Nancy Barnes: When death comes without dignity

Glenn Howatt, a data editor on our investigative team, has a rather morbid task: combing through death certificates. He looks for patterns that might lead to a story, such as drug overdoses or medical errors. He started to notice a number of deaths related to falls by patients in nursing homes, and eventually he decided to count them up. What he found was startling: more than 1,000 deaths related to falls in Minnesota nursing homes over the six-year period he analyzed.

That discovery was the genesis for a series of stories, starting today, exploring why so many people fall to (eventual) death in these homes. I urge our readers not to look away, despite the distressing nature of these stories. Nothing is more certain in life than death; we can only hope that we will be allowed the gift of dignity. In many of these stories, that is simply not the case.

As we worked on these stories these last several months, editors and reporters would literally shudder at some of the examples we had uncovered. Our minds would quickly flash forward to what would be in store for us when we grew old. Does anyone want to imagine being 90 years old, alone at night in a nursing home, struggling to get to the bathroom when no one is around to help?

Howatt, along with reporter Pam Louwagie and their editor, Kate Parry, spent several months tracking down the families of those who had died from falls, exploring the conditions that led to an individual death, and talking to nursing homes in the hopes of explaining why so many of the elderly die in such a painful manner.

Make no mistake: This is a complicated issue for both nursing homes and the families of loved ones. As journalists, our goal is not to assign guilt but to illuminate. If we can understand exactly what is happening to these residents and why, we might also be able to shed light on solutions.

One thing that became clear from the reporting, Louwagie said, was how quickly the stability of a nursing home resident can change, "how one little incident can lead to the end." But in many cases, the reporters said, families were reluctant to talk about the details that led to a fatal fall. Some patients had dementia and couldn't tell their stories. Some family members felt guilty for putting a family member in a home, or were quietly relieved that their family member's suffering was over. "We picked up on how many families feel guilty; they fear that had they been there, things might have been different," Howatt said.

Sometimes, the patients themselves recognize what a fall will mean to their quality of life. On one death certificate, the doctor noted that his patient "strongly requests let me die after pelvic fracture." That patient, who broke her hip after she was unattended in her room, ultimately died from dehydration and malnutrition because she refused food and fluids.

The reporters also discovered some clear trouble spots: Reporters talked to nursing home aides who were at wit's end trying to keep up with the needs of their patients; to children who couldn't get a straight answer about how their parents had died, and to nursing home advocates who asked whether we just wanted them to tie up old people to make sure they don't hurt themselves. (Of course not.)

In the end, however, the answers we found were less than satisfactory. The nursing homes' internal investigations are private, and the state does not require a complete review of every death by fall. Without that broader picture, it can be hard for nursing homes as an industry to identify patterns in order to understand how to best address this situation. "With so few being fully investigated by regulators," Howatt said, "we don't know the circumstances, and, in essence, the nursing home industry cannot learn from others' mistakes."

The reporters have some advice for those who are in need of care for a family member: Check out the home ahead of time; talk to other family members, and observe what is happening when no one knows you are there. Be involved in the plan for care. "I've heard again and again," said Louwagie, "that people who have loved ones there, and involved, get better care."

Meanwhile, we should all ask the question: Is this the dignified end we would want for ourselves?