Comfort measures: a qualitative study of nursing home-based end-of-life careedit
Objective: To explore how staff recognize that a resident is dying and to present a typology of comfort measures. Design: Exploratory, descriptive study involving qualitative methods and semistructured in-depth interviews with staff members of one nursing home. Setting: A 120-bed nursing home that is part of a continuum of care from independent living, to residential care, rehabilitation, intermediate, dementia and skilled care. Participants: Forty-two staff members including administrators, nurses, certified nursing assistants (CNAs), social workers, and housekeepers. Methods: On-site interviews were guided by a semistructured instrument that included open-ended questions such as, “How does care change when a resident is dying?” The interview also included questions about education, professional experience, and the frequency with which participants provide end-of-life care. Interviews were audiotape recorded, transcribed, and analyzed using grounded theory techniques. Descriptive statistics were used to provide demographic data. Results: Nursing home staff members identified physical, behavioral, and social indicators of an approaching death. Comfort care is the interrelationship between: (1) symptom management (e.g., pain, dyspnea, anorexia, and dry mouth), (2) family care (e.g. emotional support, death education), (3) interpersonal relationships (e.g., with residents, family) and, (4) complementarity between interdisciplinary roles. Comfort care is holistic and person-centered focusing on the interrelationship between physical, psychosocial, and spiritual issues. Conclusion: The terms comfort measures and comfort care are widely used in nursing homes but definitions and modes of delivery vary. In-depth exploration can be utilized to compare of current and existing practices and contribute knowledge about whether palliative care is provided in nursing homes and if so, how. Ultimately program comparisons can lead to improvements in nursing home-based end-of-life care and standards for the delivery of palliative care in this setting.