The social construction of dying in nursing homes: Implications for social work.

摘要

Purpose. To build understanding about dying in nursing homes, by developing language and concepts especially germane to dying from organ failure or frailty.;Relevance. Half of the 85+ die as nursing home residents. By understanding the social and medical factors that influence the social construction of dying in nursing homes, we can better plan for consequences and enhance end-of-life decision making.;Methodology. Two-part qualitative study consisting of a secondary analysis of ethnographic data collected over 8 months at 2 Midwestern urban nursing homes, and the collection of new data to member check preliminary findings. 1,200 pages of transcribed notes representing 45 resident/family units were re-coded to address 5 research aims concerned with developing the social context of the nursing home from the resident and family perspectives and focusing on how the possibility of dying is communicated and socially constructed. Symbolic interaction, social constructionism, and role theory provided the theoretical basis.;Findings. The social context is dominated by multiple health and social transitions, many types of losses, and a struggle to receive basic care despite the lack of nurse aide staff. While families were relieved to have their loved one in a nursing home, some family members were overwhelmed with guilt, sadness, the burden of decision making, and role strain. Some residents and families were satisfied with living and dying in the nursing home, others were not. Medical charts and care plan meetings were focused on day-to-day care, and seldom addressed the possibility of dying. Four social constructions of possible dying are proposed: Dying Allowed/Anticipated; Dying Contested; Mixed Message/Ambiguous Dying; and Dying Denied/Resisted. These constructions are the basis of, “The Social Utility and Medical Interests Model of Family Decision-Making,” which proposes that decisions are made based on the understanding of the resident's medical situation and role expectations of the decision maker.;Social work implications. An expanded role for social workers is proposed to work with residents and families dealing with crises from multiple transitions, losses, and decision making as the end of life approaches.