*4.3. Nearing Death: Intensification of Ritualization*

Mr. Bakker was only a few days at the hospice when his condition deteriorated rapidly and palliative sedation was started. His family was very involved and stayed with him most of the day. During the night, they went home to get some rest. At the start of the morning shift, one of the nurses went to care for Mr. Bakker. She explained that she always tried to attend to patients in the dying phase first, before the family would come, so she would not have to disturb them later. Mr. Bakker was in the final phases of life but the nurse felt it was important to give him a quick bed bath to freshen up. She did not want to add any stress or discomfort to the situation so she only washed the body parts she could reach without having to manipulate the body too much. The nurse noticed that his shirt was wet from sweating and doubted whether she should change it. After thinking about it, she decided to change the shirt. Mr. Bakker opened his eyes and made noises breathing in the process of changing the shirt, signaling discomfort, so the nurse tried to work as subtly as she could. Eventually, the nurse turned him on his side and positioned him comfortably using pillows. On the pillow, the nurse placed a towel to collect the occasional mucus escaping from the mouth. After caring for Mr. Bakker, the nurse paid close attention to tidying up the room. She placed the bed in the middle of the room and a chair next to the bed. The bedside table, decorated with pictures of family, was now located on the opposite side of the bed so she relocated it facing towards Mr. Bakker. On the dresser the nurse saw a bracelet Mr. Bakker used to wear and a rosary; she placed both in front of the pictures on the bedside table. When asked why she did that, she could not really explain. She stated that she always does those things because it makes her feel good to do so. She also stressed that she would not place items in the bed with the patient unless she is sure a patient has a strong connection to the items.

This situation is an example in which the state of liminality is changing because the transition to death is near. The experienced intensity and importance of the situation is expressed and marked by high degrees of ritualization and multiple layers of interpretation. In this situation, the nurse enacts the hospice ideal of a good death. In a stylized way, she washes away traces of bodily distress, making sure the client appears to the family as clean and calm. She deliberately places the bedside table with the pictures, bracelet and rosary near the patient. These objects are symbols of what is important to the patient, and by placing them, the nurse acknowledges that. By paying attention to the placement of objects in the room, she also expresses her acknowledgment of Mr. Bakker as a unique person, not just a patient who can be anybody. To a certain degree, the situation is also repetitive and standardized. Although the nurse tailors her care to the needs of this individual person, she also acts in a way that is common for healthcare professionals in the dying phase. They do not simply act this way because it is routine but because it is considered meaningful to both themselves and to the patient and his family. The practice of giving the patient a superficial bed bath in the dying phase is not purely instrumental but mostly symbolic. It is about respecting the integrity of the body, the value that is attributed to the person and the life he lived and the value that is attributed to the dying process.

Ritualization in this situation has a prophylactic function—it helps both the nurse and the family to cope with the situation. It is a way for the nurse to deal with the imminent loss of the patient. She also attempts to help the family cope by making the patient appear as dignified as possible, clean and seemingly calm. Ritualization is also expressive in this situation. Through her actions, the nurse communicates that she values Mr. Bakker as a person and values his process towards a good death.
