David Farrell's courageous words should help us to focus on what our staff as well as our residents face everyday in long-term care. Elders die in the communities we operate. Sometimes they die in the presence of relatives.  But all die in communities consisting of non-kin. These survivors probably all experience the deep emotions expressed by David Farrell. (Think of Mrs. Smith as her roommate lay dying.) I believe we would honor everyone involved if we could one day find a way to normalize discussions of death in our homes.

Kaye Brown
Duke University

I received "News from the Pioneer Network" for the first time today and this item immediately caught my attention.  

Philosophical Response:
Those who experience death in our culture are privileged.  As a mother and a nurse I've experienced birth and death a number of times and both profoundly shaped my living.  And enriched it.  What we choose to fill our days with is, to a large degree, determined by what areas of life we are willing to explore/experience.  Kudos to this gentleman for looking, for seeing, for asking.  The barriers in US culture that shield us from these experiences impoverish our living, our dying and our deaths.

Generally we equate dying with suffering, often with pain; both for the person dying and for anyone around them-family, friends, staff, the person in the adjacent bed.  Rarely does this need to be.  It usually occurs because of choices that the patient, family, staff and administrator have made. We, in health care, can profoundly effect the caliber of those choices if we have the strength and courage to look at death and dying, and observe the details.

Questions, and possible solutions, that came to mind as I reflected on this narrative were:  

Was the dying patient actually "air hungry" and in respiratory distress?  
If yes, her medication management was inadequate and unnecessary suffering for the patient and all present occurred.  
If no, then the dying patient may have been experiencing a predictable, irregular and noisy breathing pattern common to the end stage of dying and not actually be suffering.  In this case the daughter, Mr.Farrell and the roomate were distressd because they assumed the patient suffered - due to lack of familiarity with the process of dying.  

What services did the nursing home offer to the family, staff and administrator, and other patients after this lady passed away?  Did a bereavement counselor contact the family? the patient in the adjacent bed? the nursing assistants? the administrator?  Did the facility have any sort of memorial service?  

How did experiencing her mother's death in a public situation effect the daughter?  How did experiencing her neighbors public death effect the patient in the adjacent bed?

We need to ask these and so many more questions.

I am impressed that Mr. Farrell returned to this world. The average length of stay in a nursing home is about 2 years.  Most people leave by dying-either in the NH or after transfer to acute care. In a 100 bed facility the nursing assistant "will stumble upon a human dying in front of me" - weekly. Experience the loss of 50 individuals a year.  And actually they don't just stumble across them, they wash them, turn them, pray with them, talk to them, sing to them.  "The laying on of hands."  The basic, intimate human connection.  

So, truthfully, a nursing home offers a place to die.    

  "Sometimes I think: It's a good thing I have not become immune to death.  I wonder - When I become immune, I'm sunk."

Mr. Farrell's sensitivity and honesty are so necessary to good care.  But they are not sufficient, and I think it is probably a sense of this that prompted his public comments.  If we step away from our preconceptions of a nursing home and ask ourselves  "What is needed to make a good place to live for the last two years of a persons life?"   What image appears?  What needs appear? Who appears?

OK, honestly, as you conjured that image did it include death? Grief? Probably not-that is how far as a society we are from OURSELVES. Much is known about dying, much is not known.  To be good, healthy places to work, to reside and to die nursing homes need to become experts on the "much that is known".  

I would love to see this thread expand on what what individuals and facilities are or can do to create this.