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Friction among nurses from different educational backgrounds isn't new, says Fetzer. There are four different paths to becoming a registered nurse: a three-year diploma, usually offered at a hospital; a two-year associate degree from a community college; the traditional four-year bachelor's degree (also offered at UNH) and the newer direct-entry master's degree. All nurses take the same national licensing exam and, with the exception of specialists such as operating room nurses, may be paid on the same scale. New Hampshire, Fetzer notes, has an unusually high proportion of nurses with two-year degrees. To help more nurses further their education, UNH enables practicing RNs to complete their bachelor's degrees at UNH Manchester, Keene State College or Plymouth State University.

UNH is also developing a statewide initiative to ease the nursing shortage by opening a bachelor's degree program at Keene State College in 2009 and an accelerated bachelor's degree program at Plymouth State University in 2010. Through collaboration with other nursing programs, the university also hopes to expand its master's and nurse-practitioner programs into the fields of nurse-midwifery, gerontology, family practice and mental health.

A woman of seemingly boundless energy, not to mention multiple degrees, Fetzer has had 32 years of experience in clinical settings while teaching in the UNH nursing department for the past 20 years. She estimates she could earn 50 percent more outside of academia. The combination of relatively low pay and the high cost of graduate school makes many nurses reluctant to become educators. Some states have instituted loan-forgiveness programs and fellowships as enticements. With their maturity, experience and commitment, the direct-entry master's graduates are not only equipped to become educators, but also excel at being leaders in clinical settings, says Fetzer, where "we really need someone who looks at systems."

Loos was already taking a systems view when, for her graduate project, she studied the need for palliative care at Wentworth Douglass Hospital. She knew that seriously ill and dying patients often suffer when medical providers and caregivers focus exclusively on the extension of life. "When a cardiologist is trained, for example," explains Wentworth Douglass chief nursing officer Sheila Woolley, "he or she is taught to save that person, to do everything to keep that heart beating. But the reality is that sometimes we can save the heart, but everything else is going. People don't want to live that way anymore." In a national study in 2000, for example, 25 percent of terminally ill cancer patients described experiencing "unbearable" shortness of breath in the last few weeks of life. Palliative care provides treatment for pain and symptoms, but it also addresses emotional and spiritual needs by helping patients identify their end-of-life goals, which might include something like "going to Hampton Beach one more time" as well as decisions on whether or not to continue efforts to cure their illness. (Loos emphasizes that palliative care also treats anyone in pain, not just the dying. But that doesn't stop co-workers from jokingly telling her she should swap her white lab coat for a black one.)

Loos and Jennifer Gagne Tenhover '91, then a nurse practitioner at the hospital and Loos's preceptor, enlisted the help of Wentworth Douglass nurses, who screened every patient admitted to the hospital in January 2006 for various symptoms and conditions. They found that roughly a third of the 335 patients might have benefitted from a palliative-care consultation.

In May 2006, Loos graduated and also presented her findings to the bioethics board at Wentworth Douglass. In December of that year, she accepted the position of palliative care coordinator at the hospital, where she works in tandem with a newly hired doctor specializing in the field. Thanks in part to Loos' prior business experience, notes Woolley, the palliative care team has been able to take the program "from infancy to a full-fledged program in a very small amount of time." In one year, Loos has reached 70 percent of the hospital's nurses on inpatient units with a series of free classes on palliative care, plus a number of hospice workers, physical therapists, administrators and others both in and out of the hospital. In February, 39 patients received palliative care consultations, a significant number for the hospital.

Loos puts up to seven miles a day on her sturdy but feminine pumps, buzzing around the carpeted corridors of the hospital. She is going, essentially, from crisis to crisis. A woman has slipped suddenly into the labored breathing signaling that she has only hours to live; an 88-year-old man is going home with the knowledge that he is in the final phases of lung cancer. A family must come to grips with the unwelcome news that their father's pain is not caused by a curable condition, but evidence that his long-symptomless cancer is now "knocking at the door." Wherever she goes, she brings an air of calm, even with a hysterical patient who has inadvertently taken a drug overdose. "It's critical to appear self-assured and competent," Loos says, "even at moments when you don't feel that way."

She and palliative care specialist Dr. Patrick Alix are sympathetic. "Try not to feel guilty if you can't take care of your dad at home," she tells the family gathered in a lounge near a large aquarium where tropical fish glide to and fro. "I'm a hospice nurse and if it were one of my family members, I would still need a whole hospice team." But they are also blunt with people who want the truth. And many do. "Am I dying?" a patient will often ask.

"There is no cure," the doctor explains to the elderly man with lung cancer, who will receive hospice care at home. "But we will make sure you have a dignified death. If you have the feeling of suffocation, morphine will be used to blunt the sensation of air hunger."

The dose of morphine required for relief in the terminally ill can be many times higher than doctors have previously prescribed. "We've had to educate pharmacy staff, nurses and doctors to insure that we can reduce suffering at the end of life," says Woolley. The palliative care program, she adds, also benefits patients' families, who are receiving much better support, not to mention the nurses. "This has been huge," she says. "It used to be incredibly sad for the nurses. They knew it wasn't right to have someone hang on in pain."

The 88-year-old man is philosophical: "So what comes, comes," he says. Gathered in the room with him are his daughter, a social worker, a chaplain, the doctor and Loos. He speaks of his 60-year marriage and how he's the last of a group of four friends who is still alive and living at home.

Some terminal patients ask to be resuscitated or treated, no matter what. "It might not be a choice I would make," notes Loos. "I've seen the results of resuscitation in that situation, and it's not pretty. But then I haven't been that 49-year-old mother dying of breast cancer."

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