Perceptions of successful aging and good death among older adults facing the end of life in a skilled nursing facility

Most human beings experience aging. This is a natural and universal part of life. The question of what is successful aging, however, is a matter of debate amongst gerontologists. Recent definitions of successful aging have been based on aging populations with preserved functional and cognitive abilities. As such, these may not be applicable to the current aging population; whereas medical and other technological advancements prolong life, these advancements have resulted in a population which is much older and sicker than past generations. This population faces new and complex challenges at old age.

The current research addresses the perceptions of successful aging and good death, among older adults residing in skilled nursing facilities. Compared to other aging populations, this subpopulation has a poor functional and health status, and in most instances death is expected in the near future.

Death, as well as aging, is an integral part of life. There is a dissonance in the way western society responds to death. On the one hand, people react to death with anxiety, avoidance and exclusion of the dying, but on the other hand, people actively attempt to improve the remaining days of the dying patients, by focusing on their quality of life and introducing the ideas of palliative care. Although many studies have attempted to understand what good death is, published data refers mainly to younger patients, or those older adults who are well enough to be at home.

The present study evaluates how patients in skilled nursing facilities, who suffer from significant functional and cognitive impairments, define their aging experiences as well as their near death experiences and whether these are defined in terms of successful aging or good death. In the current research, a qualitative design was employed, conducting in-depth semi-structured interviews. The choice of a qualitative method enables the reader to hear the voices and be exposed to the unique perceptions held by this often neglected population. A set of predetermined open ended questions was composed based on a literature review, exploring quality of life, perceptions of successful aging and good death, and involvement in decision making.

The study population included 15 participants, aged 70 or older, and admitted in a skilled nursing facility. All suffered from life-threatening or chronic progressive illnesses, and were offered to participate by staff member who considered them to have adequate cognitive abilities. The interviews were conducted by the researcher, and were subsequently recorded and transcribed. Data analysis was conducted according to Miles and Huberman's approach (Miles & Huberman, 1994).

The interviews were analyzed and three key themes emerged; the first concerned the coping mechanisms used by the participants in light of their eminent death; the second was aging, and how it is experienced in terms of physical changes; and the third key theme was voicing wishes regarding end-of-life care. The theme ranged from expressing wishes about nursing care required due to their functional decline, through treatment options and even withholding life-prolonging therapies. Four prototypes of patients were introduced according to the latter two themes: The Submissive, The Warrior, The Optimistic, And the Waiting for the End.

The Warrior prototype doesn't accept as a given the aging process, and uses humor to deal with it. He insists on his ways and makes sure his wishes will be accepted by the treating team. The optimistic prototype has a more positive outlook on aging, and is active in the decision - making process on ward. Unlike them, the Submissive prototype associates aging with negative and pessimistic feelings including shamefulness, depression, and others. His relation with the treatment team is characterized by obedience and attempt to avoid conflict. Finally the Waiting for the End prototype perceives aging in terms of dependence on others. He is disappointed his voice isn't heard by the treatment team. 

The present research, which focuses on the elderly population in skilled nursing facilities, highlights the unique features in their perception of aging and death. It demonstrates the importance of conducting an open conversation regarding these issues. Discussion of expectations, priorities and concerns will enable defining more accurately treatment goals and better design treatment according to individual needs and preferences. The study reinforces the carers' roles in enabling such a discussion and the importance of reaching out to patients and families by inviting them to share their concerns and wishes regarding end-of-life care. This may help overcome the fear and silence surrounding the subject.