Care in final days

It is commonly assumed that single hospital rooms ensure a good death. Think again, writes Melissa Bloomer

Over recent decades, we have seen a growing tendency for including more single rooms in hospital ward design. Single rooms are often favoured by patients, are highly sought after and rarely empty.

Infection control guidelines mandate single rooms for patients who are infectious to others or immune-compromised, and the deeply ingrained cultural norms in hospitals result in nurses also lobbying for single rooms for particular patient groups, such as those who are dying.

Australians today have an overwhelming preference to die at home, and to be cared for by family until death. But our rapidly ageing population, and the shortage of family members to take on an informal carer role, has resulted in a significant increase in the number of people who die in hospital.

Family members generally prefer hospital care as it preserves the social boundaries of personal intimacy, allowing for the delegation of care tasks to professionals.

Nevertheless, when acute hospital care is aimed at resuscitation and recovery, caring for a dying patient and their family can be challenging, not only in terms of their physiological care needs, but also in terms of the emotional and social impact that a dying patient can have on those around them. Dying has come to be regarded as a private matter and privacy is considered essential to a “good death”.

Nurses justify single rooms for dying patients based on the need for peace and privacy and because having a patient die in a shared room is distressing for the other patients. Nurses also demonstrate a strong desire to hide dying away from public view as a way of lessening any anxiety and discomfort associated with death.

In terms of privacy, one recent Australian study found that the single room did provide more visual privacy and that they were noisier as a consequence of being located adjacent to toilets, the pan room and other service areas.

Not all dying patients want to be cared for in a single room either, fearing that it could lead to isolation and a loss of identity. For many, the fear of dying alone is greater than the fear of dying itself.

When the dying person does not have family or loved ones to provide support and be with them, a sense of social support and community can come from the presence of other patients in a shared room, and being part of the activity in the shared space. When the dying patient is placed in a single room, this sense of community is lost, creating social isolation and limited opportunity for interaction with others.

Patients cared for in a single room are also at greater risk of adverse events or situations that compromise their dignity as a result of decreased visual surveillance. When a nurse is caring for patients in a shared room there is an ongoing opportunity to visually assess them throughout the shift. In a single room, however, the same is not true. The evidence also suggests that patients in single rooms get a lower proportion of care time than those in shared rooms, and that the care they do receive is associated with routine or technological care.

Another issue is that ward design sees single rooms located adjacent to each other, resulting in an allocation pattern where one nurse may be caring for several patients in separate single rooms. As mentioned, when the single rooms are filled with infectious and dying patients, this creates a heavy workload. Furthermore, irrespective of the high acuity in the single rooms, the practice is to allocate nursing staff based on the “normal patterns”, rather than patient acuity.

As the number of people dying in hospital continues to rise, single rooms will remain in demand.

Assuming that dying patients want or need a single room is short-sighted, and may not be in their best interests.

Cultural norms in the acute hospital system need to change, and the dying patient’s needs should be assessed on an individual basis, acknowledging the potential negative consequences that come with single room care. Caring for a dying patient in a single room does not ensure a dignified death and may in fact result in a lonely, frightening one.

Melissa Bloomer is a lecturer in the school of nursing and midwifery at Monash University.

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