Integrating palliative care competency into nursing curricula prepares students for the complexities of end-of-life care
Few words hold as much weight as the ringing echo of “death” uttered in a room.
Despite the discomfort that can accompany discussions about death and dying, this largely taboo topic lies at the heart of every serious injury, illness and end-of-life journey. Yet imagine a patient’s expectation when facing their most vulnerable moment. They rely on their health care providers to navigate this delicate conversation with grace and expertise.
Enter Megan Lippe, PhD, MSN, RN, ANEF, FPCN, FAAN, a palliative care educator who confronts the silence surrounding mortality head-on. As an associate professor at The University of Texas Health Science Center at San Antonio’s School of Nursing, Lippe champions a bold teaching strategy: Learn to embrace the “D” word.
“How can someone talk to their patient about death if they aren’t even comfortable saying the word?” asked Lippe. “The principles of communication are important for this process. We have to balance the need to prepare patients and their families for the possibilities ahead while also understanding the power of silence and giving them space when they are facing these difficult situations.”

Lippe’s job — and her passion — is to ensure each new graduate leaves their program as a competent member of the health care team. That means they enter professional practice well-versed in addressing not only the physical symptoms of someone enduring a serious illness or injury, but also the psychosocial, emotional and spiritual needs of the patient and their family.
Need to know
In 2021, the American Association of Colleges of Nursing (AACN), an organization that establishes quality standards for nursing education, deemed palliative care an essential competency.
“The association updated their curricular guidelines, and as part of that, hospice, palliative and supportive care was named as one of four critical spheres of undergraduate and graduate nursing education,” Lippe said. “It went from nice to know to need to know.”
The Essentials: Core Competencies for Professional Nursing Education, AACN’s educational framework for baccalaureate and graduate nursing programs, provides specific guidance for the development or revision of a curriculum for each degreed program, including core competences each new graduate must exhibit.
While AACN deemed palliative care a basic human right and beneficial at any stage of a serious condition, Lippe said “nurses cannot practice what they do not know.” The End-of-Life Nursing Education Consortium, in partnership with AACN, updated its document of palliative care competency statements for undergraduate and graduate students. These statements are known by nurse educators and students as Competencies And Recommendations for Educating Nursing Students, or CARES and G-CARES (for graduate education), respectively, and are guidelines essential for enhancing care quality, supporting nurses’ professional growth and ensuring culturally competent care.
“Palliative care did not change with these updates,” noted Lippe. Rather, the language around competency was updated to better align with the new curricular standards to make them more meaningful for schools of nursing.
“We are now really speaking to the role of the nurse when patients are seriously ill or actively dying.”
One such statement now reads: “Provide culturally sensitive care that is responsive to rapidly changing physical, psychological, social and spiritual needs during the dying process and after death.” Students can now be assessed based on how well they adjust to changing needs during the imminent death period.
As one real-world example, Lippe recounts a story she often shares with students about taking care of a patient from Mexico.
“The chart documented his religion as Catholic, but [he was] Jewish. Someone made an assumption instead of asking about his spiritual or religious beliefs,” said Lippe. “These details inform how we care and interact with our patients and their families. We can unintentionally do harm by making assumptions. Every person is unique, and we must be proactive in respecting each of their values, beliefs and preferences.”
Simulating reality
Adding to her belief that nurses cannot practice what they do not know, Lippe said nurses cannot know unless they practice, and that they should practice in a safe and controlled environment.
Simulated experiences are a valuable component of nursing education, and Lippe has created several simulations inspired by real-life scenarios she experienced. One simulation walks students through several interactions with a family of a seriously ill patient that leads to the withdrawal of life-sustaining measures.
“I designed the first part to begin with the family not fully understanding what’s going on with their family member,” Lippe said.
“How long will he need the tracheostomy? We are going to Paris in one month. Will it be out by then?” asks an actor portraying the patient’s wife during the simulation. The students are tasked to interact with the family, providing information and comfort while their instructor observes.
The exercise then requires students to assess the patient and communicate with the physician. Students might use the popular SBAR (situation-background-assessment-recommendation) communication framework to identify the problem and, based on pertinent information about the patient and the patient’s condition, consider options and recommend actions.

The final phase of the simulation is Lippe’s favorite.
“After the family meets with the physician, the students further explore treatment options with them. The wife of the patient decides to withdraw life-sustaining measures, specifically the ventilator and medications to sustain blood pressure,” Lippe said.
“I love that part, to see how their jaws drop because they expect the wife to be in denial or fight for her husband’s life, so they’re like, ‘Huh?’ This situation teaches them to be prepared for families to surprise them and to quickly adapt to support their decisions, wherever the patient and family are in their journey with a serious illness,” said Lippe.
A debriefing session follows each part of a simulation to discuss the communication, care and strategies used, as well as how students felt about the experience.
“I like the idea of putting students in a simulation scenario first. It’s a safe space for them to practice and develop their care and communication strategies and receive feedback,” Lippe said.
“When we think about patients who are actively dying, it is a sacred space. We want students to be as prepared as possible to provide holistic, quality care to patients and families when they enter these sacred spaces.”
CARES competency
Achieving competency is at the heart of the knowing and practicing cycles. Nursing educators across the nation are working to enhance their curricula to teach palliative care content and assess competency, said Lippe. To support them in this endeavor, Lippe leads a national team of nursing faculty and palliative care nursing experts who are developing helpful resources through the End-of-Life Nursing Education Consortium.
“CARES and G-CARES are very broad but intended to be really helpful for curricular guidance,” Lippe said. “We also needed a competence assessment regarding specific observable behaviors of students — some way to verify that students can actually do those behaviors by graduation and demonstrate an ability to provide palliative care.”
Putting their collective experiences together, the team produced a primary palliative care nurse competence model and assessment tool, a student assessment tool that connects clinical behaviors to the CARES competency statements. It also works in conjunction with other supporting documents the team created to map each CARES statement to curricular guidelines in AACN’s Essentials framework.
“To go back to our [simulation] example, the role of a nurse is to adjust care to a patient’s rapidly changing needs physically, psychologically, socially and spiritually when a patient is dying,” Lippe said. “Is a student able to adjust through the care process based on a patient’s condition or not? If a student is in a simulation or at the bedside, I can actually watch them do this and evaluate it.”
Rethinking palliative care
For Andrya R. Rivera-Burciaga, DNP, APRN, FNP-BC, ACHPN, a student in the School of Nursing’s PhD in Nursing Science program, having a faculty member on staff who is an expert in this area and who is creating tools on behalf of the profession is beneficial.
“As an advanced practice nurse, I feel there is still a perception in the profession that palliative care isn’t as important as other spheres of care, but the updates to nursing education and tools such as these will bring an awareness that palliative care is valuable,” she said.
Lippe believes it is important for educators to see that their students are already at the bedside of so many patients who would benefit from palliative care.
“As educators, we need to re-envision and expand the who, what, where, when, why and how of palliative care education to ensure we prepare future nurses and health care professionals who will care for these patients and their families,” Lippe said.
“In taking a step back to realize where nurses are taking care of patients with serious illnesses, we find it is everywhere. Palliative care is needed throughout our community because that’s where our patients who have a serious illness live,” said Lippe.
“Our goal is to empower the workforce to improve the quality of life of patients and families living with serious illness across the disease trajectory and at the end of life.”
The future of palliative care
Because of her multifaceted expertise and dedication to advancing nursing education and palliative care, Megan Lippe, PhD, MSN, RN, ANEF, FPCN, FAAN, has been awarded fellowship into three esteemed organizations: the American Academy of Nursing, National League for Nursing’s Academy of Nursing Education and Palliative Care Nursing.
“Dr. Lippe is an exceptional leader, and she is contributing much to the advancement of care for the seriously ill by preparing our nurses,” said Betty Ferrell, PhD, FAAN, FPCN, CHPN, the principal investigator of the End-of-Life Nursing Education Consortium. “Her years of work in creating curricula, innovative teaching strategies and evaluation methods has reached over 1,100 undergraduate and 375 graduate programs.”
ELNEC is a national program dedicated to improving palliative care by equipping nurses with training in skills such as pain management and communication.
As a member and regional chair of the consortium, Lippe is working with other nursing faculty to shape the future of palliative care education. She is the lead author of the End-of-Life Nursing Education Consortium curricula, as well as the American Association of Colleges of Nursing-endorsed national palliative care competence statement revisions for both undergraduate and graduate education.
Lippe’s collaborative research efforts have likewise produced new quantitative measures to assess primary palliative care curricula and competence for advance practice and entry-to-practice nurses.
Four spheres of care
- Wellness, disease prevention. Promotes health and prevents illness through education, lifestyle modification and early-detection strategies
- Chronic disease management. Manages long-term conditions to optimize quality of life and minimize disease progression through ongoing care and support
- Regenerative/restorative care. Restores patient health and functional abilities following acute illness or injury through rehabilitation and recovery-focused interventions
- Hospice/palliative care. Provides compassionate care to relieve symptoms and improve the quality of life for patients with serious, life-limiting illnesses, including end-of-life care
Source: The Essentials: Core Competencies for Professional Nursing Education, American Association of Colleges of Nursing, 2021 (fig. 2, pg. 19).