Purpose: This study was a prospective, in-depth exploration of the experience of dying in two
nursing homes from the perspective of residents, staff, and family members.
Design and methods: A qualitative, case study design was used. Formal and informal interviews,
participant observation, and document review were the primary data collection
methods. A total of 56 declining residents were followed until death or for 6 months,
whichever occurred first.
Results: The intimate linkages between structure, process, and outcome were evident in
both nursing homes. The two homes had contrasting institutional philosophies, reflected in
staffing and environment (structure) and processes of care. Processes included different patterns
of planning, communication, and decision making. Most importantly, outcomes (residents'
satisfaction with care and quality of life while approaching death) were substantively
different.
Implications: Institutional philosophy and leadership permeate all aspects of care. A compliance-
centered, deficiency-free approach to assessing quality of care is not sufficient to address
the needs of declining residents. A client-centered philosophy that embraces "caring
for dying people," combined with integrated care planning, contributes to improved resident
outcomes.
