Introduction
End-of-life communication as part of advance care planning (ACP) with older people involves proactive and timely informal and formal conversations between an older person, their family caregiver, and a healthcare professional about, for example, future end-of-life care, the transition to the end-of-life phase, and death and dying from a holistic perspective (Rietjens et al. Reference Rietjens, Sudore and Connolly2017; Sudore et al. Reference Sudore, Lum and You2017; Schüttengruber et al. Reference Schüttengruber, Großschädl and Lohrmann2022). ACP encompasses 5 goals: respecting individual autonomy, improving quality of care and life, strengthening relationships, preparing for the end of life, and reducing overtreatment (Fleuren et al. Reference Fleuren, Depla and Janssen2020). Rather than focusing exclusively on making decisions and completing advance directives, ACP emphasizes an ongoing communicative process that supports mutual understanding and preparedness for future healthcare decisions (Rietjens et al. Reference Rietjens, Sudore and Connolly2017; Sudore et al. Reference Sudore, Lum and You2017). ACP is particularly relevant for older people, as they often experience frailty, multimorbidity, and decisions regarding end-of-life and palliative care. Nevertheless, they may engage less in ACP conversations due to vulnerability, limited ACP awareness, or difficulties discussing future decline and dying (Mohammadpour et al. Reference Mohammadpour, Sadeghmoghadam and Shareinia2018; Hopkins et al. Reference Hopkins, Bentley and Phillips2020).
End-of-life communication as part of ACP is widely recognized as an essential component of healthcare, where it is actively promoted and integrated into routine practice (Rietjens et al. Reference Rietjens, Sudore and Connolly2017; Chiang et al. Reference Chiang, Wang and Hsieh2021). However, ACP models differ across settings and populations, resulting in variation in the timing, content, and processes of end-of-life communication. At a more interactional level, recent conversation-analytic and discourse-focused literature has examined how these discussions are enacted in practice and shaped through interaction between patients, family caregivers, and healthcare professionals (Parry Reference Parry2024; Wu and Zhang Reference Wu and Zhang2024; Jia and Wu Reference Jia and Wu2025). In addition, attitudes toward ACP and its implementation into routine clinical care differ across cultures and countries. In many Asian cultures, for example, decision-making is often family-centered, and open discussions about death may be considered inappropriate or taboo (Chiang et al. Reference Chiang, Wang and Hsieh2021). In East Asian and Middle Eastern contexts, avoiding discussions about death is sometimes seen as a way to maintain hope or to protect emotional well-being (Evans et al. Reference Evans, Meñaca and Koffman2012; Brooks et al. Reference Brooks, Manias and Bloomer2019b). In contrast, Western societies typically emphasize individual autonomy, which supports more open and direct conversations about end-of-life care and ACP (Gómez-Vírseda et al. Reference Gómez-Vírseda, De Maeseneer and Gastmans2020). Moreover, variations in national healthcare systems influence how ACP is perceived, valued, and implemented (Sable-Smith et al. Reference Sable-Smith, Arnett and Nowels2018), and the roles of specific healthcare professionals, such as nursing staff, in ACP may differ accordingly (Rietze et al. Reference Rietze, Stajduhar and Purkis2024; Wilkin et al. Reference Wilkin, Fang and Sixsmith2024).
Nursing staff are uniquely positioned to play a central role in end-of-life conversations adapted to cultural and individual preferences and needs, given the trusting relationships they often build with older people and their family caregivers (Phillips et al. Reference Phillips, Johnston and McIlfatrick2020). However, many nursing staff face difficulties when initiating or engaging in end-of-life communication, such as feeling uncomfortable or lacking clear guidance (Phillips et al. Reference Phillips, Johnston and McIlfatrick2020). End-of-life conversations require specific skills and must be tailored to the unique needs of older people (Hemsley et al. Reference Hemsley, Meredith and Bryant2019; Phillips et al. Reference Phillips, Johnston and McIlfatrick2020). Understanding the fundamentals of holistic and person-centered end-of-life communication by nursing staff can support nursing staff in overcoming these barriers and enhance nurse education, research, and practice. In this study, fundamentals refer to the key elements or “building blocks” of end-of-life communication, including the necessary prerequisites, competencies, activities, and values involved in preparing for, carrying out, and evaluating holistic, person-centered conversations. They provide a foundation for guiding nursing staff in addressing sensitive topics in a manner that respects the preferences, needs, and values of older people and their family caregivers.
We have developed a theoretical framework on the fundamentals of end-of-life communication by nursing staff with older people, largely from a Dutch perspective (Peerboom et al. Reference Peerboom, Friesen-Storms and Coenegracht2023, Reference Peerboom, Friesen-Storms and van der Steen2024, Reference Peerboom, Friesen-Storms and van der Steen2025a, Reference Peerboom, Friesen-Storms and van der Steen2025b) (Box 1). To be able to use the theoretical framework internationally, refinement and validation of the framework by incorporating the insights and opinions of international experts is needed. Once validated, the theoretical framework can support nursing staff to be aware of, learn about, prepare for, carry out, and evaluate end-of-life communication. In addition, the framework could enhance nursing education and international scientific research and can be translated into interventions that empower nursing staff in end-of-life communication. Therefore, the aim of this study was to refine and achieve consensus in an international context on the theoretical framework of end-of-life communication by nursing staff as part of ACP with older people.
Methods
A Delphi study was performed (Figure 1) (Jünger et al. Reference Jünger, Payne and Brine2017) to assess the content validity of the LISTEN (Learning about the essentIal fundamentalS of end-of-life communicaTion in palliative nursing care) framework through expert review. Content validity was prioritized as the first step in a phased validation approach, given that the framework was initially developed from empirical studies involving nursing staff, other clinicians, older people, and family caregivers (Peerboom et al. Reference Peerboom, Friesen-Storms and van der Steen2024, Reference Peerboom, Friesen-Storms and van der Steen2025a, Reference Peerboom, Friesen-Storms and van der Steen2025b). Establishing content validity through international expert consensus was considered a necessary precondition before proceeding to external or real-world validation, which is recommended as a next step in future research. We conducted 2 online Delphi rounds. In each Delphi round, the panel members’ opinions on the fundamentals of the theoretical framework were recorded.
Flow-chart of the procedures in each Delphi round.
Figure 1 Long description
Flowchart sequence: Preparation, Developing the online questionnaire, Pilot testing of the questionnaire to ensure clarity and usability, Delphi round 1, Inviting selected Delphi panel members to the first questionnaire using personalized hyperlinks, Sending reminders on day 14 and 21, closing on day 28, Completing the questionnaire by the panel members, providing expert judgements on the proposed fundamentals, Analyzing the qualitative and quantitative data, Discussing the results within the research group and the working group and revising the fundamentals when necessary, Revising the questionnaire and theoretical framework by: Removing the fundamentals on which strong consensus was reached, Providing a summary of the results from Delphi Round 1, Delphi round 2, Distributing the revised questionnaire to Round 1 participants using personalized hyperlinks, Sending reminders on day 14 and 21, closing on day 28, Completing the revised questionnaire by the panel members, reconsidering initial responses in light of group feedback, Analyzing the qualitative and quantitative data, Discussing the final results within the research group and refining the fundamentals when necessary, Finalizing the validated theoretical framework.
Participants
International experts in the field of palliative care, care for older people, end-of-life communication, and nursing were invited after selection by the research group. Their expertise was assessed based on available scientific publications, online biographies (e.g., biographies of universities they were affiliated with), and previous collaborations. As the framework specifically targets nursing staff, we aimed to include primarily, but not exclusively, experts with a professional background in nursing. We also specifically selected members of the European Association for Palliative Care board of directors 2023–2027 who have a professional background in nursing and the first and last authors of the studies we included in our previous scoping review (Peerboom et al. Reference Peerboom, Friesen-Storms and Coenegracht2023). None of the participants in our previous interview studies were included (Peerboom et al. Reference Peerboom, Friesen-Storms and van der Steen2024, Reference Peerboom, Friesen-Storms and van der Steen2025a, Reference Peerboom, Friesen-Storms and van der Steen2025b). We aimed to include at least 30 participants.
Recruitment
A total of 80 potential Delphi panel members from 18 countries were first approached by email between April 22 and May 2, 2025, by a member of the research group who had the potential panel member in her professional network. F.B.A.L.P. approached those who were not in the research group’s network. The invitation email consisted of information about the study, a consent form, and a personalized hyperlink to the questionnaire. If they agreed to participate, they were asked to confirm their consent digitally by checking a box at the beginning of the questionnaire in the first round.
Data collection
Data were collected through an online questionnaire in Qualtrics (Qualtrics, Provo, Utah, USA). This questionnaire was pilot-tested by 3 researchers with a background in nursing who were not included in this study.
Demographic data (country, profession, and field of expertise) were collected at the beginning of the questionnaire in the first round. In each round, panel members were asked to rate the importance of the fundamentals using a Likert scale ranging from 1 = not important to 4 = very important. We used a 4-point Likert scale to avoid a neutral response option and to encourage stronger agreement or disagreement (Fink Reference Fink2024). We included free-text fields to allow panel members to provide additional comments, allowing them to elaborate when necessary.
In the second round, the panel members received a new questionnaire including a summary of the results of the first round (i.e., percentage agreement, median, and interquartile range [IQR]) and the reasons for revising the fundamentals. The panel members also received an overview of the individual scores they had originally assigned to the fundamentals. Fundamentals that already achieved consensus with high agreement were not presented again.
The personalized hyperlink each panel member received was linked to their email address. This allowed F.B.A.L.P. to monitor whether the personal reminder was needed and to link responses across rounds.
Data analysis
We analyzed the responses of each Delphi round with descriptive statistics. To evaluate consensus, a priori developed conservative criteria based on median, IQR, and percent agreement were used (Hohmann et al. Reference Hohmann, Beaufils and Beiderbeck2025). Fundamentals were deemed to have achieved consensus with agreement if they received a median score of ≥3, an IQR ≤ 1, and at least 80% of participants rated the fundamental 3 or 4. Consensus with high agreement was defined as a median score of 4, an IQR ≤ 1, and ≥90% of participants rating the fundamental 3 or 4. A directed content analysis was adapted to the free-text fields (Hsieh and Shannon Reference Hsieh and Shannon2005). Participants’ answers were extracted into a Microsoft Excel file. Responses were cut into small text segments and coded and summarized by 2 researchers (F.B.A.L.P. and J.H.H.M.F.-S.) based on the fundamentals and themes in the framework. The results of the analysis were then discussed with the research group. Then, we adjusted, refined, or excluded fundamentals when necessary.
Results
Participants
Of the 80 invited experts, 48 experts (60%) from 15 countries completed Round 1 (Table 1). Most participants had research or nursing background, were based in Europe, and their field of expertise was palliative care. Most of these experts (46 of 48; 96%) also completed Round 2. Participants and non-participants appeared broadly similar with respect to stakeholder group and geographic distribution based on information available during expert identification.
Characteristics of Delphi panelists (n = 48, Round 1)
Table 1 Long description
Summary of the number and percent of 48 Delphi panelists by professional background, field of expertise, and region of residence; multiple selections were allowed for background and expertise. Most participants identified as researchers, and over half also had a nursing background; smaller shares reported medicine, spiritual or psychological care, education, ethics, or other roles. Expertise was dominated by palliative care, followed by advance care planning, nursing care, and communication, with fewer specializing in care for older people, spiritual care, or other areas. Most panelists lived in Europe, with Western Europe contributing the largest share, particularly the Netherlands, and smaller numbers from England, Belgium, Ireland, and Switzerland. Southern, Eastern, and Northern Europe were represented by only a few participants each. Outside Europe, there were smaller groups from North America and Asia, and a small number from Oceania. Because several categories allow more than one response, percentages within those sections do not add up to a full total.
Round 1
In Round 1, participants rated 20 fundamentals. Sixteen fundamentals achieved consensus with high agreement, and 3 fundamentals achieved consensus with agreement (Table 2). Consensus with agreement was not reached on 1 fundamental, “Trusting intuition” (73% agreement, median = 3, IQR = 2) (Table 3). Each fundamental was revised and refined based on the experts’ comments and suggestions (Supplementary File 1). The primary feedback centered on how well the framework applies to a diverse range of individuals, including those from LGBTIQA+ communities and various cultural or religious backgrounds, as well as to both formal and informal conversations. For example, experts mentioned that not all end-of-life conversations need to be natural, open, or comfortable, as communication styles may vary across cultures (e.g., preferences regarding directness or eye contact, and whether limiting the number of people present is appropriate). Some also noted that recommendations such as minimizing distractions to create a calm atmosphere may be more relevant to formal than to informal conversations.
Total results of the Delphi rounds
Table 2 Long description
Delphi round results are reported for communication-related fundamentals grouped into five themes, showing percentage agreement and median ratings with an interquartile range. Most items achieved consensus in Round 1 without revision, typically with agreement between 90 and 100 percent and median ratings of 4 with narrow spread. Theme 1 includes self-efficacy to talk about the end of life at 100 percent agreement and a median of 4, alongside mutual trust at 98 percent and learning by doing at 96 percent. Theme 2 shows similarly strong support for attuning to others and being honest at 100 percent, and being approachable at 98 percent; a revised item combining creating a calm atmosphere with taking a seat to seek connection reached 94 percent with a median of 4. Theme 3 items such as attentive listening reached 100 percent with a median of 4, while trusting intuition started lower at 73 percent with a median of 3 and wider spread, improving after revision to verifying intuition at 80 percent with a median of 3 and narrower spread. Theme 4 fundamentals about conversational phases were consistently high, with agreement in the low to mid 90s and median ratings of 4; gently building up the conversation rose from 88 to 91 percent after revision and was later retitled. Theme 5 items on professional role, interprofessional collaboration, and involving family caregivers all showed agreement around 92 to 94 percent with median ratings of 4. Some entries document title changes across rounds, so comparisons should focus on the revised concepts rather than treating renamed items as separate fundamentals.
1 This table lists the titles of the fundamentals, with any changes to those titles noted. Each fundamental was accompanied by a description, which was revised in each round. Details of these description revisions are provided in Table 3 and Supplementary File S1.
2 Fundamentals were deemed to have achieved consensus with agreement if they received a median score of ≥3, an IQR ≤ 1, and at least 80% of participants rated the fundamental 3 or 4. Consensus with high agreement was defined as a median score of 4, an IQR ≤ 1, and ≥90% of participants rating the fundamental 3 or 4.
Details of the re-assessed fundamentals in Round 2
Table 3 Long description
Tracks how four end-of-life communication fundamentals were revised across two review rounds, listing the initial wording, the Round 1 revision, and the Round 2 revision with participant feedback summaries. In Theme 1, natural conversation is reframed as authentic and open, emphasizing safety, nonjudgment, and a person-centred approach, and noting that comfort and lightness are not always appropriate and can be culturally influenced. In Theme 2, taking a seat is merged into creating a calm atmosphere and later generalized to adopting the same physical height, with added cautions that limiting the number of people present depends on culture and that advance care planning is an ongoing process. In Theme 3, trusting intuition becomes verifying intuition, stressing that intuition should be checked with the other person to avoid assumptions and to reflect their thoughts, feelings, experiences, and needs. In Theme 4, gently building up is revised to building up the conversation, keeping the idea of adjusting pace and using prompting questions while acknowledging that conversations are not always gentle and that some added phrasing was seen as unclear. Across themes, Round 2 edits reduce prescriptive language, clarify terms that caused confusion, and highlight context and cultural variability.
Round 2
In Round 2, we included the fundamental that failed to reach consensus with agreement (73%) and the 3 fundamentals that achieved consensus with agreement (≥80%). Based on the feedback on the fundamental “Taking a seat to seek connection,” we integrated this fundamental into “Creating a calm atmosphere.”
Two fundamentals achieved consensus with agreement in Round 2, while 2 fundamentals achieved consensus with high agreement. The primary feedback concerned the wording and cultural sensitivity of several fundamentals. In particular, “Fostering a natural and open conversation” was considered potentially misleading, as it could imply that end-of-life conversations should be easy or non-confrontational; experts therefore suggested using the term “authentic” instead. Concerns were also raised that an emphasis on intuition in “Verifying intuition” might suggest a simplistic approach, whereas participants stressed that end-of-life communication requires trained skills and the ability to recognize and interpret subtle cues. Each fundamental was revised and refined based on the experts’ comments and suggestions (Table 3 and Supplementary File S1). Figure 2 and Supplementary File S2 display an overview of the final theoretical framework.
Final theoretical framework.
Figure 2 Long description
Infographic titled, Final theoretical framework. Five vertical columns. Column 1, Feeling comfortable. Self efficacy to talk about the end of life. Experiencing mutual sense of trust. Learning by doing. Fostering an authentic and open conversation. Column 2, Creating space for open communication. Attuning to the other person (s). Being easily approachable. Creating a calm atmosphere. Being honest. Column 3, Using senses and applying communication techniques. Attentive listening. Non verbal communication and observation. Being silent. Verifying intuition. Column 4, Following the conversational phases. Sensing balance between preparation and flexibility. Initiating the conversation. Building up the conversation. Evaluating and following up. Column 5, Being aware of interprofessional collaboration. Perceiving your own professional role. Interprofessional collaboration. Involving family caregivers.
Discussion
Through a structured, 2-round Delphi process involving 48 experts, this study refined the theoretical framework of end-of-life communication by nursing staff as part of ACP with older people, achieving international consensus on the content of the framework. The feedback we have received on the framework’s fundamentals in both Delphi rounds primarily focused on their applicability to diverse individuals, including those from LGBTIQA+ communities and various cultural or religious backgrounds. Although end-of-life communication is widely recognized as an essential component of healthcare, attitudes toward ACP and its integration into routine clinical care can vary significantly; not only across cultures and countries but also based on factors such as sexual orientation and gender identity. For example, this Delphi study showed that behaviors such as being honest and direct, sitting down during the conversation, maintaining eye contact, and the number of people present are highly sensitive to cultural context and should be carefully considered in end-of-life communication. We have incorporated this feedback into the framework but also emphasize that these considerations have direct implications for the practical usefulness of the framework. In its current form, the framework reflects a predominantly Western European perspective on end-of-life communication, in which individual autonomy, openness about dying, and direct communication are generally valued. In cultural contexts where family-centered decision-making, avoidance of explicit death talk, or indirect communication styles prevail, some fundamentals may need to be revised. This does not diminish the framework’s value but underscores that it should be treated as a flexible starting point rather than a universal standard.
These findings are also reported in other studies, which further explain how to address them in end-of-life communication and end-of-life care (Jünger et al. Reference Jünger, Payne and Brearley2012; Brooks et al. Reference Brooks, Bloomer and Manias2019a, Reference Brooks, Manias and Rasmussen2025; Lambert et al. Reference Lambert, Strickland and Gibson2023). Brooks et al. (Reference Brooks, Manias and Rasmussen2025), for example, highlight the importance of healthcare professionals examining their own cultural values, beliefs, and assumptions, as these can influence communication with patients or family caregivers from diverse backgrounds. They argue that awareness of one’s own cultural identity is a necessary foundation before attempting to understand others’ cultural perspectives (Brooks et al. Reference Brooks, Manias and Bloomer2019b), as also emphasized in the framework. In line with this, Stinchcombe et al. (Reference Stinchcombe, Smallbone and Wilson2017) and Rosa et al. (Reference Rosa, McDarby and Buller2023a) highlight the important role healthcare professionals play in fostering positive care experiences for older people by becoming knowledgeable about the unique needs of this population and being unassuming and accepting of individuals’ sexuality. One such need is having the opportunity to disclose their LGBTIQA+ identity in a safe clinical environment (Rosa et al. Reference Rosa, McDarby and Buller2023a). While the validated theoretical framework in this study already addresses certain cultural aspects, cultural and LGBTIQA+ sensitivity requires ongoing self-awareness and attunement to the other person, even before a conversation begins. This is reflected in the fundamentals “Attuning to the other person” and “Self-efficacy to talk about the end of life.”
Another point of feedback we have received in this Delphi study regards the concern that some fundamentals might unintentionally imply that natural end-of-life conversations should be imposed, despite the inherently complex and sometimes confrontational nature of end-of-life conversations. In our previous interview study with older people and their family caregivers, we found that they particularly value feeling comfortable, safe, seen, and heard in open, natural, and human conversations (Peerboom et al. Reference Peerboom, Friesen-Storms and van der Steen2025b). Engel et al. (Reference Engel, Kars and Teunissen2023) found in a systematic review that open and honest communication is highly valued in palliative care, while also emphasizing the importance of allowing patients and relatives time to process information. Similarly, Chen et al. (Reference Chen, Chung and Lam2022) and Ibañez-Masero et al. (Reference Ibañez-Masero, Carmona-Rega and Ruiz-Fernández2019) highlight the value of open, natural, and person-centered dialogues in end-of-life communication. Despite the strong preference among older people and their family caregivers for such conversations, a natural approach is not always appropriate or preferred. For example, during acute deterioration requiring urgent decisions, a more direct approach may be needed. Similarly, some older people may prefer structured, checklist-based discussions focused on specific care preferences. These diverse perspectives and possible preferences are now better integrated into the framework’s fundamentals. End-of-life communication, like culturally sensitive communication, requires adaptation to individual preferences and contextual factors (Fakhri et al. Reference Fakhri, Engelberg and Downey2016).
Our Delphi panel revealed divergent views on the role of intuition in end-of-life communication. While the majority of participants strongly supported the importance of validating intuition in these conversations, some cautioned that relying too much on intuition could overshadow the importance of trained communication skills. A growing body of evidence supports the fundamental role of intuition in nursing practice. Valenzuela and Marcos (Reference Valenzuela and Marcos2019) describe nursing intuition as personal knowing based on knowledge, clinical experience, and the nurse-patient relationship, enabling interpretation of health and illness in context. Similarly, Melin‐Johansson et al. (Reference Melin‐Johansson, Palmqvist and Rönnberg2017) define intuition as a cognitive process grounded in knowledge, self-awareness, and experience, complementing evidence-based practice and supporting clinical decision-making. This highlights that the use of intuition in end-of-life communication does not replace the need for trained communication skills but rather complements and enhances the skills nursing staff already possess or develop, ultimately supporting the quality of this uniquely sensitive form of communication. Still, it remains important that specific interpretations are verified by nursing staff to ensure that it reflects the thoughts, feelings, experiences, and needs of the older person.
The added value of the framework does not lie in introducing entirely new communication techniques, but in structuring the specific conditions, tensions, and professional awareness required for end-of-life communication within ACP. Recent conversation-analytic and discourse-focused research has illuminated how end-of-life discussions are interactionally organized in practice, including how sensitive topics are introduced, how uncertainty is communicated, and how patients and professionals jointly navigate emotionally complex moments (Parry Reference Parry2024; Wu and Zhang Reference Wu and Zhang2024; Jia and Wu Reference Jia and Wu2025). While this body of work offers valuable descriptive insights, it addresses a different question than the one this framework is designed to answer. Rather than analyzing conversational sequences, the framework makes explicit the professional, relational, and reflective dimensions that nursing staff need to develop to engage meaningfully in end-of-life conversations across both formal and informal encounters and in their dual role of initiating and sustaining communication over time.
In this sense, the framework complements rather than competes with conversation-analytic approaches and addresses a practical gap that descriptive interaction research alone cannot fill. The framework is not intended as a checklist, nor are all fundamentals required in every conversation. Instead, the fundamentals are designed to promote awareness, self-awareness, learning, preparation, and reflection on the key dimensions of end-of-life communication. By addressing complementary aspects of communication practice, the framework provides flexibility and relevance for the diverse realities and sensitivities that nursing staff encounter in end-of-life care.
The fundamentals can be translated into nursing practice through targeted interventions and training programs that prepare nursing staff to take an active and central role in person-centered end-of-life conversations, both in initial education and continuing professional development. Integrating the framework from the start of their careers helps position end-of-life communication as a fundamental nursing skill. Training can focus on raising awareness of the fundamentals and coaching nursing staff in applying the fundamentals in daily practice, not only during formal end-of-life conversations but also in informal conversations. By incorporating methods such as reflection, role-play, and feedback, education can support nursing staff in recognizing and strengthening their own communication patterns while developing the confidence and sensitivity needed to respond effectively to the needs of older people and their family caregivers (Fuoto and Turner Reference Fuoto and Turner2019; Laranjeira et al. Reference Laranjeira, Afonso and Querido2021). The framework may also strengthen international research on end-of-life communication. The fundamentals can be translated into outcome measures, which help to observe and analyze complex communication processes.
Although the framework provides considerable opportunities for translation into nursing practice, education, and research, it may entail a risk that introducing its structured fundamentals into clinical practice may inadvertently formalize what are naturally informal conversations. Once nursing staff become more aware of the key elements involved, there is a risk that such conversations are approached more purposefully. Although this increased awareness generally has positive effects (e.g., enhancing confidence, sensitivity, and person-centeredness) (Peerboom et al. Reference Peerboom, Friesen-Storms and Coenegracht2023, Reference Peerboom, Friesen-Storms and van der Steen2024), it may also reduce the spontaneity of informal conversations, making them feel more structured or even formal. The extent of this risk likely depends on the clinical setting and on individual experience with end-of-life communication. In healthcare, increased formality has been shown to reduce spontaneity and a person-centered approach, leading to a more reserved and depersonalized environment (Montgomery et al. Reference Montgomery, Lainidi and Georganta2024). Patients, in turn, report feeling most comfortable and best able to share personal values when healthcare professionals communicate with empathy, informality, and openness (Zwakman et al. Reference Zwakman, Jabbarian and van Delden2018). Informal end-of-life conversations can be valuable for older people when they are not yet ready to engage in more formal conversations and decision-making (Bergenholtz et al. Reference Bergenholtz, Missel and Timm2020; Mikaelsson et al. Reference Mikaelsson, Eriksson and Stenfors2025). Because these conversations often feel less pressured and more open-ended, they enable older people and their family caregivers to begin reflecting on their values, wishes, and preferences at their own pace (Peerboom et al. Reference Peerboom, Friesen-Storms and Coenegracht2023, Reference Peerboom, Friesen-Storms and van der Steen2024, Reference Peerboom, Friesen-Storms and van der Steen2025a). To address the potential risk of inadvertently formalizing what are naturally informal conversations, nursing education and training should highlight the importance of preserving flexibility and responsiveness. Reflective exercises and guided supervision can help nursing staff balance the use of the framework’s fundamentals with the informality that often makes these conversations meaningful.
Strengths and limitations
This study has several strengths. First, both Delphi rounds had relatively high response rates, and most fundamentals reached consensus with high agreement, strengthening the reliability and credibility of the findings while minimizing attrition bias. Second, providing participants with summaries of group results, individual responses, and rationale for revisions improved the transparency and rigor of the Delphi process. Several limitations should also be noted. First, although the Delphi panel comprised experts from 15 countries across 4 continents, most participants were from Western Europe. This may limit the global generalizability of the findings and create uncertainty regarding the framework’s applicability in settings where the perceived role of nursing staff differs from that in Western Europe (Ng and Wong Reference Ng and Wong2021). Recruitment was based on purposive selection through the research group’s professional networks and publicly available scientific profiles, which inherently reflects existing collaborative ties and may have introduced a geographic bias toward Western Europe. Broader representation was actively sought, but achieving proportional global representation within the scope of this study was not feasible. This geographic imbalance should be considered when interpreting the findings, and future validation studies in non-Western contexts are recommended. In addition, approximately half of the experts reported experience in nursing care, ACP, or communication. As participants may have indicated only their primary area of expertise, other relevant experience across domains may not have been fully captured. Nevertheless, this should be considered when interpreting the findings, as these areas are central to the study topic. Second, language and cultural differences may have led to varying interpretations of the fundamentals, potentially affecting consistency in responses. Third, although we strengthened the content validity of the framework, this does not constitute full validation in real-world settings. While the framework shows strong potential, further empirical research is needed to examine how it can be applied in clinical and educational contexts and to evaluate aspects such as usability, reliability, and its contribution to supporting nursing end-of-life communication.
Future research
Several areas for future research can be identified. First, although the framework emphasizes the need to adapt end-of-life communication to individual, social, contextual, and cultural factors, further refinement may be appropriate. Empirical studies could develop and test practical guidance and illustrative examples to strengthen its applicability to culturally and LGBTIQA+ sensitive communication. Second, given the focus on the Western European setting, the generalizability of the present findings could be limited. Future research could therefore examine the framework’s validity in other geographical contexts. Finally, translational research is needed to operationalize the theoretical framework into specific nursing interventions. As the framework itself is not an intervention, future studies should first translate its fundamentals into educational or practice-based approaches tailored to nursing staff needs, followed by feasibility, implementation, and effectiveness studies in clinical practice.
Conclusion
This Delphi study refined and validated a theoretical framework for end-of-life communication by nursing staff, resulting in a set of fundamentals grounded in both clinical and academic expertise. The framework contributes to a deeper understanding of both formal and informal end-of-life communication and offers practical guidance for nursing staff, care assistants, and nurse practitioners working with older people. While designed as a flexible framework to raise awareness and support person-centered end-of-life communication, its effective use depends on thoughtful application, cultural sensitivity, and professional judgment. Future research should confirm the validity of the framework in broader geographical contexts beyond Western Europe and inform its implementation in nursing education and clinical practice.
The LISTEN project
This study is part of the LISTEN project, which aims to build and validate a theoretical framework of the fundamentals of end-of-life communication between nursing staff (i.e., nurses, care assistants, and nurse practitioners) and older people (i.e., 65 years or older and receiving care or palliative care in home care, nursing home, or hospital settings [e.g., due to frailty or chronic illness]). The previously developed theoretical framework is based on a scoping review (Peerboom et al. 2023), 2 interview studies with nursing staff (Peerboom et al. 2024) and older people and family caregivers (Peerboom et al. 2025b), and a focus group study with multiple disciplines (Peerboom et al. 2025a). The theoretical framework consists of 5 themes (“Feeling comfortable,” “Creating space for open communication,” “Using senses and applying communication techniques,” “Following the conversational phases,” and “Being aware of interprofessional collaboration”) and 20 fundamentals (Supplementary File S1).
The framework emphasizes that nursing staff should feel comfortable to talk about the end-of-life, in both private and professional contexts. For example, experiencing a trusting relationship and learning by doing can help nursing staff feel comfortable and engage in natural and open end-of-life conversations. In addition, nursing staff can create space for open communication by, for example, attuning to the other person and being easily approachable. When engaging in the conversation, nursing staff may use their senses and apply appropriate communication techniques, such as by attentive listening and trusting their intuition. Although end-of-life communication does not need to follow strict phases, certain phases may be identified. Nursing staff seek balance between preparation and flexibility in the conversation and gently build and evaluate the conversation as part of a continuous process. Interprofessional collaboration is important in each part of the communication process. Nursing staff should be aware of their own role in end-of-life communication and work together based on these roles. In addition, family caregivers should be actively involved while ensuring that the older person remains central to the care process.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1478951526104106.
Competing interests
This work was supported by the Netherlands Organization for Health Research and Development (ZonMw, grant number 10040022110005).
Ethical approval
The study was approved by the Research Ethics Committee of the Faculty of Health, Medicine and Life Sciences (FHML-REC) of Maastricht University (FHML-REC/2024/073).
Open access
