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Objectives: Although the experiences of family caregivers have received attention, little research has specifically explored caregivers’ confidence. Evidence shows that caregivers of hospice patients do not feel confident or prepared to care for relatives or friends who die at home. Aim: We aimed to elicit the views, feelings, and experiences of primary caregivers who provide unpaid care to dying family members in the home setting to better understand what contributes to their confidence during end-of-life care. Design: The exploratory, cross-sectional design involved semistructured, in-depth interviews. A narrative analysis that focused on form and content was chosen to analyze the data. Participants: Sixteen bereaved caregivers (14 individuals and 1 brother/sister dyad) from the midwestern United States who received support from 1 hospice participated in the study. Results: Four storylines running longitudinally through the interviews were identified as shaping, giving meaning to, and contextualizing caregivers’ confidence: values/relationships, stories of terminal illness, needs, and support. Caregivers’ confidence is shaped by the terminal illness of the person for whom they care and caregivers’ values and relationships. It is also influenced by their needs and the sources and strength of support they receive. Conclusions: This research developed understanding about family provision of end-of-life care at home. Better comprehension of caregivers’ experiences can help professional hospice and palliative care staff to understand what aids caregivers to be more confident.

Aim To explore the experience and the preparedness of family carers in their caregiving role as best interest decision‐makers of a relative living with advanced dementia. Background The prevalence of dementia is a global issue. The role of being a carer of a relative living with dementia does not necessarily lessen once they are admitted to a nursing home. Best interest decision‐making including end‐of‐life care decisions need to be made and reaching these choices can be challenging. The preparedness of family carers in this role needs greater understanding. Design Descriptive qualitative study. Methods During 2015 twenty semi‐structured interviews were conducted of family carers of nursing home residents living with advanced dementia, then analysed using Braun and Clarke's thematic analysis. Results Three themes were identified: (1) Caring for someone living with dementia. The impact on the carer's holistic well‐being and their experience of being a best interest decision‐maker; (2) Accessing support. The influential nature of formal and informal networks; (3) Perceived knowledge and understanding of the dementia trajectory of carers and nursing staff. Conclusion The experiences and preparedness of informal carers is a reflection of their personal response, but the distress experienced highlights the significant need of adequate support availability and of enhancing nursing staffs’ dementia expertise to maximize their role in facilitating best interest decision‐making. This has significant implications for nursing practice and for service user and nursing staff education. Considering the global impact of dementia, our findings have international relevance to similar nursing homes across the world.

Background Several studies have highlighted the need for improvement in palliative care delivered to older people long-term care facilities. However, the available evidence on how to improve palliative care in these settings is weak, especially in Europe. We describe the protocol of the PACE trial aimed to 1) evaluate the effectiveness and cost-effectiveness of the ‘PACE Steps to Success’ palliative care intervention for older people in long-term care facilities, and 2) assess the implementation process and identify facilitators and barriers for implementation in different countries. Methods We will conduct a multi-facility cluster randomised controlled trial in Belgium, Finland, Italy, the Netherlands, Poland, Switzerland and England. In total, 72 facilities will be randomized to receive the ‘Pace Steps to Success intervention’ or to ‘care as usual’. Primary outcome at resident level: quality of dying (CAD-EOLD); and at staff level: staff knowledge of palliative care (Palliative Care Survey). Secondary outcomes: resident’s quality of end-of-life care, staff self-efficacy, self-perceived educational needs, and opinions on palliative care. Economic outcomes: direct costs and quality-adjusted life years (QALYs). Measurements are performed at baseline and after the intervention. For the resident-level outcomes, facilities report all deaths of residents in and outside the facilities over a previous four-month period and structured questionnaires are sent to (1) the administrator, (2) staff member most involved in care (3) treating general practitioner, and (4) a relative. For the staff-level outcomes, all staff who are working in the facilities are asked to complete a structured questionnaire. A process evaluation will run alongside the effectiveness evaluation in the intervention group using the RE-AIM framework. Discussion The lack of high quality trials in palliative care has been recognized throughout the field of palliative care research. This cross-national cluste

Background The predicted demographic changes internationally have implications for the nature of care that older people receive and place of care as they age. Healthcare policy now promotes the implementation of end-of-life care interventions to improve care delivery within different settings. The Gold Standards Framework in Care Homes (GSFCH) programme is one end-of-life care initiative recommended by the English Department of Health. Only a small number of care homes that start the programme complete it, which raises questions about the implementation process. Aim To identify the type, role, impact and cost of facilitation when implementing the GSFCH programme into nursing care home practice. Design A mixed-methods study. Setting Nursing care homes in south-east England. Participants Staff from 38 nursing care homes undertaking the GSFCH programme. Staff in 24 nursing care homes received high facilitation. Of those, 12 also received action learning. The remaining 14 nursing care homes received usual local facilitation of the GSFCH programme. Methods Study data were collected from staff employed within nursing care homes (home managers and GSFCH coordinators) and external facilitators associated with the homes. Data collection included interviews, surveys and facilitator activity logs. Following separate quantitative (descriptive statistics) and qualitative (template) data analysis the data sets were integrated by ‘following a thread’. This paper reports study data in relation to facilitation. Results Three facilitation approaches were provided to nursing home staff when implementing the GSFCH programme: ‘fitting it in’ facilitation; ‘as requested’ facilitation; and ‘being present’ facilitation. ‘Being present’ facilitation most effectively enabled the completion of the programme, through to accreditation. However, it was not sufficient to just be present. Without mastery and commitment, from all participants, including the external facilitator, learning and initia

Objectives • Understanding the perceptions of patients and informal caregivers in advanced COPD. • Understanding what is lacking in PC provision in advanced COPD. Original Research Background Although chronic obstructive pulmonary disease (COPD) is recognized as being a life-limiting condition with palliative care needs, palliative care provision is seldom implemented in this population. The disease unpredictability, the misconceptions about palliative care being restricted to cancer and only being relevant in the last days of life prevent a timely integrated care plan for patients with advanced COPD. Research Objectives To explore patients and informal caregivers' experiences during the disease trajectory and to understand their perceptions on palliative care integration in COPD. Methods Ten individual interviews with adult patients suffering from advanced COPD (GOLD stages 3 and 4) and their informal caregivers were conducted and recorded. Data analysis was performed through thematic analysis. Results Six different themes were identified. Patients reported a feeling of personal guilt and a sense of discrimination by healthcare professionals with regard to their smoking habit. Informal caregivers mentioned their caring experience of loved-ones with a “self-inflicted disease” and their distress over acute exacerbations with a sense of helplessness in the case of dyspnoea. Both groups underlined their knowledge about the disease trajectory and the importance of having a palliative care support, which is currently lacking, addressing all multidimensional aspects of advanced COPD. Conclusion These findings informed the second phase of the study, which involves healthcare professionals in a collaborative inquiry group as part of a participatory action research project. This group will aim to develop and try out new ways to integrate PC into outpatients' services for people with severe COPD.

Aims and objectives To explore family perspectives on their involvement in the timely detection of changes in their relatives’ health in UK nursing homes. Background Increasingly, policy attention is being paid to the need to reduce hospitalisations for conditions that, if detected and treated in time, could be managed in the community. We know that family continue to be involved in the care of their family members once they have moved into a nursing home. Little is known, however, about family involvement in the timely detection of changes in health in nursing home residents. Design Qualitative exploratory study with thematic analysis. Methods A purposive sampling strategy was applied. 14 semi-structured one-to-one telephone interviews with family members of people living in 13 different UK nursing homes. Data were collected from November 2015 to March 2016. Results Families were involved in the timely detection of changes in health in three key ways: noticing signs of changes in health, informing care staff about what they noticed, and educating care staff about their family members’ changes in health. Families suggested they could be supported to detect timely changes in health by developing effective working practices with care staff. Conclusion Families can provide a special contribution to the process of timely detection in nursing homes. Their involvement needs to be negotiated, better supported, as well as given more legitimacy and structure within the nursing home. Relevance to clinical practice Families could provide much needed support to nursing home nurses, care assistants, and managers in timely detection of changes in health. This may be achieved through communication about their preferred involvement on a case-by-case basis as well as providing appropriate support or services.

BackgroundIn dementia care, a large number of treatment decisions are made by family carers on behalf of their family member who lacks decisional capacity; advance care planning can support such carers in the decision-making of care goals. However, given the relative importance of advance care planning in dementia care, the prevalence of advance care planning in dementia care is poor. AimTo evaluate the effectiveness of advance care planning with family carers in dementia care homes. DesignPaired cluster randomized controlled trial. The intervention comprised a trained facilitator, family education, family meetings, documentation of advance care planning decisions and intervention orientation for general practitioners and nursing home staff. Setting/participantsA total of 24 nursing homes with a dementia nursing category located in Northern Ireland, United Kingdom. Family carers of nursing home residents classified as having dementia and judged as not having decisional capacity to participate in advance care planning discussions. ResultsThe primary outcome was family carer uncertainty in decision-making about the care of the resident (Decisional Conflict Scale). There was evidence of a reduction in total Decisional Conflict Scale score in the intervention group compared with the usual care group (−10.5, 95% confidence interval: −16.4 to −4.7; p < 0.001). ConclusionAdvance care planning was effective in reducing family carer uncertainty in decision-making concerning the care of their family member and improving perceptions of quality of care in nursing homes. Given the global significance of dementia, the implications for clinicians and policy makers include them recognizing the importance of family carer education and improving communication between family carers and formal care providers.

Introduction Many people living with advanced dementia live and die in nursing care homes. The quality of life, care and dying experienced by these people is variable. Namaste Care is a multisensory programme of care developed for people with advanced dementia. While there is emerging evidence that Namaste Care may be beneficial for people with dementia, there is a need to conduct a feasibility study to establish the optimum way of delivering this complex intervention and whether benefits can be demonstrated in end-of-life care, for individuals and service delivery. The aim of the study is to ascertain the feasibility of conducting a full trial of the Namaste Care intervention. Methods and analysis A feasibility study, comprising a parallel, two-arm, multicentre cluster controlled randomised trial with embedded process and economic evaluation. Nursing care homes (total of eight) who deliver care to those with advanced dementia will be randomly allocated to intervention (delivered at nursing care home level) or control. Three participant groups will be recruited: residents with advanced dementia, informal carers of a participating resident and nursing care home staff. Data will be collected for 6 months. Feasibility objectives concern the recruitment and sampling of nursing homes, residents, informal carers and staff; the selection and timing of primary (quality of dying and quality of life) and secondary clinical outcome measures (person centredness, symptom presence, agitation, quality of life, resource use and costs and residents’ activity monitored using actigraphy). Acceptability, fidelity and sustainability of the intervention will be assessed using semistructured interviews with staff and informal carers. Ethics and dissemination This protocol has been approved by NHS Wales Research Ethics Committee 5 (ref: 17/WA0378). Dissemination plans include working with a public involvement panel, through a website (http://www.namastetrial.org.uk), social media, academic

Objectives: Although the experiences of family caregivers have received attention, little research has specifically explored caregivers’ confidence. Evidence shows that caregivers of hospice patients do not feel confident or prepared to care for relatives or friends who die at home. Aim: We aimed to elicit the views, feelings, and experiences of primary caregivers who provide unpaid care to dying family members in the home setting to better understand what contributes to their confidence during end-of-life care. Design: The exploratory, cross-sectional design involved semistructured, in-depth interviews. A narrative analysis that focused on form and content was chosen to analyze the data. Participants: Sixteen bereaved caregivers (14 individuals and 1 brother/sister dyad) from the midwestern United States who received support from 1 hospice participated in the study. Results: Four storylines running longitudinally through the interviews were identified as shaping, giving meaning to, and contextualizing caregivers’ confidence: values/relationships, stories of terminal illness, needs, and support. Caregivers’ confidence is shaped by the terminal illness of the person for whom they care and caregivers’ values and relationships. It is also influenced by their needs and the sources and strength of support they receive. Conclusions: This research developed understanding about family provision of end-of-life care at home. Better comprehension of caregivers’ experiences can help professional hospice and palliative care staff to understand what aids caregivers to be more confident.

Background Care homes provide personal care and support for older people who can no longer be supported in the community. As part of a larger study of integrated working between the NHS and care homes we asked older people how they accessed health care services. Our aim was to understand how older people resident in care homes access health services using the Andersen model of health care access. Methods Case studies were conducted in six care homes with different socio-economic characteristics, size and ownership in three study sites. Residents in all care homes with capacity to participate were eligible for the study. Interviews explored how residents accessed NHS professionals. The Andersen model of health seeking behaviour was our analytic framework. Findings Thirty-five participants were interviewed with an average of 4 different conditions. Expectations of their health and the effectiveness of services to mitigate their problems were low. Enabling factors were the use of intermediaries (usually staff, but also relatives) to seek access. Residents expected that care home staff would monitor changes in their health and seek appropriate help unprompted. Conclusions Care home residents may normalise their health care needs and frame services as unable to remediate these which may combine to disincline older care home residents to seek care. Care access was enabled using intermediaries -either staff or relatives-and the expectation that staff would proactively seek care when they observed new/changed needs. Residents may over-estimate the health-related knowledge of care home staff and their ability to initiate referrals to NHS professionals.

Although members of the United Kingdom (UK) South Asian population appear to have an elevated risk of developing dementia, this population accesses dementia services less frequently, compared with the majority white population. The disparity between the prevalence of people with dementia and the reported incidence of dementia, especially among South Asian populations (the UK‟s largest ethnic minority), is of concern to public health service providers. This study aimed to identify the socio-cultural issues in accessing dementia services in the population living in Blackburn with Darwen [BwD], in the Northwest of England. This qualitative study explores how members of the BwD South Asian Indian and Pakistani population perceive dementia, and how their family members engage with local dementia care services and with healthcare professionals providing dementia services. Data collection included: three focus groups with thirteen people involved in a community project; two interviews with people living with dementia and their family members; and eight interviews with nine dementia services healthcare professionals [HCPs]. The data was analysed using thematic analysis. The findings suggest that members of the South Asian population are under-represented in dementia diagnostic services. Firstly, this appears to be due to a lack of knowledge in the Muslim South Asian Indian and Pakistani community about the nature of dementia. Various negative perceptions of dementia, influenced by cultural beliefs, were also identified which lead to people with dementia being stigmatised and hidden from public view by their families. This may explain why health professionals report that this population seeks help at a later stage of the illness, and thus there is an argument for public health services to develop culturally relevant outreach programmes.

Background: Dementia is characterised by a set of symptoms that affect the functioning of the brain. It is estimated that there are 850,000 people living with dementia in the UK and 46 million people worldwide – more than 60% of whom are women. In the UK, approximately one third of people with dementia live in care settings where staff may apply restrictive interventions guided by legislative frameworks. Aim: To understand the management of restrictive intervention practice by mental health workers in an acute mental health setting for people with dementia. Methods: An interpretive descriptive study was undertaken. Vignettes were developed using evidence based literature, case law and practice guidance and used to frame semi-structured interviews. Mental health workers and practice leaders were purposively sampled and interviewed from an English NHS Foundation Trust which provides mental health services across two counties. Thematic analysis of data was undertaken which followed six phases and utilised NVIVO-10. Results: Four key themes were identified: 1) legislation, 2) policy, 3) training and supervision and 4) person-centred restrictive intervention practice. Discussion: Practice leaders are able to translate knowledge from legislation to frame restrictive intervention policy, practice guidance and training content for mental health workers. Mental health workers can then deliver restrictive intervention practice based on person-centred care principles although specific characteristics such as gender may not be acknowledged as shaping a person’s experience of dementia. A ‘Model of Translated Ways of Knowing’ was developed that demonstrates the knowledge journey from legislation to practice. Conclusions: Restrictive intervention practice can be enabled when legislation, case law, research and national policy are translated into an accessible format for mental health workers. Translated knowledge can then facilitate person-centred restrictive interventions for peo

Aim To explore the experience and the preparedness of family carers in their caregiving role as best interest decision‐makers of a relative living with advanced dementia. Background The prevalence of dementia is a global issue. The role of being a carer of a relative living with dementia does not necessarily lessen once they are admitted to a nursing home. Best interest decision‐making including end‐of‐life care decisions need to be made and reaching these choices can be challenging. The preparedness of family carers in this role needs greater understanding. Design Descriptive qualitative study. Methods During 2015 twenty semi‐structured interviews were conducted of family carers of nursing home residents living with advanced dementia, then analysed using Braun and Clarke's thematic analysis. Results Three themes were identified: (1) Caring for someone living with dementia. The impact on the carer's holistic well‐being and their experience of being a best interest decision‐maker; (2) Accessing support. The influential nature of formal and informal networks; (3) Perceived knowledge and understanding of the dementia trajectory of carers and nursing staff. Conclusion The experiences and preparedness of informal carers is a reflection of their personal response, but the distress experienced highlights the significant need of adequate support availability and of enhancing nursing staffs’ dementia expertise to maximize their role in facilitating best interest decision‐making. This has significant implications for nursing practice and for service user and nursing staff education. Considering the global impact of dementia, our findings have international relevance to similar nursing homes across the world.

Objectives • Understanding the perceptions of patients and informal caregivers in advanced COPD. • Understanding what is lacking in PC provision in advanced COPD. Original Research Background Although chronic obstructive pulmonary disease (COPD) is recognized as being a life-limiting condition with palliative care needs, palliative care provision is seldom implemented in this population. The disease unpredictability, the misconceptions about palliative care being restricted to cancer and only being relevant in the last days of life prevent a timely integrated care plan for patients with advanced COPD. Research Objectives To explore patients and informal caregivers' experiences during the disease trajectory and to understand their perceptions on palliative care integration in COPD. Methods Ten individual interviews with adult patients suffering from advanced COPD (GOLD stages 3 and 4) and their informal caregivers were conducted and recorded. Data analysis was performed through thematic analysis. Results Six different themes were identified. Patients reported a feeling of personal guilt and a sense of discrimination by healthcare professionals with regard to their smoking habit. Informal caregivers mentioned their caring experience of loved-ones with a “self-inflicted disease” and their distress over acute exacerbations with a sense of helplessness in the case of dyspnoea. Both groups underlined their knowledge about the disease trajectory and the importance of having a palliative care support, which is currently lacking, addressing all multidimensional aspects of advanced COPD. Conclusion These findings informed the second phase of the study, which involves healthcare professionals in a collaborative inquiry group as part of a participatory action research project. This group will aim to develop and try out new ways to integrate PC into outpatients' services for people with severe COPD.

BackgroundIn dementia care, a large number of treatment decisions are made by family carers on behalf of their family member who lacks decisional capacity; advance care planning can support such carers in the decision-making of care goals. However, given the relative importance of advance care planning in dementia care, the prevalence of advance care planning in dementia care is poor. AimTo evaluate the effectiveness of advance care planning with family carers in dementia care homes. DesignPaired cluster randomized controlled trial. The intervention comprised a trained facilitator, family education, family meetings, documentation of advance care planning decisions and intervention orientation for general practitioners and nursing home staff. Setting/participantsA total of 24 nursing homes with a dementia nursing category located in Northern Ireland, United Kingdom. Family carers of nursing home residents classified as having dementia and judged as not having decisional capacity to participate in advance care planning discussions. ResultsThe primary outcome was family carer uncertainty in decision-making about the care of the resident (Decisional Conflict Scale). There was evidence of a reduction in total Decisional Conflict Scale score in the intervention group compared with the usual care group (−10.5, 95% confidence interval: −16.4 to −4.7; p < 0.001). ConclusionAdvance care planning was effective in reducing family carer uncertainty in decision-making concerning the care of their family member and improving perceptions of quality of care in nursing homes. Given the global significance of dementia, the implications for clinicians and policy makers include them recognizing the importance of family carer education and improving communication between family carers and formal care providers.

Background: As the population ages, it is likely that the number of older adults admitted to nursing homes (NHs) will increase. NH residents are more likely to have multiple comorbidities and have a greater use of healthcare services than older adults living in the community. It is unclear how length of stay in a NH varies between residents and across NH facilities. Aims: This study aims to provide a comprehensive, up to date summary of published research exploring factors associated with the length of stay of older adult's residing in NHs. Methods: A systematic review of published, peer reviewed and grey literature. Electronic searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL, Proquest, the Cochrane Library, Web of Science, the Campbell Library, SCOPUS and Social Care Online. Papers were included if they were observational, epidemiological studies exploring the influence of at least two predictive variables on either length of stay before death or mortality in adults aged over 65 years residing in NHs. Results: The electronic searches identified over 11,000 papers, of which 56 met the initial inclusion criteria. The findings suggest that increased age, being male, functional dependence in ADLs, cognitive impairment and urinary incontinence may be related to increased mortality. Contact with primary care services, hospital admissions, medication use, placement from hospitals and residence in facilities with nursing may also be associated with decreased survival. Conclusions: The predictive characteristics identified could facilitate recognition of residents approaching end of life and inform treatment choices. Although the value of using length of stay as an indicator of quality of care is debatable, variation within and across NHs warrants further attention. Internationally comparable data collected by studies such as the PACE study could be used to further research in this area.

Background: Higher acuity of care at the time of admission to long-term care (LTC) is resulting in a shorter period to time of death, yet most LTC homes in Canada do not have formalized approaches to palliative care. Namaste Care is a palliative care approach specifically tailored to persons with advanced cognitive im-pairment who are living in LTC. The purpose of this study was to employ the ecological framework to identify barriers and enablers to an implementation of Namaste Care. Methods: Six group interviews were conducted with families, unlicensed staff, and licensed staff at two Canadian LTC homes that were planning to implement Namaste Care. None of the interviewees had prior experience implementing Namaste Care. The resulting qualitative data were analyzed using a template organizing approach. Results: We found that the strongest implementation ena-blers were positive perceptions of need for the program, benefits of the program, and fit within a resident-centred or palliative approach to care. Barriers included a generally low resource base for LTC, the need to adjust highly developed routines to accommodate the program, and reliance on a casual work force. Conclusions: We conclude that within the Canadian LTC system, positive perceptions of Namaste Care are tempered by concerns about organizational capacity to support new programming.

Background The provision of institutional long-term care for older people varies across Europe reflecting different models of health care delivery. Care for dying residents requires integration of palliative care into current care work, but little is known internationally of the different ways in which palliative care is being implemented in the care home setting. Objectives To identify and classify, using a new typology, the variety of different strategic, operational, and organizational activities related to palliative care implementation in care homes across Europe. Design and methods We undertook a mapping exercise in 29 European countries, using 2 methods of data collection: (1) a survey of country informants, and (2) a review of data from publically available secondary data sources and published research. Through a descriptive and thematic analysis of the survey data, we identified factors that contribute to the development and implementation of palliative care into care homes at different structural levels. From these data, a typology of palliative care implementation for the care home sector was developed and applied to the countries surveyed. Results We identified 3 levels of palliative care implementation in care homes: macro (national/regional policy, legislation, financial and regulatory drivers), meso (implementation activities, such as education, tools/frameworks, service models, and research), and micro (palliative care service delivery). This typology was applied to data collected from 29 European countries and demonstrates the diversity of palliative care implementation activity across Europe with respect to the scope, type of development, and means of provision. We found that macro and meso factors at 2 levels shape palliative care implementation and provision in care homes at the micro organizational level. Conclusions Implementation at the meso and micro levels is supported by macro-level engagement, but can happen with limited macro strategic dr

Background: Caring for dying people can contribute to moral distress experienced by healthcare professionals. Moral distress can occur when this caring is restricted by organisational processes, resources or the provision of futile care. These factors apply to end of life care in nursing homes but research is lacking. Aim: To describe how nursing home staff experience moral distress when caring for residents during and at the end of life. Methods: An interpretive descriptive design, using the critical incident technique in semi-structured interviews to collect data from nursing home staff. Data were analysed using a thematic analysis approach. Setting: Four nursing homes in one large metropolitan area. Participants: A total of 16 staff: 2 nurse managers, 4 nurses and 10 care assistants. Findings: Participants described holding ‘good dying’ values which influenced their practice. The four practice-orientated themes of advocating, caring, communicating and relating with residents were found to influence interactions with residents, relatives, general practitioners, and colleagues. These led staff to be able to ‘do the right thing’ or to experience ‘powerlessness’, which could in turn lead to staff perceiving a ‘bad death’ for residents. Conclusion: When there are incongruent values concerning care between staff and others involved in the care of residents, staff feel powerless to ‘do the right thing’ and unable to influence care decisions in order to avoid a ‘bad death’. This powerlessness is the nature of their moral distress.

Background The provision of institutional long-term care for older people varies across Europe reflecting different models of health care delivery. Care for dying residents requires integration of palliative care into current care work, but little is known internationally of the different ways in which palliative care is being implemented in the care home setting. Objectives To identify and classify, using a new typology, the variety of different strategic, operational, and organizational activities related to palliative care implementation in care homes across Europe. Design and methods We undertook a mapping exercise in 29 European countries, using 2 methods of data collection: (1) a survey of country informants, and (2) a review of data from publically available secondary data sources and published research. Through a descriptive and thematic analysis of the survey data, we identified factors that contribute to the development and implementation of palliative care into care homes at different structural levels. From these data, a typology of palliative care implementation for the care home sector was developed and applied to the countries surveyed. Results We identified 3 levels of palliative care implementation in care homes: macro (national/regional policy, legislation, financial and regulatory drivers), meso (implementation activities, such as education, tools/frameworks, service models, and research), and micro (palliative care service delivery). This typology was applied to data collected from 29 European countries and demonstrates the diversity of palliative care implementation activity across Europe with respect to the scope, type of development, and means of provision. We found that macro and meso factors at 2 levels shape palliative care implementation and provision in care homes at the micro organizational level. Conclusions Implementation at the meso and micro levels is supported by macro-level engagement, but can happen with limited macro strategic dr