An ethnographic approach to studying non-intervention in the context of deterioration and dying in care homes

Background: Older people who live in care homes have complex health and care needs. As a result, a careful consideration of the potential benefits and burdens of proposed interventions are required at times of deterioration. Despite growing acceptance that non-intervention can be clinically appropriate, studying non-intervention is challenging for researchers, who are tasked with ‘seeing’ things that are not immediately visible.

Aim: To explore non-intervention in the context of deteriorating and dying in care homes.

Methods: We combine data from two ethnographic studies conducted in care homes in England between 2018 and 2021.

Results: Through the presentation of two cases, of Alice and of Arthur, we identify two forms of non-intervention that occurred in care homes. These are not transferring deteriorating residents to hospital, and not pushing foods and fluids to deteriorating residents with swallowing difficulties. We draw on these cases to describe three ways in which ethnography enabled us to study non-intervention. An ethnographic approach enabled us to: (1) identify the negatively defined content of non-intervention (the events and actions staff avoided or sought to prevent from occurring and avoided engaging in); (2) identify the positively defined content of non-intervention (the alternative events and actions staff engaged in instead); and (3) explore in what contexts staff practiced non-intervention as a chosen form of care.

Conclusions: An ethnographic approach enabled us to examine the ways staff understood different forms of non-intervention, to identify the work involved in ‘doing’ non-intervention and to examine the practices staff used to distinguish non-intervention from neglect. We consider directions for future research, and methods to study non-intervention which do not require the researcher’s physical presence within the researched context. As the recent COVID-19 pandemic highlighted, being present within the care home is not always a viable option and alternatives should be explored.