• Gill Livingston, Catherine Pitfield, Jackie Morris, Monica Manela, Elanor Lewis-Holmes, and Hannah Jacobs.
• Mental Health Sciences, UCL, London, UK. g.livingston@ucl.ac.uk
• Int J Geriatr Psychiatry. 2012 Jun 1;27(6):643-50.

ObjectiveThe aim of this study is to examine barriers and facilitators to care home staff delivering improved end-of-life care for people with dementia.MethodIndividual qualitative interviews of 58 staff in a 120-bed nursing home where the staff and the residents' religion differed were carried out. Interviews continued until a maximum variation sample was achieved and theoretical saturation was reached.ResultsThe staff felt warmly towards the residents and felt they could recognise when they were near death. Care staff, nurses and doctors did not see themselves as a team and communicated poorly with relatives about approaching death. The staff used opaque euphemisms and worried about being blamed. They were often unaware of or had concerns about the validity of advance care plans. They knew of the religious rituals around death but frequently misunderstood religious tradition.ConclusionThe staff require education and support about discussing and implementing plans around care at the end of life in dementia and about cultural issues around death to improve practice. This would enable the staff to implement advance care plans, knowing that they will be supported. Education would encompass communicating the complicated, unpredictable path of dementia near the time of death explicitly but sensitively, including recognising that people often do not hear difficult messages and are unable to take on large quantities of information at once. The staff need to know about the resident's religious and cultural ideas as well as ritual practice.Copyright © 2011 John Wiley & Sons, Ltd.

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