Although the average length of stay in Australian nursing homes is less than one year, a significant number of residents remain more than five years, forming a core of long-term residents. Where there is also a stable staff, the death of a long-term resident may mark the end of many significant relationships. Should all deaths in the nursing home be treated with equal significance? Are there some residents whose deaths have a greater impact than others? As in the wider community do some residents command respect commensurate with their standing in the nursing home community? Each nursing home will have unique stories about the impact of the deaths of long-term residents. We dedicate this chapter to one of our loved and respected long-termers, a woman of 99 years, our oldest resident at that time, whose influence was of great significance to staff. Her real name is used with permission of her next of kin.
Ita was a proud spinster (‘MissIta English, if you please. I have never married nor have I regretted it’), cultured, whimsical, forthright, perceptive and astute. Clipped and precise in her enunciation, Ita was increasingly outraged by the decline in the English vocabulary. A wonderful storyteller, intensely devoted to the memory of her family, Ita would enchant us with tales of her schooldays and youth in a small rural community. It had not been easy for Ita to take the very big step from independent living to the nursing home. However, always philosophical as well as practical, when she had outlived all her relatives and close friends, when her physical disabilities increased, Ita decided there was nothing to be done but to ‘put myself in a home’.
Reluctant to give up her independence, she was admitted initially for a trial period.
Recalling the lives and deaths of many residents in her care, the charge nurse wrote at the time of Ita’s death:
Grey hair swept up into a carefully secured crown Ita reigned as the ‘Grand Old Lady’ of the nursing home for over 11 years. Her mind alert and her memory recall remarkable, she was acutely observant and her tongue could be razor sharp if she considered criticism necessary. Although she did not leave her room for the last four years of her life, she always knew before 9 a.m. who was doing the cooking for the day. There would always be someone talking to Ita as she was so prepared to share the experiences of her long life and her interest in the outside world. Conversations with me would always begin, ‘My dear, did you know…?’ In a discussion about her age Ita said, ‘My dear, I have lived through the reigns of six monarchs’ and then proceeded to list them all, noting the list included ‘Edward, the uncrowned King’. When Ita celebrated her 99th birthday she was proud to sit up in bed and have residents and staff sing ‘Happy Birthday’ and share her cake with them. After this day Ita was able to tell people she was in her 100th year but she considered that she had lived long enough. When asked to what she attributed her long life she replied: ‘Good, clean, simple living and a belief in God.’ Ita said her prayers every night and would often tell me who she had prayed for. Her nightly prayer went something like this; ‘Thank you God for today, and may I walk with you tomorrow.’ Ita was in full control of her life right up until the hour she died, six weeks after her 99th birthday.
Being in control meant knowing every staff member by name. Many, many members of staff found their way into Ita’s corner in the very end room to share news of a birthday, an engagement, a broken romance or to confide work pressures.
As with any true confidante, Ita would never disclose those secrets, except to advise the director of nursing that various staff members were on her mind and in her prayers. Another measure of control was to ensure that not one item of her personal possessions was ever moved without permission. Hence, the walking frame, not used for four years, remained by the bed, finally being removed only after thorough consultation. A further example of Ita’s autonomy (and perhaps a contributing factor towards her longevity!) was her hair care. No member of staff could ever remember Ita’s hair being washed. ‘It’s not dirty so why wash it!’ Thorough, daily brushing ensured Ita’s hair retained its shine, length and thickness until the day of her death.
In her many philosophical conversations about life and death, Ita was quite clear that she had lived long enough. Much to the chagrin of the staff Ita had decided she would not be around for her 100th birthday; she had no desire to fulfil other people’s desire for publicity, drama and celebration. Sensing our disappointment she was, nevertheless, quite determined. Perhaps she also knew that the gastric ulcer she had ‘grown to accept as one of life’s constant companions’ would end her life.
On the day the ulcer finally eroded, Ita refused to regard it as a cause for panic or undue disturbance. Word spread quickly through the nursing home and one by one staff came to say their goodbyes in many and various ways. For one special nurse, in clear and firm voice, Ita recited part of her favourite poem: ‘Oft, in the stilly night,/
Ere slumber’s chain hath bound me’.
Staff offered Ita the calm reassurance they knew she would appreciate: ‘Ita, it’s Ruth.
I’ll be on till nine o’clock.’ Flowers arrived not the impersonal arrangements delivered by outsiders but jonquils from the laundry staff ’s home garden, a posy picked from the nursing home garden and daphne from another staff member. One nurse who had known Ita for nearly 11 years ‘I started four days after Ita came here so I’ve known her all that time’ came for a final visit. Staff who had known Ita for a much shorter time or not at all personally, also came to pay tribute and express solidarity: the new occupational therapist, the ground-floor charge nurse and those who were going off duty. Others stayed away only because their sadness was too much to bear, or they didn’t know what to say.
While many days in the life of a nursing home are predictably routine, there are others where chaos reigns supreme. This was one of those days: staff shortages, another resident requiring immediate hospitalisation, doctors coming at inconvenient times, no volunteer available to sit with Ita and no staff member to spare. Amid the flurry someone checked with Ita about her desire to see the priest. When Father Coster arrived from the other side of town with apologies for the delay, Ita’s reply was typical of her thoughtfulness for others, ‘Fancy your coming all that way’. The director of nursing, hesitant about demonstrating any favouritism amongst residents yet also mindful of a close relationship developed through daily conversations on the morning round, chose to sit with Ita for a while. No words were adequate, no words were necessary.
As Ita grew weaker her physical distress was evident. Hasty discussions were held amongst staff and with Ita’s next of kin. Should we send her to hospital? If she is haemorrhaging internally shouldn’t we arrange for a blood transfusion? Questioned about how she was feeling, and whether there was anything she needed, Ita
responded with gentle and patient stoicism, ‘It’s the pain’. Ita was told her doctor was on his way. Content with that reassurance, Ita expressed a desire for no other intervention. Staff ambivalence was evident. No-one wanted to watch Ita suffering, yet no-one wanted to see her moved. The doctor was now in regular contact by phone, for he too was distressed. She was his oldest patient and his favourite.
Caught in the dilemma of suspecting a perforated ulcer but knowing there may not be time to get her to hospital, the doctor agreed with staff that Ita would not wish to be moved. Her previous expressed wish to avoid active treatment was honoured.
Amid the flurry of activity in other areas of the nursing home, Ita’s corner retained an air of calm, a centre of peace amid anticipated climax. Ita’s charge nurse, on duty since 7 a.m., was still there at 5 p.m. trying to arrange a substitute for the regular evening nurse, who was sick, in order to ensure Ita would be surrounded by familiar faces. The ground-floor charge nurse, already busy with crises in her own area, remained long past her official going home time to show care and support for her colleagues. Offers of voluntary assistance came from night staff: ‘I could come on earlier just to sit with her’. No-one wanted a stranger to be in charge of Ita’s final nursing care. Ita, the all-knowing, counselled her charge nurse, whom she knew had been there all day. ‘You go, my dear. You’ve already done more than enough.’ After a quick consultation with Ita, her two close friends, staff and doctor it was decided sufficient morphine should be given to maintain her comfort, including increased amounts in the event of haemorrhage. In the end, the disease process took its course;
a philosophy espoused by Ita. She did not want to live to be 100.
As Ita lived, so she died in full control of her surroundings, able to make decisions and, as always, thoughtful and considerate of others. Nursing home life must always go on. However, it was a very subdued atmosphere that pervaded this community the following day as staff, residents and their relatives heard the news.
One nurse spoke for us all, ‘It will take someone very special to fill that bed.’