Development and implementation of a supportive care model for cancer patients in the last days of life: A hospital-based program

Abstract

Objective

The quality of end-of-life care for cancer patients in China remains unsatisfactory, particularly during their last days and hours, highlighting an urgent need for improvement. This study is aimed to develop and implement a hospital-based quality improvement (QI) program to provide supportive care for terminally ill cancer patients, with the goal of improving the quality of death of cancer patients and family satisfaction.

Methods

This QI program primarily included three phases: developing evidence-based practice standards and related materials; conducting stratified training and providing the bundled supportive care strategies; and implementing quality supervision. The supportive care provided to terminally ill cancer patients and their families consists 30 bundled strategies divided into 5 parts: recognition and confirmation that the person may enter the last few days of life, end-of-life communication, patient-centered supportive care, family-centered supportive care and bereavement support for the family. The quality of death of cancer patients was assessed from the perspective of charge nurses and family members using the Good Death Inventory (GDI), and family satisfaction was evaluated using the Family Satisfaction with Advanced Cancer Care-2 (FAMCARE-2) scale.

Results

One hundred and fourteen patients from five hospitals located in Beijing, Nanjing, and Kunming were provided the supportive care between May 2023 to August 2024, and 112 (98.2%) nurses and 103 (90.4%) families completed the follow-up evaluation. The total GDI score, which ranges from 54 to 378 with higher score indicating a better quality of death, was recorded as 299.81 ± 53.70 from the perspectives of nurses and 310.76 ± 49.55 from family members. The FAMCARE-2 score ranging from 17 to 85 with higher scores indicating greater satisfaction was 80.52 ± 8.75, with scores for symptom control, information support, family support, and patient psychological support at 23.73 ± 2.80, 18.87 ± 2.25, 18.94 ± 2.35, and 18.98 ± 1.95, respectively.

Conclusions

This study systematically implemented supportive care strategies tailored to the needs of patients and their families at the end of life through a hospital-based program and achieving satisfactory outcomes. The systematic approach and innovation of the program are worthy of further promotion.

Introduction

Cancer remains a major cause of death worldwide although cancer treatment methods continue to improve. In China, the number of deaths due to cancer accounts for nearly 1/4 of the deaths from various causes each year.¹ According to statistics of the National Cancer Center of China and the International Agency for Research on Cancer (IARC), it is estimated that the number of cancer-related deaths in China reached 2.57 million cases in 2022, accounting for 26.4% of the global total number of cancer deaths.^2,3 Patients with cancer in the terminal stage of life are not only faced with complex and refractory physical symptoms, but also endure significant mental and psychological sufferings.^4,5 At the same time, their primary caregivers have to deal with various changes in the patient's condition, treatment decision-making, as well as the physical, psychological, social, and economic burden of long-term care, and experience grief and sadness after the death of their loved ones.⁶ Therefore, both terminally ill cancer patients and their families urgently need more professional support and care from health care providers.

Conventional medicine tends to prioritize disease treatment while often overlooking the importance of supportive care for patients nearing the end of life. In recent years, China has released several policy documents that highlight “the importance of prioritizing people's health in development strategies, thoroughly implementing the Healthy China Action, and providing people with comprehensive and lifelong health services”.^7,8 Consequently, within the framework of building a Healthy China, improving the practice and quality of care for terminal cancer patients has become an urgent task. Nurses, who are the health care professionals with the most frequent interactions with cancer patients, play important roles and responsibilities in end-of-life care practice. Therefore, enhancing their practical capacities is an important measure to improve the quality of death in patients with advanced cancer.

Despite the growing emphasis and advancements in palliative care in China, studies indicate that the quality of end-of-life care for cancer patients is still not optimistic, particularly in their final days and hours of life.9, 10, 11 Our research team conducted studies to assess the quality of death of terminally ill patients with cancer and the knowledge and practice behaviors of oncology nurses regarding the end-of-life care. The findings revealed that their quality of death was poor, and they are often ignored, abandoned and objectified; nurses are lacking in practical guide for delivering end-of-life care, as existing standards predominantly focused on technical procedures, failing to encompass comprehensive, patient-and family-centered supportive care practices that holistically address physical, psychological, and spiritual needs.^12,13

This study adopts a problem-oriented approach to initiate a hospital-based quality improvement (QI) program. It aims to implement evidence-based bundled supportive care strategies for terminally ill cancer patients and their families through standardized hospital practice protocols and to reinforce through continuous quality supervision. This approach seeks to enhance the quality of care for cancer patients in their final stages, and then to improve the quality of death of cancer patients and family satisfaction.

Methods

Study design and participants

The Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0¹⁴ served as the framework for planning this QI program. This program, as part of the hospitals’ high-quality development reform and innovation initiatives, received approval and support from the Beijing Medical Management Center. It was initiated by a tertiary cancer hospital in Beijing and jointly carried out by other four hospitals located in Beijing, Nanjing, and Kunming from May 2023 to August 2024. This research was conducted in accordance with the Declaration of Helsinki, and ethics approval was granted by the Ethics Committee of Beijing Cancer Hospital (Approval No. 2020KT23). Informed consent was obtained from patients, families and nurses included in the study before the supportive care was implemented.

In this hospital-level change of nursing practice, nurses provide the bundled supportive care strategies after a cancer patient was identified as being in the last few days of their life. Nurses in charge of the terminally ill cancer patients and the primary family caregivers were recruited to complete the follow-up evaluation following the patient's death. The criteria for including nurses were: (a) possession of valid practice qualifications, (b) provision of bedside care to the deceased patients, and (c) voluntary participation in the study; but those nurses who were rotation nurses or continuing education nurses from other hospitals were excluded. For family caregivers, the inclusion criteria consisted of: (a) being 18 years of age or older, (b) having no communication barriers, and (c) voluntary participation in the study; caregivers with a history of mental illness or an employment relationship with the patient were excluded.

The sample size was calculated using the G∗Power 3.1.7 software. Taking data from our previous study¹² into account, a Wilcoxon signed-rank test (one sample case) was used, with a significant alpha level of 0.05 (one tail) and a power (1−β) level of 0.90, for detecting a moderate effect size of 0.30 to compute the required sample size, which was n = 102. Plus 10% of the sample loss, and the estimated sample size should be 114 cases.

Procedure and intervention

After forming a QI team, in-hospital nursing practice standards and related materials for implementation were compiled by the hospice and palliative care specialist group. Subsequently, head nurses and nurse educators were assembled to participate the training, and then they returned to the department to complete the training for all other nurses. When the bundled supportive care strategies were provided for terminally ill cancer patients and their families, the hospice and palliative care specialist group offered follow-up assistance and guidance, and meanwhile quality supervision was conducted by the quality supervision group. The procedure is illustrated in Fig. 1.

Fig. 1.

Three-phase procedure of this QI program. QI, quality improvement.

Phase 1: pre-implementation preparation

Formed the QI team. The nursing department administrators were tasked with the design, coordination, and management of the program. Hospice and palliative care specialist group, familiar with the knowledge and skills and had extensive practical experience in the field of end-of-life care, was in charge of providing standardized training and assistance for nurses during the implementation process. A quality supervision group, composed of quality control commissioners from the nursing department and head nurses, was responsible for supervising the implementation of the bundled supportive care strategies. Two postgraduate students were assigned as data collection staffs to conduct follow-up evaluation of patients' quality of death and families’ satisfaction.

Developed the in-hospital end-of-life supportive care practice standard and related materials. An evidence-based supportive care strategies checklist was constructed and validated for usability in our previous study.¹⁵ It covers five key components and 30 items: recognition and confirmation that the person may enter the last few days of life (3 items), end-of-Life Communication (4 items), patient-centered supportive care (8 items), family-centered supportive care (8 items) and bereavement support for family (7 items) (Supplementary Table S1). Based on the 30 bundled supportive care strategies, we developed the "End-of-life supportive care practice standard" for nursing practices. This standard includes the end-of-life supportive care strategies and guidance materials intended to assist clinical nurses in their practice. These guidance materials cover the techniques for identifying patients approaching the last days of life through patient manifestations and prognosis tools, methods for assessing and managing those common symptoms experienced by the dying patients, discharge preparation checklist (Supplementary Fig. S1) if terminally ill patients decide to be discharged, and so on. We also compiled several pamphlets for family caregivers, including “Warm Companionship: how to provide home-based hospice care for loved ones”, “Administrative matters to handle after the loss of loved ones”, and “Bereavement coping manual” (Supplementary Fig. S2–4).

Phase 2: implementation of the supportive care

Conducted stratified training. Next, we constructed a stratified training course.¹⁶ First, we provided offline training for head nurses and nurse educators from all clinical departments. Subsequently, the nurse educators returned to their respective departments to train other nurses, ensuring that all staff could implement this practice standard homogenously throughout the process.

Implemented the bundled supportive care strategies. When a patient in the ward was approaching the final days of life, the charge nurse initiated and implemented the appropriate supportive care strategies as outlined in the supportive care practice standard. During the implementation process, the hospice and palliative care specialist group offered assistance and guidance whenever the nurses faced challenges or required help. If the dying patient planned to be discharged home or transferred to another medical institutions, the charge nurse would complete the preparations in accordance with the discharge checklist, Meanwhile, the pamphlet of “Warm Companionship: how to provide home-based hospice care for loved ones” would be provided to the family members, and continued to offer follow-up care support until the patient died. After the patient passes away, the charge nurse would provide the family member with the pamphlets of “Administrative matters to handle after the loss of loved ones”, and “Bereavement coping manual” and contact the family members by phone in approximately one week to offer bereavement counseling and support.

Phase 3: post-implementation quality supervision

A two-level supervision mechanism was established at both hospital and departmental levels to promote the implementation of various supportive care strategies. A steering group, comprised of quality control commissioners from the nursing department and head nurses, was responsible for supervising the implementation of the end-of-life supportive care practice standard, as well as training and evaluation across all departments. The Nursing department has consistently made improvements based on the brief report, analysis, and feedback regarding the quality supervision outcomes.

Measurements

Demographic data on patients and their family caregivers using self-designed questionnaires were collected. This included information on patients' gender, age, marital status, educational level, beliefs, primary caregiver, and type of medical payment, as well as family caregivers’ gender, age, marital status, educational level, beliefs, relationship with the patient, and duration they spent accompanying the patient.

This study focused mainly on evaluating the quality of death experienced by terminal cancer patients. The Chinese version of the Good Death Inventory (GDI) was used to measure the quality of death for terminally ill cancer patients from the nurse's perspective and the family member's perspective respectively to avoid the deviation caused by one-sided evaluation. The GDI was originally developed by Miyashita et al.^17,18 from Japan based on a series of good death research in 2007, and it evaluates the quality of death from the bereaved family member's perspective. The GDI is comprised of 18 domains of a good death, including 10 core domains (1–10) that most Japanese consistently rated as important and 8 optional domains (11–18) that were not as consistently rated as important by Japanese individuals. Each of the 18 domains has three items, and thus 54 components of a good death were asked using a seven-point Likert scale (1: absolutely disagree, 2: disagree, 3: somewhat disagree, 4: unsure, 5: somewhat agree, 6: agree and 7: absolutely agree). The score of each domain ranging from 3 to 21 and the total score ranging from 54 to 378 can be calculated, with a higher score indicating a more important domain for a good death. Tseng¹⁹ from Taiwan translated the GDI into Chinese and found that the Chinese version (Taiwan) has adequate psychometric properties. Further, Yang et al.²⁰ adjusted the Chinese version of the GDI to better align with the linguistic expressions used in the mainland and to expand the applicability of this observer-rated instrument for nurses evaluating the quality of death. The reliability and validity of the new Chinese version of GDI were evaluated among 180 oncology nurse specialists; scale-level content validity index (S-CVI/Ave) of the total scale was 0.97 and the CVI of each item was 0.67–1.00; the total scale's Cronbach's α was 0.950.²⁰ Cronbach's α of the total scale in the present sample was 0.946, and the domains' Cronbach's α were 0.725–0.959, indicating good-to-excellent internal consistency.

Satisfaction is one of the important indicators in the quality assessment system of medical services. The Family Satisfaction with Advanced Cancer Care-2 (FAMCARE-2) was used to assess the perceived satisfaction of family caregivers with end-of-life care. This instrument was developed by Aoun et al.²¹ in 2010 based on FAMCARE, and its use has been expanded to encompass not only home care but also hospitalization and community care. FAMCARE-2 comprises 17 items categorized into four dimensions: management of physical symptoms and comfort (5 items), provision of information (4 items), family support (4 items), and patient psychological care (4 items). Each item adopts a 5-point Likert scale, yielding a total score ranging from 17 to 85 points, with higher scores indicating greater satisfaction. Jin et al.²² rigorously standardized the Chinese version of this instrument and confirmed its strong reliability and validity. In this study, Cronbach's coefficient of the scale was 0.955, as well as 0.882, 0.854, 0.841, and 0.781 for each dimension, respectively.

Data collection

When the bundled supportive care strategies were provided to the patient, the charge nurse proceeded to document the demographic information of the patient and their family, along with the implementation of each measure in the supportive care strategies checklist. When the patient passed away, the charge nurse handed over these materials to the data collection staffs. Subsequently, the GDI questionnaire would be distributed to the charge nurse within 1 week following the patient's death and it should be returned once completed. Meanwhile, the GDI and satisfaction questionnaires from the family members were collected in approximately 2 weeks via telephone.

Statistical analysis

The data were collected in a file compatible with Excel Statistics and subsequently transferred to an IBM SPSS Statistics, Version 22.0 for Windows (SPSS Inc., Chicago, USA) for statistical analysis. Appropriate descriptive statistics, including frequency, percentage, means, and standard deviations, were used to describe the characteristics and study variables of the patients and family caregivers. Given the non-normal distribution of the data, Wilcoxon tests for the complete paired samples were performed to compare the differences between nurse-rated GDI and family member-rated GDI. A statistical significance level of 0.05 was established.

Results

Characteristics of the patients and their family caregivers

A total of 114 patients from five hospitals were provided the bundled supportive care strategies, of which 112 nurses completed follow-up evaluation of patients' good death, with 2 questionnaires not filled out (yielding an effective response rate 98.2%). Additionally, 103 family caregivers completed follow-up evaluation of their satisfaction and patients’ good death, with 11 family members lost to follow-up (yielding an effective response rate 90.4%).

The age of the patients was (64.83 ± 13.69) years, with a median of 67.5 years and an age range of 19.0–88.0 years. The average age of family caregivers was 50.39 years (± 13.97) with a median of 50.0 years, ranging from 20.0 to 89.0 years. Regarding their relationship with the patients, 32.0% were spouses, 55.3% were children, 7.8% were parents, and 4.9% were classified as others. Of the caregivers, 67.0% lived with the patients, whereas 33.0% lived separately. The frequency of daily patient companionship showed that 73.8% accompanied patients every day, 5.8% did so 4–6 days a week, 18.4% for 1–3 days a week, and 2.0% less than once a week. Table 1 presented the other characteristics of the patients and their family caregivers.

Table 1.

The characteristics of the patients and their family caregivers [N (%)].

Variables		Patients (n = 114)	Family caregivers (n = 103)
Sex	Male	49 (43.0)	59 (57.3)
	Female	65 (57.0)	44 (42.7)
Religious belief	Yes	3 (2.6)	3 (2.9)
	No	111 (97.4)	100 (97.1)
Marital status	Unmarried	2 (1.8)	2 (1.9)
	Married	91(79.8)	92 (89.3)
	Widowed or divorced	21 (18.4)	9 (8.7)
Educational status	Primary school or less	36 (31.6)	11 (10.7)
	Junior middle school	29 (25.4)	21 (20.4)
	Senior high school or technical secondary school	18 (15.8)	17 (16.5)
	Junior college education	10 (8.8)	17 (16.5)
	Undergraduate degree or above	21 (18.4)	37 (35.9)
Cancer type	Gastric cancer	22 (19.3)	_
	Colorectal cancer	18 (15.8)	_
	Lung cancer	17 (14.9)	_
	Breast cancer	11 (9.6)	_
	Esophagus cancer	11 (9.6)	_
	Pancreatic cancer	8 (7.0)	_
	Cholangiocarcinoma	6 (5.3)	_
	Liver cancer	2 (1.8)	_
	Bladder cancer	2 (1.8)	_
	Ovarian cancer	2 (1.8)	_
	Melanoma	2 (1.8)	_
	Hypopharyngeal cancer	2 (1.8)	_
	Peritoneal mesothelioma	2 (1.8)	_
	Cancer in other sites	9 (7.9)	_

Good death of terminally ill patients with cancer

We collected the good death evaluations of cancer patients made by nurses and the family members, and a comparison was conducted, as presented in Table 2. Among these domains, 13 domains showed no significant differences, while for the remaining 5 domains, the scores evaluated by family members were higher than those evaluated by nurses.

Table 2.

The quality of death of cancer patients from the perspective of charge nurses and family members.

Scores of the GDI	Nurse-rated GDI (Mean ± SD)	Family member-rated GDI (Mean ± SD)	Z	P
	(n = 112)	(n = 103)
Total score	299.81 ± 53.70	310.76 ± 49.55	−0.411	0.681
1. Physical and psychological comfort	14.96 ± 6.05	16.45 ± 5.21	−1.139	0.255
2. Dying in a favorite place	15.83 ± 6.25	16.15 ± 6.38	−0.168	0.867
3. Maintaining hope and pleasure	15.06 ± 5.76	16.29 ± 5.58	−1.664	0.096
4. Good relationship with medical staff	19.80 ± 2.72	19.46 ± 3.63	−0.626	0.531
5. Not being a burden to others	16.53 ± 5.40	18.22 ± 4.36	−2.273	0.023a
6. Good relationship with family	19.19 ± 3.64	19.67 ± 3.04	−1.899	0.058
7. Independence	9.19 ± 6.76	10.38 ± 7.25	−0.803	0.422
8. Environmental comfort	18.16 ± 4.40	18.68 ± 3.90	−0.880	0.379
9. Being respected as an individual	19.77 ± 2.34	19.49 ± 3.52	−0.238	0.812
10. Life completion	16.74 ± 4.80	17.51 ± 4.97	−1.364	0.173
11. Receiving enough treatment	19.76 ± 2.74	19.56 ± 3.36	−0.392	0.695
12. Natural death	19.50 ± 3.58	20.07 ± 3.15	−2.086	0.037a
13. Preparation for death	18.23 ± 4.65	19.74 ± 2.95	−2.897	0.004b
14. Control over the future	16.28 ± 5.29	17.48 ± 4.87	−2.013	0.044a
15. Unawareness of death	15.02 ± 5.53	17.35 ± 4.90	−3.894	< 0.001c
16. Pride and beauty	15.84 ± 5.12	16.12 ± 5.98	−0.327	0.744
17. Feeling that one's life is worth living	17.25 ± 4.34	17.90 ± 4.48	−1.122	0.262
18. Religious and spiritual comfort	11.16 ± 6.74	10.40 ± 7.53	−1.601	0.109

GDI, Good Death Inventory; SD, standard deviation.

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

The satisfaction of family caregivers with end-of-life care

Based on the satisfaction evaluation of 103 patients' family caregivers, the scores of the FAMCARE-2 were calculated and shown in Table 3.

Table 3.

The scores of family satisfaction (N = 103).

Scores of the FAMCARE-2	Mean ± SD
Total score	80.52 ± 8.75
Management of physical symptoms and comfort	23.73 ± 2.80
Provision of information	18.87 ± 2.25
Family support	18.94 ± 2.35
Patient psychological care	18.98 ± 1.95

FAMCARE-2, Family Satisfaction with Advanced Cancer Care-2; SD, standard deviation.

Discussion

As China's economic, cultural, and medical model continues to advance, hospice care has emerged as a pivotal focus in medical development, leading to increased attention on the quality of death for terminally ill patients from patients, families, and health care professionals.

This is a top-down reform program that takes improving the quality of end-of-life care for cancer patients as its breakthrough point. Based on the bundled supportive care strategies for the end of life formulated through scientific methods in the early stage, we developed a hospital-based QI program to implement these strategies through standardized hospital practice protocols. In summary, the program presents three advantages. Firstly, the supportive care strategies cover detailed and comprehensive contents, ranging from identifying the final stage of life to providing support during the mourning period, encompassing care for both patients and their families, and addressing physical, psychosocial and spiritual needs. This enables nurses to no longer be confused about what they can do when facing the sufferings of actively dying cancer patients and their families, and provides robust guidance for their practice. Secondly, developing practice standard and related materials, along with conducting stratified training provides a foundation for the implementation of supportive care strategies, thereby enhancing nurses’ knowledge and skills in end-of-life care. This ensures they not only know what to do but also how to do it. Lastly, providing nurses with solutions to their challenges and conducting quality supervision provide a strong guarantee the supportive care is implemented in clinical practice. These advantages ensure that both patients and their families can receive comprehensive, professional, and effective support and care throughout this difficult journey at the end of life.

Improving the quality of death for patients serves as the primary measure for evaluating end-of-life care quality. This study examined the quality of death for patients from the perspectives of both nurses and family caregivers. As shown in Table 2, there were no significant differences in the scores of the 13 domains, indicating that the evaluation results obtained from both perspectives tend towards consistency and the quality of death presented in this study is relatively true and reliable. The total GDI score from the nurses' perspective in this study was 299.81 ± 53.70, surpassing the 245.40 ± 36.91 reported in our previous study¹² in 2018. Zhao et al.²³ conducted a study in China to evaluate the quality of death from the perspective of family members between 2014 and 2016, with a total GDI score of 241.20 ± 39.45, whereas the score was 310.76 ± 49.55 in this study. These findings indicate that satisfactory outcomes were achieved through this QI program. It must be acknowledged that the quality of care for terminally ill cancer patients may also improve due to the promotion of national systems in recent years. Therefore, historical control bias and performance bias due to various confounding factors within the time span and the Hawthorne effect may exaggerate the effectiveness of this QI program. The remaining 5 domains of Not being a burden to others, Natural death, Preparation for death, Control over the future, and Unawareness of death, the scores from family members significantly higher than those from nurses. This discrepancy may stem from the nature of these domains, which pertain to family dynamics and communication, thus preventing nurses from gaining a deep understanding of patients’ wishes, arrangements and feelings.

Oftentimes, family members play an important role as informal caregivers. During the end-of-life process, informal caregivers experience grief and bereavement.²⁴ The World Health Organization (WHO) advocates for supporting not only patients, but also their family caregivers.^25,26 Accordingly, grief and bereavement support are essential to high-quality end-of-life care. Among the supportive care strategies formulated in this study, both Family-centered supportive care and Bereavement support for the family are involved in end-of-life care, which also reflects the comprehensiveness and scientific nature of these strategies. We employed the FAMCARE-2 to evaluate the satisfaction of family caregivers following the implementation of these measures, aiming to understand their subjective experiences with end-of-life care provided and the disparity between their expectations and reality. The findings in Table 3 revealed that the average total score of FAMCARE-2 for 103 family caregivers was 80.52 ± 8.75, with the scores across four dimensions being 23.73 ± 2.80 for management of physical symptoms and comfort, 18.87 ± 2.25 for provision of information, 18.94 ± 2.35 for family support, and 18.98 ± 1.95 for patient psychological care. In contrast, the study by Jin et al.²² involving 220 Chinese family caregivers of advanced care patients reported an average total score of FAMCARE-2 was 74.8 ± 8.9, with domains scores of 22.1 ± 2.8, 17.6 ± 2.1, 17.4 ± 2.2, and 17.8 ± 2.2, respectively. The results from our study surpassed those of previous research conducted in China. Although the populations in the two studies varied, the finding was still encouraging, as it provides preliminary evidence that the supportive care strategies are helpful in improving family satisfaction. In comparison to the results from Germany,²⁷ Australia,²⁸ and Thailand,²⁹ while the scores in this study are also relatively high, it is also necessary to consider the variations in methodology, as well as the distinct background, policies and health systems of each country. In addition, the 9.6% dropout rate among family members in this study might have introduced some bias in the results and an inflated perception of family satisfaction, as families of patients experiencing severely distressed were less likely to respond.

Despite the overall positive evaluation of patients' quality of death through the implementation of this program, we have received feedback from nurses regarding the difficulties and challenges encountered in the process of the strategies implementation. A significant concern lies in the implementation of strategies promoting end-of-life communication. For instance, the strategies checklist outlines that when patients enter the terminal phase, health care providers are expected to update both patients and their families on the current disease status and prognosis. When the disease is irreversible, it is essential to guide the advance care planning process, confirm the patient's preferences regarding end-of-life resuscitation, and assist in the completion of Do Not Resuscitate (DNR) documents. However, within the Chinese cultural context, some family members, motivated by a desire to protect the patient emotionally, are reluctant to disclose bad news to the patient and often prevent nurses from disclosing the truth, thereby hindering the effective implementation of these strategies. This situation also leads to confusion among clinical nurses regarding the appropriate moment to implement the strategies. If these strategies are only put into practice after a sudden deterioration in the patient's condition, it may be too late. Additionally, although the strategies emphasize the importance of providing psychological and emotional support to patients and their families, nurses indicate that despite gaining numerous communication skills during their training, the heavy workload in clinical practice restricts their communication time and undermines their confidence in their communication abilities, ultimately resulting in unsatisfactory implementation of supportive strategies. Future efforts may focus on developing end-of-life communication training programs tailored to nurses' needs and grounded in evidence-based practices, as well as exploring the application of digital health interventions in nurse training to further improve the quality of end-of-life care.

Limitations

This research has some limitations. This study is a hospital-based QI program for end-of-life care. After the implementation of the supportive care strategies, follow-up evaluations of the quality of death of patients and the satisfaction of their families were conducted. A concurrent control group was not included, and comparisons with the results of historical studies were made in the discussion. This design may weaken the persuasiveness of the research findings. In the future, it is essential to conduct more rigorous concurrent control studies to evaluate the impact of the bundled supportive care strategies on improving the quality of death for patients and the satisfaction of their families. Secondly, the evaluations of the quality of patient's death and satisfaction from the family members were collected after a period of time following the patient's death. This may introduce recall or grief-related bias and thereby affect the accuracy of the evaluation results. Additionally, this study examined the effects from the perspectives of patients and their families, but did not consider its impact on nurses. Expanding the evaluation metrics to include nurses is necessary to gain a more comprehensive understanding of its positive effects.

Conclusions

In conclusion, this research developed a hospital-based QI program to implement the bundled supportive care strategies for patients with terminal cancer and their families, addressing physical, psychological, social, and spiritual needs. By developing in-hospital practice standard and related materials, conducting stratified training, offering assistance for nurses and conducting quality supervision, the bundled supportive care strategies have been integrated into clinical practice and implemented. This QI program achieved satisfactory outcomes in improving the quality of death of cancer patients and the satisfaction of their family caregivers, and its systematic approach and innovation are worthy of further promotion. Future studies should focus more on developing tailored measures based on the contextual resources at the different implementation stages, applying the bundled supportive care strategies within a randomized controlled design and broadening the scope of evaluation to assess its impact on health care staff as well.

CRediT authorship contribution statement

Yuhan Lu: Conceptualization, Methodology, Program administration, Resources, Writing – reviewing and editing. Xiaoting Hou and Renxiu Guo: Methodology, Data curation, Formal analysis, Writing – original draft. Wenhua Yu and Xiaoxiao Ma: Methodology, Data curation. Ling Yuan, Guoxia Chen, Li Liu and Yunhua Wang: Program administration, Resources, Data Curation. Yujie Zhou and Xue Zhang: Data curation, Resources. All authors have read and approved the final manuscript.

Ethics statement

The study was approved by the Ethics Committee of Beijing Cancer Hospital (Approval No. 2020KT23) and was conducted in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants provided written informed consent.

Data availability statement

The data that support the findings of this study are available from the corresponding author, YL, upon reasonable request.

Declaration of generative AI and AI-assisted technologies in the writing process

No AI tools/services were used during the preparation of this work.

Funding

This work was supported by the Reform and Innovation Initiatives Program for the High-Quality Development of Municipal Hospitals in Beijing. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

Declaration of competing interest

The authors declare no conflict of interest. The corresponding author, Prof. Yuhan Lu is an editorial board member of Asia–Pacific Journal of Oncology Nursing. The article was subject to the journal's standard procedures, with peer review handled independently of Prof. Lu and their research groups.

Appendix A. Supplementary data

The following is the Supplementary data to this article: