Cultivating knowing and relationships: A grounded theory of quality of death in the nursing home

Understanding quality of death in the nursing home is mandated both by demographics and morality in an aging society. Nursing home residents are among the oldest and most physically and mentally frail members of our society. Today, approximately 40% of people die in nursing homes in the Untied States. Despite being a relatively commonplace event, death in the nursing home and the quality of it, are understood in limited terms. A recent dimensional analysis on palliative care in the nursing home poses “quality of death” as an outcome that could improve the experience of death in the nursing home for all involved. Quality of death assumes explicit acknowledgement of death as the event of interest, and embraces dying as an imperceptible time period that precedes it. This emergent mode grounded theory study applied qualitative event analysis techniques to prospectively verify and refine this emergent concept by delineating dimensions embedded in quality of death. Using observations, interviews, and document review, events in the lives of residents receiving palliative care were analyzed according to grounded theory methods. Through a focus on events surrounding residents? deaths, the Grounded Theory (GT) “Cultivating Knowing and Relationships” emerged. This GT provides a process whereby certified nursing assistants (CNAs) come to understand and know their residents. These CNAs develop personal relationships with residents to whom they are initially assigned for care. As they cultivate relationships with these most frail older people who are at the end of their lives, the CNAs create reciprocity and achieve gratification in their work. The findings of this study challenge current understanding of what constitutes quality, the meaning of palliative care, and the experience of death in the nursing home. By focusing on human interaction and emotional connections, Cultivating Knowing and Relationships has the potential to transform current approaches to care of those who die in nursing homes