Mechanisms by which end-of-life communication influences palliative-oriented care in nursing homes: A scoping review

Developing a question prompt list for family caregivers concerning the progression and palliative care needs of nursing home residents living with dementia

Objective

Communication around a palliative approach to dementia care often is problematic or occurs infrequently in nursing homes (NH). Question prompt lists (QPLs), are evidence-based lists designed to improve communication by facilitating discussions within a specific population. This study aimed to develop a QPL concerning the progression and palliative care needs of residents living with dementia.

Methods

A mixed-methods design in 2 phases. In phase 1, potential questions for inclusion in the QPL were identified using interviews with NH care providers, palliative care clinicians and family caregivers. An international group of experts reviewed the QPL. In phase 2, NH care providers and family caregivers reviewed the QPL assessing the clarity, sensitivity, importance, and relevance of each item.

Results

From 127 initial questions, 30 questions were included in the first draft of the QPL. After review by experts, including family caregivers, the QPL was finalized with 38 questions covering eight content areas.

Conclusion

Our study has developed a QPL for persons living with dementia in NHs and their caregivers to initiate conversations to clarify questions they may have regarding the progression of dementia, end of life care, and the NH environment. Further work is needed to evaluate its effectiveness and determine optimal use in clinical practice.

Innovation

This unique QPL is anticipated to facilitate discussions around dementia care, including self-care for family caregivers.

Timing of Goals of Care Discussions in Nursing Homes: A Systematic Review

OBJECTIVES

Discussions between health professionals and nursing home (NH) residents or their families about the current or future goals of health care may be associated with better outcomes at the end of life (EOL), such as avoidance of unwanted interventions or death in hospital. The timing of these discussions varies, and it is possible that their influence on EOL outcomes depends on their timing. This study synthesized current evidence concerning the timing of goals of care (GOC) discussions in NHs and its impact on EOL outcomes.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Adult populations in NH settings.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Embase, and Cumulative Index of Nursing and Allied Health from January 2000 to September 2022. We included studies that examined timing of GOC discussions in NHs, were peer-reviewed, and published in English. Quality of the studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

Screening of 1930 abstracts yielded 149 papers that were evaluated for eligibility. Of the 18 articles, representing 16 distinct studies that met review criteria, 12 evaluated the timing of advance directives. There was variation in the timing of GOC discussions and compared with discussions that occurred within a month of death, earlier discussions (eg, at the time of facility admission) were associated with lower rates of hospitalization at the EOL and lower health care costs.

CONCLUSIONS AND IMPLICATIONS

The timing of GOC discussions in NHs varies and evidence suggests that late discussions are associated with poorer EOL outcomes. The benefits of goal-concordant care may be enhanced by earlier and more frequent discussions. Future studies should examine the optimal timing for GOC discussions in the NH population.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

Implementation, barriers, and recommendations for further development of advance care planning for the last phase of life in nursing homes in Germany (Gut-Leben): protocol for a mixed-methods study

BACKGROUND

Nursing home entry often marks the transition into the end-of-life. In 2018, Germany legally introduced reimbursement for advance care planning (ACP according to § 132 g SGB V) in nursing homes that applied for ACP approval to improve end-of-life care. The Gut-Leben project aims to evaluate the implementation and barriers of ACP in nursing homes in Germany, with a special focus on the federal state of Lower Saxony, and provide practical recommendations for further development of end-of-life care.

METHODS

This mixed-methods study spreads across five work packages (WP) over a three-year period. WP 1 will explore the approval process, implementation, and barriers to ACP in nursing homes. Data will be collected through a national postal survey in a random sample of n = 600. WP 2 will explore whether documented ACP reports are applicable as a data source for research (expecting up to 500 available ACP reports). In WP 3a and 3b, data on the ACP process will be collected in n = 15 approved nursing homes in Lower Saxony over a 12-months period. For WP 3a and WP 3b, data on ACP conversations (n = 600) and on end-of-life care paths (n = 300) will be collected by facilitators and nurses of the respective nursing homes. In WP 4, residents' characteristics upon entry and changes in these characteristics over the length of stay are analyzed, utilizing claims data from the AOK Lower Saxony (expected sample of about 100,000 people entering nursing homes over a 10-years period). WP 5 connects, interprets, and reflects on the findings from WP 1-4 through focus groups and individual interviews with facilitators, nursing staff, residents, relatives, and care providers. Within a participatory approach, a practice advisory board will be set up existing of personal of nursing homes and will be closely involved in the whole research process.

DISCUSSION

In summary, the Gut-Leben project provides insight into the implementation and barriers of ACP in nursing homes according to German legislation for the first time, including practitioners' and residents' perspectives. Insights will help the further development of ACP in Germany through practical recommendations based on quantitative and qualitative data.

Family caregivers' experience of communication with nursing home staff from admission to end of life during the COVID-19 pandemic: A qualitative study employing a transitional perspective

OBJECTIVES

Family caregivers' (FCs) caregiving in nursing home (NH) moves across 3 main phases: transitioning relatives to long-term care, worsening of a relative's conditions, and end of life; each phase brings specific challenges that FCs must confront. Moreover, during the COVID-19 pandemic, strict mandatory visitor restrictions affected communication modalities. This study explored FCs' experience of communication with NH staff during the COVID-19 pandemic from admission to end of life.

METHODS

A descriptive qualitative study with inductive content analysis was performed in 7 Italian NHs from May to June 2021. NH managers purposively identified 25 FCs at different phases of their caregiving trajectory: transitional (i.e., admission in the previous 8 weeks, n = 8), deterioration-in-condition (i.e., acknowledged changes in care needs of their relative after trigger events, n = 10), and end-of-life phase (i.e., death expected in the next weeks or a few months, n = 7), who were interviewed.

RESULTS

Regardless the phase of caregiving trajectory, what mattered most to FCs was the opportunity to have regular and sensitive discussions with health-care professionals. The need of in-person communication increased nearing death. The COVID-19 pandemic enhanced FCs' need to interact with health-care professionals they trusted. Knowledge of residents' preferences mitigated FCs' turbulent emotions throughout the overall caregiving trajectory.

SIGNIFICANCE OF RESULTS

Findings suggest that in-person contacts should be prioritized and facilitated when possible, particularly at the end of life; nonetheless, meaningful communication can occur also through remote modalities. Investments in training health-care professionals about effective long-distance communication and supportive skills can help trusting relationships to be established. Open discussions about residents' care preferences should be encouraged.

Lived experiences of end-of-life communication among nursing home staff: An interpretive phenomenological study

AIMS

To explore and understand lived experiences of end-of-life communication among nursing home staff.

DESIGN

Interpretive phenomenological study.

METHODS

In-person, semi-structured, in-depth interviews were conducted from May to August 2021 with 21 nursing home staff members involved in end-of-life communication (four managers, four chief nurses, three chief medical officers, three nurses, three psychologists, two occupational therapists, one chief nurse aide and one nurse aide). Data were analysed by van Manen's hermeneutic approach, which uses the lifeworld existentials of spatiality, corporeality, temporality and relationality to guide reflection on the human experience. Data were reported according to the Consolidated Criteria for Reporting Qualitative Research.

RESULTS

Thirteen categories were identified and framed within the four existentials. Regarding spatiality, end-of-life communication took place in a physical, mental, socio-cultural and professional competence space. With regard to corporeality, interviewees reported difficulties in managing their own feelings and those of family caregivers. For temporality, interviewees reported delays in end-of-life communication due to staffing issues and an increase in urgent and temporary relief admissions to nursing homes. To compensate, they tried to assure that all interactions that did take place were of high quality. Finally, with regard to relationality, interviewees lived end-of-life communication through their relationships with family caregivers and colleagues. The supportive role of colleagues was expressed as teamwork, which helped promote reflexivity about how to tailor communication, manage challenging emotions and situations, set aside time for communication, and prepare family caregivers for death.

CONCLUSION

End-of-life communication was an all-encompassing experience for nursing home staff. The supportive role of colleagues was stressed across all existentials, suggesting that teamwork is essential in delivering effective communication at the end-of-life.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to this study, which addresses the experiences of nursing home staff only.

A Situation-Specific Theory of End-of-Life Communication in Nursing Homes

High-quality end-of-life communication between healthcare professionals (HCPs), patients and/or their family caregivers (FCs) improves quality of life and reduces non-beneficial care at the end of life. Nursing homes (NHs) are among the contexts at the forefront of these conversations. Having a solid theoretical basis for the role of end-of-life communication in NHs in transitioning to palliative-oriented care can offer indications for research, practice, education, and policy related to geropalliative care. This study aimed to develop a situation-specific theory of end-of-life communication in NHs by refining an existing theory. A four-step integrative approach was employed that included: (1) checking the assumptions for theorization; (2) exploring the phenomenon through multiple sources; (3) theorizing; and (4) reporting. All elements of the existing end-of-life communication theory in NHs were confirmed: end-of-life communication improved the understanding of FCs about their relatives' health conditions, shared decision-making, and reflections on the desired preferences of residents/FCs for care at the end of life. Furthermore, the family environment affected the burden of FCs in the decision-making process. Finally, time and resource constraints, regulations, visitation restrictions due to the COVID-19 pandemic, and social and cultural values influenced the quality and timing of communication. The study findings confirmed the impact of the political, historical, social, and cultural context on end-of-life communication, thus providing the basis for a situation-specific theory.

Registered Nurses’ Experiences of End-of-Life Care in Nursing Homes of South Korea: A Qualitative Study

This study aimed to qualitatively describe how registered nurses (RNs) experienced and perceived end-of-life (EOL) care for older residents in South Korean nursing homes. The participants included 11 nurses with experience of providing EOL care for older residents in six nursing homes. Data were collected through one-on-one in-depth interviews using semi-structured questions from 27 December 2019 to 22 October 2020. Around 1–2 interviews were conducted for each participant, and each interview lasted between 40 min and two hours. The interview data were analyzed using qualitative content analysis. Eight sub-themes were identified and abstracted under three themes: (a) “feeling fulfilled for doing my best until the last day,” (b) “defensive coping due to legal and institutional limitations,” and (c) “requirements for effective EOL care.” This study suggests that there are many challenges and issues regarding EOL care at nursing homes. In order to provide effective EOL care to older residents, the foundation of the EOL care system, as well as skills training, should be strengthened. Furthermore, securing qualified nursing manpower and achieving institutional improvement by reducing obstacles are warranted.

Family-oriented interventions in long-term care residential facilities for older people: A scoping review of the characteristics and outcomes

INTRODUCTION

Family-oriented interventions in long-term care (LTC) residential facilities are heterogenous in design, characteristics, and outcomes.

OBJECTIVES

To synthesize characteristics (e.g., type, provider, and duration) and outcomes of family-oriented interventions in LTC residential facilities.

METHODS

We followed the JBI methodology and searched seven databases for quantitative, qualitative, and mixed method studies that reported family-oriented interventions in LTC residential settings for older people; defined in this review as ≥60 years. Interventions that included residents, resident families, health professionals, or any combinations of these three were included if the study reported post-intervention assessment of at least one family-related outcome.

RESULTS

Thirteen studies met the inclusion criteria. Interventions were found to be multifaceted, and education was the most common element. Nurses were the most common intervenors, and most interventions had more than one target (residents, resident families, or staff). Most outcomes were related to family involvement, satisfaction with care, quality of life, communication, symptom management, and shared decision making, and none of the studies reported a negative impact.

CONCLUSIONS

Family-oriented interventions were associated with high care quality and better resident-staff-family partnership. Staff education and staff-family conversation are relatively cheap interventions to help family involvement, facilitate shared decision-making, and improve family satisfaction.

Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions

OBJECTIVES

Intensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs).

DESIGN

Cross-sectional analysis.

SETTING AND PARTICIPANTS

1449 NHs.

METHODS

Nationwide 2016-2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR.

RESULTS

In high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH.

CONCLUSIONS AND IMPLICATIONS

These findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.

Interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes: A mixed-methods systematic review

BACKGROUND

Most people with dementia transition into nursing homes as their disease progresses. Their family caregivers often continue to be involved in their relative's care and experience high level of strain at the end of life.

AIM

To gather and synthesize information on interventions to support family caregivers of people with advanced dementia at the end of life in nursing homes and provide a set of recommendations for practice.

DESIGN

Mixed-Methods Systematic Review (PROSPERO no. CRD42020217854) with convergent integrated approach.

DATA SOURCES

Five electronic databases were searched from inception in November 2020. Published qualitative, quantitative, and mixed-method studies of interventions to support family caregivers of people with advanced dementia at the end of life in nursing home were included. No language or temporal limits were applied.

RESULTS

In all, 11 studies met the inclusion criteria. Data synthesis resulted in three integrated findings: (i) healthcare professionals should engage family caregivers in ongoing dialog and provide adequate time and space for sensitive discussions; (ii) end-of-life discussions should be face-to-face and supported by written information whose timing of supply may vary according to family caregivers' preferences and the organizational policies and cultural context; and (iii) family caregivers should be provided structured psychoeducational programs tailored to their specific needs and/or regular family meetings about dementia care at the end of life.

CONCLUSION

The findings provide useful information on which interventions may benefit family caregivers of people with advanced dementia at the end of life and where, when, and how they should be provided.

The role of end-of-life communication in contributing to palliative-oriented care at the end-of-life in nursing home

BACKGROUND

Clear communication about a person's poor prognosis and limited treatment choices improves the quality of end-of-life care.

AIMS

To investigate how end-of-life communication may contribute to palliative-oriented care at the end-of-life in nursing homes according to both families' and nurses' perspective. Secondly, to identify the contextual factors internal to the nursing home that may influence the timing and quality of communication. Thirdly, to confirm the foundations for a first theory of end-of-life communication.

METHOD

This study is a descriptive two-tailed embedded multiple-case study. A secondary analysis of 23 family carer-nurse paired interviews was performed.

FINDINGS

Several contextual factors influenced the timing and quality of communication that, in turn, impacted end-of-life care by promoting family understanding, fostering shared decision-making between healthcare professionals and resident/family carers, and improving the knowledge of residents' and family carers' preferences (ie drivers of transition towards palliative-oriented care). Family carers' preferences had the strongest influence in guiding the care approach, while residents' preferences were poorly known and had a limited impact on the end-of-life care goal. Complex and dynamic interactions within and between drivers and contextual factors emerged, providing preliminary evidence for a first end-of-life communication theory.

CONCLUSION

Findings suggest the need to promote a familiar atmosphere and quality relationships, and improve the knowledge of a resident's preferences to ensure that end-of-life care is consistent with their desires.

Educational needs in palliative care of Primary Health Care nurses

ABSTRACT Objectives: to understand the experience of Primary Health Care nurses with palliative care and their educational needs on the topic. Methods: an exploratory study, with a qualitative approach. The data was collected through 19 focus groups involving 181 nurses. In interpreting the results, the thematic analysis was used. Results: the knowledge presented by nurses in palliative care proved to be limited. Gaps were identified in the definition of palliative care and in the philosophical principles that guide it. The experiences described highlighted the need for continuing education regarding the definition and philosophy of palliative care, patient eligibility, integral care to the patient and the family, interpersonal communication and difficult news, performance in a multi-professional team, and end-of-life care. Final Considerations: the analysis of the perceptions of Primary Health Care nurses about palliative care can help identify the obstacles to improving the provision of this care modality.

Communicating With Nursing Home Residents About End of Life

Approximately 33% of the 1.2 million older individuals residing in nursing homes have the capacity to discuss their preferences for end-of-life care, and 35% will die within their first year in the nursing home. These conversations necessary to promote care consistent with the resident's preferences are often limited and most often occur when the resident is actively dying. The purpose of this secondary analysis was to understand the resident's perspectives on end-of-life communication in the nursing home and suggest approaches to facilitate this communication. We interviewed 46 participants (16 residents, 10 family members, and 20 staff) in a Southeast Florida nursing home from January to May 2019. The data were analyzed using descriptive and pattern coding and matrices to decipher preliminary categories and thematic interpretation within and across each participant group. Two themes emerged from this secondary analysis that residents assume others know their end-of-life preferences, and past experiences may predict future end-of-life choices. Residents and family members were willing to discuss end-of-life care. Study findings also suggested that past experiences with the end-of-life and critical illness of another could impact residents' and family members' end-of-life care decisions, and that nurses' recognition of subtle signs of a resident's decline may trigger provider-initiated end-of-life conversations. Future research should focus on strategies to promote earlier end-of-life discussions to support independent decision-making about end-of-life care in this relatively dependent population of older adults.

End-of-life discussions in residential care homes improves symptom control: a national register study

BACKGROUND

In Europe, residential care homes (RCHs) rather than hospitals are the most common care facilities for the older adult and the place where most deaths occur in this age group. There is a lack of knowledge regarding end-of-life (EOL) discussions and how they correlate with symptoms and symptom relief.

OBJECTIVE

The aim was to examine the correlation between EOL discussions and symptom occurrence, symptom relief and prescriptions or PRN drugs against symptoms for care home residents.

METHODS

All expected deaths at RCHs from 1 October 2015 to 31 December 2016 and registered in the Swedish Register of Palliative Care were included. Univariate and multivariate logistic regression were used to compare the RCH residents, or their family members, who had received documented EOL discussions with a physician (the EOL discussion group) and the non-EOL discussion group.

RESULTS

The EOL discussion group (n=17 071) had a higher prevalence of pain, nausea, anxiety, death rattles and shortness of breath reported, compared with the non-EOL discussion group (n=4164). Those with symptoms were more often completely relieved and had more often been prescribed PRN drugs against that symptom in the EOL discussion group. All differences remained significant when adjusting for age, time living in unit and cause of death.

CONCLUSION

The results indicate that EOL discussions are correlated with higher prevalence of symptoms, but also with better symptom relief and prescription of symptom drugs PRN when symptomatic. A possible explanation for this is that the EOL discussion can work as an opportunity to discuss symptoms and treatment for symptom relief.

Qualitative research on end-of-life communication with family carers in nursing homes: A discussion of methodological issues and challenges

Aim

To identify and summarize the challenges of conducting qualitative research exploring end-of-life communication between healthcare providers and bereaved family carers in nursing homes.

Design

A descriptive qualitative study based on in-the-field-notes and research diaries collected during a primary study involving 32 bereaved family carers and 14 nurses across 13 Italian nursing homes in 2018-2019.

Methods

Two trained female nurses conducted semi-structured, in-depth, open-ended interviews and recorded "in action" (i.e. reflections reported as in-the-field-notes) and "on action" (i.e. retrospective reflections within the team reported immediately in the research diaries) narratives, with the aim of identifying challenges encountered during the research process. A content analysis process was performed to analyse the narratives collected.

Results

We identified three major categories of challenges: (a) obtaining approval from the ethical committee; (b) approaching nursing homes and family carers; and (c) dealing with participant-related impairments (i.e. memory, emotional, physical).

What contributes to family carers' decision to transition towards palliative-oriented care for their relatives in nursing homes? Qualitative findings from bereaved family carers' experiences

OBJECTIVES

Family carers (FCs) of nursing home (NH) residents are best placed to notice deteriorations that signal impending death in their relative, which can open a conversation with healthcare professionals (HCPs) about adjusting the care plan. We explored contributors to bereaved FCs' decision to transition towards palliative-oriented care for their relatives in NHs.

METHODS

This qualitative descriptive study used a phenomenological design. Thirty-two bereaved FCs across 13 Italian NHs completed semi-structured interviews. Additional data were collected on NH referrals to palliative care services (PCS) in the 6 months before study start and treatments provided in the last week of life. Content analysis with a combined inductive and deductive approach was applied to identify codes and fit them into an a priori framework. When codes did not fit, they were grouped into new categories, which were finally gathered into themes.

RESULTS

FCs reported four types of "trigger events" that made them doubt that their relative would recover: (1) physical deterioration (e.g., stopping eating/walking or swallowing problems); (2) social confirmation (e.g., confirming their relative's condition with friends); (3) multiple hospitalizations; and (4) external indicators (e.g., medical examinations by external consultants). A "resident-centered environment" helped FCs recognize trigger events and "raise awareness of the possibility of death"; however, the "need for reassurance" was pivotal to a "gradual transition towards palliative-oriented care". When participants did not recognize the trigger event, their relative continued to receive curative-oriented care. NHs that referred residents to PCS discussed palliative-oriented care more frequently with FCs, had a lower nurse-to-resident and nurse aide-to-resident ratio, and administered more palliative-oriented care.

SIGNIFICANCE OF RESULTS

Trigger events represent an opportunity to discuss residents' prognosis and are the starting point for a gradual transition towards palliative-oriented care. Adequate staffing, teamwork, and communication between FCs and healthcare professionals contribute to a sensitive, timely shift in care goals.

A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home

BACKGROUND

With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable healthcare professionals to gather information about the resident's wishes for care at the end-of-life and organise the care plan accordingly.

AIM

To explore nurses' perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents.

DESIGN

A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semi-structured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted.

RESULTS

Twelve themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses' perspective. Five antecedents (i.e. life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e. healthcare professional-resident and healthcare professional-family carers communication, knowledge of family carers' preferences, knowledge of residents' preferences, family carers and residents understanding, and shared decision-making), while curative-oriented and palliative-oriented care goals emerged as consequences.

CONCLUSION

This study provides insight into the nursing perspective of end-of-life communication between healthcare professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition towards palliative-oriented care by using and improving knowledge about family cares' and resident's preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision-making.