Palliative (farewell) culture in shared housing arrangements

At the end of 2021 there were around 4.6 million people in need of care in Germany, almost 81% of whom were cared for at home [18]. Home care is maintained for a long time. Haumann showed that this setting is preferred when care is needed [6] and 20% of those surveyed could imagine moving into a shared housing arrangement (SHA) if their care needs increased. Only 5% would consider moving into a long-term care facility (LTCF). The reasons for moving into an LTCF or another form of assisted living include increasing age, progressive dementia and increasing care needs. In addition to these personal factors that influence the decision to move, there is a growing burden on relatives and the challenge for them to provide rising levels of care. The onset of neuropsychiatric symptoms, a deterioration in general health, and polymedication are additional factors [1, 17, 23].

The LTCFs are the most common places of relocation in Germany when care dependency arises. Alternative forms of housing still do not appear in the national statistics, although these have been promoted in Germany for years [3, 15]. Klie et al. estimated that around 3100 SHA exist in Germany [12]. The fundamental principles of SHA are autonomy and participation in an everyday living environment, including security and normality for the people living there [4, 5, 11, 12]. The target group of alternative living places, such as SHA, are care-dependent people and those with cognitive decline or dementia [2, 26]. From a professional point of view, it is evident when a person moves into a SHA that this move is usually the last and the final phase of life begins, even if this cannot be precisely determined in terms of time [14, 19].

Kojer and Heimerl [13] showed that the oldest and most care-dependent people are worthy of palliative care and should benefit from palliative care as well. A palliative culture within organizations has been mainly considered in nursing homes and development processes have been initiated [7, 22]. Studies in SHA consider death and dying exploratively or descriptively from the perspective of different actors [21, 25]. The people living in SHA, the interaction with all actors, and the simultaneous “guest status” of the nursing service raise questions about how death and dying are dealt with and the attitude towards death and dying in this form of living [12]. A palliative culture integrated into the daily life of care-dependent people seems necessary as a basis for life in SHA. How professional nurses practice this culture is the subject of this article. It is about a practiced palliative (farewell) culture.

This qualitative study aimed to identify, analyze, and subsequently reconstruct everyday professional knowledge and professional nurses’ collective patterns of action as a group. The guiding research question was: “to what extent do SHA enable a palliative (farewell) culture in everyday nursing practice?”

The research-based interest lies in different forms of everyday knowledge and the conditions for the actors. Everyday knowledge is embedded in specific contexts, is therefore indexical and can only be understood in a situation-dependant context. Applying the documentary method according to Bohnsack enables exploration of the relevant systems of the groups involved [20]. The practice of nurses in SHA is reconstructed [9]. Care services that started providing care in SHA by 2014 at the latest were included. They were also asked to have experience in dealing with death and dying to be able to be involved in the discussion. The relevant care services were taken from a list of SHA in Bavaria from 2017. A total of 11 outpatient Bavarian care services were contacted in December 2017 with a personal letter, including the information letter and the informed consent for the study. After 1–2 weeks, a telephone inquiry was made, and further verbal explanations were given in response to queries from the care services. Convenience sampling was used. In total, six nurses and nurse assistants from two care services in three SHA were recruited for the group discussions at the beginning of 2018. The group discussions took place on site and were recorded using a recording device. Written consent was obtained for participation. The guided interviews were conducted by CW. The guiding was based on the current literature, and consultation with an initiator of SHA regarding its relevance for nurses was undertaken [5, 12, 21]. In addition, two pilot interviews with experienced nurses from nursing homes and palliative care units supplemented the preparation to ensure the necessary structure while maintaining the greatest possible openness and flexibility [20]. After each group discussion, CW prepared a postscript to record the situational context [16]. The individual group discussions were transcribed in MAXQDA version 12 (Verbi Software GmbH, Berlin, Germany), which the researcher (CW) anonymized [20]. Data analysis was based on the documentary method [9]. At the beginning of the analysis, the thematic course of the discussion was worked out. A formulating interpretation for the presentation of the thematic sequence and the structuring of the content aspects followed. In the third step, data analysis was directed from “what was said” to “how it was said”. The formal structure was reconstructed, making different orientations of participating nurses visible and enabling homologies to be sought both within and outside the case [9]. The researcher conducting the study (CW) has many years of experience as a nursing professional and a nurse educator. Information on the researcher was given when requested in the information and clarification letter. One person (CW) analyzed the data and discussed them with others during the colloquia in the master’s program and with the supervisor. The consolidated criteria for reporting qualitative research (COREQ) formed the basis for preparing the article [24].

The central orientations reconstructed from the group discussions are presented to initiate a conversation about palliative (farewell) culture.

Both participating care services have been working in SHA since they were established. In one care service, the nurses work only in the SHA; in the other, they also work in the outpatient sector outside the SHA. Due to illness, only two people took part in the group discussion in Care Service 1 and four people were involved in the group discussion in Care Service 2. All participating persons’ professional experience working in SHA was between 9 months and 7 years. Table 1 shows the participating nurses with their qualifications. Group discussion 1 lasted 40 min and 17 s; the second group discussion lasted 51 min and 13 s.

Nurses in SHA are generally open to a palliative (farewell) culture, practice it, and constantly develop it further. This is based on the fundamental principles of SHA “autonomy”, “participation”, and “normality”, which aim to enable life until the end [11]. From the nurses’ perspective, relatives and GPs are relevant for implementing a palliative (farewell) culture. Relatives can act as co-players and opponents, depending on whether the collaboration is successful. Collaboration relies on the presence of relatives, the relationship between relatives and nurses, and their different perspectives. This is also shown by Reitinger et al., who see communication and relationship building with relatives as a challenge [21]. Relatives, therefore, feel left alone with the responsibility [21]. If this feeling is shared with passively acting nurses, this can challenge cooperation even more. An insufficiently clarified assumption of responsibility may exacerbate the distance to the relatives described in the study. The results of the existing studies, therefore, coincide here, and the findings of this study can deepen the organization of relationships and communication based on the orientations presented. A longer dying phase makes it easier for nurses and relatives to exchange information and prepare for it together. Similar results concerning good cooperation with other stakeholders were found in another study [25]. The collaboration with GPs is perceived as positive. From the nurses’ point of view, the care options in SHA provide the necessary proximity to provide palliative care as the only care service in normal dying processes. The hospice service or the palliative care team are therefore not included, although they are well known [25]. In contrast, Worch et al. recommended increased cooperation with hospice services in their longitudinal study [27]. The hospital as an opponent was not explicitly presented, as this perception of nurses was only clearly expressed in one group; however, the nurses’ statements reflected the results of the other two studies, and there appears to be barely improved cooperation [21, 25].

Volunteering, an essential form of support in SHA, was not mentioned in either of the two group discussions [12]. The need for early communication becomes apparent in the cooperation between the various players in the palliative (farewell) culture. Living wills as an option for self-determination are viewed ambivalently. While in one SHA, it is mandatory to present a living will when moving in, the other care service states that these are rarely available but even if they are available their validity is doubted and communication with relatives is used instead. This corresponds to the “dialogue-based decision-making” (p. 896) that patients want, as they do not see the living will as a definitive document [10]. Despite this positive attitude of nurses toward the palliative (farewell) culture, it is visible that a structured approach in the sense of advance care planning has not (yet) started [8].