A Framework for Categorizing Social Interactions Related to End-of-Life Care in Nursing Homes

Purpose: Almost half of people age 85 and older who die annually in the United States die as nursing home residents, yet because it is not always clear who is close to death, not all residents who might benefit from end-of-life care receive it. The purpose of this study is to develop a framework for organizing social interactions related to end-of-life care and to characterize the social construction of dying in two nursing homes. Design: Secondary analysis of qualitative ethnographic data collected before the death of 45 residents who were selected for the study on account of their "declining” health status. Methods: Field notes, medical chart data, and transcribed interviews corresponding to 45 residents in two nursing homes in a large Midwestern city were analyzed using qualitative descriptive methods guided by symbolic interaction and role theory. The data were also grouped by resident to facilitate the development of cases that illustrate the categories of social interactions. A second reader also categorized all the resident cases into one of five categories as a means of verifying the model. Results: A new framework of five categories to name the stance toward the possibility of dying is presented and illustrated with cases. The categories include: dying allowed, dying contested, mixed message dying, not dying, and not enough information. Cases are provided to illustrate the importance of recognizing the impact that social interactions can have on care. Over half the resident cases were classified as mixed message dying or not enough information, which speaks to the ambiguity regarding care plan goals found in the two nursing homes in the study. Implications: Social interactions related to the health care and dying status of a nursing home resident help to construct a social reality, and that social reality can affect the care the nursing home resident receives. Conversations about goals of care, and how these goals will be operationalized are important issues for discussion among residents (to the extent able), family, staff, and physicians. Social interactions, or the lack thereof, matte