Dying and death within the culture of long-term care facilities in Canada

Aim and objective. To identify the influence of the culture in Canadian long-term care facilities on the awareness of impending death and initiation of a palliative approach to care for residents aged 85 years and older. Background. Many long-term care residents die after long, dwindling dying trajectories, yet palliative care is often not provided until within a few hours or days of death. Design. Focused ethnography. Methods. Data were collected in three long-term care facilities in south-central Ontario, Canada, through interviews with residents, family members and staff members, observation, artefact review and a focus group. Data were analysed using a constant comparative technique. Results. Four cultural influences on the awareness of impending death and consequent initiation of a palliative approach to care were identified: (i) the care demands in long-term care facilities and the resources available to meet these demands; (ii) the belief that long-term care facilities are for living; (iii) the belief that no one should die in pain; and (iv) the belief that no one should die alone. Conclusions. Commonly held beliefs about the role of long-term care facilities and what is viewed as acceptable care in them mediated the acknowledgement of dying. Late initiation of palliative care was the consequence. In addition, the contextual factors of a low staff-to-resident ratio and reduced staff preparation for palliative care were also influential for a delayed response to dying. Implications for practice. Because strongly held long-term care cultural beliefs underlie care, more timely palliative care for long-term care residents is likely to require the development of an understanding that living and dying are not dichotomous, but rather unfold together from admission until death. Enhanced staff-to-resident ratios and staff training on palliative care will also be necessary to permit long-term care facility staff to focus beyond the currently expected day-to-day care of living residents to provide high-quality end-of-life care throughout the often protracted decline to death for residents of long-term care facilities.