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The influence of long-term care culture on awareness of impending death Open Access


Other title
long-term care facility
nursing home
end-of-life care
advanced old age
palliative care
Type of item
Degree grantor
University of Alberta
Author or creator
Cable-Williams, Beryl
Supervisor and department
Wilson, Donna (Nursing)
Examining committee member and department
Keating, Norah (Human Ecology)
Kovacs-Burns, Katherina (Health Sciences Council)
Froggatt, Katherine (University of Lancaster, Faculty of Health and Medicine)
Ross, Carolyn (Nursing)
Strain, Laurel (Sociology)
Faculty of Nursing

Date accepted
Graduation date
Doctor of Philosophy
Degree level
Despite their proximity to death because of advanced old age and disability necessitating institutionalization, the oldest-old have rarely been the recipients of a comprehensive palliative approach to care or the focus of palliative care research. This lack has been attributed prognostic uncertainty in the context of chronic progressive diseases and poor resident-to-staff ratios. Research has not been undertaken to examine the influence of beliefs and values about dying and death, or contextual factors on the end-of life care provided there. This research study addresses this gap using a two-stage mixed methods approach. In the first stage, all LTC residents who died over a 12 month period in three LTC facilities were described based on a review of decedent records. In the second stage, ethnographic methods were used to uncover cultural influences on the development of an awareness of impending death. Sixty-eight percent of deaths were of the oldest old, and 63.1% were of women. Advance directives had been completed for 97.3% of the 182 decedents. Ninety percent of deaths occurred in the LTC facility. Death was most commonly attributed to dementia and pneumonia, or other progressive, chronic conditions. Impending death was identified it seemed certain that death would occur within a few days or hours. Thematic analysis of the ethnographic data revealed that a generalized awareness of human mortality was maintained until within a few days of death. Clinical awareness of impending death was acknowledged when significant changes in the dying resident’s status necessitated a change in care routines. Four themes related to the influence of LTC culture on awareness of impending death were identified: (a) the belief that LTC facilities are places for living, not for dying, (b) the context of limited resources (c) the belief that that no one should die alone, and (d) the belief that no one should die in pain. This report concludes with a discussion of the findings of this research study in relation to the existing discourse on LTC facilities as places for living, and the absence of a palliative care discourse that is appropriate in the context of age-related frailty.
License granted by Beryl Cable-Williams ( on 2011-09-30T15:46:31Z (GMT): Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. Where the thesis is converted to, or otherwise made available in digital form, the University of Alberta will advise potential users of the thesis of the above terms. The author reserves all other publication and other rights in association with the copyright in the thesis, and except as herein provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.
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