Relationship between birthday and deathday in the institutionalized elderly.

To identify a facet of death prediction with the subsequent prevention of premature deaths was the underlying motivator of this study. Previous samples from the general population give credence to individuals for their will to live until a significant event occurs. One such event is the birthday with an associated dip in the numbers of deaths in the quarter pre-birthday and a rise in the quarter post-birthday. The celebration of the birthday signifies a ceremony which unifies an individual to the society in which the person belongs. Because 20% of the population aged 55 and older were found to die while residing in a Nursing; home the death-dipâ€"death-rise phenomenon surrounding the birthday, and the Nursing; home as a promoter of an intact society were the specific interests of this investigator. The study focused on 173 elderly subjects who died while residing in one of two long term care facilities. Most subjects were Caucasian, Christian, and widowed, with a mean age of 83. In this descriptive ex post facto study the hypothesis, this stated that the death-day in the group of institutionalized, would occur with greater frequency in the quarter following the birthday, and was not supported. Findings in Facility 1 showed a death-dip in the quarter prior to the birthday. Both Facility 1 and Facility 2 had the greatest frequency of deaths occurring in the second quarter after the birthday. The dip-rise phenomenon surrounding the birthday was found for those subjects who had a previous acute hospital admission. There were fewer admissions (18%) to the hospital in the quarter pre-birthday with the greatest frequency of admissions (30%) in the quarter post-birthday. Another incidence was the greatest number of deaths occurring on Sunday with the speculation that in the long term care facility, Sunday as the most frequent day for visitation, was personally significant to most individuals. Implications for all care providers in the long term care facility to promote the celebration of individually significant events may contribute to the maintenance of dignity and control in the elderly patient as well as the prevention of premature death.

RELATIONSHIP BETWEEN BIRTHDAY AND DEATHDAY IN THE INSTITUTIONALIZED ELDERLY by Margaret Susan Fewkes A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah August 1982 © 1982 MARGARET SUSAN FEWKES All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis ~ubmitted by Margaret Susan Fewkes This thesis has been read by each member of the following supervisory committee and by majority vote has been found to be satisfactory. j) f)/A;H~ Chainnan: M~Dimond, R.N., Ph.D. 3 ~ J'i8t . , Kath~~.tff. Charles C. Hughes, .. THE UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of The University of Utah: I have read the thesis of Margaret Susan Fewkes in its final form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate School. Ph.D. Member. Supervisory Committee Approved for the Major Department Linda K. Amos, Ed.D., F.A.A.N. Chairman; Dean Approved for the Graduate Council ~;I ;:arne; /L(1. . cIaY~OIl:Ph .D . Dean of The Graduate School ABSTRACT To identify a facet of death prediction with the sub­sequent prevention of premature deaths was the underlying motivator of this study. Previous samples from the gen­eral population give credence to individuals for their will to live until a significant event occurs. One such event is the birthday with an associated dip in the num­ber of deaths in the quarter prebirthday and a rise in the quarter postbirthday. The celebration of the birth­day signifies a ceremony which unifies an individual to the society in which the person belongs. Because 20% of the population aged 55 and older were found to die while residing in a nursing home the death-dip--death-rise phe­nomenon surrounding the birthday, and the nursing home as a promoter of an intact society were the specific inter­ests of this investigator. The study focused on 173 elderly subjects who died while residing in one of two long term care facilities. Most subjects were Caucasian, Christian, and widowed, with a mean age of 83. In this descriptive ex post facto study the hypoth­esis, which stated that the deathday in the group of in­stitutionalized elderly would occur with greater fre- quency in the quarter following the birthday, was not supported. Findings in Facility 1 showed a death-dip in the quarter prior to the birthday. Both Facility 1 and Facility 2 had the greatest frequency of deaths occurring in the second quarter after the birthday. The dip-rise phenomenon surrounding the birthday was found for those subjects who had a previous acute hospital admission. There were fewer admissions (18%) to the hos­pital in the quarter prebirthday with the greatest fre­quency of admissions (30%) in the quarter postbirthday. Another incidence was the greatest number of deaths occurring on Sunday with the speculation that in the long term care facility, Sunday as the most frequent day for visitation, was personally significant to most individ­uals. Implications for all care providers in the long term care facility to promote the celebration of individually significant events may contribute to the retainment of dignity and control in the elderly patient as well as the prevention of a premature death. v CONTENTS ABSTRACT . . . . . . . . . . . . . . . iv LIST OF TABLES AND FIGURES ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . vii . viii Chapter I. INTRODUCTION AND REVIEW OF LITERATURE. 1 II. III. Introduction . . . . . . . . . . . . . . .. 1 Problem Statement . . . . . . . . . . . .. 3 Literature Review: Conceptual Framework 3 Literature Review: Clinical Implications 12 Hypothesis and Research Question . . . . 15 Assumptions and Limitations . . . . . . 16 Rationale and Significance of the Study 16 DESIGN OF THE STUDY . Design . . Setting Population . Sample . . Operational Definitions Instruments . . . . . . Data Collection Procedures RESULTS AND DISCUSSION 20 20 20 22 22 22 24 26 27 IV. SUMMARY AND IMPLICATIONS FOR NURSING 47 APPENDIX: DATA COLLECTION TOOL . 54 REFERENCES 56 LIST OF TABLES Table 1 Summary of Descriptive Characteristics of Study S a.Inp 1 e . . . . . . .. ......... 28 2 Quarter in which Subjects Die Following Birthday . . . . . .. ..... 30 3 Quarter in which Subjects are Hospitalized Following Birthday . . . . 32 4 Correlations Between Age and Selected Variables 34 5 Relationship Between Facilities Concerning Positive Orientation . . .. .... 36 6 Characteristics of Study Sample for Frequency of Visits and Length of Stay 38 7 Major Causes of Death . . 8 Death Rate by Month and Quarter . 9 Monthly Census 39 41 42 ACKNOWLEDGMENTS Time is a precious commodity. To the persons who shared part of their lives with me in an endeavor to perpetuate the power in learning, a significant debt is owed. This group of individuals includes my committee members Margaret Dimond, Kathleen King, and Charles Hughes who believed in the final draft; Georgine Burke whose guidance in the research process was immeasurable; the anonymous facilities whose stimulating generosities - provided the ability to proceed beyond the data collec-tion process; the elderly individuals who let me borrow for a time their final story; and my friends and family who survived. ) CHAPTER I INTRODUCTION AND REVIEW OF LITERATURE Introduction One of man's greatest fears is death. Explanations for this fear of death include its unpredictable and in­evitable nature (Kubler-Ross, 1975). Clearly, to be able to identify a facet of death prediction, with the possi­bility of preventing a premature death, has enlightening implications. Investigators citing variables affecting longevity and physical health refer to the biological, sociological, and psychological sciences~ For example, biological vari­ables point to the family health history and behavioral habits including exercise regimen, tobacco and/or alcohol use, and dietary intake. Sociological variables are fa­milial and environmental influences, marital and economic status, occupation, and level of education (Schulz, 1978). A psychological variable is the accumulation of unde.sir­able life events, e.g., divorce or death of a spouse (Thoits, 1981). A 19th century physician, Daniel Hack Tuke, as relat­ed by Weiss (1972), countered skeptics who believed that "no state of mind ever affected the humors of the hlood" 2 (p. 104). Tuke further states: We have seen that the influence of the mind upon the body is no transient power, that in health it may ex­alt the sensory functions, or suspend them altogeth­er; excite the nervous system so as to cause the var­ious forms of convulsive action of the voluntary mus­cles, or to depress it so as to render them power­less; may stimulate or paralyze the muscles of or­ganic life, and the processes of Nutrition and Se­cretion- causing even death; that in disease it may restore the functions which it takes away in health, reinervating the sensory and motor nervous power, and,assisting the vis medicatrix Naturae to throw o,ff disease action, or absorb morbid deposi ts . (p . 104) Since the date of this statement studies have advanced the indications that psychological variables affect longevity. These variables present opportunities for intervention. A high risk group facing and having experienced many psychological changes are elderly people. Approaching death plus the possibility of relocation to an institution are both anxiety producers. The National Center for Health Statistics, as reported by Ingram and Barry (1977), es-timate that one out of five persons who died in the U.S. during 1972'aged 55 and older died while a resident of a nursing home. Although it is estimated that 5% of the aged population are nursing home residents this indicates the number of persons in nursing homes at anyone time. If one were to do a longitudinal study the 20% rate would indicate the probability of an individual spending a part of life or dying in the long term care facility. These statistics alone should be motivating factors for those 3 persons working with the elderly to become experts con­cerning the multiple variables affecting longevity. Im­plications for not only preventing a premature death but dignifying it as well are important to humanistic care of aging people. It has been suggested that one psychological vari­able affecting longevity is the ability of a person to actually postpone death until an anticipated event such as an anniversary or holiday has occurred. Phillips and Feldman (1973) examined the presence of a death peak after the date of birth in a population of mostly notable in­dividuals. The significance of a person's "will" over death becomes especially interesting in this context. This study describes the relationship between birth­day and deathday in the institutionalized elderly. Fac­tors which influence this relationsh1p are also described. Problem Statement Is birthday related to deathday in the institution­alized elderly? Will to Live Literature Review: Conceptual Framework As noted by Tuke in the 19th century it has been sug­gested that the psyche has a potentially powerful role in its influence over the body concerning disease and death. 4 Early in the 20th century a typical course of typhoid fe-ver was described by Thomas Mann (1901/1959) in Budden-brooks. When the "fever is at its height" and the patient is lingering between life and death "there may well up in him a sense of renewed energy, courage, and hope, then, however far he may have wandered on his distant path, he will turn back-and live" (p. 600). Engel (1968) and Schmale coined the "giving-up--giv-en- up" complex. They maintain that emotions do not cause the biological response of the body but do contribute to the pathological processes. Initially, they studied the occurrence of sudden death in unusual circumstances and classified each according to the psychological setting in which it occurred. Most of their population died an-ticipating the episode of the death of a loved one. The next larger group died during situations of great fear. Unusual as these circumstances were, however, they noted some similarities. One commonality in both groups was that all experienced some type of environmental change associated with a feeling of powerlessness. To advance the giving-up--given-up complex Engel (1968) and Schmale refer to their clinical practice work-ing with the forementioned individuals. They state: The total biologic economy of the organism is al­tered at times in such a way that its capability to deal with certain potentially pathogenic process­es is reduced, permitting disease to develop. (p. 298) 5 They derive five patterns surrounding illness onset. First, people experience feelings of helplessness and hopelessness. Second, individuals may have a sense of loss of control, thus affecting their self-image. Third, the person feels less satisfied with personal relation­ships. Fourth, individuals may lose a sense of continu­ity among past, present, and future. Fifth, the patient is reminded by the current situation of past experiences when he/she has felt powerless, thus invoking reminders of earlier unresolved conflicts and promoting a cumula­tive effect. This state of disequilibrium is further explored by Arsenian (1962)~ He maintains that every person has a tension threshold with specific levels causing overload or deficit. When the personal tension threshold is reached, personality disorganization occurs and restora­tion is dependent on one's internal and external support systems. One of the three major sources affecting ten­sion is loss. The elderly become particularly vulnerable to tension overload or deficit having accumulated many losses during a lifetime. Arsenian (1962) outlines dif­ferent types of loss. First, is the catastrophic loss which occurs when someone loses someone or something that was a major source of tension relief. Second, a person may experience loss in the area of a chronic insufficien­cy of basic needs and be unaware though it affects gener- 6 al personal interactions. If a person truly has a limit to what can be endured then it is possible to also lose the ability to cope resulting in "the last straw" which may "shift the life balance from hope to surrender" (Ar-senian, 1962, p. 670). Types of loss for the elderly may accumulate in var-ious areas (Arsenian, 1962; Atchley, 1980; George, L., 1980; Reichel, 1978). Generally, these are the biolog-ical, psychological, and sociological domains with the associated changes affecting self-esteem and identity, personal feelings of usefulness or utility, and slower reaction times to name a few. The will to live is a significant factor in health assessment. Review of significant events regarding the general population may be a factor in the will to live for a certain event. Significant Events Emile Durkheim (1915/1954) provided the conceptual framework for significant events and social integration. There can be no society which does not feel the need of upholding and reaffirming at regular intervals the collective ideas which make its unity and its personality. Now this moral remaking cannot be achieved except by the means of reunions, assemblies, and meetings where the individuals, being closely united to one another, reaffirm in common their com­mon sentiments; hence come ceremonies, either in their object, the results which they produce, or the processes employed to attain these results. (p. 427) An individual in his turn, if he is strongly at­tached to the society of which he is a member, feels that he is morally held to participating in its sor- 7 row and joys; not to be interested in them would be equivalent to breaking the bonds uniting him to the group; it would be renouncing all desires for it and contradicting himself. (p. 400) This statement is the basis for indications that nursing homes have the capability to continue the sentiments of society in the celebration of events. Various events have been explored which have the po-tential for a person to extend his/her life until that significant event occurs. Because a person celebrates an event within that society, it is apparent that human (psy-chological desires) and environmental (social norms) forces may affect displayed behavior. The human forces are revealed in the following: Reaching the significant event may be defined "as reaching a lifefs goal and one partially may be relieved of a sense of failure; that is, feelings of accomplishments may be important to dying people" (Labovitz, 1974, p. 218). Having a feeling of accomplishment, the older person can experience dying with dignity. Concerning social forces and social norms, the events are significant because as an individual ac-cepts these norms, Labovitz (1974) then believes that "one should have birthdays and should be happy to have them; should celebrate an anniversary; and should ac-knowledge the importance of patriotic days" (p. 218). In a review of the literature, several types of events including political, spiritual, emotional, and personal 8 anniversary events were examined. Phillips and Feldman (1973) explored a "death dip" before the political occasion of U.S. presidential elec-tions from 1904 to 1968. It was noted that people would delay their death in order to witness the outcome of the election, and it was concluded that there was a signif-icant dip in U.S. mortality before U.S. presidential elec-tions. Thomas Jefferson died on July 4, 50 years after the Declaration of Independence was signed. His physi-cian relates the following statement surrounding Jeffer-son's death (Peterson, 1970): About seven O'clock of the evening of that day, he awoke, and seeing me staying at his bedside ex­claimed, nOh Doctor, are you still there?" in a voice, however, that was husky and indistinct. He then asked, "Is it the Fourth?" to Which I replied t "It soon will be." These were the last words I heard him utter. (p. 1008) Thus, there is further evidence that timing of death is related to' significant political events. Religious holidays are considered significant events for some individuals and are often referred to as part of the "Holiday Syndrome" (Cattell, 1955). These holidays, such as Christmas and Yom Kippur, represent times usually associated with family togetherness. "They are days of recreation, in the denotative sense, physical, emotional, and spiritual, as well as times of re-evaluating one's relationship to oneself, family, and the past and future and God" (Cattell, 1955, p. 42). Depending on a person's 9 coping abilities holidays may be times of either emo­tional pleasures or painful reminiscences. Phillips and Feldman (1973) observed an associated death dip before Yom Kippur using cities with presumably a high Jewish population. Christmas was not examined since Christmas occurs on the same day each year and Yom Kippur occurs at a different date each year. This was done in order to control for the effect of seasons on mortality. A point of interest is that Freud died on Yom Kippur in 1939 (Rosenzweig 1 1970). Reports exist that the intertwining of "emotional deadlines and anniversary reactions" is significant. The "classical anniversary reaction" in this context is re­lated to , though different from the fixed date anniver­sary such as birthday_ According to Hilgard (1953) what occurs in this event is that a traumatic event 1 such as a parent's death, is experienced by an individual as a child. If the individual has children and his/her family life parallels his/her childhood such that there is a child of the same sex as the parent who experienced the traumatic event 1 then when the child reaches the age of the traumatic event the parent may experience many acute symptoms of illness and psychosis. Weiss (1958), and Fischer and Dlin (1972) have also been able to observe in their clients the illness of emotional origin with re­lation to the anniversary of a significant event. 10 The final event of concern is the fixed anniversary such as birthday_ Phillips and Feldman (1973) examined the relationship between birthday and deathday of famous people, with- the resultant data showing a death dip prior to and a death peak after the date of birth. Kunz and Summers (1979-1980) suggest that the birthday as an inte­grating event is an important event for all persons, not just famous or notable individuals. Alderson (1975) fo­cused his study between month of birth and month of death in the elderly population and found in those individuals aged 75 and older there was a 1% overall excess during the birthmonth and the 3 succeeding months indicating a significance higher than expected by chance. Using an identical analysis for 65 to 74 year olds, he found no significance. Another contribution to the study of birth­day related deaths in those individuals 75 and older was by Barraclough and Shepherd (1976). Their birthday re­lated group was less likely to be confused. Thus, the personrs orientation to time becomes significant. For example, a confused person may be able to tell you his/ her birthday, but is totally unaware of the current date. The significance of a birthday related death becomes less relevant when the person is disoriented to time. The studies concerning the birthday related to death­day have not gone without opposition. Baltes (1977-1978) examined the relationship between significant yearly 11 events and time of death of the age range 1 to 19 with­out finding any overall significance. She refers to the cognitive psychological models of development in that the "concept of time is not present in very young chil­dren and becomes differentiated not prior to the age of 10 in general, for example, in Piagetian theory" (p. 166). The most recent discrepancy was reported by Schulz and Bazerman (1980) who indicate that a more careful anal­ysis of the data is needed and that the higher mortality rates in relation to birthday lies in statistical art fact. They do not negate the significance of the impact of significant events on timing of death, however, they are asking for a closer look at the significance of cer­emonial events in favor of more important personal an­ticipated events such as the birth of a grandchild. Sev­eral conceptual questions become significant in this con­text. Schulz and Bazerman (1980) are asking for clari­fication of the "psychological processes that may under­lie such phenomena" (p. 260). Relating to the explanation that a person anticipates a significant even~, the ques­tion is what does it mean to look forward to something? Schulz and Bazerman (1980) ask, "Does a state of positive anticipation precipitate neurochemical changes that have a positive effect on health" (p. 260)? They suggest that when significant events are anticipated a behavior change occurs in the individual, resulting in the exposure of 12 decreased stress. This is the opposite effect found to occur in rats (Weiss, 1972) when they are exposed to stressors which induce neurochemical changes that pre­cipitate negative effects such as ulcers. People who are integrated in a society may exhibit a will to live until a significant event occurs in order to participate in a particular ceremony of that society. Thus, the conceptual rramework principally employed the combination of significant life e.vents and social inte­gration (Durkheim, 1915/1954) with the death-dip--death­rise phenomenon surrounding the event of birthday (Phil­lips & Feldman, 1973). Literature Review: Clinical Implications The will to live becomes especially significant when dealing with relocation of an elderly individual to an institution. Many losses follow this individual to the institution. Besides many of the biological losses al­ready experienced, a catastrophic loss such as a fall with a resultant broken hip may have occurred. For many peo­ple, the move to an institution represents personal losses such as leaving a home and precious possessions. Social losses remove them from friends. Losses of identity and utility concern the individual who is in unfamiliar sur­roundings and routines. Philosophical losses along with 13 the other losses represent questions of what is the joy in living, what is the purpose, and what is now the will to live (Arsenian, 1962)? One of the major characteristics to appear concern-ing loss is that of control loss with resultant feelings of depression, helplessness, and physical decline (Schulz, 1976). Schulz examined the concepts of both control and predictability in the institutionalized elderly. "Per-sonal control is generally defined as the ability to man-ipulate some aspect of the environment" (Schulz, 1976, p. 64). Positive effects of control have been found to be enhanced by predictability, as with the results found among rats receiving unpredictable shocks. These rats showed considerably more ulceration than the rats receiv-ing predictable shocks (Weiss, 1972). Schulz conceptualized that being visited by a friend-ly college student as a patient in an institution was a significant positive event for the control subjects who were being able to exert control over the frequency and duration of visits. Results of the study demonstrated that the predict and control groups were consistently and significantly superior on indicators of physical and psy-chological status, as well as levels of activity, than the subjects who had no control. The relevance of these findings to the process of aging is evident. This study demonstrates that the decline in physical and psychological status and lev- 14 el of activity associated with increased age can be inhibited or reversed by making a predictable or con­trollable significant positive event available to aged individuals. (Schulz, 1976, p. 572) George, L. (1980) further illuminates the loss of autonomy in connection with relocation to an institution. She points out that even the simple personal decision as what to eat is often no longer under the control of the individual. The patient is often dependent on the per-sonnel of the institution for even his/her social support and/or rewards and punishments. Phillips and Feldman (1973) suggest motives which underlie the general desire to experience a ceremony. Often rewards are associated with the "realization of an appropriate identity to a ceremonial occasion" (p. 694). Labovitz (1974) suggests that on the birthday interaction with more people may oc-cur along with receiving gifts and praise. "In short, there may be more stimuli in the ways of attention and re-wards received than on most other days" (Labovitz, 1974, p. 220). Because a person may have visits from signifi-cant others on the birthday, at those times planned, mean-ingful communication occurs and results in finalizing re-lationships, relieving guilt, and putting one's affairs in order. The person can die peacefully once unfinished business is accomplished. The individual in the institution may be emotionally starving with a progressively decreasing interest in sur- 15 viving (Lipsitt, 1969). Personnel must be alert to sub­tle changes in mood in elderly patients, and must be aware of the possibilities of self-injurious behavior in old age. Kastenbaum and Mishara (1971) list five signif­icant life threatening maneuvers. The patient may (1) refuse to take medications, (2) fail ~o follow orders of the physician, (3) smoke or drink against against medical advice, (4) refuse to eat, or more subtly, seem to accept food but ingests and retains very little, and (5) sit­uate him/herself in a hazardous environment such as near a drafty window. These are presented as warnings for personnel in the institution when more obvious self-in­jurious behaviors are not so apparent. It is necessary to understand signs of loss of a will to live in order to instigate intervention. Hypothesis and Research Question Hypothesis The deathday in the group of institutionalized el­derly will occur more frequently in the quarter following their birthday. Research Question What variables are associated with the institution­alized elderly group who exhibit deathday/birthday cor­relation? 16 Assumptions and Limitations Assumptions Assumptions underlying this study were as follows: First, that the elderly individual looks forward to his/ her birthday. Second, that the birthday given to the in­stitution was accurate. Th1rd, that death occurs with a permanent cessation of all vital functions. Fourth, that the census report listing all individuals who died was accurate. Limitations Limitations identified include the following: First, that the findings cannot be generalized beyond the sam­pling unit due to design and sample size. Second, that the medical records may not be accurate, or may be accu­rate with missing information. Third, that there are many significant events in an individual's life and birth­day is only one of those events. Some cultures may not even consider the birthday as a significant event. Rationale and S~gnificance of the Study Current studies relating deathday and birthday have focused on populations outside institutions. The ratio­nale of this study was based on the statistics that dur­ing 1972 20% of the population aged 55 and older died while a resident of a nursing home (Ingram & Barry, 1977). This investigator was interested in demonstrating that 17 the institution promotes the social norms of its commu­nity by celebrating significant events such as birthday. Realizing that other events may be more personally sig­nificant, birthday was chosen as an event that all per­sons experience. The significance of the study focused on the many facets inherent in nursing. First, a more general facet, is the accepted fact that nursing as a science is still in its fledgling years (Diers, 1979; George, J. 1980; Polit & Hungler, 1978). Second, gerontology has only recently been included in nursing education as a separate course as demanded by the increasing numbers of our elderly pop­ulation. Third, to be able to advance death prediction and contribute to the concept of death as a science for nursing curriculum means that the fear of death is eased as it becomes manageable, enabling more time to concen­trate on continued growth. Kastenbaum and Mishara (1971) advanced the concept of premature death in old age. Many standards for what con­stitutes normal birth and conditions of the neonate have been established. With these standards belongs the well accepted concept of premature birth. Included in this is the fact that our society has long placed emphasis on youth. However, with revived interest in older adults and aging, it should be understandable that the concept of premature death in old age is finding relevance. As a relatively 18 new concept it is found without criteria and definition. Nurses in hospitals and long term care facilities are frequently confronted with a dying patient. "How can we be enablers of good deaths without the guidance and mo­tivation provided by acceptable criterialt (Kastenbaum & Mishara, 1971, p. 73)? In not knowing what an appropriate death is it is harder yet to know if a premature death has occurred. These criteria will take some time to be estab­lished, but it may be safe to say that "all avoidable deaths are premature" (Kastenbaum & Mishara, 1971, p. 73). The definition of a premature death in this study refers to a person who may have died due to the lack of quality nursing care. The promotion of lifesaving .measures for the terminal patient who prefers death is not the intended meaning of preventing a premature death. Nurses are in a most advantageous position for health maintenance and disease prevention by observation and in­tervention, thus helping to avoid the premature death. These premature deaths may take place in the context of suicide, self-injurious behavior, or lack of knowledge concerning health maintenance and disease prevention. As related to this study the nurse's intervention is impor­tant. The nurse may promote the prevention of a social loss by including in the initial health history those events and methods of celebration which are personally sig­nificant to an individual. Coordination with activity 19 personnel in providing those activities should be encour­aged. Family members, nurses, social workers, volunteers, and all care providers should be involved in developing and implementing this program. To contribute to a person's dignity, respect, and consideration in continuing to celebrate events in a per­sonal manner puts our elders back in a society that has, for some, partially discarded them. Care providers in long term care facilities help determine how many of their participants will spend the rest of their lives, and should it not be spent being filled with life, continued growth, and happiness? One may be able t·o prevent a premature death by knowing what event is personally significant to an individual .and providing a predictable positive event. CHAPTER II DESIGN OF THE STUDY Design A descriptive ex post facto correlational field study design was used to explore the relationship between birth­day and deathday in the institutionalized elderly. Setting The setting for data collection included two skilled nursing home facilities in Salt Lake City, Utah. Both nursing homes were licensed to accept skilled levels of care as required by Medicare and Medicaid. To ensure the anonymity of these facilities they are referred to as Fa­cility 1 and Facility 2. The facilities were comparable in their broad range of rehabilitative services which in­cluded physical, speech, and occupational therapy_ Sig­nificant differences between the two sites included the total number of beds available which was 154 for Facility 1 and 119 for Facility 2. Facility 1 employed a master's prepared social worker (MSW) who was there daily. Fa­cility 2 employed an MSW who was there 1 to 2 times a week. Facility 1 had fewer turnovers in the recreational 21 staff than Facility 2 which was reflected in continuity of services. For example, birthdays were honored in the following manner in Facility 1: First, there was general recognition for each person's birthday with his/her name placed on a birthday list board and also placed on the general calendar for that month. These boards were post­ed in a conspicuous place. Second, ribbons were pinned to the clothing of each person in the morning of the day of his/her birthday. Third, each person received a piece of cake and a card on the day of his/her birthday. Fourth, was a general birthday party held once a month at which time each person who had a birthday that month would go to the front of the group, the group would applaud the person, and the person would say a few words. It was re­ported by staff to be a very exciting celebration for the participants. Facility 2 celebrated birthdays in the following man­ner: First, there was general recognition for each per­son's birthday with his/her name placed on a bulletin board at the beginning of the month. Second, once a month was a general celebration with. one birthday cake. These general birthday celebrations were inconsistent due to the high turnover of recreational staff. Third, up until spring 1981 each person received an individual cake on his/ her birthday. Name tags were not used on the individual's birthday. 22 P~u~tfun The population examined were elderly individuals over the age of 65 who died between October 1, 1979 and Septem­ber 30, 1981 while residing in a skilled nursing facility in Salt Lake City, Utah. A 2 year time interval was cho­sen to reflect duplication of significant patterns. Sample The convenience sample included all individuals who died at age 65 years or older while residing at two skilled nursing facilities in Salt Lake City, Utah. One subject who was 90 years old at death had no recorded birthdate and was eliminated from the study. From the total of 174 subjects the sample size consisted of 173 subjects. Those subjects who were discharged from the facility and died in the hospital were not included in the study. Operational Definitions Birthday is the date given by the patient or respon­sible party as date of birth. Whether accurate or not, it is that date the person inherently considers birthday, unless it is inaccurate due to inappropriate recording by the nursing home facility. Deathday is the date designated as date of death by nursing home personnel or physician. Death is defined in a biological sense as a permanent cessation of all vital 23 functions without the presence of a mechanical ventilator. Individuals were defined as oriented when they are accurately cognizant of time, place, and person, through medical records from combined physician, nurses, social worker, and activity director notes. Orientation clas­sification for Facility 1 was obtained from medical rec­ords with a confirmation from the social worker. The diagnosis of senile dementia, organic brain syndrome, or some derivative thereof was not classified as disoriented on diagnosis alone. Because orientation may alter prior to death, the orientation time marker was considered 2 months before deathday. Quarter was defined as a specified 3 month period. The first quarter began the day of the birthday. The fourth quarter consisted of the 3 months just prior to the birthday. Elderly were those individuals who died at age 65 years or older while residents of the institution, also referred to as patients or subjects. Institution was defined as two designated skilled nursing facilities caring for people with chronic/long term health problems, or short term rehabilitative or re­cuperative needs. Both skilled nursing facilities were licensed for Medicare and Medicaid. Medicare refers to the medical assistance provided in Title XVIII of the Social Security Act. Medicare is a health insurance pro- 24 gram administered by the Social Security Administration for persons aged 65 years and over and for disabled per­sons who are eligible for benefits. Medicaid refers to the medical assistance provided in Title XIX of the Social Security Act. Medicaid is a state administered program for the medically indigent. Skilled nursing facility re­fers to certification as a skilled nursing facility under Medicare and/or Medicaid. Instruments The data collection tool utilized was developed by this investigator (see Appendix). Clarification of the information collected refers to the corresponding item number on the data collection tool. Item 5: Refers to age at last birthday. Item 8: If the patient who re­sided at the facility was admitted to the hospital with a length of stay longer than 30 days the admission date to the long term care facility was recorded as date of readmission to the facility. Item 9: If the patient had multiple hospital admissions the first available date was recorded as date of admission to hospital and only if it was before original admission to the nursing home. A hos­pitalization which did not result in direct admission to the nursing home with a 7 day grace period was not includ­ed in this study. Item 10: Each 30 day interval was giv­en credit for 1 month length of stay in the facility. 25 Thus, 1-59 days counted as a 1 month length of stay even though it was only 1 day less than 2 months. The time interval that the patient spent in the hospital was not subtracted for length of stay in the facility. As noted previously, if the patient spent longer than 30 days in the hospital and returned to the facility the readmission date began the length of stay count. The length of stay was counted for the current facility only. The patient may have been in another facility prior to admission to Facility 1 or Facility 2. Item 11: If the patient died on his/her birthday the number of days after the birthday was counted as O. Item 13: Orientation time marker for patients at the facility for less than 2 months became the orientation noted on admission. For patients who were aphasic, orientation was evaluated on an individual basis as reflected by charting, and as was the case in Facility 1 after verbal input from the social worker. Item 17: In the case of multiple marriages the date of death of the last spouse was entered. Item 18: Step-children were in­cluded in whether the subject had living children. Item 19: If the husband/wife of the subsequently deceased spouse was also a patient in the facility, visits were counted as daily only if they actually did have visiting privileges. Visits by nursing home personnel were not considered visits by friends or family members. Item 20: Senile dementia was not included as a cause of death. "Probable" cause 26 of death was considered as cause of death. Item 21: If metastatic cancer was the disease entered as cause of death the primary site was considered the body system in­volved. If the primary site was not noted the site of metastasis was entered. Data Collection Procedures Permission was obtained from the respective nursing home administrators to use their facilities for the pur­poses of this study. Subjects were selected from a master census list in which all admissions and discharges Clive and dead) were recorded. Request for the anonymity of patients was obliged by referring to their hospital number on the data collection tool. All information gathered and coded was performed by this investigator. Medical records were obtained for study patients between October 1, 1979 and September 30, 1981. CHAPTER III RESULTS AND DISCUSSION The Statistical Package for the Social Sciences (SPSS) at the Universi ty of Uta·h Computer Center was used to analyze the data. The data analysis involved compu­tation of frequency distributions, cross-tabulations, and some correlational analysis. To discuss the findings in­corporporating both Facility 1 and Facility 2 it was nec­essary to use the! test for the statistical significance of differences between the two independent groups mean values. No significant difference was found in the vari­ables of age and length of stay between facilities. The chi-square was used for variables which were nominal lev­el in nature to determine if any statistical relationship was present. There were no significant differences be­tween facilities in sex and marital status. A description of the demographic characteristics of sample subjects are displayed in Table 1. Because the majority were Christian (89%) and Caucasian (95%) the percentage of each religious and ethnic affiliation is not shown. Of sample subjects, the greater percentage were female (55%), the mean sample age was 83 years old, most were widowed (57%), and 61% died within 6 months of Table 1 Summary of Descriptive Characteris·tics of Study Sample Sample Percent. na Range Sex: Males 45.1 78 Females 54.9 95 Age: 65-102 65-69 5.8 10 70-74 8.7 15 75-79 13.8 24 80-84 27.8 48 85-89 24.8 43 90-94 15.1 26 95-99 3.4 6 100-104 .6 1 Marital Status: Single 4.6 8 Married 30.6 53 Divorced/Sep. 6.9 12 Widowed 56.6 98 Unknown 1.2 2 Length of Stay (months) 1 day- 1 38.7 67 9.4 yrs. 2-6 22 38 6-12 5.2 9 12-24 9.3 16 24-60 17.3 30 60-120 7.5 13 ~ = 173 for each sample characteristic. 28 Mean 83 17.4 months 29 their admission to the long term care facility. Nearly 39% died within the first ·month of admission. The latter may reflect the severity of the illness or perhaps the effect of relocation. Table 2 shows the percentage of subjects who died at specific quarters surrounding their birthday. The hypoth­esis, which states that the deathday in the group of in­stitutionalized elderly will occur more frequently in the quarter following their birthday, was not supported. It is interesting to note the trend in time of deaths which occurred in Facility 1. The lowest death rate was in the quarter prior to the birthday (Quarter 4). It was noted by Phillips and Feldman (1973) that there is a statisti­cally significant death dip in the month before the birth­month. In both facilities the highest death rate was in the second quarter (3 to 6 months) after the birthday (Quarter 2). Perhaps the patient still enjoys and rem­inisces his/her birthday celebration within the 3 months after the birthday and when the effects of the celebration have lessened, the patient at that time, 3 to 6 months after the birthday, loses his/her will to live. Facility 2 showed a general death dip the quarter before (Quarter 4) and after (Quarter 1) the birthday. The relationship may be explained in part by the more consistent interest in birthday celebrations found in Facility 1 and there­fore the interest of the patient to postpone his/her death Table 2 Quarter in which Subjects Die Following Birthday Quarter Facility 1 2 3 4 % 27 31 23 19 1 (n)a (29) (34) (24) (21) % 20 35 23 22 2 (n)b (13) (23) (15) (14) 30 31 in order to celebrate that event. The research question which asks what variables are associated with the institutionalized elderly group who exhibit deathday/birthday correlation has lost signifi­cance due to the lack of support of the hypothesis. There is, however, meaningful information which can be ascer­tained in examining relationships between other variables. This investigator examined the possibility of a re­lationship between birthday and the date of admission to the hospital. If a person has the capability of post­poning his/her death surrounding a significant event would it not be possible that many people would not die but would be vulnerable to a physical illness instead and at that point be hospitalized? Because many patients in the study sample were admitted to the long term care facility without benefit of a hospitalization this resulted in the exclusion of 54 subjects. Thus, £ = 119. As shown in Table 3 the lowest percentage (18%) of patients admitted to the hospital was in the quarter before the birthday (Quarter 4). The largest percentage (30%) was in the quarter following birthday (Quarter 1). There are prob­ably multiple reasons for this occurrence. Regardless, it does indicate the birthday as a pivot point, or signif­icant event, at which time to make decisions or allow ill­ness to intervene. The Spearman Rank Correlation Coefficient was the Table 3 Quarter in which Subjects are Hospitalized Following Birthday Quarter Subjects 1 2 3 4 % 30.3 28.5 23.6 17.6 36 34 28 21 an = 119 (combined facilities). 32 33 statistic chosen to examine selected variables where one or both are measurements of at least ordinal data. It was noted that the females in the facility tend to be older r = .14, p~05, have lived in the facility longer r = .31, p5.001, are widowed ~ = .44, p~.OOl, and have been wid­owed longer ~ = .46, p<.Ol. This follows the national trend of females living longer with the resultant con­sequences. Table 4 indicates, in general, that the older the patient, the fewer number of days after the birthday· that hospitalization takes place. This may occur following a birthday celebration at which time there were urgent re­quests by family members for an evaluation of health sta­tus. The patient, knowing his/her health status was in question, may have wanted to wait until after the birth­day to avoid missing the visits he/she may have been an­ticipating. The birthday as a milestone may invoke one to action. Alderson (1975) examined the birthday/death­day correlation and could not find the consistency of death following birthday of persons aged 65 to 74, but did find consistency in those individuals 75 years and older. Another interesting trend found in Table 4 is the older the patient, the fewer the number of visits. The older the patient, generally, the longer the length of stay in the facility. The explanation for this finding suggests that friends and relatives do not feel the need to visit Table 4 Correlations Between Age and Selected Variables Variable Number of Days Per-son" is Hospitalized After Birthday Length of Stay Widowed Frequency of Visits * p<.05. ** p5· 01 . ***P5· 001 . Age n rrho 119 -.15 173 .45 171 .27 158 -.18 34 p .05* .001*** .001*** .01 ** 35 as frequently as their confidence builds in the care their loved one is receiving. Another explanation is that vis­iting on a frequent basis tends to become overwhelming when one has many other responsibilities which were over­looked during the more acute time of the patients illness. To determine if a statistical relationship exists between facilities concerning the patients orientation, the chi-square was employed since these variables are nominal in nature. Table 5 shows those individuals in each facility who were positively oriented to each of the spheres of time, place, and person. The significant dif­ference found in time and place may be attributed to meth­od of data collection. Orientation in Facility 1 was in­terpreted after verbal input from the social worker. Ori­entation in Facility 2 was gathered in chart review and left to the investigators interpretation according to findings in the chart. The charting in Facility 1 of ori­entation was more consistent. From the total sample only 68 (42%) were oriented to time. As previously noted by Barraclough and Shepherd (1976) their birthday related group was less likely to be confused. This may explain in part why the results were not significant to support the hypothesis. To interpret findings correlating ori­entation with other selected variables, this information may be helpful. There were several interesting trends concerning fre- Table 5 Relationship ,Between Facilities Concerning Positive Orientation Positive Orientation to: Facility 1 2 Timea (g) (35) (33) % 35 54 Placeb (g) (39) (37) % 39 62 Personc (~) (48) (37) % 48 62 (~) (7) (5) Unknown % 6.5 7.7 aCorrected x. 2(1) = 5.13, p~.05 bCorrected x.. 2(1) = 7.13, p$.Ol cCorrected x 2(1) = 2.48, p>.05 Total Sample (68) 42 (76) 47.2 (85) 52.8 (12) 7 36 37 quency of visits and specific characteristics of the study sample as found in Table 6. Generally, a person died few­er days after the birthday if the frequency of visits was greater. The birthday may be a more significant event when the patient expects visitors. A case could be pre­sented here in comparing the significant positive event of a visit by a friendly college student (Schulz, 1976) and the tendency for people who have a higher frequency of visitors to die closer to their birthday. Another interesting finding is that the frequency of visits increases when the person is more oriented. Gen­erally, it is more enjoyable to visit someone who knows who you are and is more congnizant of activities taking place around him/her. Persons who are widowed tend to have fewer visits. An explanation for this is the fact that those individuals who are married have spouses who visit almost daily. This means that for those people who tend to be together each day the relationship con~inues into the long term care facility. Another trend is that those who have children tend to be visited more often than those without. Again, taking into consideration that per­haps children would have more contact with their parents normally than would their parent's friends, this relation­ship would also continue into the long term care facility. Information concerning major cause of death, death rate, and day of death was gathered. Table 7 depicts the Characteristics Number of Days Person Dies After Birthday Orientation: Time Place Person Widowed Children Table 6 Characteristics of Study Sample for Frequency of Visits and Length of Stay Frequency of Visits Length of Stay na rrho E. na rrho 158 -.16 .025* 148 -.24 .002***** 162 .14 147 -.25 .001*** 161 .23 147 -.27 .001 161 .21 158 -.26 .001*** 171 .20 153 -.18 .015* an does not equal 173 due to missing information in some cases. * p5· 05 . **p<.Ol. ***p<.OOl. E. * .041** .002** .003 .005** w 00 Table 7 Major Causes of Death Disease <.!!) a %b Organ (.!!) a %b Heart Disease (30) 19.9 Lungs (47) 30.5 Cancer (27) 17.9 Heart (38) 24.7 Pneumonia (27) 17.9 Brain (32) 20.8 Infectious Process (22) 14.6 Gastro- (15) 9.7 (not incl~ pneumonia) intestinal CVA (21 ) 13.9 aSummation of n does .not equal 173 because only the major diseases and organs involved are listed. bSummation of percentage does not equal 100 because only the major diseases and organs involved are listed. tv \0 40 major causes of death and which major organs were in­volved with greatest frequency. This compares to the ma­jor causes of death in Utah for 1979 and 1980 with the leading cause being heart disease followed by malignancy, accidents, cerebrovascular disease, pulmonary disease, and pneumonia (Monthly Vital Statistic Report, 1981). The death rate by quarter shown in Table 8 follows a combined pattern of increased deaths during colder weather months and during the period between July and September, 1981. No explanation is offered for this lat­ter increase. Refer to Table 9 for census information on Facility 1 and Facility 2. Of particular note was the day of the week that most deaths occurred. Figure 1 depicts the definite trend of most deaths occurring on Sunday (18%). There are multiple explanations for this finding. There may be decreased staffing on Sunday, therefore, a person may not be as­sessed as quickly as when a full staff is available. It may be harder to find medical coverage on this day of the week. It is suggested that neither of these explanations are sufficient in that the next highest rate of death oc­curs on Friday (17%). This investigator is in favor of the anticipation of significant visits on Saturday and Sunday, and as they occur or do not occur a person can then die either in peace having settled his/her affairs, or despondent due to the lack of anticipated visitors. Table 8 Death Rate by Month and Quarter 1979 1980 Facility Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 1 % Died Monthlya 5.5 4.2 1.6 7.3 4.0 3.4 3.5 2.5 7.7 .9 .9 6.3 % Died Quarterly 11.3 14.7 13.7 8.1 2 % Died Monthlyb 3 4.1 1 0 8.7 0 2.4' 0 0 1.1 2.1 1 % Died Quarterly 8.1 8.7 2.4 4.2 1980 1981 Oct Nov Dec Jan Feb Mar Apr May Jun Jul __ A.ug ~.~ 1 % Died Monthly 2.7 8 3.4 5.1 .9 1.8 1.8 6.8 1.7 3.3 4.8 3.2 % Died Quarterly 14.1 7.8 10.3 11.3 2 % Died Monthly 5 2 4.1 4 8.7 4.6 1.2 2.2 2.1 4.2 5.4 2.2 % Died Quarterl~ 11.1 17.3 5.5 11.8 aAverage death rate per month = 11.41%. bAverage death rate per 'month = 8.63%. ~ I-L Table 9 Monthly Census 1979 1980 Facility Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 1 Mean Census 128 119 125 124 124 118 115 120 117 113 111 112 % Total 83 77 81 81 81 77 75 78 76 73 72 73 Capacity 2 Mean Census 99 98 97 94 92 82 84 88 87 93 94 98 % Total 83 82 81 79 77 69 70 74 73 78 79 82 Capacity 1980 1981 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 1 Mean Censusa 112 112 117 118 114 109 114 118 119 120 125 125 % Totalb 73 73 76 77 74 71 74 77 77 78 81 81 Capacity 2 Mean ceasusc 101 101 98 100 92 88 87 92 97 96 93 92 % Total 85 85 82 84 77 74 73 77 81 80 78 77 CaQacity aAverage monthly census = 118. bAverage % capacity = 77%. CAverage monthly census = 93. dAverage % capacity = 78%. ~ l:\j ~ cd = C» 2 .£...., C» ~ p::; ..c= ~ C» Q 15 ~ / • / , ! ' " -- --- ; '. l ; ?---'~-' . , --',, , ,I / r _I : I, .: ._ .... ;I' "" " "'". .... x---..,.. x", ,xI . X I " X "" ~x .......... " J ., .... • ••• < . " ."....,' ..•... "/ ..•... '. /. " "'" , /." ....... . '" . 'e- '.. 0. . .. / , ....0 .-.-, .:---- .'.' " , / e-----e FACILITY 1 ................... FACILITY 2 X x NATIONAL Saturday Sunday ..... , .. , .......... . Monday Tuesday Figure 1. Death rate by day of the week. Wednesday Thursday X Friday ~ W 44 Friday as the day of death may occur with greater fre­quency because this day is often considered a milestone in that another week has been conquered and can be con­sidered an accomplishment. With that knowledge a person is free to die having exhibited his/her last contribution to society. It should be noted that Facility 1 experienced a de­crease in deaths on Tuesday. One of the activities which occurred on Tuesday was that bed patients were visited and offered wine or punch. Facility 2 had a decrease in death rate on Tuesday and Thursday. This facility offered spe~ cial outings on both of these days. One would expect an approximate percentage of 14.3% of deaths for each day of the week. The Monthly Vital Statistic Report from 1978 for the year 1976 reports death percentage for each day of the week much as expected as depicted in Figure 1. Consideration must be granted for the small n of 173 compared to a 10% sample of all deaths in the United States, however, the trend exhibited in both facilities is noteworthy. During the course of data collection it was this in­vestigator's experience to find in several charts verbal­izations or experiences which occurred surrounding dif­ferent patients prior to their death. Some circumstances may reflect the severity of disease, patient intuition, and/or the lack of a will to live. 45 The first individual noted to be oriented stated on August 6, 1981, "Leave me alone I want to die. H This person died on August 9, 1981 of unknown causes. Another patient who had been looking forward to her daughter's visit from California on March 31, 1981 died April 1, 1981 after the anticipated event occurred. This patient was not noted to be dying prior to the visit. A third patient who was 102 years old on June 3, 1980 who especially en­joyed the birthday celebration died July 24, 1980. An­other individual, 94 years old, who enjoyed participating in the Heart Fund Drive Rock & Roll-a-thon and noted to be the oldest one there, died a week after that event. A fifth individual who was admitted to a facility on Oc­tober 21, 1980 and believed he was there to die, did die on November 9, 1980. Another occurrence involved three men who died within a week after celebrating Fathers Day. Normally 1.6% of this sample of men should die each week. In this case 3.9% died following this significant event. The fact that the hypothesis was not supported is significant. The greater percentage (58%) of subjects were disoriented to time. In a facility with subjects who are mostly oriented to time a different trend for birthday/ deathday correlation may possibly be observed. The fact that there was a decrease in the quarter prior to the birthday in Facility 1 suggests that patients in a long term care facility, that consistently celebrates birthdays, 46 do maintain some social norms by anticipating events and living until the particular event occurs. CHAPTER IV SUMMARY AND IMPLICATIONS FOR NURSING Patients who resided and subsequently died while in one of two skilled nursing long term care facilities in Salt Lake City, Utah served as the convenience sample for a descriptive ex post facto study on the relationship be­tween birthday and deathday in the institutionalized el­derly. Of a total population of 174 subjects aged 65 years and older who died during a specified 2 year period only one was excluded from the sample. Chart review was conducted by one investigator at which time information was gathered and coded with complete anonymity of patient and facility. Correlations between facility and specific variables were determined. It has been suggested that people may possibly post­pone their death until a significant event, such as a birthday, occurs. When people are integrated in a society they participate in ceremonies thus contributing to the unity of that society. Because a significant number of people die in nursing homes, a place reflecting its own society, it was this investigatorts interest to describe the birthday/deathday relationship in that setting. 48 The findings were reported using both descriptive and correlation analyses. The hypothesis, which states that the deathday in the group of institutionalized elderly would occur more frequently in the quarter following their birthday, was not statistically supported. However, it was discovered in Facility 1, as a facility that consis­tently celebrated birthdays, that there was a death dip in the quarter prior to the birthday. It was interesting to note that in a facility that consistently honored the social event of birthday there were more people who may have postponed their death in order to witness the in­creased praise and gifts they might expect on that day. Both facilities experienced the greatest death rise in the second quarter which was 3 to 6 months after the birth­day. Knowing that some people will not die near their birthdays but may postpone admitting to an illness until after, subjects were investigated retrospectively for those who had a recorded hospital admission prior to living in the institution. This revealed a dip in the number of hospitalizations in the quarter immediately prior to the birthday with a peak in the number of hospitalizations in the quarter immediately after the birthday. This points to the importance of the birthday as a milestone in mak­ing decisions regarding health or allowing illness to in­tervene. 49 Variables examined included orientation, length of stay in the facility, age, sex, frequency of visits by friends and/or relatives, and marital status. Some in­teresting trends found were that both people who died closer to their birthday after it occurred and those who were accurately oriented had a greater frequency of visits. The older patient usually had fewer visits. This may re­flect that the older patient is more likely to be widowed. Perhaps those with the greater frequency of visits main­tain social norms and orientation because of the more fre­quent contact with members of the community who keep them informed of current events. Information concerning major causes of death was gathered and generally comparable to the major causes of death in Utah for 1979 and 1980. The one exclusion was that accidents did not have a significant standing in this sample of subjects as cause of death. Because different events may become personally sig­nificant to people in various settings it was with par­ticular interest to note the trend in the combined facil­ities of a greater percentage of deaths occurring on Sun­day. This may reflect the goal of an event which is pe­culiar to the society of a nursing home. The event in focus is that of visiting with friends and/or relatives which most often occurs on Sunday. The patient may live until being able to experience a day that brings many re- 50 wards. Implications of these findings for nursing practice relate to the quality of care given to elderly patients. The nurse must be cognizant of and promote social norms in a facility where many people are forced to disengage. By doing this the nurse may be restoring and preventing further loss from occurring. The indications of circum­stances surrounding death allows the nurse to become more familiar with death predictors. Easing the fear of death through this information allows more time to spend with the patient in continued growth. If the nurse takes the time to develop activities surrounding those events that the patient expresses personally significant, then dignity and a sense of control by the patient may be reinforced or renewed. By providing a predictable positive event at intervals, the nurse may help prevent a premature death. It is necessary to utilize the talents of all care providers, including relatives and volunteers, in cele­brating events on an individual basis. Events may be an­nounced in various groups that the patient is involved with such as physical therapy, reality orientation, or poetry reading. Individual calendars should be kept at each bedside marked with personal events and how they will be celebrated. The patient should be able to keep track of all activities, major and minor, on the calendar in­cluding being able to schedule visitors and other care 51 providers. Many people merely say they will be coming by and never indicate the time or day. The patient is often afraid to leave the room in fear of not being found when a valued visitor arrives. Another point of intervention is in knowing when the patients' psyche can reflect biological and psychological vulnerability, such that clinicians may be able to pre-vent disease and suicide respectively. The nurse must be available for ventilation of patients' concerns. Many times the patient won't ask for time as he/she observes a busy nurse and according to Kastenbaum and Mishara (1971), "it is too risky to antagonize those powerful people upon whose goodwill one's survival seems to depend" (p. 80). Implications for the physician and the nurse are that they "may be the first, and last professional to whom an elderly person turns before he turns on himself" (p. 78). One of nursings historical researchers Florence Night-ingale (1859/1980) enlightens us with the vital importance of sound observation. It must never be lost sight of what observation is for. It is not for the sake of piling up miscel­laneous information or curious facts, but for the sake of saving life and increasing health and com­fort. (p. 103) Nurses are in a unique position to positively influence the health and well-being of institutionalized aging peo-pIe. Thus, they can help to prevent a premature death. Skills in observation, therefore, must be perfected in or- 52 der to evaluate patients changes and incorporate appro-priate interventions. Kalish (cited in Vernon, 1973) relates his thoughts in the following: Dignity, physical discomfort, and human relationships are just as important for the person with a few hours left to live as for an individual with a life expec­tancy of 50 years. Dignity is not synonymous with stoicism or quiet resignation; physical comfort is not synonymous with heavy sedation; human relation­ships do not consist of perfunctory visits from the family and cheerful falsehoods received from the hospital staff. (p. 29) Not one person should have to leave this life alone and isolated in his/her thoughts because nurses were not pur-suing their full capabilities in promoting life at its fullest potential for all individuals. Future research should be conducted concerning ex-actly which events in the institution are personally sig-nificant to those elderly individuals. When the patient is first admitted to the nursing home, important events specific to that person should be recorded, and promoted. At regular intervals the events should be reviewed and changes made in the plan of care as necessary. This may reflect two things. First, upon the death of the individ-ual a closer analysis may be focused between the person-ally significant event and the relationship to deathday. Second, is whether there is an evolution of changing in-terest in various events in relation to increased length of stay in the facility. It may reflect what social norms 53 are encouraged in the nursing home as a special part of society. Different motivators played a part in this study. One was to increase an understanding of death in the in­stitution. The other was to delve into the heart of an often separated society, the nursing home, by preventing a complete divorce from its natural spouse, the general population, through increased awareness that life should continue to its greatest potential wherever human beings are making their home. APPENDIX DATA COLLECTION TOOL Item Information Collected 1 Subject # 2 Hospital # 3 Facility 1 2 4 Sex: Male 1 Female 2 5 Age 6 Date of birth 7 Date of death 8 Date of admission to institution 9 Date of admission to hospital 10 Length of stay in facility 11 # of days after/before birthday that patient died 12 # of days after/before birthday that patient was admitted to the hospital 13 Orientation: Time 1-yes Place l-yes Person 1-yes 2-no 2-no 2-no 14 Religious preference: 1-Christian 2-Jewish 3-Eastern 5-0ther 15 Ethnicity: 1-Anglo 2-Hispanic 3-Native Amer­ican 4-Black 5-Asian 16 Marital status: 1-Single 2-Married 3-Div/Sep 4-Widowed 17 Date of death of spouse Item Information Collected 18 Living children 1-yes 19 # of visits by friends and/or family members: 5-Each day 4-Each week 3-Twice a month 2-Each month 1-Less than each month O-no visits 20 Cause of death by disease 21 Cause of death by body system 55 REFERENCES Alderson, M. Relationship between month of birth and month of death in the elderly. British Journal of Preventative and Social Medicine, 1975, 29, 151-156. Arsenian, J. Situational factors contributing to mental illness in the elderly. Geriatrics, 1962, 17, 667- 674. Atchley, R. C. The social forces in later life: An introduction to social gerontology. Belmont, Ca.: Wadsworth, 1980. Baltes, M. M. On the relationship between significant yearly events and time of death: Random or sys- , tematic distribution? Omega, 1977-1978, 8(2), 165- 172. - Barraclough, B. M. & Shepherd, D. M. Birthday blues: The association of birthday with self-inflicted death in the elderly. Acta Psychiatrica Scandina­via, 1976, 54, 146-149. Cattell, J. P. The holiday syndrome. Psychoanalytic Review, 1955, 42, 39-43. Diers, D. Research in nursing practice. Philadelphia: Lippincott, 1979. Durkheim, E. The elementary forms of the religious life (J. W. Swain, trans.). London: Allen & Unwin, 1954. (Originally published, 1915.) 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