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Creating community at end o lie
Bringing ourDying Home
Dr Debbie Horsall, Kerrie Noonan and Assoc Pro Rosemary Leonard
May 2011
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AcknowledgementsFirstly we would like to extend our warm
and appreciative thanks to all the participants
in this research. Tey opened their hearts
and oten their homes to tell us about their
experiences and stories o caring. Tis was
not always an easy task or the storytellers, or
or the researchers. alking about intimate,
emotional and important issues takes time
and requires courage. We thank you all or
taking the time and or having the courage totalk to us. We hope that we have done your
stories justice in this report.
Nike Read was our extremely capable
research assistant or the rst 18 months o
this project. We thank her or her tenacity,
her attention to detail, her humour and her
sheer hard work in getting this project o
the ground. We also appreciated her skill
and warm, inclusive sense o humanity
as she talked with potential participants,
community members, and organisations in
the area. We missed her when she let.
o the mentors, sta and management
involved in HOME Hospice during the
lie o this project we thank you or your
assistance throughout, your involvement
as participants and your eedback. A desire
to research and document the work already
being done by HOME Hospice inspired thisresearch; we hope you are similarly inspired
when reading about the work you have done.
Te research was unded through a
partnership grant with the University o
Western Sydney and Cancer Council NSW.
We were ortunate indeed to have Gill
Batt as our industry partner rom Cancer
Council NSW as part o our research team.
We appreciated Gills extensive experience in
the area. She provided expert and valuable
advice, timely eedback and excellent strategic
suggestions, and was always encouraging and
positive about the research.
Te Social Justice and Social Change
research group o the University o Western
Sydney auspiced the project and we are
thankul or the support and guidance o
Dr Peri OShea and Dr Janette Welsby
in the planning, implementation andadministration o the research. I ever we
did not know the answer to a question,
they did! Also, thanks to Andy Horsall
or prooreading, editorial comments and
suggestions or uture directions.
Finally, we would like to thank the talented
CCNSW Publications eam or the editing
and design o this report.
Referencing guide
Horsall, D, Noonan, K and Leonard, R
(2011) Bringing Our Dying Home: Creating
Community at End o Lie. Research Report,
University o Western Sydney.
Te research was unded by the University o
Western Sydney and Cancer Council NSW.
ISBN: 978-0-646-55666-6
Te researchers warn Aboriginal and orresStrait Islander people that this publication may
contain images o people who are deceased. We
do not wish to upset or cause distress to living
relatives and community members.
Tis report can also be downloaded rom the
Cancer Council NSW website
www.cancercouncil.com.au.
32
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4 5
Contents
Acknowledgements 2
Bringing our Dying Home: Te project at a glance 6
Overall ndings 7
Key ndings and research themes 8
Teme 1. It takes a community: Each and every one o you had this little part to play 8
Teme 2. Resisting isolation and staying connected: Enablers o caring networks 9
Teme 3. Te ordinary becomes the extraordinary: Everyone doing a
little bit makes a broad and strong net 9
Teme 4. Its a process o transormation: developing death literacy 9
Note on style 9
Background to Bringing our Dying Home 10
owards an alternative: Community responses to dying 10
Building social capital 12
Te mentoring program 12
Methodology and methods 13
Objectives o the research 13
Our research questions 13
Research design 13
Recruitment and participants 14
Participant Group 1: Primary carers and their support networks who had a relationship
with HOME Hospice 14
Participant Group 2: Individual interviews with community mentors and carers 15
Participant Group 3: Workshop participants 15
Participant Group 4: Primary carers and their support networks who had no relationship
with HOME Hospice 16
Methods and analysis 16Focus group procedure 17
Interview procedure 17
Ethical considerations 18
Data analysis 18
Findings and discussion 18
Teme 1: It takes a community: Each and every one o you had
this little part to play 19
Teres a strength in numbers 19
You were absolutely crucial: Core and outer networks 22
Teme 2: Resisting isolation and staying connected: Enablers o caring networks 24
Its worth making the eort 24
Agency o the dying person 26
Clear and controllable communication 27
Being light-hearted 28
Weve been there beore: Previous experiences 29
Determined to cope without getting help: Barriers to orming care networks 31
Teme 3: Te ordinary becomes the extraordinary: Everyone doing a little
bit makes a broad and strong net 31 What the networks did: Te tasks o caring 32
Lie, in a sense, just continued on: Keeping things normal 35
Teme 4: Its a process o transormation: developing death literacy 36
It was a joy and a privilege: ransorming the literature through alternative stories o care 36
ransormat ive eects on individuals : developing knowledge and skills 38
Changes in attitudes to death and dying? 40
Rippling out: Developing a communitys capacity to care 41
All these new people: Ive just got to know them 42
Stronger, closer, deeper, warmer 44
Changes in amily relationships 45
Outside o amily 45
Negative eects on the relationships 46
Conclusion and uture directions 47
Key ndings 47
Teme 1: It takes a community: Each and every one o you had this little part to play 47
Teme 2: Resisting isolation and staying connected: Enablers o caring networks 47Teme 3: Te ordinary becomes the extraordinary: Everyone doing a little bit makes
a broad and strong net 47
Teme 4: Its a process o transormation: Developing death literacy 47
Looking orward: Its about the community caring 48
Epilogue 49
Reerences 50
Appendix 1: Focus group schedule 54
Appendix 2: Interview schedule individual carers and mentors 55
Appendix 3: Inormation sheets and consent orms examples 56
Toughts 62
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6 7
Overwhelmingly peoples desire is to
experience dying and/or death at home,
suggesting an urgent need to examine
community-based approaches to end-o-lie
care. Tis study does just that as we shit the
attention rom the needs o the terminally
ill person and carer to the wider, inormal
caring community. Tis report documents
the Bringing our dying home: Creatingcommunity at end o l ie research project,
a two-year qualitative project undertaken by
the Social Justice Social Change Research
Group (UWS) in conjunction with HOME
Hospice and Cancer Council NSW.
Historically, end-o-lie (EOL) research about
caring has emphasised burden, stress and
dependency, however caring at EOL also has
the potential to increase social networks and
contribute to social capital and community
capacity. We were interested in the quality
and eect o networks that are established, or
strengthened, as a result o caring or a person
who has chosen to die at home. We wanted to
understand, rom the point o view o carers
and their caring networks, how being involvedin caring or someone can positively impact
amily, riends and the wider community.
Using photo voice and network mapping
in ocus groups (n=9), interviews (n=8) and
workshops (n=2), we collected 96 visual and
oral narratives o caring and support. Te age
range was seven to 90 and groups comprised
two to 17 people. Specically we asked:
How communities come together as
inormal networks o carers
What is the orm and nature o these
networks?
What did people do to care?
What are the eects on the inormal
network, or community, in caring or
their dying people at home?
Overall ndings
While most people in Western countriescontinue to say that they would preer
to die at home there continues to be a
large discrepancy between this preerence
and actual practice. Most people die in
institutionalised care usually a hospital
resulting in the modern death becoming
cellular, private, curtained, individualised
and obscured (Buchan, Gibson & Ellison
2011, p. 4). Tis type o death can mean
that people die badly in places not o
our choosing, with services that are oten
impersonal, in systems that are unyielding,
struggling to nd meaning in death because
we are cut o rom the relationships which
count most to us (Leadbeater & Garber
2010, p. 18). Tat most people do not
experience dying and/or death in places o
their choosing is an astonishing act; a act
that, collectively, we are either ignorant oor just silent about. It is a act that speaks to
our ailings as a society at a time o lie that
occurs or each and every one o us. Clearly
research, policy and service provision in
Australia are ailing to meet the needs and
desires o the majority o people. Te reasons
or this ailure are beyond the scope o this
report but our ndings lead us to ask the
ollowing questions:
What i we reocused our research, policy
and service provision initiatives at EOL to
a social, community-participation
approach that enabled people to choose
where they wish to experience dying and
death, and then worked to enable that to
happen?
What i we provided evidence about
how people already care or each other and
members o their community, and we
made public their knowledge about what
to do and how to do it?
A clear nding in our research was that
people oten thought they were not
allowed to die at home. What i it were
general knowledge that you were allowed?
What i we had a national conversation
about EOL and place o death within
the ramework o social justice? It is unjust
that the majority o people want to die at
home, yet this choice is not supported.
It is time that the kinds o death we the
living are prepared to tolerate, imagine or
realise (Buchan, Gibson and Ellison2011, p. 4) became a topic o public
debate and scrutiny. Te latest edition o
Cultural Studies Review(March 2011)
and the 2011 HOME Hospice
conerence, Live, alk, Die, are two current
initiatives beginning this debate in the
Australian context.
What i the Home Death Movement (o
which there is undoubtedly a global one),
named itsel as such and claimed a place at
the decision-making table?
Bringing our DyingHome: Te project ata glance
Home-based care at end o
lie oers the opportunity to
reconceptualise dying as the
business o individuals, communities
and societies, including, but not
constrained to, the provision o
palliative care.
(Rosenberg 2011, p. 27)
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8 9
In the research reported here we ound that
people can and do care or their dying at
home with the help o inormal networks
o community members. And they do it
well. Tis is not to say that it is easy: its not.
However, people overwhelming elt privileged
and honoured to be involved in a caring
network at EOL. Participants successully
mobilised and negotiated complex webs o
relationships and engaged in acts o resistance
to the Western, expert-based approach to
EOL care. Te knowledge and skills theydeveloped as a result o the experiential,
embodied learning about caring at EOL
contributed to the development o social
capital and community capacity or the
people in this study. Peoples relationships, on
the whole, increased and intensied and these
changes were maintained over time.
Te inormal caring networks and relationships
underwent transormation as a person was
supported to die at home. Tis transormation
occurred as social relations and networks were
mobilised to support and help with caregiving
and as people developed their death literacy.
However, to ensure that these inormal caring
networks are sustainable and the people
who provide unpaid caring are not exploited
and isolated, inormal carers and networks
need supporting. Carers need permissionand practical hands-on help to gather caring
networks together and to negotiate the type
o help they need. HOME Hospice already
provides community mentoring that does just
this. Some religious, spiritual and intentional
communities also seem to play this role.
Organisations and services that provide paid
care at EOL also need to take on a more
active role in promoting death literacy and
acilitating and supporting inormal caring
networks rom a community development or
health promotion perspective.
Tis research contributes signicantly to the
growing body o research and practice that
reocuses EOL care rom an individualised,
private and medicalised approach to a
communal and social approach emphasising
relationships, community participation and
strengthening community capacity (Street,
2007; Stijernsward, 2005; Kumar, 2005;
Rumbold, 2009; Rosenberg & Yates, 2010,
2007). Emerging rom this research is an in-
depth understanding o the role and nature o
inormal care networks in EOL care at home.Te challenge now, as Leadbeater and Garber
state, is to create social networks that:
Key ndings andresearch themes
Theme 1.It takes a community:Each and every one of you had
this little part to play(FG 8)
Without exception participants in this study
believed that it takes a community o people
working together to enable someone to
experience dying and death at home. Tese
communities, or caring networks, comprise
an extraordinary set o complex relationships
that are continuously negotiated during the
process o caring. Both primary carers and
members o the network conceptualised
these networks as comprising core and outer
networks that played dierent but vital and
complementary support roles.
Theme 2. Resisting isolation and
staying connected: Enablers of
caring networks
People resisted the potential isolation and
social exclusion oten associated with caring
by working hard to stay connected with each
other. Te people doing this work included
the carer, members o the caring network
and the dying person themselves. Central tostaying connected was clear and controllable
communication, oten using technology
to good eect. In all but one o the ocus
groups there were people who had previous
experience o being with a dying person and
they were motivated to use their knowledge
and experience to help support others.
Additionally we ound that humour and
remaining light-hearted enabled people to
stay engaged in the process o caring.
Theme 3. The ordinary becomes
the extraordinary: Everyone doing
a little bit makes a broad and
strong net (FG 3)
Here we ound an overwhelming diversity o
caring tasks people engaged in. It was clear
that providing what was actually needed, notwhat people assumed was needed, was the key
to successul support. We also ound that the
main motivation or the tasks people engaged
in was to keep lie as normal as possible or
the primary carer and immediate amily.
Theme 4. Its a process of
transformation: Developing death
literacy (FG 3)
Being part o a caring network was, without
exception, transormational at individual and
collective levels. People developed knowledgeand skills about caring and about the process
o dying that empowered them and that
many then took into other networks and
communities. We ound evidence that social
capital was increased as a result o caring
and that the communitys capacity to care
improved. We ound, overall, that peoples
and communities death literacy developed as
a result o their experiences.
In reality these themes are not as discrete as
we have made them here, with many overlaps
and interconnections. Excerpts rom the
transcribed data and photographs are woven
throughout as we wanted to keep the voices
o the participants central. In order to protect
peoples privacy all data excerpts are identied
by a number assigned by us. All names have
been changed. We have not edited or changedpeoples actual words.
Note on style
Te style o writing in this report may
dier rom some readers expectations o a
research report. Tis is intentional on our
part. In our writing up o the research we
aimed or accessibility in our writing style.
In the pursuit o democracy and the sharing
o knowledge we believe that the results o
research should be as accessible to as many
people as possible.
Help people to achieve what is
most important to them at the end
o lie. That will require the creation
o a network o health and social
supports so that people can die at
and closer to home, with the support
o their amily and riends, as well as
proessionals. (2010 p. 18)
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10 11
terminal illness. Presently the medical model
and the health service approach to palliative care
dominate the community response to EOL care.
Tere is, as a result, an abundance o research
describing both carer and patient risk actors
and the optimal kind o services required to
support caregivers and people with a terminal
illness they care or at home (see Foreman,
Hunt, Luke, & Roder, 2006; Hudson, 2003;
McWhinney, Bass & Orr, 2005; Palliative Care
Australia, 2004; ang, 2003; Zapart, Kenny,
Hall, Servis & Wiley, 2007).
Te interaction between the community
experience o death and dying, attitudes
towards death and an aging population has
sparked discussion about the sustainability
o the current top heavy models o EOL
care. Tere is growing acknowledgement
about the lack o grassroots approaches
to EOL care, raising concerns about the
sustainability o current models o care and
the proessionalisation o carer and patient
support. Additionally, a growing number
o recent reviews o home death research
have noted that uture policies and clinical
practice need to ocus on empowering
amily members and providing community
education about EOL care (Gnomes &
Higginson, 2008; ang, 2003).
Community development has been dened
as any set o initiatives that develops the
social resources o the community to enhance
quality o lie (Kellehear, 2005). Community
development models compared to the medical
and health services models have a distinctly
dierent approach to end-o lie care.
Community approaches to end o lie care
are not new services. Tey are community
members acting towards each other in new
and constructive ways to improve their own
capacity or end-o-lie care. Any proessional
rationalisation o these changes into simpler
orms o direct services provision is a
regressive and important threat to community
empowerment (Kellehear, 2005 p. 100).
In the Australian context, we are not
aware o any documented programs with
a community development approach that
ocus on EOL care to enable people to die at
home. Te dominant model o volunteering
in palliative care is the co-ordinated team
o palliative care volunteers who provide a
range o services or the terminally ill and
their carers. Tey provide services such as
transport, respite and emotional support,
and while these services certainly support
carers, they exist to support the provision oormal palliative care services. In contrast,
community development approaches invite
active participation and exist to enable
ordinary people to work towards the common
goal o enabling their loved ones to remain
at home. It is through this working together
that greater understanding is built and the
individuals within a community are drawn
together. One o the goals o the community
development approach is to help individuals
and communities develop sustainable ways to
care or their dying by building social capital.
Background toBringingour Dying Home
In Australia about 140,000 people die each
year and 75 per cent o these deaths are
expected (Palliative Care Australia, 2004).
Most people, thereore, need some orm
o end-o-lie (EOL) care, with up to 90
per cent o people with a terminal illnessspending most o the nal year o lie at home
(PCA, 2004). Inormal caregivers are central
and essential to this EOL care (PCA, 2010;
Tomas et al, 2010). Te average length o
community-based palliative care is 119 days,
o which 117 days o care is provided by
amily, riends, neighbours and community
members (Rumbold, 2009).
About 2.3 million people in Australia
provide long-term care to loved ones. It is
estimated that unpaid carers contribute $20
billion to the Australian economy (Palliative
Care Australia, 2004). In 2004 Palliative
Care Australia released a report titled Te
Hardest Ting We Have Ever Done: Te
Social Impact o Caring or erminally Ill
People in Australia. It noted that although
70 per cent o people die in institutions,up to 90 per cent o people with a terminal
illness spend most o the nal year o their
lie at home (Rumbold, 2010). Given
this, the report outlined many issues or
carers, such as adverse physical, social
and psychological eects o caring such as
stress, sleep disruption, atigue, amily and
social isolation. Tis decit or problem-
based approach to research dominates the
research landscape. Te ew studies that
have described the positive aspects o caring
or a loved one with a terminal illness have
noted an increase in personal satisaction and
commitment, and caring as an expression
o love and increased intimacy (Aranda &
Hayman-White, 2001; PCA, 2004).
Despite the overwhelmingly limited view
o caring in the literature (see Foreman,
Hunt, Luke & Roder, 2006; Hudson, 2003;
McWhinney, Bass & Orr, 2005; Palliative
Care Australia, 2005; ang, 2003; Zapart,
Kenny, Hall, Servis & Wiley, 2007) and the
dominant experience o the terminally illdying in institutional care, the vast majority
o people continue to express a desire to l ive
at home and die at home when they have
a terminal illness (Hudson, 2003). Despite
this, the majority o people in Australia die
in institutions (abour et al, 2007). Te
most common reasons people are admitted
to hospital are carer breakdown and
symptom control. Te concept o a good
death appears to have been superseded
by the concept o a managed death that
requires proessional support and knowledge
(Kellehear, 2005) and takes place in a hospital
or, more rarely, hospice.
Towards an alternative:
Community responses to dying
wo distinct approaches to communityresponses to EOL are: 1) community-based
programs, and 2) community development
programs (Kumar, 2005). Community
care or community-based programs reer to
medical and health services provided to people
within their homes or community clinics as
compared to the hospital setting. Community
development approaches depend on community
participation, which reers to the individuals,
networks o people, communities o riends
and neighbours who, together, participate in
the end-o-lie care o a ellow citizen with a
The love
shared
between
mother and
son
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support person. Tis approach generates
social capital through community-building
as the mentor assists the carer in mobilising
their personal community. Te mentor helps
the carer to organise this network o riends,
amily and neighbours, as well as providing
education and a context or this personal
community to be involved in the care o a
person dying at home. Te programs ocus
is thereore on the inormal volunteers that
exist, waiting to be mobilised, in the carers
personal community. On average thesepersonal communities comprise 14 people
and can be as large as 35 people (HOME
Hospice, 2008). HOME Hospice has
partnered with the Cancer Council o NSW
and has a clearly dened program o support
or carers who are caring or someone with
a terminal illness that complements other
essential services being used by the carer
and their loved one, including volunteer
services. As a community development
program HOME Hospice embraces the
work o Proessor Allan Kellehear (2007),
who acknowledges that the establishment
o networks and development o trusting
and caring relations are important goals o
community development programs at EOL.
HOME Hospice aims to generate social
capital through community-building andmobilising the carers personal community.
Tis community capacity-building approach
to EOL care is a unique model within
the Australian context and served as the
initial ocus or this study, which aimed to
understand how a person dying at home can
strengthen, build or transorm social capital
within the local community. In this research
our understanding was developed using a
social network analysis approach (Carpentier
& Ducharme, 2007), which is a relatively new
eld o research in the literature on caring.
Methodology andmethods
Objectives of the researcho understand how being involved in
caring or someone dying at home impacts
on amily, riends and the wider community.
o collect narratives o caring networks
regarding the quality and eect o social
networks that are established, orstrengthened, as a result o a person dying
at home.
o contribute to knowledge about a
community development approach to EOL
care.
Our research questions
How do relationships and social networks
change as a result o being involved in
caring or someone in their home?
What is the nature o these relationships?
How does being involved in a caring
network aect peoples attitudes towards
dying at home?
Research design
o answer the above questions we used a
creative qualitative approach employing
the techniques o photo voice and network
mapping, combined with group and
individual interviewing. Te research was
designed to be as inclusive as possible. We
held the view that caring or someone at
the end o their lie, either as a primary
carer or a member o the caring network,
is an emotionally charged and complex
Building social capital
Because the term social capital has been
used widely and rather loosely, we need to
explain how it is dened and used in this
research. Following Putnam (1993), social
capital is oten dened as those eatures o
social organisation, such as trust, norms and
networks, that can improve the eciency o
society by acilitating coordinated actions.
However, other theorists, including Coleman
(1988) and Putnam (2000), see social capital as
a resource (oten the primary resource) that is
open to all groups and communities. Certainly,there is evidence that social capital is capable
o producing a variety o positive outcomes
beyond economic advantage, such as improved
health and wellbeing (Halpern, 2005).
While many studies o social capital take a
macro or economic development view where
the emphasis is on the unctioning o whole
societies (e.g. Putnam, 2000; Woolcott
& Narayan, 2001), the micro position as
presented by Lin, Cook and Burt (2001),
ocuses on specic networks and the benets
that accrue to the people within them.
Whereas the macro and developmental
approaches take a normative position that
social capital is a social good, and oten use
methods involving attitudinal surveys, in the
micro approach the outcomes are a matter o
empirical investigation and attitudinal data
is usually rejected as too subjective (Adam &
Roncevic, 2003).
Because the present research aims to identiy
the changes in the size, strength and natureo networks o people involved in caring
or a terminally ill person, it adopts the
micro position. We examine whether caring
networks expand or increase in density and
whether they are perceived to give benets
to the members. However, attitudes are
not excluded. Human relationships are not
purely instrumental and concepts such as
trust, norms and shared values may underpin
social capital networks. Rather than ignoring
these key concepts, this research encourages
participants to talk about their personal
eelings and attitudes arising rom their
experiences within the network.
The Mentoring ProgramTe HOME Hospice Mentoring Program is
an example o a community developmentapproach to EOL care in the Australian
context. Te HOME Hospice program has
been in operation or 28 years or carers
who want to care or a terminally ill person
at home. Te HOME Hospice model is
about education and learning, building
community, developing and strengthening
the bonds between people such as amily,
riends and neighbours [and] is about
building the capacity o the community to
care (HOME Hospice, 2008). Mentors,
once invited by a carer, act as a guide and
Dianne
wanted a
gravestone
with hands
in prayer so
they gave
her photos to
choose from
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1514
Participant Group 2: Individual
interviews with mentors and
carers
Te HOME Hospice mentor has the personal
experience o caring or a loved one and
providing mentoring support to caregiversand the personal communities o people
living with a terminal illness at home.
Inormation about the project was sent out
to all o the mentors associated with HOME
Hospice, inviting them to participate in the
research project. Six mentors responded.
All six were rom the Greater Western area
o Sydney. Interviews lasted about one hour
and were audio-recorded and conducted in
places chosen by the mentors. One mentor
chose to write her responses to
our questions.
Participant Group 3: Workshop
participants
Trough HOME Hospice and Cancer
Council NSW networks two workshops were
conducted by HOME Hospice, one each in
Western Sydney and the Northern Beaches.Te purpose o the workshops was twoold:
rstly they enabled local HOME Hospice
mentors to get to know the researchers, and
second they were able to experience rst-hand
a modied version o the photo voice and
ocus group method. Te workshop invited
participants to take photos to represent
their experiences o caring and these photos
were used in a group brainstorm exercise
that helped elicit knowledge rom the group
about the supports, services and caregivers
needs when caring at EOL. Working within
experience. As such we used methods that
enabled the research participants to choose
their level o participation when speaking o
their experiences. As researchers we needed
to be particularly sensitive when asking
people to talk about emotional issues that
could leave them eeling vulnerable and
exposed. Methods needed to be employed
that could enable participants to remain in
control, as much as possible, and to hopeully
fourish as a result o the researching process
(see Horsall & itchen, 2010). Creative,qualitative research methods are increasingly
being employed in such situations (Horsall
& Welsby, 2007; Davidson, 2004) to provide
conversational spaces or people to speak i
and how they want about deeply elt issues,
enabling researchers to understand what
matters and is important to participants, and
why. Creative methods can also enable people
to notice what has become amiliar and
everyday, to get beneath the surace o things,
and articulate the amiliar (Halen-Faber &
Diamond, 2002). Tis is important as social
relations are oten invisible, not talked about,
or are seen as an unremarkable part o peoples
everyday lives. Te methods o photo voice
and participatory network mapping enabled
us to careully and sensitively document these
subjective experiences in this research.
Recruitment and participants
Four types o participants took part in
this study. Firstly, primary carers and their
support networks who had a relationship with
HOME Hospice via a community mentor
(n= 48); two carers opted to be interviewed
without their networks; HOME Hospice
mentors (n=6) and primary carers and their
networks who had no relationship with
HOME Hospice (n=29). Primary carers
could be currently caring or someone at
EOL at home, or have previously cared or
them. In total 96 people participated with
ages ranging rom seven to 90, representing
17 caring networks. Te number o people
attending the ocus groups ranged rom
two to 17. Recruitment took place through
three recruitment strategies: via HOME
Hospice and the mentors; through two
research workshops conducted with carers
and mentors (n= 11), which was both a
recruitment and sampling strategy, and
through local newspapers. Tese strategies aredescribed below.
Participant Group 1: Primary
carers and their support networks
who had a relationship with
HOME Hospice
Recruitment took place through the HOME
Hospice network, via advertising in the
newsletter and website and people opting
in to the project as part o the HOME
Hospice general inormation to carers
package. In order to opt in, people contacted
the HOME Hospice organisation about the
research project. I, on this contact, they
were prepared to be involved in the research
their permission was sought to orward their
contact details to the researcher(s). Opting
in was entirely voluntary and withoutcoercion. Participants in this group were
rom the Greater Sydney region only. Tis
recruitment strategy involved attending
HOME Hospice sta meetings, establishing
relationships with current mentors, and
employing a research assistant who was
a volunteer community mentor. Four
o the resulting ocus groups were with
primary carers and their networks, and were
organised primarily with the carer. Te th
was instigated and organised by a young
person who had motor neuron disease.
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o analysis o the maps during the ocus
groups and interviews.
Focus group procedure
Te ocus groups and interviews oten took
place in peoples homes, usually those o the
primary carers, around a table and usually
with ood. Tey lasted between two to ve
hours and were tape-recorded with peoples
permission. As a research team we were
continuously deeply moved and amazed thatpeople opened their homes and their hearts to
us during this process. Te conversations were
oten lled with equal measure o laughter
and tears as people spoke about some o the
most intimate moments o their lives.
Te ocus groups/interviews began with
people looking at the photos that had been
taken. Participants were then asked to
select one or two photos that particularly
stood out or them, and to give the photo/s
a title. Te discussion began with people
explaining their photos and the title they had
given. Tis then led to in-depth discussion
o signicant caring activities and the role
o the caring networks (see appendix 1 or
schedule o questions). Te second activity
was network mapping in which two large
pieces o butchers paper were used to drawmaps o networks and relationships pre and
post-caring. Tis mapping was acilitated
by drawing two network maps on butchers
paper: one representing the network beore
caring, the other ater caring. People wrote
their names (or had their names written)
on the paper, then dierent coloured pens
were used to connect people together: red
or a strong connection, blue or medium
and yellow or light. We were worried at the
outset that people might eel conronted
with having to describe a relationship as
yellow, or that dierentiating between
the types o relationships might be dicult.
However, this was not so (apart rom one o
our youngest participants who made all her
lines red). People got it quickly, and this
activity was usually one o high energy, much
talking and laughter and discussion. When
complete the researcher held up the two
maps and asked people what they noticed:
how were they dierent and what did this
mean to them? Tis activity was usually very
quick and chaotic as people covered thepieces o butchers paper. While in most cases
participants drew the maps, the researchers
drew the maps i requested or i people were
hesitant.
Interview procedure
Interviews were semi-structured, and lasted
or about one hour in the home o the
participant. We asked mentors to describe
experiences o caring and their experiences
as a mentor. One mentor chose to respond
to us in writing via email, rather than in a
ace-to-ace interview. We also interviewed
two carers (one current, one past) about their
experiences o caring. Both these carers had
initially responded to participating in the
research project and requested individual
interviews rather than ocus groups. Allinterviews were audio recorded with
participants permission. In the interviews the
photo voice method was not used, but people
were asked to draw network maps. I they
did not wish to do this they were asked to
orally describe changes in the networks. (See
appendix 2 or interview schedule).
a community development ramework,
it provided an overall impression o what
the networks look like and what it takes to
mobilise ormal and inormal networks.
Participant Group 4: Primary
carers and their support networks
who had no relationship with
HOME Hospice
In July 2010 the Cancer Council o NSW
provided additional unding or us to widenour participant sample. Tis was in response
to the diculties we had experienced in
recruitment or group 1 and the act that
we were interested in discovering how
people who were not associated with
HOME Hospice mobilised care networks.
Recruitment or this group took place
through the local media in the Sydney
metropolitan and Greater West region. Te
University o Western Sydney media unit
sent out press releases about the project to all
local newspapers in these areas. A telephone
number and email address were provided so
that people could contact us i they wished,
again an opt in process. Tis proved to be
a successul recruitment strategy, with 42
people contacting us over a six-week period.
While many o these people ell outside the
scope o the research (the person they hadcared or had died more than three years ago,
they were not able to bring together their
support network or a ocus group, and/or
they wished to complain about local services),
we did secure our ocus groups in this
period. Tree o these groups were in NSW
and one in the AC.
Methods and analysis
Participants were given cameras two weeks
beore ocus group meetings and asked to re-
cord the signicant care and support activities
they engaged in. Te visual data (photos) was
then discussed and analysed by participants
in a series o in-depth interviews or ocus
groups. Te ocus groups and interviews
also included a network mapping activity in
which participants were asked to draw mapso relationships pre and post-care, indicating
via coloured textas the strength and intensity
o relationships. Tese maps were initially
analysed by participants in the interviews/
ocus groups. Te research team conducted a
thematic analysis o the recorded data. Tis
involved a dual approach: enabling themes to
emerge and purposively looking or answers
to our questions.
Participatory network mapping is a visual
activity that literally asks the participants to
map their networks and record changes to the
relationships pre and post-caring. Making the
map as a collective exercise is dierent rom
the procedure usually employed by network
theorists (Knox, Savage & Harvey, 2006),
which utilises individual questionnaires in
which participants list names and identiyrelationship strength through a Likert scale
or similar method, and the inormation is
collated and analysed by the researchers with
no participant input. Network mapping has
not been used in the context o EOL caring.
Nevertheless, the advantage o the group
approach to network mapping in this research
was that participants saw the results and gave
interpretive eedback about the nature o the
networks and any changes they saw occurring
in size, density and strength o relationship.
Hence the participants provided a rst level
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knowledge sharing and the eeling that people
are supporting each other in something extra-
ordinary.
Theme 1: It takes a community:
Each and every one of you had
this little part to play(FG 8)
Te terms community or networks o
carers/support networks can run the risko being so broad as to become bland and
meaningless (Kellehear, 2005). Tese terms,
while debated in the academic literature, had
meaning or participants who were clear and
articulate about what a network/community
was and who was included. Tey were also
very clear about its importance in the context
o caring: its central to everything that weve
been doing(FG 7). Here we spend some time
describing what is meant by care networks
rom the perspectives o the people we spoke
to. Unsurprisingly, perhaps, this description
comprised: amily, riends, work colleagues,
neighbours, community and service groups,
and proessionals. What did surprise us was the
inclusion o pets, the importance o global and
virtual networks, and the seemingly complex
nature o relationships that people mobilised
and negotiated.
Theres a strength in
numbers (FG 2)Family members such as siblings, spouses,
children and parents were central to all o the
networks we spoke to, with immediate amily
attending ocus groups: there was my sister,
Lesley, me, my kids ... they used to come over
and try and spend time with Nan (FG 4).
For one group the immediate amilywas
the support network: the network o care andsupport was the amily (FG 6), and or another
caring brought the immediate and extended
amily closer together:
I think it was a coming together. A
coming together o the amily not just
the immediate amily but the extended
amily aunts, uncles ... whatever our
dierences may have been, during
this time we all came together and did
whatever we could not only or each
other, or Mum and or Dad. (FG 4)
Ethicalconsiderations
Tere were several important ethical
considerations in this project. First, it was
important that participants understood
the project rationale and what the research
team intended to do with the photographs
and other inormation collected. Second,
it was important to get peoples consent
to be involved. All participants signed aninormation sheet/consent orm at the
beginning o ocus groups/interviews or
workshops that provided details about the
project, the use o photography and what
would be done with data collected (see
appendix 3 or samples o inormation sheets
and consent orms). For those participants
who were under 18 they and a parent or
guardian signed on their behal. When
looking through photographs people were
also asked to remove any that they did not
want to be used urther in research. Tese
were destroyed. All the photographs in this
report and in other publications are by
members o the research team and are used
with the permission o participants. Te
project received UWS ethics clearance prior
to commencement.
Data analysisTe rst level o analysis took place in the
ocus groups/interviews in which participants
were asked to give meaning to their
photographs and the network maps. Tis was
in order to gain the stories o participants and
to understand what was important to them,
in terms o caring, the generation o social
capital and the development o communities
at this time.
With participants consent, interviews were
audio recorded and later transcribed. Te
research team then conducted a concurrent,
two-pronged thematic analysis. We analysed
the data to see what emerged: what were
the key ideas, concepts and themes that
people spoke about? What did they think
was important? What were they were telling
us? What was the overall story? Tis was
an emergent, data-driven process. At the
same time we conducted a theory-driven
analysis: how did the data answer ourresearch questions? What were the omissions,
things not said that we expected due to
our knowledge o the current theory and
literature, and what was said that we did not
expect? Tis combined process was lengthy
due to the in-depth nature o the data.
Findings anddiscussion
Four themes emerged rom the verbal and
visual data: It takes a community, Resisting
isolation and staying connected, Te ordinary
becomes the extraordinary, and Its a process
o transormation. Tese are discussed in
the ollowing pages along with a number o
sub-themes. Te themes are illustrated withdata quotes and photos rom participants.
Te photos with titles are ones chosen by
participants during the ocus groups. Tose
without titles have been chosen by us as
representative o a theme, or point, we are
showing. Te themes demonstrate a rich and
complex description o both the everyday
tasks o caring and how caregivers manage
the inormal and ormal networks in order
to continue to care at home. All o this has a
cumulative eect in which caring networks
are transormed through relationships,
Every
Wednesday
So community can come rom
riends, amily, neighbours, but it
can also come rom people you
dont know very well ... and its
dierent or every amily and Im yet
to experience anyone who doesnt
have anybody. (M3)
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I was there or not so it was a routine (M3).For one ocus group the local shopkeepers
also played an important role in the caring
network: there are particular shopkeepers or the
aged in that area who actually look ater them.
Who really do (FG 7).
While we did not specically ask about
proessional support rom palliative care
teams or the health proession more generally,
in two o the nine ocus groups health
proessionals were present: Im one o the
palliative care nurses (FG 9), illustrating their
central role in the support network as ar as
the carer was concerned. Te proessional
support rom GPs who oten: came to the
house every day (M1),was seen by one carer
as someone: who was going to give me a hand
like an insurance policy or something(FG
8). Palliative care and community nurses inparticular received special mention:
I remember the nurses coming to our
home to help my mother and they were
antastic. They got involved with the
amily nothing was too much. They
were so helpul to my mother my
mother was 48 when my ather passed
away. It was a very hard time or her,
nancially as well, What are we going
to do. Three kids and all the rest
o it but the nurses said, Look, well
take care o this, well help you with
that. They just helped her in whatever
emotional way they could as well as in
other ways. Nothing was too much or
them and i they had to stay longer they
would. (FG 5)
Possibly there was a great deal more to be
said about the helpulness o proessional
support, but not much more was said. Tis
is probably because this type o support was
not within the scope o the study and we did
not ask direct questions about proessional
support. However, it can be seen rom the
above quotes that this level o support and
care was vital in providing a saety net or the
carers, a sense that there were people with
specialised, practical skills who were available
to help as needed: well I guess just knowing
that Mum had pain relie and that we had someproessional help (FG 9).
While pets were not a universal theme across
all groups, they were spoken about at three
ocus groups as central to the caring o the
dying person, and were seen as vital or the
amily and close riends who visited the
house. In three o the groups animals were
present throughout the ocus group. Indeed
or one o the groups, the amily dog could
be heard contributing at poignant moments.
When pets were spoken o it was with such
Friends were dierentiated as either riends
o the primary carer: my riends didnt reallyknow Mum very well but they all came and
did a chore to help me (M3), riends o the
dying person: she obviously had lots o people
around her who loved her very much and who
were willing to use that window o opportunity
that they had to spend time with her and to do
things or her because this is where she wanted
to be (FG 9), or riends o amily, particularly
school riends o the children o the primary
carer.
Work colleagues were central to the care
network: it would have been very hard i both
eds and my work (places) were not as good
as they were (FG 2), and were oten relied
upon by the carer who needed to trust: that
they would rise to the occasion and do that and
o course they did and its just wondrous and
so good (FG 7).Work colleagues were alsodierentiated between those o the primary
carer and the dying person. Tis is well
illustrated in the ollowing quote:
Interestingly, a close review o the data shows
that neighbours were not talked about a great
deal. Perhaps this is because being part o a
caring network at such an intimate time o
lie means they were perceived more as riends
rather than neighbours? Neighbours were
mentioned as people who: might have popped
in and said, Gday (FG 4), providing minimal
care and contact, through to neighbours: who
lived two doors down, would walk down thestreet every morning and pick up the Daily and
put it in their letterbox or them (FG 7).
Community organisations such as churches
or spiritual groups were able to mobilise and
organise support or the carers amilies: Beryl
and her (church) group we c ame home one
day and there were big containers o pumpkin
soup that these young teenagers had made (FG
2). People spoke o their church sending out
email alerts or prayer, or at weekly ser vices
providing the congregation with updates and
reports regarding what the amily needed:
in the church group there was a lovely girl who
used to come every Friday, and there was an
older priest there who gave her permission to
bring communion (M4). Service clubs played
a similar role: so twice a week the service clubs
would look ater him and send someone to takehim out or a couple o hours so that was good,
and I did use the community care volunteers
to ring him every morning at 8 oclock whether
LEFT: Walking
the dog and
talking
RIGHT: Life
goes on for
the rest of the
family
I had to laugh at the two dierent reactions rom the workplace. (People rom)
my work went out and bought masses o rozen ood, sot drink, wine, un stu
to eat like chocolates and things that they thought the kids would like. They also
bought meals that they thought the kids could cook lots o pasta and pasta
sauces. They arrived on the doorstep which is that photo o ... our receptionist
with all our rozen ood. Teds oce arrived with a $700 bottle o Grange and a
bunch o fowers, which was also lovely but it was a dierent reaction. (FG 2)
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intensity and regularity that we have included
them here as part o the caring network. Tey
were seen as good listeners, allowing people
who were caring to connect, or grieve, or just
be, perhaps providing much needed space
rom the intensity o the caring relationships.
There was always the sharing o the
pets and the discussion o the pets. It
was always a way to connect with you
and connect with the kids. When other
people would come in the pet would beshown to the other person and it sort o
brought people together. It was such an
emotionally charged time and we were
all constantly holding on to our tears
and having the pets was a nice thing
breaks the ice cushions the blow a
little bit. (FG 1)
Pets also provided care and comort to the
dying person as well as members o the amily
and caring network:Te cat used to sleep with
ed up in the bedroom when ed would lay
down during the day (FG 2).
You were absolutely crucial (FG 8):
Core and outer networks
What was interesting to us as we read
the data was peoples clear dierentiation
between what we now call the core and
outer networks. Both the carers and the
people comprising the care network made
this distinction. Te ability to see and be
seen as belonging to a dierent part o the
network and what this entails, demonstrated
the complexity o the networks, how they
comprise themselves, how they act and how
they are used by the carer/s. Te core and the
outer networks could not unction without
each other, demonstrating a sophisticated set
o relationships. Below a member o a care
network describes the nature and roles o the
core and outer networks:
I thought that you were the core
team, the inner, the absolutely-there
ones and your dedication, love,
determination, practical pair doing
the hard work. Then theres the next
layer who are encouraging, arming,
being a sounding-board, doing some
o the work, providing ood, refecting,
driving, shopping, that kind o thing.
Then there are these people who can
be strangers ... that come in [with] the
medical inormation and assessment,
the practical equipment and know-
how and the respite i the second layer
are not available or are tired. They
can be called on. And the spiritual
care and inspiration. Maybe there are
other circles: these people hold all that
and these people hold them and then
theres the person in the middle being
held. (FG 8)
Te core group was seen as: amazing(FG
2), and it was generally agreed that: havingsomeone pass away at home would be a lot
harder without that core group around you
(FG 2). However, both the core and outer
networks were vital, providing important
but dierent types o emotional and physical
support. Te carer in particular used the core
and outer networks dierently:
Yes, well I wanted to keep a public
ace. I wanted to keep like, Im doing
OK. Then thered be other people, like
maybe Shelia and Carol, who Im not
doing OK. Then when Jenny would
come it would be, Now I can breathe.
Now I can step back. Now I can go and
have that time to recharge. (FG 9)
Core members were usually immediate
amily daughters, spouses, children o the
dying person, and/or long-term riends. Te
network members oten consciously decided
what level o support they could give, and
where they then tted within the network, as
shown below:
Yes, I decided that I would be a
sounding board or Deb. Any time
she rang, wed talk so I tried to be in
contact and talk but I did eel conficted
about not doing some o the physical
caring and I knew that that was needed
... it elt like being a second tier
support role to play. (FG 8)
Te core and outer networks then were
not haphazard groupings o people; theywere deliberate and conscious both in how
they comprised themselves and how they
were used.
When the emotional need or us got
greater, we stopped depending on
our peripheral social circle as much
as we probably didnt want to make
ourselves as vulnerable. (FG 6)
As one person youd never be
able to get through singly. I would
be in the corner crying and that
would have been the end o it but
with all the support that I got so
its important to know this and that
theres a network out there. (FG 5).
Diagram showing the various layers of
support. Drawn by participant during a
focus group
Sometimes like that cat, having an
animal (like our dog) ... you can go
out and have time with that animal,
pat it or grieve or talk to it, whatever,
what youre eeling and eel like
youre not being questioned or
thinking the way you do. Theres no
speaking back, it is just there to let
out what youre thinking. (FG 1)
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theme in interviews and ocus groups was the
belie that community and social connections
were vital to peoples wellbeing, and that
they are desirable or the dying person and
the carers. Te dialogue below illustrates that
connections oten needed to be worked at:
Remaining connected was an active task that
took: hours and hours o phone calls(FG 7)
rom members o the amily and was built
into the dying persons care plan. In the above
example it was important or this amily
that the person being cared or continued
to be an active and present member o
their community or as long as possible:
taking Mum to places taking her because she
couldnt get there hersel (FG 9). On occasion,
physical changes to the house enabled this to
continue: this ramp helped Deanne get out and
about(FG 4). Te above quote also shows
how inormal caring networks can make
strategic use o services, linking inormal
and ormal caring networks.When getting
out and about was no longer possible due
to increasing railty (physical or emotional),
then the amily and/or members o the caring
network took the community into the home.
In the example directly below, people rom
the caring network came into the home to
support the carer, with a fow-on positive
eect or the person being cared or.
I called it Joy or a couple o reasons.
One was that a group o us school
mum riends had come ... because she
[carer] couldnt come and have coee.
We had a routine Friday or whatever
day so we had come and I did some
scone making lessons which was
hilarious because I cant cook anyway.
So that was part o it and the other part
was Clares (dying person) response to
We were interested in how participants
dened their own caring networks based on
their actual experiences o being part o one.
It became clear to us that participants had a
sophisticated understanding o the complex
web o relationships that comprises a caring
network, and that they were able to mobilise,
negotiate and maintain many o these
relationships at an emotionally and physically
charged time in their lives.
Theme 2: Resisting isolation and
staying connected: Enablers of
caring networks
I think thats beautiul because its a
photo that says were not keeping her
to ourselves. Were not isolating were
sharing. Were bringing in riends,
were having a moment. This is a
celebration o the lie that is and that is
going to be. (FG 9).
Much o the literature on caring talks
about the potential or social isolation and
disconnection, especially or the primary
carer (PCA, 2004; Hudson, 2003). People
in this research were aware that isolation
could be damaging or themselves, or their
amily members and riends and the dying
person: when people go into palliative care in
the home in the last months it must be very,
very tough on the ones that lose outside contact
because then theyve only got themselves to think
o and their pain and loss o leaving the amily
(FG 4). Tey were equally clear that no-one
could do this particular work o caring by
themselves, that the network was crucial to
enabling the person to die at home: I didnt
want to have this group without acknowledging
that I really relied on you. Tere were things
that all o you did and all o you gave and was
just crucial in that process o [him] dying the
way he wanted to die (FG 8); and enabling
the primary carer/s to keep caring: when
youre it you just get more and more exhausted
and youve just got to keep giving when theres
nothing more to give (FG 3). Te previous
section clearly showed that people in this
study, on the whole, resisted being isolated, or
trying to care alone. Instead they were active
participants in a complex web o relationships
that, in our words, comprised a caring
network.
So how did these caring networks come
to exist? Did they just happen, or was
there work involved? I so, who did the
work? What enabled caring networks to be
connected?
Its worth making the effort
People spoke abouttheir desire to keep
connected either or themselves as carers,
or or the dying person or both. A strong
Theres a strength in numbers
and knowing that youve got good
people around you who dont care
what you say, dont care what you
look like, dont care how things are,
but will always be there or you and
not just say theyll be there or you.
They do things sometimes without
you even noticing and dont expect
to be appreciated. (FG 2)
Sara: One o our tasks has been
to maintain connections with the
outside world ... which didnt
happen very oten i we didnt
provide that opportunity or provokethat opportunity ...
Kerrie: You made the extra eort to
build these connections.
Sara: Yeah ...
Dawn: One o the things that was
built into Dads package was that
the person who came in on one day
o the week would take Dad with
him to go and get the Friday sh
and the ruit and some milk or bread
or whatever ... so that was putting
the connection between Dad and
his carer with each o those ...
Sara: Dad and his community and
keeping him engaged with the
outside world.
Kerrie: Keeping your Dad engaged
what dierence did that make to
you as carers?
Dawn: It gives you things to talk
about. Who did you see?, Oh
you must have seen Rob, or I
saw Chris today and ... Its a way
o communicating and maintaining
those connections. (FG 7)
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Have you ever seen Death at a
Funeral or something like this? It
was just like that. Completely arcical
moments. Im laughing at them thinking
you cant help but laugh. This is an
amazingly blurry time but there were
just some hilarious moments. (FG 8)
And with the laughter sometimes,
theres an aspect o black humour,
isnt there? ... Stuart lost the ability
to be able to communicate with the
right words, but he didnt know that.
It was OK when it was us wasnt it?
This poor plumber came and these air-
conditioning guys and hes telling them
exactly what he wanted and you could
see that he really knew what he wanted
but the words were totally wrong. Now
you should be able to laugh at that.
A lot o people would think we were
being very irreverent laughing ... but
we couldnt help ourselves. You have
to see the unny side ... it was like a
release valve.(FG 5)
Humour being able to see the unny side
seemed to enable people to be themselves,
stay connected and provide care and support.
Even though, as the last quote shows, this
may be considered inappropriate by some,
this aspect provided a release valve or people
and provided a dierent quality to the
caring relationship. In many ways this is an
alternative story o caring. Stories o caring
are oten ocused on the dicult and dark
times, o which there were many or our
participants. And while people oten shed
tears in the ocus groups and interviews, there
were as many examples o laughter as people
told these alternative stories.
Weve been there before (FG 5):
Previous experiences
I had a reasonable amount o
experience with dying people because
Id nursed my mother at home untilshe died, or six months previously to
that. So I had gone through that whole
experience o having someone close
to me die at home and that was a very
good experience. (FG 8).
In many ways this sub-theme also ts with
the transormational eects o being with
someone who is dying. People used their
previous experiences to support others in the
work o caring, either directly in doing the
hands-on tasks, or as an advocate in resisting
the health system when necessary. Teirliteracy about death the skills, attitudes and
knowledge they gained, whether rom positive
or negative experiences appeared to provide
them with the ability and motivation to be
central members o urther caring networks,
enabling: maybe a bigger support because o
the related experiences (FG 4). Members o
eight o the nine ocus groups had previous
experience with the death o someone close to
them. Tis may have been in a hospital: my
husband was in a nursing home (FG 1), or at
home: both my parents died at home (FG 9).
One person did resist getting a mobile
during the time o caring as they eared being
overwhelmed by phone calls, showing that
communication can become another dicult
task to be managed.
Te landline telephone was also seen as a vitallink to networks and amily, and provided a
much-appreciated means o support:
Can I talk about the phone? I know
Liam and Debra had a pick-up phone
landline phone and Deanne was
laying down and couldnt come to
the phone. So then they organised a
cordless phone and that allowed Liam
to take it to her and/or one o the girls
visiting. It was a lot easier ... I think it
was signicant that people were ringing
and checking how she was, how you
were. Mum loved ringing her sisters as
well and that still continued. You can
probably conrm that Aunty? Having
chats with Mum on the phone. (FG 4)
echnology enabled networks to stay
inormed and in touch, enabled people to
give and receive support rom anywhere, at
any time, reminding us that caring networks
do not need to always be physically present to
be doing the work o caring:
Being light-hearted(FG 3)
Tis sub-theme captures a less tangible
enabler o establishing and maintaining a
caring network. While there is no doubt
that caring or someone at EOL is hard work
emotionally, physically and spiritually a
sense o un, or play, was apparent in many o
the stories:
I tried to take a picture o the
computer screen o the email
messages because Teds cousin,
Brenda, in England and his brothers
and a lot o riends overseas and
in Australia used to email Ted. He
would get a lot o strength rom those
emails. Some were long, some small
that was very important or him
because towards the end he didnt
want to talk to people except or the
chosen ew. It was too hard too
much energy but he loved getting
the text messages and emails. (FG 2)
There was laughter too. You and
Pete made everybody laugh, as
usual. (FG 2)
There was lots o laughter and lots
o storytelling. It was very noisy; it
was like being in the middle o a
henhouse. (FG 7)
When someone is dying you have just
got to be there or people. You cant go
in there with ideas; you just go along
and sort o eel your way. (FG 5)
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Te HOME Hospice mentors we inter viewed
were mentors because o the personal
experiences that they used as the oundation
to support other carers via their work or
HOME Hospice. Five out o the nine ocus
groups, plus the two carers we interviewed,
had used a HOME Hospice mentor or
support to a greater or lesser degree.
One group elt that they were well supported
already through their existing networks, so
did not make ull use o the mentor:
Another group talked about how HOME
Hospice enabled the carer to support her
mother to die at home:
I was at a riends place and I wasreading an ad in a local paper about
caring or the dying at home. I ound
it and cut it out. Clare was still at
home then and I thought it might be
something or her to look at later on.
Im glad I did that because it led to
things down the path that I would never
have imagined. I never had a lot o
support when my husband
was sick. (FG 1)
In many ways it seems that the role HOME
Hospice played was as a saety net: people
knew they existed, that an organisation
was there that actively supported dying at
home, and this gave carers and the networks
permission and condence to undertake the
caring tasks: I think people get rightened and
dont realise they have that option. I knew I did
because Id spoken to HOME Hospice (FG 2).
One carer especially appreciated the strength
they developed rom just knowing HOME
Hospice was there, combined with thephysical presence o the mentor:
HOME Hospice also provided inormation
people ound useul to use at home, in their
own time:
Determined to cope without
getting help: Barriers to forming
care networks
Despite the almost universal recognition
among participants that staying connected
was essential or carers and the dying person,
we did identiy a number o barriers to caring
networks being established or being able to
unction. Some people were determined to
cope, earing the judgement o others i they
asked or help. An experienced mentor said:
What I noticed was the universal reluctance to
ask or help ... perceptions o what that might
mean in negative terms about ... their ability
to care suciently (M5). Tis could leadto people wanting todo: it all himsel and
he ound it really hard (M4). In one group
people had been oered help but the amily
resisted:people coming into the house when
your husbands not well (FG 6). Tis could be
compounded by carers narratives o privacy:
were private people. We dont believe in running
over there and going in the house and then
run over here and come into this one. We say,
Gday, and thats it (FG 4), or being proud:
people are there but its that accepting o their
help or eeling proud or not eeling proud Im
ne, Im ne(FG 4). Or it could be that
people who want to help dont know what to
do, or how to oer support:people dont know
how to deal with you when you are dealing with
a situation like this. Friends dont know how to
support you or what to say (FG 6).Where the
people being cared or at home were elderly,
their riends and neighbours were oten also
elderly, which could mean that they: were
supportive but ... not in good health, but they
were morally supportive but couldnt physically
help out(M3). One or any combination othese reasons led to one o our ocus group
participants asking: so what do you do ...
you pull back, but then that leads to a sense o
isolation as well(FG 6).
We have included this small section here as
it is important to recognise potential barriers
to being connected and receiving help while
caring or someone. It is a small section as
this was not a strong theme. Te majority o
participants were part o a caring network
and did ask or, give and/or receive support.
Tis was to be expected as the design o our
research was such that we purposeully sought
to speak to people who had been part o a
network o support.
Theme 3: The ordinary becomesthe extraordinary: Everyone doing
a little bit makes a broad and
strong net (FG 3)
There are some things that you can
give away. You can give away a task ...
No matter how much support you have,
some things you are compelled to do
or yoursel and thats where the load
comes. So being able to give away
some things reduces that. Cos i youre
trying to carry everything ...(FG 1)
Then I looked or help and ound
HOME Hospice at that time my GP
recommended that I might be able
to get their help. So I had support
and the old books that came with
that to read about preparing or
dying and how to care or someone.
Armed with those I managed to care
or Mum until she died at home,
which was a great experience or
everybody: her amily and me,
and it was our rst experience, but agreat one. (M3)
We had loads o networks. I think
thats why we didnt use our HOME
Hospice mentor very much because
we had this very strong inner core
group more amily than anything
else and then we had the outer core
group. They werent really outer
they were still very close the mums
rom school, parents like that.
Then we had the Internet:
cyberspace calls.(FG 2)
In act, when HOME Hospice came
on the scene and I understood
their philosophy and rationale it
was also a great comort because
their avowed purpose was to assist
people to continue having the
support and encouraging others, i
you like, to support us like riends
and amily to come in and be
part o the amily. That just gave
me a great deal o heart, and as
things did get harder and harder
I just ound it this might seem
paradoxical or strange but in one
sense it was easier coping at home
because I had help where it was
needed, but there was a lot o timewithin that 24-hour day, even though
we had carers coming in at various
times, there were still many, many
hours consecutively where I was
able to cope, I elt at the time and
Ive not changed my opinion very
eectively. (C1)
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Practical stu mainly, such as sitting
with someone talking to them, cooking,
cleaning, mowing the lawns, doing the
running around, taking the children,
making phone calls, which is huge I
think, to stop the carer rom having
to constantly reiterate ... What else?
Taking them to and rom hospital,
sitting with them so the carer can get
out and have a coee. Whatever it be
anything. (M2)
At the outset o this research we believed it
important to operationalise caring. Tere is
literature that tells us what primary carers
do (see Zapart et al, 2007) but we were
particularly interested in what the caring
networks did. What did riends, amily,
neighbours and work colleagues actually do?
We believe this is important inormation. I
people are to help, then it is useul to know
what people nd helpul. I people are to
resist being isolated as they care or someone,
then what are the tasks people do to help
them resist this?
Initially it was dicult to get the caring
network to talk about what they did to
help, with comments such as I did nothing
orJulie (carer) was extraordinary (FG 1).
We wondered i this hesitation was due to adeep respect and admiration or the primary
carer; a desire not to diminish the work the
carer had done, or a eeling that what other
individuals had contributed was insignicant
compared to the overall work o the carer.
Oten it took the carer to begin to discuss the
tasks they had ound helpul and/or the tasks
o the caring network became apparent in the
discussion o the photographs. Eventually we
elicited narratives o caring in which the tasks
people did to support the dying person, the
primary carer and amilies, emerged. Overall
the narratives showed that the tasks o caring
were as diverse as the number o people in the
research. Tis cannot be overemphasised, with
people saying: everyone dies diferently and has
diferent needs (M3), and: its no good telling
them to meditate when a good bottle o wine
is what they need (M3). We ound that while
there was a wide diversity o tasks, there were
also some commonalities. Food, or example,
cropped up in every discussion. Penguins in
only one!
What the networks did: The tasks
of caring
While we wish to provide a sense o the
breadth o tasks people engaged in, we want
to avoid presenting lists that could be slightly
tedious. However we, and the participants,
believed that the concrete things people did
to help provide important inormation or
carers and caring networks. So, with a desire
to be both interesting and useul, we have
chosen to present this section in the
ollowing ways:
Te photographs illustrate tasks that people
chose to talk about. We have not been able
to include all o them, but we have included
those that cropped up the most oten or
discussion.
We have included quotes where people
refect upon these tasks or quotes that
encapsulate the commonalities or dierences
in the ocus groups and interviews.
We then go on to discuss the theme o
lie goes on, which people spoke about in
relation to why they provided support, and
what they were hoping to achieve.
33
She didnt need massage
or meditation lessons, she
needed rewood. (M3)
With the jug Mum used
to love a cup o tea thats
why ... wed get the jug on
and make a cuppa. (FG 4)
Like, the postie brought us themail ... hed just hop o his bike
and come to the door because
the door was open so that was
the mail one. Then my sister-in-
law would come down and do
the washing, the vacuuming,
eed the cats ... Games
playing board games. (FG 5)
I drove him to therapy because they told him he shouldnt drive ater chemo. A couple o times
I took him there and drove him back ... I did a lot o driving with them while Mum was with Dad.
Took on a bit o responsibility driving the car around. Thats why I chose the keys. (FG 2)
Their amilies were amazing. I Sharon ever needed taking
anywhere or brought back I never had to think about lits
there were people who would magically appear to erry her
around without me having to ask.(FG 2)
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Well, obviously whenMark spends Tuesday and
Wednesday with us, it gives
Grace and Barry time to go
dancing in the evening or just
have a rest, do whatever they
have to do. (FG 3)
Id just like to thank our builder up
here too. Hes not only a wonderulriend but has put wheels on the
billiard table, a door down the back,
built the veranda. (FG 2)
Yeah. Well, I came to be with
him ... but in terms o what I
can do, I can be with that sort
o process with the person
and just be totally present with
whats happening. (FG 8)
Practical stu mainly, such as sitting with someone
talking to them, cooking cleaning, mowing the lawns,
doing the running around, taking the children, making
phone calls, which is huge I think, to stop the carer
rom having to constantly reiterate ... Taking them to
and rom hospital, sitting with them so the carer can
get out and have a coee. ... Anything. (M2)
Life, in a sense, just continued on
(C1): Keeping things normal
Even though the work o caring could be
hard, or there has been a shitty result today
(FG 2), the caring network most oten saw
their role as striving to keep lie as normal
as possible, or business as usual with a ew
modications (FG 3), or carers and
amilies. Te ollowing dialogue illustrates
this well:
Tis striving or normality in the most
extraordinary circumstances was also seen as
important or the dying person: I think she
wanted to eel normal as well(FG 9).
She still had contact with the real
world because she would want to know
what we were having or dinner, what
went on in the kitchen. Were her boys
being ed and who was bringing what,so ... it gave her normality. She could
still be the mother o the house. (M3)
One person even elt that this normality
contributed to the person living longer than
expected:
Pat: Gina has more activities per
square inch than any child Ive
ever known.
Arthur: Thats the heart o the
amily too. Youve got to give
Jude time as well and youve got
to keep Ginas normal lie still
unctioning.
Pat:All those lovely people who
used to take Stuart to woodwork
classes, bowling.
Liz: It was marvellous that things
were really good.
Arthur: Just keeping the ball
rolling. We did the cricket because
Stuart was a big cricket an and
all the rest o it. We helped Gina
with homework numerous
assignments and dierent
challenges ... and cooking, groceryshopping, things like that. Wed
just go and buy bags o groceries
and bring it down. (FG 5)
Stuart lived a lot longer than
everyone expected and I think
thats because o that normality and
riends dropping in. (FG 5)
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act that Id give almost anything or
Stuart to still be here and hes not, but
still it has been a joy. (FG 5)
It would be tempting to think that talking
about eelings could be idealised and perhaps
even sentimentalised. We did not nd this.
Te quotes above show what we ound:people were able to talk about their eelings
in a way that captured the positives and
negatives; there was a joy and grey hollow.
No participant said it was easy. But they did
speak about the deeply proound nature o
their experiences. When participants spoke o
their eelings in being with the dying person
they said they elt: incredibly