Nurses play a critical role in recognising and responding to end-of-life needs in aged care, often identifying signs of decline up to a year before death.
However, there are challenges preventing consistent, high-quality care during this crucial time, new research has found.
Led by Flinders University's Research Centre for Palliative Care, Death and Dying (RePaDD), as part of the End of Life Directions for Aged Care [ELDAC] project, the study involved interviews with nurses and care workers across 15 aged care services in three Australian states.
It reveals that while nurses are deeply attuned to the needs of residents nearing the end of life, they are often constrained by limited resources, inefficiencies of care processes, and limited training.
"As Australia's population continues to age, nursing staff within our aged care system are at the frontline, with palliative and end-of-life care a core aspect of their job," says lead author Dr Priyanka Vandersman, from RePaDD and Flinders' ELDAC team.
"Just over one-third of deaths among Australians aged over 65 occur in residential aged care. With sector-wide reforms underway, including mandated care hours and 24/7 registered nurses, there is a strong need to ensure that quality care is not only being delivered, but also understood in practice."
This is particularly critical in light of recent findings from the Registry of Senior Australians and Flinders University, which found no clear link between increased care minutes and improved resident experiences or clinical outcomes.
Given the complex nature of end-of-life care, the study provides important insights, with nurses emphasising the need for time, training, and flexibility to respond in ways that reflect residents' individual needs.
The findings point to the value of complementing staffing reforms with broader support for clinical judgment, communication, and person-centred care.
The study found that nurses can often detect a prolonged period of irreversible decline-lasting six to twelve months before death-through both clinical assessments and intuitive cues developed from long-term relationships with residents.
These early signs, such as changes in mood, behaviour, or social engagement, are key opportunities for timely person-centred care planning.
"Participants described this pre-terminal phase as requiring a nuanced and proactive approach," says Dr Vandersman.
"But time pressures, documentation demands, and a resource limitation can make it difficult for nurses to act on their insights."
While nurses understand what constitutes good end-of-life care, including early planning, open communication, emotional support, and comfort-focused practices, they reported difficulty delivering this consistently.
Some were unable to remain with dying residents due to staffing shortages, while others described situations where limitation in resources led to unnecessary hospital transfers.
Co-author Professor Jennifer Tieman, Director of RePaDD, says the findings underscore the need for cultural and structural change.
"Good end-of-life care doesn't begin in the final hours - it begins much earlier - and the system needs to recognise and support this," says Professor Tieman.
"Nurses need support and time to identify early decline and respond with care that is aligned with each person's needs and wishes."
As the aged care sector continues to evolve, the authors say the research highlights the importance of complementing structural reforms with targeted workforce training, practical support, and sector-wide cultural change.
Encouraging early conversations and planning around end-of-life care should become a routine part of practice, ensuring that care is not only timely and coordinated, but also aligned with the values and preferences of each individual.
The paper, ''Early planning makes for a good death': residential aged care nurses' views on caring for those in the last months of life' by Priyanka Vandersman & Jennifer Tieman is published in the journal BMC Nursing. DOI: 10.1186/s12912-025-03411-3. The ELDAC Project is funded by the Australian Government Department of Health and Aged Care.
