Andrea Sherman, PhD is the President of Transitional Keys and Project Director of the Consortium of New York Geriatric Education Centers at New York University College of Nursing. Dr. Sherman Chairs the Humanities & Arts Committee of the Gerontological Society of American, and is on the Leadership Council of The American Society on Aging. She holds a doctorate in Dance and Gerontology and is a Fellow of The New York Academy of Medicine.
How is staff expected to handle the death of residents in a nursing home?
I think it’s really hidden, unfortunately. At a recent training in a nursing home, the staff said they don’t even refer to dying when someone has died or if they’re dying, they use the term “the person has gone to Chicago.” So you may be on a shift and you may come in and someone would say “Oh that person went to Chicago.” And new staff members were totally confused because they literally thought that person had gone to Chicago and wondered how they could go when they were so sick. This common practice of using code names to refer to when a person is dying, or when they have died, alarms the other residents. There’s always a fine line between acknowledging death and not alarming other residents—even though many older adults feel that when they come to a nursing home that it’s their last stop. I think the use of code names is intended to help the other residents but it doesn’t help the staff. We should find a balance between supporting the staff, residents, and family. Quite often, staff don’t have an opportunity to say goodbye to the older adults they’re caring for. We live in a culture in which dying is not talked about and I don’t think staff are given a great deal of support in those settings.
Is culture change helping the acknowledgement of death?
It’s helping more, but one of the things that happens is that staff have what’s called “chronic compounded grief” or they suffer from accumulative loss. This is when staff work with an accumulation of patients who have life threatening illnesses. I do think those are grief specific issues in terms of staff, and hopefully we’re at the beginning of seeing some change, but it’s problematic.
What role does staff play in the dying process?
I have phenomenal stories, caregivers and nurses in particular, who—often when the older adult they are caring for has an episode and ends up in the hospital—they will go visit the older adult. One nurse described an experience where the family came from all over to be with this older person and the older person shooed the entire family out of the hospital and she said to the nurse “Hold me, please hold me.” And she died in the nurse’s arms … not her family’s. That’s a really poignant description of a relationship. Staff observes all kinds of interactions with people who are dying and their families and friends. In some places there is music that is used to sort of soothe the dying process—recreational therapists might introduce that or a chaplain might be involved. I think the team approach in the palliative care movement is the best approach: a team involved in the dying process to support everybody. That would be ideal. And it would be a social worker, a dietician, a therapist, a chaplain, a physician, everybody. It’s really important to ask the staff to be part of a vigil when a resident if dying, especially if there isn’t any family and even if it means juggling a schedule. In some places there’s sort of a mentor system where a more experienced staff member might buddy with a less experienced staff member. The mentoring system works really well. In the cutting edge places there’s a symbol that’s used to communicate to everyone on the floor or unit that a person is in their last hours. It lets the staff know, it lets the residents know. There needs to be a systematic, institutionalized approach. In some settings it’s a really ideal practice when someone has died, not to move a new resident into that room for 24 hours. In symbolic remembrance of that person, staff might place something on the bed.
What else should staff members do to recognize the death of a resident?
When a resident has died, some staff are now ritualizing their ongoing activities to allow people to speak about the person who has died. They acknowledge it, and then they allow people to speak. Some places may have a photograph of the resident in a place where spontaneous memory sharing can occur. Sometimes people have cards for staff to sign and then they will mail them a few weeks after the death. It’s important to let staff go to funerals. There are memorial services, which a facility might have once a month to recognize all of the people who have died in that month. Reminiscence sessions and using humor are both really important. In some instances, memory boxes are created and then those boxes are given to the families by the staff. I think it’s really important to develop formalized rituals and ways for people to say goodbye.
Do you think it gets easier for a staff member to say goodbye?
I think it’s always hard. Institutions need to realize that if they don’t let the valve off on grief for staff members, they are going to lose them. The turnover rate is high in nursing homes. They need to set up systems. One staff member told me that when a resident died she didn’t know what to do, and would go into an office and lock the door so she could cry. In a work force shortage environment, this issue isn’t going to get any better unless it’s addressed. Culture change isn’t just changing the culture for the residents or the patients, but for the staff and family as well. Opportunities should be provided for them to say goodbye when the person is alive, to vigil while the person is dying, and to grieve when it’s over.