Background: All people have different postures while sleeping. Most people will prefer a lateral position. In the last days and hours before dying, patients are usually to be found in a supine position. In literature so far it has never been questioned whether the supine position is the most comfortable posture for every dying person and its possible consequences for the quality of dying.

Aim: To explore or hospice patients wish to be helped in their natural body posture of preference (NBPP) and whether NBPP contributes to an improvement of quality of dying.

Methods: In an explorative observational study, patients with immanent risk of dying were questioned about their favorite position during sleep. Besides they were asked whether they would like to be helped in this position in the last hours of life. After a confirmative answer, patients were assured to be nursed in their favorite posture during their final hours. To evaluate the maintenance of this promise, photographs were taken to capture the wanted position directly following the interview and directly after dying.

Findings: 14 out of 22 patients died in their NBPP; 1 person died acutely, 5 patients returned home and 2 patients were still alive at the end of inclusion. All relatives reported that seeing their beloved one dying in a familiar and comfortable posture provided support and comfort. The natural position diminished their relative’s impression of suffering dying. Nurses were positive toward helping patients in their NBPP.

Conclusions: This first explorative intervention study about NBPP provides a visualization of concrete wishes and supports the assumption that hospice patients have a need and opportunity for their unique need to be known until the moment of death. Relatives and professionals are positive about this careful personalized intervention to improve comfort in the last hours of the dying patient.

Verboeket-Crul C, Thien N, Teunissen S (2016) Natural Body Posture of Preference in the Dying Process: An Explorative Observational Study in a Hospice Setting. Arch Palliat Care 1(1): 1005.

Dying process, Hospice patients, Natural body posture of preference, Palliative care

All people have different body postures while sleeping. Most people will prefer a lateral position. In the last days and hours before dying, patients are usually to be found in supine position. After death as well, people are often placed in supine position. This attitude is in line with the Western historical and cultural notion that the supine position of a dying person expresses dignity and peace. Throughout history, dead persons pictured in paintings are lying virtually supine. In some nonWestern countries, it was traditional to die in foetal posture. Those people were also buried in this position, as can be learned from pictures in foetal position on tomb stones [1]. In literature so far, it has never been questioned whether the supine position is the most comfortable posture for every dying person and its possible consequences for the quality of dying [2]. In the Netherlands and other Western countries, the attention to position is limited to whether or not to apply alternating positions to prevent bedsores or as an intervention against rattle during the dying process [3-5].

Driven by the wish to ameliorate the quality of personalized care for dying patients, we conducted a pilot study to explore the applicability of the ‘natural body posture of preference’ during the dying process.

Keypoints

1. A lateral posture is the most preferred position for most patients.

2. Patients have a need for and the opportunity to die in their posture of preference.

3. Relatives and professionals are positive about the application of patients’ natural body posture of preference.

Design An explorative intervention study was performed from March 2015 to February 2016.

Aim

The aim of the study was to explore whether: 1. Hospice patients wish to be helped in their natural body posture of preference (NBPP) during the dying process; 2. NBPP can be realized in the dying process in hospice care; 3. NBPP contributes to an improvement of quality of dying.

Setting and population

For this study a purposive sample was performed in academic hospice Demeter in the Netherlands.

Exclusion criteria were age ≤ 18, psychiatric disorders, intellectual or cognitive impairments and language barrier. Saturation was defined as the point at which no new information or themes were observed.

Intervention

Application of the patients’ ‘natural body posture of preference’ during the dying process. NBPP is derived from the unique personal body posture during sleep (before the life threatening disease) and defined by the patient during an explorative interview and a photo session.

Data collection and measures

Data were prospectively and purposively collected from semistructured interviews by the principal investigator (PI). Patients were questioned about their trusted, ‘own’ posture during sleep and whether they would like to be helped in this position during the last hours of life. After a confirmative answer, patients were assured that they would be nursed in their favourite posture during their final hours. To evaluate the adherence to this promise, photographs were taken by a professional photographer directly after the interview to capture the preferred position. The pictures were included in the patient record so that all professionals involved in caring for the patient, were aware of the patients preferred position. After death, a photograph was taken by the nurse present during the dying process. The pictures taken before and after dying were compared with each other by the PI to explore if the patient was deceased in his natural preference of body posture. If it was not possible to take a photograph after dying, the reports of the last hours in the patient record were studied to check if the patient died in the preferred position. Patient characteristics were prospectively collected after informed consent was given. Saturation was realized when no information about the NBPP was found.

Reflective data were collected from semi-structured interviews with relatives about their experience with the intervention. Staff nurses participated in two focus groups to share their experiences of helping patients in their NBPP during the dying process.

Patient anonymity and ethics approval

Patients were informed by the PI about the study and the ability to decline to participate. Patients were asked for consent to use their characteristics, qualitative and anonymized data and individual photos for the study. After verbal consent was obtained, this was recorded in the patient record. If patients dropped out, consent was obtained to use the data up until the moment of dropout. The methods of consent and the use of data for research questions were approved by the local ethics committee of the University Medical Centre Utrecht, the Netherlands (15-365/C).

Saturation of data, which means differences in posture, was realized after 22 interviews and 24 photo sessions (Appendix 1, (Table 3)). Thirteen patients were female, the mean age was 70 and the mean length of stay was 43 (Table 1). Fourteen patients died in their NBPP; 1 person died acutely, 5 patients returned home and 2 people were still alive at the end of inclusion (Table 2). Most patients gave permission to be photographed after death. Reasons for not being photographed were unexpected death, returning home, still being alive at the end of inclusion,nursesforgetting to take a photograph. Some patients refused, as illustrated by the following quotes:

“It is private.”

“I think it is an unpleasant idea to be photographed when I have no control anymore.”

“As a soldier I experienced the bombing of Rotterdam and I saw a lot of misery that I don’t want to be reminded of. No, for me no pictures when I am dead.”

Patients were eager and at ease to speak about their sleeping position.When pictures of patients were taken in their natural preference of body posture in bed, most of them showedan expression of relaxation on their face and closed their eyes with a subtle smile. A few patients found it difficult to admit these sensations. The feelings patients experienced in their preferred sleeping position were described as “safe”, “trusted”, “feels just right for my body”. Patients were also asked whether they would like to be helped in their posture of preference in the last hours of life. All patients gave a confirmative answer and wanted to be nursed in their favorite posture during their final hours. One patient mentioned it was difficult for her to imaginehow she would feel at that time:

“Yes, I think so, but actually I have no idea. I don’t know how I will feel in the last hours of my life.”

In general patients preferred a lateral position but 9/ 22 patients were only able to lay in a ‘forced’ supine position due to physicaldiscomfort like ascites fluid and pain caused by bone metastases:

“The comfortable and safe feeling of sleeping I used to experience, has vanished. It is misery. It is a forced posture instead of a preferred posture.”

The explorative interviews and photo sessions gave a deeper understanding into the posture of preference, which included more than simply a supine or lateral position. The posture of the hands, arms and feet were also important for feeling comfortable and at ease: for example, a raised leg and a hand underneath the cheek. Patients mentioned the importance of environmental factors as well. One patient said:

“Both my hands should rest on my belly; I have done this all my life. I prefer a rounded pillow that rests underneath my head and part of my shoulders. The bed sheets should be pulled up to my shoulders, my arms and hands underneath the blankets. The window must be open that is very important to me. It should be warm under the blankets. Above the blankets, I prefer it to be it a little bit chilly.”

Other important aspects patients mentioned were having a pillow or a blanket of their own, the position of the head of the bed or a pillow to support the back, legs or side of the body.

Relatives

Relatives were informed by the PI, professionals or patients themselves. Four relatives responded positively about helping their beloved ones in their posture of preference. They allagreedwith the idea that a preferred posture contributed to comfort during the last hours of life and it was a reassuring thought for them. Relatives reported that seeing their beloved one dying in a familiar and comfortable posture, provided them with support and comfort. Relatives shared the impressionof suffering by patients being reduced when they were helped in their NBPP during the last hours of life. His wife said:

“My husband lay on his right side, which is how he always used to sleep at home. It looked familiar to me, he looked relaxed. And when he finally died it looked like he had a nice smile on his face.”

Some felt uncomfortable with the idea that their deceased beloved ones would be photographed, it was a confrontational thought for them.

Three relatives chose to place their deceased family member also in the posture of preference in consultation with the nurse. It seemed unnatural to place the patient back in a supine position while he died in lateral position. A son said:

“When my father died, we put on a nice suit,buthe didn’t look like our dad, because he never wore a suit. Because he died in his natural posture we were able to stay closer to who he really was and we put on his favourite vest he always used to wear. It really was dad. First my daughters didn’t want to see their grandfather, they were scared to see him. Finally, they went to see him and both said: it is just the granddaddy we used to know. I am sure it made it easier for them because their grandfather was placed in a familiar sleeping position with his daily clothes on and this image gave comfort and support to my daughters.”

Professionals

Twenty-five nurses participated in two focus groups.

In general,nurses were positive towardhelping patientsin their posture of preference in the last hours of their life. In doing so, they experienced feelings such as “special and intense”, ”soft”,“like she was sleeping,” “thankfulness and satisfaction.” Some professionals found it difficult to mark the dying process which was necessary in order to help the patient into his posture of preference. A few nurses mentioned anuncomfortable feelingof voyeurism when they took a photograph of a patient after death even though the patient had given permission to do so.

Viewing the patients’ records, professionals often reported about repositioning during the last days of life but they did not write about the posture of preference in the last hours of life. One nurse wrote:

“Miss R. died on her right side. Her posture of preference was a supine position but this was not possible because of repositioning.”

Reasons for preferring repositioning above the posture of preference were a vulnerable, red skin and painful sores. Some caregivers questioned if repositioning was necessary during the dying process:

“During the second part of the night I tried to reposition her but she reacted to my touch and I decided to allow her to remain in her posture of preference. I felt that she was comfortable and there was no reason to help her in another posture.”

There was no consensus between nurses whether to reposition a patient or not during the dying process. When patients remained in their posture of preference for quite a while, nurses wondered if patients remained comfortable in their familiar posture. Small nuances, such as shifting both legs, shakinga pillow or moving the patienta little bit, were made to ensure that the patient stayed comfortable.

This first explorative intervention study about the natural body posture of preference provides a visualization of concrete wishes and supports the assumption that hospice patients have a need and the opportunity for their unique need to be known until the moment of death. Relatives and professionals are positive about this careful personalized intervention to improve comfort in the last hours of the dying patient. The lateral position with individual differences is the most preferred posture, while the supine position is experienced as forced due to physical discomfort like pain.

Strengths and weaknesses

Some considerations should be made. To the best of our knowledge, this study is the first exploration of a patient-drivenintervention to ameliorate the quality of dying. However, the research period was an intense and time-consuming exploration in itself. It was more difficult to include relatives than patients which is why more patients are included. The small sample of patients, relatives and professionals does not make it possible to draw solid conclusions. Moreover, the saturated experiences of relatives required to answer the question of whether posture of preference improves the quality of dying are lacking. This is explained by incomplete instructions for the involved nurses during late evening and weekend shifts. An additional questionnaire could have been helpful. Finally, photography as a research method is not yet validated in the field of heath care.

Strength is that when nurses pay attention to and help patient in their posture of preference, it is a valuable experience for patients, their relatives and professionals. Another strength is that it led to appreciated discussions between professionals choosing repositioning or posture of preference, whether to photograph a deceased patient or not.

The challenge for future research is to develop a suitable mixed-methods approach to find out if posture of preference significantly ameliorates quality of life, dying and bereavement.

Appendix 1

Table 1: Patient characteristics N=22

Table 2: Applied intervention, N=22

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4. Geijteman ECT, Dekkers AGWM, Zuylen L van. “10 jaar Zorgpad Stervensfase”(Ten years of care process in the dying phase). Dutch J Med. 2015.

5. Richtlijn: Zorg in de stervensfase. (National guideline Care in the dying phase). Version 1.0 National Comprehensive Cancer Center Consulted. 2015.