Social regulation activities in end-of-life: a qualitative study on completion of advance directives in Swiss nursing homes.

BACKGROUND: In Switzerland as in many countries, steady trend is observed in nursing homes to promote writing of advanced directives (ADs). Implementation of ADs reflects the rise in public concern for the persons' right to self-determination and informed decision. The issue of end-of-life conditions is particularly acute in situations with dementia. This article investigates how ADs interventions in nursing homes strive simultaneously to behave in line with the principles of care ethics and with the intention to respond to legally binding instructions. Healthcare to dying residents with dementia in nursing homes is interpreted in light of the Regulation theory. METHODS: Nursing home palliative care reference nurses were contacted through questionnaire. One hundred twenty-one addresses were reached, 69 responses were collected, giving a response rate of 57%. In order to deepen the understanding, 10 semi-directive interviews were conducted in 10 different nursing facilities with 12 palliative nurses. RESULTS: Presently, Swiss nursing homes are lacking a model of AD suitable to people with dementia. The study sheds light on dissimilarities in the purpose assigned to ADs' procedure in the different facilities. Discrepancies in end-of-life care practices reveal more the influence of structural and organisational devices specific to each setting than conflicting views on end-of-life care principles. We analyse the interpretation of the Law and its implementation in the participating NHs as compromises that could be accounted for as a form of social regulation. CONCLUSION: Dementia accentuates the uncertainty inherent to end-of-life trajectories. The implementation of standardised procedures aimed at collecting the wishes of the person deprived of his or her discernment is source of dissonances with regard to the multiple interests involved in these care situations. In this context, the drafting of ADs during end-of-life care in NH correspond to new normative constraints requiring new collective regulation actions.

[Risk in the elderly home dwelling: a relational object]. / Le risque chez les personnes âgées à domicile: un objet relationnel.

Risk is an unavoidable "partner" of the life course for single home dwelling elderly, especially in the older age. The primary concerned person is not the only one to make decisions, his/her proxy and the community care professionals are also involved. Crisscrossing the point of view of these three types of actors with the same situation shows that risk is a notion which has to be problematized. Due to the large part of underlying life principles its understanding can't easily be objectified nor easy to reach by consensus. The three case studies presented suggest a dynamic grid of interpretation for an approach of risk concept.