to an oral opioid. Unlike most patients, Patient C preferred diuretic dosing in the evening and this was arranged.

Gradually, as a therapeutic alliance was achieved and she became physically more comfortable, Patient C gave the provider more latitude with medication adjustments. She remained on the unit for 6 months. She mellowed with time as her physical needs intensified, and she died peacefully with her family at her side.

Discussion

The current article does not cover all of the issues that palliative care teams encounter when caring for terminally ill individuals with BPD. A plethora of literature exists about the biological and psychosocial etiologies of BPD (Amiel, 2010; Bland et al., 2007). Hill (2005) listed typical behaviors, and Gunderson (2011) discussed psychiatric treatment and pharmacotherapy.

The nursing literature focuses on effective approaches. According to Groves (1975), alliance and support of staff is discussed often in the literature and may be more critical than work with the patient. Bland and Rossen (2005) recommended supporting clinical supervision of nurses working with individuals with BPD. It is an intensive, interpersonally focused, one-to-one or group relationship in which the supervisor (e.g., a psychiatric clinical nurse specialist) facilitates clinical competence in other individuals. This competence is accomplished through the provision of education and emotional support and by overseeing and being responsible for the quality of the care. Cleary, Siegfried, and Walter (2002) found most nurses working with individuals with BPD welcomed clinical supervision and were willing to spend one or more hours per month on education and training.

Hill (2005) listed four predictors of success for nurses working with individuals with BPD. The first predictor is a nursing supervisor with strong clinical hospice skills who recognizes the strengths and weaknesses of staff. The second predictor is consistency in approach. The third predictor is assigning a primary nurse who would be least likely to personalize the aggressive and abusive criticisms that are likely to occur. Finally, the fourth predictor is the consultative relationship between the hospice nurse and psychiatric nurse.

In addition, the literature emphasizes the importance of using an interdisciplinary team approach for individuals with BPD. The development of a written treatment plan that clearly delineates the goals of care and expected behavior for clinicians and patients is necessary. Specific suggestions for developing such a plan are available (New York State Department of Health AIDS Institute's Clinical Guidelines Development Program, & the HIV Clinical Education Initiative, n.d.).

In a survey of 65 psychiatric nurses, James and Cowman (2007) found that a majority believed team disagreements lead to inadequate care. To avoid different approaches to the management of individuals with BPD, these researchers recommended the use of standard treatment protocols for inpatient and outpatient settings.

Nursing Implications

Hospice staff are likely to be involved in the care of individuals with BPD. Because individuals with BPD have great difficulty managing emotions and maintaining relationships, helping them die comfortably and peacefully can be a difficult journey. Vexing at times, individuals with BPD challenge clinicians to recognize and control responses, keep judgments at bay, and attempt to see the world through the eyes of individuals with BPD (Cassidy, 2000). Lack of psychiatric training should not intimidate hospice nurses because expertise in death and dying more than compensates. Learning about BPD and working as a team to meet challenges helps the palliative care team broaden its repertoire of caregiving skills. Connecting with these individuals who have had few if any satisfying connections in their lives embodies the essence of healing.

Advanced practice nurses who serve as providers for individuals with BPD must be willing to go back to the basics. The nursing process requires that nurses individualize, contextualize, and priori-tize patient issues. To do this, advanced practice nurses in palliative care must be willing to get to know patients and their families very well (an essential investment of time), identify the most pressing issues (because hospice care by its nature generally means that the trajectory of care is time limited), conduct research as to what interventions might work, and have an open mind toward potential solutions even if they seem somewhat avant-garde. Finally, advanced practice nurses should share successes and failures with other care-givers to enhance the delivery of quality palliative care to terminally ill individuals with BPD.

Conclusion

The clinical team members who provided care for individuals with BPD found the work to be challenging and rewarding. There is a need for more information about the unique end-of-life care needs of terminally ill individuals with BPD. Death with dignity is something one desires for oneself and for one's loved ones, and death does not differentiate between those who have and those who do not have mental illness.

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Authors

Ms. Terpstra is Advanced Practice Nurse, Medicine Service, and Ms. Williamson is Hospice and Palliative Care Program Coordinator and Educator, U.S. Department of Veterans Affairs, Veterans Health Administration, Battle Creek VA Medical Center, Battle Creek, Michigan.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Terry L. Terpstra, MSN, RN, AGPCNP-BC, ACHPN-BC, Advanced Practice Nurse, U.S. Department of Veterans Affairs, Veterans Health Administration, Battle Creek VA Medical Center, 5500 Armstrong Road (114N), Battle Creek, MI 49037; e-mail: terry.terpstra@va.gov.

Received: February 08, 2019
Accepted: March 25, 2019
Posted Online: June 12, 2019

10.3928/02793695-20190531-01

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