Purpose: This qualitative study aimed to explore and interpret the meaning and essence of end-of-life care as experienced by nurses in internal medicine wards caring for patients who had completed advance directives (AD). It sought to understand the psychological conflicts, ethical dilemmas, and evolving perceptions of care encountered by nurses during the end-of-life process. Additionally, the study focuses on providing foundational data to support the clinical implementation of the AD system, thereby contributing strategies that improve the quality of end-of-life care and uphold patients' rights and dignity in hospital settings. Methods: A qualitative content analysis was conducted using in-depth, semi-structured interviews with 12 nurses from internal medicine wards in tertiary hospitals located in Seoul and surrounding metropolitan areas. Participants had direct experience in providing end-of-life care for patients with ADs. Interviews focused on capturing nurses’ real-life experiences and reflections related to such care. Data were analyzed systematically following the eight-step qualitative content analysis method proposed by Downe and Wamboldt, allowing for the identification of meaningful categories, themes, and patterns. Results: Analysis revealed five major themes and 16 subthemes. The major themes included: (1) Experiences of repeated end-of-life care and advance directives in internal medicine wards, reflecting the frequent encounters of nurses with terminally-ill patients and their ADs; (2) Multifaceted experiences of end-of-life care based on ADs, suggesting the complexities of care shaped by the presence or absence of ADs; (3) Limitations and dilemmas in AD implementation, highlighting the ethical conflicts arising from low public awareness and inconsistent clinical practices; (4) Shifts in perceptions of life and death, including the development of practical attitudes towards death through repeated exposure to dying patients, illustrating the evolving views of nurses; and (5) Hopes for improving end-of-life care in internal medicine wards, emphasizing the need for enhanced care environments, educational support, and institutional backing. Conclusion: The findings underscore the importance of increasing awareness and improving the clinical application of ADs. Establishing systematic support structures is essential to respect patient autonomy and enhance the quality of end-of-life care in internal medicine wards.

Purpose: In this qualitative descriptive study, we aimed to explore the experiences of nurses providing end-of-life (EOL) care in an emergency department (ED) setting and identify the associated challenges and implications for clinical practice. Methods: Twelve nurses with over 1 year of EOL care experience in the ED were interviewed. The collected data were analyzed using thematic analysis, as outlined by Braun and Clarke. Results: Five main themes with corresponding subthemes were identified: (1) Inadequate Environment for EOL Care, including physical environment barriers for a dignified death and emotional restraint in a chaotic setting; (2) Impact of Life-Sustaining Treatment Decision Complexity, encompassing complicated dynamics of family decision-making and compromised care quality in the decision-making process; (3) Managing Care Relationships in Physician-Limited Settings, manifested as navigating limited physician communication and bearing the emotional weight of EOL care; (4) Challenges in Protecting Patients’ Rights, characterized by powerlessness in the face of silent patients and confusion from reversed decisions by families; and (5) Actualizing Compassionate EOL Care, ensuring dignity through purposeful actions and navigating environmental barriers to dignified care. Conclusion: We highlight the need for systematic changes in the ED to better support EOL care, including the development of culturally sensitive communication protocols, shared guidelines for decision-making, and improved collaboration between healthcare professionals. These findings provide valuable insights into enhancing EOL care in EDs. Future efforts should focus on policy changes, tailored education programs, and support systems that address the multifaceted needs of patients, families, and healthcare providers.

Nurses in an intensive care unit (ICU) often play key roles to improve the quality of end-of-life care. During those times, many nurses report they feel ambivalent in the caring between life and death. The purpose of this study was to analyze the concept of ambivalence that ICU nurses often experienced in end-of-life care. As a method, this study was conducted with the concept analysis using the hybrid model Schwartz-Barcott and Kim (1986) presented, naming the complex and dual feelings nurses experience during end-of-life care in ICU as ambivalence. In the theoretical phase and from the literature review, characteristics of ambivalence were identified. During the fieldwork phase, in-depth interviews were conducted with five nurses. In the final phases, a theoretical description was extracted of ambivalence in ICU nurses during end-of-life care. In terms of results, external factors (i.e., realistic context, contradictions in nursing activities themselves) and internal factors (i.e., personal tendencies, conflicting perceptions of dying, occupational awareness of nurses, role conflicts) were derived as antecedents of ICU nurses’ ambivalence during end-of-life care. Attributes were divided into intrinsic and existential dimensions. Intrinsic dimensions resulted in "coexistence of opposing equivalent values," "uncertainty," "hiddenization," "value confrontation may occur sequentially," and "absence of willingness to resolve." In existential dimensions, the following conflicts were derived: "pressure on work versus sympathy about family grief," "helplessness due to failure of medical care versus sadness for patient death" and "role as a nurse versus sadness felt during end-of-life care.” The results are organized into negative assessments of oneself and adaptations to ambivalence. In conclusion, through this concept analysis, the hope is that ICU nurses will be able to prevent progressing to burnout by accurately and actively facing and managing their own feelings during end-of-life care. Furthermore, this research is expected to serve as the cornerstone of developing theories for clinicians who provide end-of-life care.