"A room full of chairs around his bed": being present at the death of a loved one in Veterans Affairs Medical Centers

Visitor Restrictions, Palliative Care, and Epistemic Agency: A Qualitative Study of Nurses' Relational Practice During the Coronavirus Pandemic

Efforts to curb spread of COVID-19 has led to restrictive visitor policies in healthcare, which disrupt social connection between patients and their families at end of life. We interviewed 17 Canadian nurses providing palliative care, to solicit their descriptions of, and responses to, ethical issues experienced as a result of COVID-19 related circumstances. Our analysis was inductive and scaffolded on notions of nurses' moral agency, palliative care values, and our clinical practice in end-of-life care. Our findings reveal that while participants appreciated the need for pandemic measures, they found blanket policies separating patients and families to be antithetical to their philosophy of palliative care. In navigating this tension, nurses drew on the foundational values of their practice, engaging in ethical reasoning and action to integrate safety and humanity into their work. These findings underscore the epistemic agency of nurses and highlight the limits of a purely biomedical logic for guiding the nursing ethics of the pandemic response.

Dying From COVID-19: Loneliness, End-of-Life Discussions, and Support for Patients and Their Families in Nursing Homes and Hospitals. A National Register Study

CONTEXT

Preparation for an impending death through end-of-life (EOL) discussions and human presence when a person is dying is important for both patients and families.

OBJECTIVES

The aim was to study whether EOL discussions were offered and to what degree patients were alone at time of death when dying from coronavirus disease 2019 (COVID-19), comparing deaths in nursing homes and hospitals.

METHODS

The national Swedish Register of Palliative Care was used. All expected deaths from COVID-19 in nursing homes and hospitals were compared with, and contrasted to, deaths in a reference population (deaths in 2019).

RESULTS

A total of 1346 expected COVID-19 deaths in nursing homes (n = 908) and hospitals (n = 438) were analyzed. Those who died were of a more advanced age in nursing homes (mean 86.4 years) and of a lower age in hospitals (mean 80.7 years) (P < 0.0001). Fewer EOL discussions with patients were held compared with deaths in 2019 (74% vs. 79%, P < 0.001), and dying with someone present was much more uncommon (59% vs. 83%, P < 0.0001). In comparisons between nursing homes and hospital deaths, more patients dying in nursing homes were women (56% vs. 37%, P < 0.0001), and significantly fewer had a retained ability to express their will during the last week of life (54% vs. 89%, P < 0.0001). Relatives were present at time of death in only 13% and 24% of the cases in nursing homes and hospitals, respectively (P < 0.001). The corresponding figures for staff were 52% and 38% (P < 0.0001).

CONCLUSION

Dying from COVID-19 negatively affects the possibility of holding an EOL discussion and the chances of dying with someone present. This has considerable social and existential consequences for both patients and families.

Dying alone and lonely dying: Media discourse and pandemic conditions

BACKGROUND AND OBJECTIVES

This paper explores current concerns and practice related to older people dying alone in Intensive Care Units, care homes, and at home through media discussions during the Covid-19 pandemic and before. It addresses the historically-situated concept of a good death and a bad death and suggests why dying alone, whether completely alone or without significant others physically present, may be considered a bad death.

METHODS

As evidence for collective fears about dying alone, we explored the treatment of these deaths in media using headline examples from the US New York Times and the English Guardian newspaper from the 19th century through Sept. 2020.

RESULTS

A search of the New York Times located 39 articles with either lonely dying or lonely death in the headline. The Guardian had 25 articles with use of the term, but unlike the New York Times, no obituaries were included. Although the deaths profiled were deemed unusual, deaths by suicide were only minimally classed as dying alone. The condition of dying alone is represented as a stigmatised death. Themes addressed: 1) dying alone is a nonnormative event; 2) this death matters; and 3) where people die alone, societies should honour the death and learn from it.

DISCUSSION AND IMPLICATIONS

Contemporary dying involves conditions for which we are unprepared as a society. We seldom address our civic obligations to each other. Few people have discussed their wishes about their preferences in dying and whether and how they want to be accompanied at their death, if possible. This is an invisible constraint of modern healthcare. Because of limited discussions and preparation, these deaths may lead to disenfranchised grief for the mourners. Cultural and societal responses to lonely dying are important in easing the emotional burden of dying alone, helping individuals prepare for this possibility and better integrating death with the life course. Recommendations include inclusion of accompaniment/nonaccompaniment at death as part of advance care planning and mitigation if this condition occurs. It is essential for individuals to find their own still point of acceptance within competing societal narratives of privileging the self in dying alone and the value of social connection.

"Who would want to die like that?" Perspectives on dying alone in a long-term care setting

The discourse of dying alone is negatively weighted and models of a good death identify not dying alone as a key outcome. Understanding why dying alone is viewed negatively and its effects on care is a priority. In separate focus groups with long-term care residents, family caregivers, and staff, we identified evidence for four different perspectives on the importance of presence at the time of death. However, while each individual had their own unique perspective on dying alone, the predominant view expressed across respondent groups was that having human connection near the end of one's life was important.

Family Care During End-of-Life Vigils

An end-of-life vigil is the act of being with another toward death. A family vigil at end-of-life occurs when significant others gather by the bedside of dying individuals in the weeks, days, or hours prior to the death event. It is not unusual for nurses to be present, bear witness, and share in this human experience. This article reviews seminal and current research regarding the meaning and structure of the lived experience of vigil keeping for a dying family member, and translates research to inform nurses regarding family care during the transition at end-of-life.

Between the patient and the next of kin in end-of-life care: A critical study based on feminist theory

BACKGROUND:

For the experience of end-of-life care to be 'good' many ethical challenges in various relationships have to be resolved. In this article, we focus on challenges in the nurse-next of kin relationship. Little is known about difficulties in this relationship, when the next of kin are seen as separate from the patient.

RESEARCH PROBLEM:

From the perspective of nurses: What are the ethical challenges in relation to next of kin in end-of-life care?

RESEARCH DESIGN:

A critical qualitative approach was used, based on four focus group interviews.

PARTICIPANTS:

A total of 22 registered nurses enrolled on an Oncology nursing specialisation programme with experience from end-of-life care from various practice areas participated.

ETHICAL CONSIDERATIONS:

The study was approved by the Norwegian Social Science Data Service, Bergen, Norway, project number 41109, and signed informed consent obtained from the participants before the focus groups began.

FINDINGS AND DISCUSSION:

Two descriptive themes emerged from the inductive analysis: 'A feeling of mistrust, control and rejection' and 'Being between hope and denial of next of kin and the desire of the patient to die when the time is up'. Deductive reinterpretation of data (in the light of moral distress from a Feminist ethics perspective) has made visible the constraints that certain relations with next of kin in end-of-life care lay upon the nurses' moral identity, the relationship and their responsibility. We discuss how these constraints have political and societal dimensions, as well as personal and relational ones.

CONCLUSION:

There is complex moral distress related to the nurse-next of kin relationship which calls for ethical reflections regarding these relationships within end-of-life care.

"He's on his dying bed": Next-of-kin's experiences of the dying body

For family members of dying patients who have grown accustomed to providing daily body care, the transition from home to hospital is stressful. The authors used the experiences surrounding death for 78 U.S. veterans who died in a Veterans Affairs hospital. The research is based on interviews conducted with the decedent's next-of-kin. Secondary qualitative analysis of previously-coded transcribed interviews was used. Themes of social disorganization and a loss of control over the body emerged. Next-of-kin experienced the physical and functional breakdown of their loved one's body. Understanding the nature of the loss of control may help alleviate the loss of control may help alleviate the strain on families.

"I was ready to take him home": next-of-kin's accounts of loved one's death during hospice and palliative care discussions in Veterans Affairs Medical Centers

This study explored next-of-kin's retrospective accounts of hospice and palliative care discussions for hospitalized veterans. In-depth, face-to-face interviews were used to generate narrative accounts of 78 next-of-kin's experience of their loved one's hospital care during the last days of the patient's life. One-third of participants reported taking part in a hospice or palliative care discussion during the patient's final hospitalization. In over one-half of those cases, the patients died before discharge or transfer to hospice or palliative care was accomplished. Hospice and palliative care discussions in the hospital setting shaped family perceptions of the patients' care, directed family efforts in the days prior to death, and engendered anticipation of remaining quality time with the patient. Discussions about hospice or palliative care have meaning, emotional impact, practical effects, and unintended consequences for next-of-kin. Social workers in hospital settings can play a critical role in supporting family members through the hospice and palliative care discussion process and facilitate timely care transitions. They also can attend to the psychosocial concerns of family members, particularly when death occurs prior to discharge to hospice or transfer to an inpatient palliative care service.

"Don't get weak in your compassion": bereaved next of kin's suggestions for improving end-of-life care in Veterans Affairs Medical Centers

OBJECTIVES

To analyze bereaved next of kin's suggestions for improving end-of-life (EOL) care in Veterans Affairs (VA) Medical Centers (VAMCs).

DESIGN

Qualitative.

SETTING

This study was part of a larger study testing the effectiveness of a multimodal intervention strategy to improve processes of EOL care in six southeast U.S. VAMCs (Best Practices for End-of-Life Care for Our Nation's Veterans-BEACON Trial).

PARTICIPANTS

Bereaved next of kin (n = 78) of veterans who died between 2005 and 2010.

MEASUREMENTS

Data addressing praise, criticism, and recommendations for enhancing EOL care were abstracted from semistructured interviews of next of kin and aggregated into a code labeled "Suggestions." Content analysis proceeded iteratively through data review, comparison, and negotiation of emergent themes and integration of all coauthors' insights and interpretations into the evolving interpretive scheme.

RESULTS

Next of kin provided examples that resonated with their conceptions of quality EOL care. They also described distressing situations and perceptions of deficits in care. Major themes derived were compassionate care, good communication, support for family visits and privacy, and the need for death preparation and postdeath guidance. The fifth theme, unique to this study, was the salience of the relationship between the veterans and their families and the VA and the expectations this engendered in terms of dignity and honor.

CONCLUSION

Interventions that support staff's ability to convey compassion, communicate information to families and other staff, listen to patients and families, prepare families for the individual's death, and provide consistent, coordinated information regarding after-death activities may optimize EOL hospital care for veterans.