JOURNAL OF PALLIATIVE MEDICINE

Volume 18, Number 5, 2015

Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2014.0316

Conversations about End of Life:

Perspectives of Nursing Home Residents,
Family, and Staff

Gail L. Towsley, PhD, NHA,1 Karen B. Hirschman, PhD, MSW,2 and Connie Madden, RN, MS1

Abstract
Background: Care in nursing homes (NHs) often overlooks individual values and preferences. Residents
voices are critical to discussions about preferences, yet there remains limited research on conversations about
the end of life (EOL) from the perspective of older adults who reside in NHs.
Objective: The aim of this study was to describe the communication, content and process, related to EOL
conversations among residents, family, and staff.
Methods: We used semistructured interviews in this qualitative, descriptive study to describe conversations
about EOL preferences. We examined participants conversation, when it occurred, and what was discussed.
We queried about barriers to and facilitators in discussing EOL care in the NH setting. We interviewed residents
(n = 16), family (n = 12), and interdisciplinary staff (n = 10) from four NHs.
Results: The overarching thememissed conversationsdescribes EOL-related communication. Residents,
families, and staff rarely talked about EOL care preferences, nor did they pass along information about
preferences or initiate conversations about EOL care with each other. Three categories explained missed con-
versations: inquiry (No one asked); assumptions (presence of an advance directive [AD], They know me);
and conveying (lack of conveying information or wishes). Existing barriers and lacking facilitators resulted in
missed opportunities to hold conversations about EOL preferences.
Conclusions: Not all residents wanted to have conversations, but many wanted to be asked about their pref-
erences. Missed conversations may adversely affect the quality of EOL care. Conversations with residents can
be initiated by asking residents who they would like involved in the conversation and drawing upon the
experience of others.

Introduction health care system, symptom experience, and both current

and end-of-life (EOL) care preferences, yet rarely happens in

A bout 1.4 million adults age 65 and older reside in

nursing homes (NHs),1 and an increase in the percentage
of people who die in NHs is anticipated.2 NHs are unique
depth. Even when advanced care planning was emphasized,
protocols for discussions about when a patients health care
wishes should be planned for or recorded were nonexistent.8
settings; they serve as places of both residence and care. When wishes were recorded, documents often were not in
Residents often have multiple chronic conditions, need as- agreement with the residents verbal wishes.9 Fosse and
sistance with activities of daily living, and the NH is often the colleagues (2014)10 found in their review of EOL experi-
last place they receive care.35 Knowing resident preferences ences that residents wanted to be involved in EOL related
is essential to providing high-quality care. Palliative care, choices, but family and staff did not always recognize resi-
specifically, is a person-centered model that integrates indi- dent preferences or ability to consent to preferences.10
vidualized physical and psychosocial care to enhance quality Research indicates quality of care in NHs is subopti-
of life for individuals and families.6,7 mal, with deficits in staff training, symptom management,
Person-centered care is fundamental in palliative care and treating residents with dignity and respect, and communica-
includes heightened exchange of information about the tion.1113 Few NHs have systematic approaches to elicit and

1
University of Utah College of Nursing, Salt Lake City, Utah.
2
University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania.
Accepted December 22, 2014.

421
422 TOWSLEY ET AL.

communicate information about resident preferences;14 Methods

therefore staff may be unaware of resident preferences for For this qualitative, descriptive study we used semistructured
EOL care. During care preference discussions, surrogate interviews to describe communication (content and process)
decision makers perspectives often overshadowed residents and barriers to and facilitators for conversations about EOL
perspectives.15 Research has primarily relied on family and preferences from the perspective of residents, family, and
staff reports and resident perspectives are generally unrep- staff. The University of Pennsylvania institutional review
resented. board reviewed and approved this study.
Approximately 19%40% of residents have completed a
living will or health care power of attorney.1618 Upon NH Sample
admission, residents and/or families are notified of facility
policy regarding advance directives (ADs);19,20 however, we Residents, family members, and interdisciplinary staff
know little about conversations regarding EOL preferences. members from four NHs in southeastern Pennsylvania (three
Conversations may be unlikely to occur when residents urban, one suburban) were eligible if they were English
physical or mental conditions are stable.19 Research has speaking and able to participate in an interview per social
generally focused on completion of an AD, with data derived worker and interviewer judgment. Family participants in-
from chart reviews, family informants, and hospitalized or cluded relatives or designated surrogates. The social worker
community-dwelling older adults. Including family mem- or administrator made initial contact with potential partici-
bers, who are often the decision makers for NH residents pants and asked if the principal investigator could talk with
unable to make decisions for themselves due to impairment, them about study participation. Upon verbal agreement, met
is essential. Moreover, understanding providers perspectives or telephoned participants, set a time, and reviewed the
on coordinating and providing care is also important to com- purpose of the study and completed informed consent.
munication. Most importantly, residents voices are critical to
Measures
discussions about preferences. Advance care planning and
EOL experiences have been explored with NH residents.21,22 Semistructured interviews were conducted with residents,
Yet there remains limited research on these conversa- family, and staff to elicit information about any conversations
tions from the perspective of older adults who reside in NHs. they had participated in regarding resident/family member
Therefore, the purpose of this study was to describe the preferences for EOL care. We began by asking residents, If
communication, content and process, related to EOL con- you were sicker than you are now or at the end of your life,
versations among residents, family, and staff. We examined what is important to you? We then probed what would be
participants conversation, when it occurred, and what was important for family and staff to know, as well as what
discussed. We queried about barriers to and facilitators for psychosocial and/or physical care would be important.
discussing EOL care in the NH setting. Questions and probes (see Table 1) explored their preferences

Table 1. Questions and Probes from Semistructured Interviews

Questions Probes
If this were the last place you live and when you think Values: What do you think will be important to you in
about the end of your life, including dying, what is your final days? (physical comfort, pain control,
important to you? presence/no presence of family or friends, not thinking
What is important for those who are caring for you in the about it, not talking about it)
nursing home to know? Location of death: Where would you prefer to die?
What is important for family members and friends who Comfort: Who would you like to spend time with in your
care for you to know? final days? (family, friend, clergy, pet, caregiver)
What do you think would support or comfort you in your
final days? (being with family, friends, alone, praying
or being prayed for, singing, reminiscing, picture,
being informed about health state, expressing anger or
frustration, music, TV, pet, clergy, reading)
What conversations have you had about your final days When did the conversation occur? Did an event lead to
with family members/friends? How did you feel about the conversation?
having these conversations?
Im going to ask you to think back to when you were What did you think about that conversation? Was it a
admitted to the nursing home. When you came here, positive or negative experience for you? Why/why
what conversations did you have with [nursing home not?
personnel: SW, nurse, doctor] about what you would Were you asked about your preferences related to your
like your final days to be like? final days?
When you came to the nursing home, did nursing home [orders for resuscitation, hospitalization, comfort/
personnel ask you your preferences related to [advance palliative care]
directive]? When should conversations like this take place?
Who should be involved in these conversations?
What do you think are the challenges to talking about
ones final days? Facilitators?
CONVERSATIONS ABOUT END OF LIFE 423

and the conversational contexts: Who did you talk to? What Table 2. Sample Characteristics of Nursing Home
did you talk about? When did conversations occur? Family Residents (n = 16), Family (n = 12), and Staff (n = 10)
and staff were asked variations of the same questions and
Mean (SD) or
probes. Demographic and clinical information was collected Characteristic percentage
from residents medical record; family and staff demo-
graphics were collected during the interview. Residents
The interviewer recorded the meeting and took notes dur- Age, years (range 64100) 88.4 (8.0)
ing and immediately following interviews to document con- Gender
Female (n = 10) 62.5%
textual information, such as emotional responses, interview Male (n = 6) 37.5%
location, length, and any occurrences (e.g., interruptions). Race
Interviews were conducted face to face in a confidential African American (n = 9) 56.3%
setting, audiorecorded with permission, and ranged from 20 More than one race (n = 1) 6.3%
to 60 minutes; one family member interview lasted almost White (n = 6) 37.5%
two hours. Recordings were transcribed verbatim and re- Marital status
Widowed (n = 13) 81.3%
viewed and compared to the recording; interview notes were Education
added to the final transcript. Two interviews were not re- < 12 years (n = 3) 18.8%
corded, one due to participant preference and one due to High school graduate (n = 5) 31.3%
equipment failure. Detailed field notes were taken through- Some college or trade school (n = 2) 12.6%
out the interviews and written in transcript format immedi- College graduate (n = 4) 25.0%
ately after the interviews. Transcripts were organized and Postgraduate (n = 2) 12.5%
Days in the NHa (range 1182115) 803.19 (616.35)
managed using NVivo software version 9 (QSR Interna- Cognitive Performance Scale 0.93 (1.33)
tional, Burlington, MA). Score (n = 14) (range 05)
Family
Analysis Age, years (range 5279) 61.3 (8.5)
23 Gender
Content analysis (conventional approach) was employed Female (n = 11) 91.6%
to describe communication about EOL among residents, Male (n = 1) 0.08%
family, and staff. Following coding procedures outlined by Race
Miles and Huberman, data chunks (words, phrases) were African American (n = 5) 41.6%
organized using directed and open coding.24 To understand White (n = 7) 58.3%
Marital status
the content and process of communication we conducted Married (n = 8) 66.0%
directed coding focused on key concepts (e.g., who, what, Education
when) from our research questions. We examined aspects of High school graduate (n = 3) 25.0%
conversations based on when the conversation occurred and Some college or trade school (n = 2) 16.6%
the content of the conversation. Open and selective coding College graduate (n = 2) 16.6%
was conducted to organize categories and conceptualize di- Postgraduate (n = 4) 33.3%
Relationship to NH resident
mensions and linkages of key concepts.23,25 Research team Spouse (n = 1)
members independently reviewed two different transcripts to Child (n = 7)
verify the coding scheme and cross-checked codes and ca- Sibling (n = 2)
tegories. Team members discussed coding differences until Niece/nephew (n = 2)
consensus was obtained. A final coding scheme guided the Staff
analysis. Codes were collapsed into categories; analytic notes Age, years (range 4373) 56.4 (11.9)
delineated and described the most robust codes and cate- Gender
gories. Categories were refined to develop themes.26 Female (n = 9) 90.0%
Male (n = 1) 10.0%
Race
Data management and rigor African American (n = 3?) 30.0%
White (n = 3) 30.0%
Rigor of analysis was ensured with an audit trail doc- Marital status
umenting analytic decisions such as adding, deleting, or Married (n = 7) 70.0%
reworking code names and synthesizing categories and Education
themes.27 Members of a qualitative analysis group external to High school graduate (n = 1) 10.0%
the research team provided feedback on preliminary codes, Some college or trade school (n = 1) 10.0%
College graduate (n = 4) 40.0%
categories, and analytic decisions.28 Memos reflected ana- Postgraduate (n = 4) 40.0%
lytic deliberation and peer review (e.g., answering the ques- Staff position
tion, What is this about?)26 to dissect and confirm or Chaplain (n = 2)
redirect analytic processes taken by the investigative team. Nurse (n = 2)
Social worker (n = 2)
Admissions coordinator (n = 1)
Results Recreation therapist/activities (n = 2)
Twenty-four residents were invited to participate: seven Psychologist (n = 1)
Years worked in NH setting (range 545) 14.6 (13.3)
declined, one was ineligible; 16 agreed and provided written
consent. Fifteen family members were invited; three declined. a
Days in NH = date of admission to NH to date of interview.
Ten staff members were invited; none declined. Table 2
424 TOWSLEY ET AL.

Table 3. Reasons for Missed Conversationsa

Categories Definition Exemplar
Inquiry Conversations where residents and family were Regarding staff inquiring about EOL
asked or not asked about preferences related preferences:
to end of life. Predominantly, No one They never asked me. (family)
asked. No, I wasnt questioned at all. (resident)
Assumptions Ways residents, family, and staff believed They know: Just know her. I havent asked
resident preferences were already known her.. I know she didnt want them to suffer
(they know and presence of AD). and she wouldnt want to suffer. (family)
Presence of advance directive: I know what it
means, they [staff] know what it means.
(family)
Conveying How resident preferences related to end of life No. No, thats just confidence. Because who
were conveyed (to others). would I pass it on to? I wouldnt tell her
family and thats confidential. (staff)
a
Exchanges that did not occur or were not continued between residents, family, and/or staff related to EOL preferences of residents: who
residents talked to, what they talked about, and when they talked about it.

presents the demographic and clinical information for 16 sible party and thats Social Services. Thats not Nursing
NH residents, 12 family members, and 10 staff members. (staff). Other participants conveyed someone in the NH ob-
The overarching theme that emerged from the analyses was tains ADs upon resident admission and two staff participants
missed conversations. Barriers to and facilitators for having said the directive may be discussed at care conferences.
conversations were identified.
Assumptions. These included ways residents, family,
Missed conversations and staff believed resident preferences were already known
by others. Assumptions were based on how a person re-
The overarching theme, missed conversations, described
sponded in a previous experience, their relationship with the
EOL-related communication in this sample. Residents,
resident, or knowledge of a document, such as an AD. Two
families, and staff did not routinely, if ever, discuss EOL care
main assumptions were expressed: They know my prefer-
preferences, pass along information about preferences, or
ences and presence of an AD.
initiate conversations about preferences with each other.
They talked about current food preferences, daily activities,
They know. Many residents and families conveyed
medications/medication changes, or burial plans. Conversa-
that residents EOL preferences were known because of
tions did not commonly include discussion of a living will/
previous experiences (e.g., witnessing decisions made for
AD, preferences for code status or hospitalization, use of
another relative) and those decisions would be replicated.
hospice, or other care practices that might bring residents
They know all about me (resident). Just know her.
comfort. Interviews revealed inconsistencies in the process of
I havent asked her, but from other experiences with friends
discussing EOL treatment preferences in the NH (e.g., dis-
and my father I know she didnt want them to suffer and she
cussions held in care conference, at admission, or only if
wouldnt want to suffer (family). Some residents stated staff
resident was on hospice)and revealed inconsistencies in
would know certain preferences because of their current
staff roles (e.g., not my job). Eliciting preferences about
routines (e.g., prayer at night). Other than inquiring about
EOL was not integrated into care provision.
psychosocial activities on admission, staff did not discuss
ways they knew resident preferences. Two staff members
Reasons for missed conversations
talked about residents being like family. You just build up a
The theme of missed conversations about residents EOL relationship and you know so much about them, like you are
preferences weaves through three categories (see Table 3): part of the family (staff).
inquiry, assumptions, and conveying.
Presence of an advance directive. Residents, family,
Inquiry. Residents and families stated they were not and staff conveyed different ways resident preferences were
asked by NH staff about preferences related to EOL. They known to others (including ADs), which created the notion a
never asked me. They never asked me questions (family). conversation might not be needed. I know what it means;
Residents also reported not being asked about other EOL- they [staff] know what it means (family). Residents, family,
related preferences, such as pain management. No, I wasnt and some staff stated an AD for a resident was provided to the
questioned at all (resident). When probed if topics such as NH and could be referred to as needed. They had a guide-
code status were discussed, for example, upon admission, line (family). However, the presence of an AD did not
some family members stated, I dont remember. A few guarantee care was provided in the way families expected.
staff members reported they do not initiate conversations One family member believed because a code status form (do-
about EOL at admission because they are eliciting resident not-resuscitate order) was on file, they would not be ap-
preferences related to psychosocial activities. That wouldnt proached about intensive treatments, and when they were
be with the resident. That would usually be with the respon- approached they were surprised.
CONVERSATIONS ABOUT END OF LIFE 425

She had a Do Not Resuscitate order. And yet the hospital family, and staff. Missed conversations occurred when (1) no
called me and asked me about intubation. I said, well, she one inquiredresidents or families were not asked about
doesnt want to be resuscitated. And they said, Well, intu- their preferences related to EOL; (2) assumptions were made
bation is different than resuscitation. I was under the im- by residents, family, or staff that wishes were known; and (3)
pression that Do Not Resuscitate is just let me go (family). conveying resident information lacked a formalized process
Another family member felt their relatives living will was to converse about or share resident wishes.
not read or followed because of the intensive approaches to Asking what is important to residents corresponds with the
care. Though he had had the living will, and had it at the nationwide campaign to elicit resident perspectives in sup-
nursing home, I think he [doctor] had never read it (family). port of person-centered care.29,30 Despite providing care to
A few residents and family reported not having any type of many at EOL, NHs largely focus on rehabilitation and re-
AD (e.g., living will). storing function.31 Facilitating conversations about EOL
contradicts this focus. While a couple of staff members stated
Conveying. Another category related to missed con- certain components of preferences (e.g., AD) were revisited
versations was the lack of (mostly) conveying wishes. This in quarterly care conferences, this was not expressed ubiq-
category was influenced by the role or expectation of the uitously among staff. Residents and family reported that
person receiving information about resident preferences. other EOL preferences (e.g., symptom management, psy-
Staff opinions varied over the confidentiality of information chosocial preferences) were not discussed. Some residents
and whether it should be communicated to other staff. For one thought talking about EOL was normal but one described it as
staff member, the reluctance to convey information was negative. Perceptions concerning the normalcy of EOL21
influenced by concern for adhering to regulations (e.g., may influence willingness to have a conversation.
HIPAA). One staff member in particular shared several en- Assumptions referred to ways residents, family, and staff
counters where residents told her their wishes, but she did not believed their wishes were already known. The presence of
share the information with other staff. Even if they were part an AD may have averted conversations and created the as-
of the interdisciplinary team, the response to residents stating sumption that resident EOL preferences were known. How-
their preferences in an informal way (e.g., in the hallway), ever, ADs have limited scope:32 they have not been shown to
was, You need to put it in writing or Have you talked reduce unmet needs,18 to facilitate conversations, or to en-
with your [daughter/son]? (staff). Two staff participants hance planning for EOL.33 Staff sentiments suggested they
stated they could put information about wishes in the resi- viewed residents like family,11 which may have created as-
dents chart, and two staff explained their referral process for sumptions regarding residents preferences and confusion
sharing information with other staff if information arose between personal and professional relationships.21
during conversation. Generally, staff did not describe ways Existing literature has focused on the completion of an
they facilitated information sharing about EOL preferences. AD;17 our research has revealed that conversations around
Staff had beliefs about their role for querying or conveying the content of ADs was sparse. Similar to the finding of Fosse
resident preferences related to EOL, which influenced whe- and colleagues,10 we found residents wanted to be involved
ther resident preferences were communicated to or among the in decision making concerning care. Staff reported residents
interdisciplinary team. Conversing with other staff about often conveyed preferences informally, but no process was
informal conversations with residents or specific topics (e.g., evident to integrate these wishes into a systematic or formal
a resident receiving hospice) was considered a breach of trust way of conveying preferences. Furman and colleagues found
and outside their role. No. No, thats just confidence. Be- that systematic processes to elicit goals of care in NHs were
cause who would I pass it on to? I wouldnt tell her family and lacking.14 The absence of a process for reporting resident
thats confidential (staff). However, sharing information wishes expressed informally may result from limited train-
was also seen as part of the job. The team should share a lot ing, support, or knowledge about person-centered care11 or
of.. Just like I know the medical stuff, I think that its an facilitating such discussions.14
obligation of staff to really know the person.. We put notes Our findings illustrate missed formal and informal op-
in the chart, but obviously, I cant document every interac- portunities for conversations about EOL preferences among
tion (staff). Care conferences were mentioned by a few staff residents, family, and staff. However, key elements were
as a place for clarification of resident wishes. identified that could facilitate changing missed conversations
into conversations that involve residents, family, and staff
Barriers and facilitators in EOL conversations and elicit or account for resident preferences. First, the ex-
perience of others (see Table 4) was identified as a way to
We identified barriers and facilitators in communicating
initiate EOL conversations. Older adults residing in NHs are
about EOL preferences among residents, family, and staff
in close proximity to other residents and witness EOL ex-
(see Table 4). Barriers included the difficulty of having a
periences firsthand. Hallway conversations may serve as a
conversation, not having a person to talk to, and not being
cue residents are thinking about their EOL preferences, be-
knowledgeable enough to have a conversation. Two facili-
lieve EOL planning is normal,21 and want to convey their
tators for conversations about EOL preferences included the
wishes. For example, staff follow-up with residents after a
experience of others and feeling comfortable with a conver-
hallway comment could segue into a formal conversation and
sation partner.
prevent a missed conversation.
Second, conversations related to EOL may depend on the
Discussion
persons involved. Residents, family, and staff expressed
In this paper we describe missed opportunities for com- feeling comfortable with the person or making the person
munication about EOL preferences among NH residents, comfortable helps facilitate conversations. Asking residents
426 TOWSLEY ET AL.

Table 4. Barriers and Facilitators in Conversations about End of Life

Barrier Exemplar
Conversations are difficult: Characteristics of There is thisin a way this discomfort with feeling that because
conversations are difficult, included of religious beliefs there is going to be a difference in attitudes
encountering differing opinions and denial; of some of the staff members to this. And as I said, I felt this
concern of being judged; and beliefs about strongly in the [Southern Rose House], that some of the nurses
talking, such as talking about EOL is not typical were never the same after they heard that I had asked that he be
or viewed as negative or unpleasant. taken off medication. And I think they looked at this as if I was
committing a great sin, that this was Gods work and I should
leave it up to God. There was some undercurrent of the
disapproval. (family)
Some people are very outspoken about it. Some people are scared
to talk about it and dont talk about it, but as human beings we
have to face reality and so you talk about it when you have to.
(resident)
You have to know your own biases and make sure that youre not
imposing them. And you know, people deal with things in
different ways, they hear different things. So you need to help
them, but also you know its always a matter of giving a certain
amount of space and allowing things to unfold and supporting
that. (staff)
Conversations require knowledge: General lack of knowledge and peoples discomfort talking about
characteristics of conversations death. General lack of knowledge about what one can or cant
Requiring knowledge was primarily expressed do with ADs and living wills. People arent willing to take
as a barrier by family and included lack of doctors on, be forceful if needed. Bad communication about this
knowledge about ADs and communication stuff. (family)
strategies. I need to be knowledgeable to talk to my family. Or at least say to
them this is something you need to think about. Or be sensitive
to their needs, and have empathy. (family)
Conversations depend on the people involved: You want to discuss it with those people closest to you or people
Having a conversation about EOL was primarily that you trust. Like here I like to talk to [Cassie], but I dont
identified by residents and depends on who is think anybody else. Ill talk to you because youre doing a
involved in the conversation. study. (resident)
Just that, if I had a nurse that I felt really wanted to hear it. I have
the feeling that the nurses are just going from one person to
another and they have enough.. So you just dont have the
feeling that they can spend much time with you. (resident)
There are only a few people Id want to share anything with.
(resident)
Facilitators
Experience of others: The experience of friends, Especially when someone else dies you kind of really start talking
family, residents of having a health problem, about it when you lose a friend or another relative or when
dealing with EOL and/or dying was identified by someone you know dies. Because normally thats the topic of
all three groups as a good time to initiate conversation. (family)
conversation. If somebody close passes.that makes it easy. It opens the door a
little bit. If somebody has an illness, if there is a clergy person
around. (family)
Comfort and support from or with person involved Being comfortable with the person you are talking to would make
in the conversation: it easier. If you dont like that person why would you confide or
Feeling comfortable and supported serves as a talk intimately because to me this is very intimate. You know.
facilitator if individuals feel comfortable and So, yeah, being comfortable with the person that youre talking
trust the person(s) they are talking to in a to. (family)
conversation about EOL. Staff participants They have to be here and have one person get their confidence,
conveyed the importance of taking interest in the someone they can talk to, be it one of the nurses who some of
resident they are talking to and being present in them are very wonderful. Theyve seen life and they know what
the conversation. life is about. (resident)
They [residents] dont want to talk around their roommate. So I
will say, Lets go to the chapel, or Lets go downstairs and have
a cup of tea. Lets go to a private place where we can talk. So
they appreciate privacy and confidentiality. So thats an
enablerprivacy, confidentialityand also if they can feel that
youre genuine, like Im really into you. I am here for you. You
have to relate that and if they feel that, then you know, I think
thats half the battle. (staff)
CONVERSATIONS ABOUT END OF LIFE 427

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EOL care preferences were not always clear between resi- providing end-of-life care in nursing homes. J Palliat Med
dents, family, and staff, possibly reflecting differences in 2003;6:4557.
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life: Family advocacy in the nursing home. J Palliat Med
Conclusions 2010;13:573579.
13. Teno JM, Clarridge BR, Casey V, et al.: Family perspec-
Future studies may (1) examine the actual conversations tives on end-of-life care at the last place of care. JAMA
that occur within and among residents, family, and staff 2004;291:8893.
around EOL preferences to confirm content of conversations; 14. Furman CD, Kelly SE, Knapp K, et al.: Eliciting goals of
and (2) develop a structure for conversations and measure the care in a nursing home. J Am Med Dir Assoc 2007;8:
outcomes and conversation quality. Missed conversations e35e41.
resulting in lack of knowledge about resident preferences 15. Bradley EH, Blechner BB, Walker LC, Wetle TT: Institu-
may adversely affect quality of EOL care.34 Conversations tional efforts to promote advance care planning in nursing
with residents can be initiated by asking residents who they homes: Challenges and opportunities. J Law Med Ethics
would like involved in the conversation and drawing upon the 1997;25:150159.
experience of others. These approaches embrace person- 16. Hirschman HB, Abbott KM, Hanlon AL, et al.: What fac-
centered care and are attainable for both family and staff. tors are associated with having an advance directive among
older adults who are new to long term care services? J Am
Acknowledgments and Author Disclosure Statement Med Dir Assoc 2012;13:82.e782.e11.
17. Resnick HE, Schuur JD, Heineman J, et al.: Advance di-
The authors would like to graciously thank the NH resi- rectives in nursing home residents aged > or = 65 years:
dents, family, and staff for their time and participation in this United States 2004. Am J Hosp Palliat Care 2008;25:476
study, and of the unwavering mentorship of Dr. Mary Ersek 482.
during this project. This research was supported by In- 18. Teno JM, Gruneir A, Schwartz Z, et al.: Association be-
dividualized Care for At-Risk Older Adults (T32-NR009356), tween advance directives and quality of end-of-life care: A
National Institute of Nursing Research, Ruth L. Kirschstein national study. J Am Geriatr Soc 2007;55:189194.
NRSA Postdoctoral Fellowship. 19. Bradley EH, Peiris V, Wetle T: Discussions about end-of-
life care in nursing homes. J Am Geriatr Soc 1998;46:
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