Read the comments and revise the Discussion accordingly. Revise based on the originial Discussion. Then write point-by-point responses to each reviewer’s comment. Use English only, and do not need to show me how you analyse. Just the revised text and the point-by-point responses.
Comments:
1.there needs to be a clearer focus on how the new knowledge you have generated supports nurses and the advancement of nursing practice
2.The discussion is very long, and there is insufficient synthesis with the extant evidence. The discussion is not for repeating the findings. Rather it is to make concise key points about what and how these findings contrast or build on what was already known. I would strongly encourage you to refine this section.
3.Line 56-60, I am not sure this statement belongs here.
4.please review this section as not all of the information presented is relevant here
5.Line 56, what is a ‘policy environment
6.Here, the big role of the family members in relation to the patient her or himself in Chinese culture context comes to the fore. P. 20 very long and heavy chapter. Could it be condensed or divided into smaller parts to improve readability. I would always start this with the results of this study and then tell and compare the results of this study with previous studies. E.g. p. 21 last line. "This is similar to our study..." p. 22. This study includes important content to international audience.
7.There are some conclusions drawn that have neither a literature review nor research to support them. It is also not entirely clear whether this is deductive or inductive logic employed here.
8.In the discussion section, the recommendations for practice/research/education should have been approached in greater depth. Please discuss whether or how the findings can be transferred to other populations or consider other ways the research may be used.
9.Theoretical and methodological limitations should be deeply emphasized. There’s also a lack of consideration for potential biases specific to your specific and qualitative-only approach.
5. Discussion
Overall, our findings provide an insight into the complex dynamics of client–provider end-of-life communication in Chinese hospital settings from the perspectives of patients with advanced illnesses, their family caregivers and healthcare providers. Based on field data about participants’ experiences and perceptions, we determined two end-of-life communication states: protective and open. The former is characterised by dominant family involvement, truth concealment and restricted end-of-life topics. The main characteristics of the latter are dominant patient participation, truth disclosure and rich end-of-life topics. Several factors related to the patient, family, and healthcare provider may affect the change in end-of-life communication from protective to open. A common factor shared across the three parties is the comfort level of talking about the end of life. Another factor that patients and families share is their perceived burdens, although there are subtle differences between patients and families. Other factors include patient treatment engagement, families’ expectations, values and trust in healthcare providers, providers’ available time and priority in practice, end-of-life communication awareness, and end-of-life care knowledge and communication skills.

The first important finding of our study is the coexistence of two end-of-life communication states, protective and open. Some aspects related to protective end-of-life communication, such as the heavy intervention of the family in decision-making and withholding the diagnosis from the patient, are discussed in some studies (Lin et al., 2019; Tang, 2019) and frequently attributed to cultural influences and compared with other cultures (e.g., collectivism versus individualism). Such compositional approaches rely on the cross-cultural comparative paradigm and provide several cultural dimensions that are clear and consistent to some extent (Hofstede, 2001). Nevertheless, it has been criticised as a static perspective to categorise culture and may result in stereotyping and over-generalisation (Zhu, 2019). One of the reasons is that it is possible to find both ends of the cultural dimensions in one culture (Osland et al., 2000). As shown in our findings, our participants also described open end-of-life communication in addition to protective end-of-life communication. Dominant patient involvement in open end-of-life communication manifests patient autonomy, which may challenge previous understandings of traditional cultural beliefs and their influence on end-of-life communication in the Chinese context. Stocklassa et al. found that most Chinese patients with advanced-stage cancer prefer to know about their diagnosis and prognosis and be respected as individuals (Stocklassa et al., 2022). This patient autonomy may be related to the influence of Western individualistic values and increased awareness of people’s rights (Pun et al., 2018). This result suggests that healthcare professionals should avoid some preconceived assumptions based on traditional cultural beliefs and instead proactively identify the roles of patients and families in end-of-life communication and choose appropriate communication strategies.

Regardless of the protective or open state of end-of-life communication, participants highlight the significance of family involvement, support, and family consensus. On the one hand, this perception may be related to familism, which values supportive family relationships and prioritises the family over the individual (Campos et al., 2014; Choi et al., 2018). On the other hand, as there are no relevant national-level legal provisions on living wills in Mainland China (Zhang et al., 2022), although there were some attempts, and Shenzhen is the first city in Mainland China to recognise living wills legally (Yin et al., 2023), patient’s preferences for end-of-life care has not been well documented; therefore the family still plays a significant role in the decision-making when the patient is incompetent in making medical decisions (Leng et al., 2022). In light of this, family participation needs to be respected; however, family attitudes and behaviours that conceal the truth prevent full patient involvement in end-of-life communication. Participants mentioned that family members may withhold the truth due to their perception of the patient’s personality, their emotional connection to the patient, or as a form of self-protection. This implies that there is a need to explore why some family members withhold the truth and adopt targeted communication strategies in practice. Meanwhile, it is essential to note that not all family members wish to conceal the truth and may struggle with when and how to disclose it, leading to helplessness in decision-making. Therefore, healthcare providers may need to understand the family’s willingness to tell the patient the truth. More importantly, they are expected to take a greater leadership role in truth-telling. Due to the inconsistency of end-of-life care preferences between patients and family caregivers (Chuang et al., 2020), it is necessary to go beyond relying solely on family members to understand patient preferences (Pun et al., 2020). Healthcare professionals should provide education and guidance to family members regarding truth-telling and truly incorporate the patient’s voice and choices into the decision-making process, ultimately promoting better outcomes.

Our study discovered that truth disclosure was seldom conducted directly but rather through indirect means such as suggestive informing, including intentional silence, as reported by participants. This may align with the high-context communication style in the Chinese context (Kim et al., 1998). Similarly, indirect communication approaches are also recommended to initiate end-of-life communication with older Chinese American patients, such as using another person’s end-of-life care experience (Chi et al., 2018). However, there is still a lack of detailed indirect communication strategies for implicitly disclosing the truth to the patient in the context of serious illness. The non-verbal cues may be culturally appropriate and helpful for healthcare providers and families wanting to tell the patient the truth. More case studies with clear background information and application scenarios of culturally appropriate communication strategies may provide valuable knowledge and practical directions.

Medico-legal and policy-related issues are essential to create environments and establish confidence for healthcare providers to communicate end-of-life topics (Turnbull et al., 2023). However, implementing protective medical measures in Mainland China may affect the willingness and confidence of medical staff to communicate with patients regarding end-of-life topics, indulge and fuel the dominant family participation in end-of-life communication, providing a basis for protective end-of-life communication. Protective medical measures refer to the medical measures taken to prevent vulnerable patients, including terminally ill patients, who are not suitable for their informed consent, from having negative and pessimistic emotions after learning the true disease information and affecting the treatment effect, so that their family members exercise informed consent on their behalf (Wang et al., 2013). They are considered to have a profound ethical foundation, have been enacted in the “Regulations on the Administration of Medical Institutions” in 1994, and are widely practised in healthcare settings in Mainland China (Hahne et al., 2020). However, there are some inherent contradictions in the protective medical measures. For example, they are intended to safeguard patients’ life and health interests, while families are often informed of the condition and treatment plan. In addition, protective medical measures are based on the assumption that patients are unwilling to accept adverse news about their condition and know the actual condition is not conducive to the patient’s health (Li and Li, 2021), which is not supported by the current research evidence (Tang et al., 2006; Tang, 2019; Stocklassa et al., 2022). More importantly, the current provisions related to protective medicine are only scattered in medical-related laws and regulations, and the relevant provisions are vague, with no specific explanation of their specific implementation scope and procedures. This allows flexibility for healthcare professionals to implement these measures in practice, while also explaining the coexistence of protective and open end-of-life communication at an institutional level. With the development of China’s social economy and the awakening of modern people’s awareness of autonomy, whether protective medical measures based on traditional culture and cognition is suitable for the current medical cultural environment and whether it is conducive to promoting end-of-life communication, deserves in-depth consideration and appropriate adjustment.

Healthcare professionals, families, and patients were considered a triad of experts (Dalkin et al., 2018), and our study results show that the factors related to each triad member may affect end-of-life communication. People’s comfort level of talking about the end of life was quite individual and related to their attitudes towards death, similar to the previous findings (Bergenholtz et al., 2020; O’Connor et al., 2020). The common comfort around end-of-life topics among the three parties is essential for open end-of-life communication. Educational interventions improve physicians’ comfort with end-of-life communication (Schmit et al., 2016; Miller et al., 2018). However, the effect of these interventions on comfort has not been demonstrated among other groups despite positive impacts on death attitudes (Chu and Jang, 2021; Zhang et al., 2024). Tailored educational programs for all three parties may be necessary as this could promote end-of-life communication based on promoting comfort levels in all three parties.

Terminally ill patients and family caregivers may experience multifaceted burdens (Emanuel et al., 2000; Wen et al., 2019). Participants highlighted three burdens on patients (i.e., economic burden, symptom burden and emotional burden) and three burdens on family caregivers related to caregiving, decision-making and emotion. Perceived higher stress levels in these areas appear to be associated with a tendency toward open end-of-life communication. Patient’s symptom burden was found to be related to their information needs (Verhoef et al., 2022), and the family caregiver’s decisional burden calls on an early decision-making process incorporating the patient’s values (Yamamoto et al., 2017), which partly explains their tendency towards open end-of-life communication. According to Johnson et al. (Johnson et al., 2007), patients with advanced illness share common concerns about being a burden on their families. They may adopt several strategies to minimise the burden, including planning for future care. This is similar to our study, in which the patients' emotional burden motivated them to engage in or initiate end-of-life communication, thus leading to open end-of-life communication. Whether these burdens are expressed directly by patients or families or learned by healthcare providers through assessment tools, the above burdens may be essential signals that patients and families desire open communication in the context of serious illness.

Participants described time constraints as a barrier towards open end-of-life communication, which was also found in previous research (Bennett and O'Conner-Von, 2020). The survey results showed that relevant training is beneficial in decreasing providers’ commonly perceived barriers, including time constraints (Chan et al., 2020). Although end-of-life communication has been considered a vital component of the care provided at the end of life (Olsson et al., 2021) and hospitals remain the primary setting for end-of-life care (Virdun et al., 2015; Weng et al., 2022), it is not currently a priority for hospital staff in Mainland China. Providers’ end-of-life communication awareness is mainly derived from their own experiences. A systematic end-of-life communication and quality evaluation system should be established to encourage providers’ end-of-life communication practices. Moreover, relevant education and training must be strengthened to improve providers’ end-of-life communication awareness, knowledge and skills, especially emotional and psychological support and managing family disagreements. This also helps providers establish a trusting relationship with families and lays the foundation for open end-of-life communication.
5.1 Strengths and limitations of the work
Our study has several strengths. Firstly, the data came from a large sample of key stakeholders in end-of-life communication (19 patients, 22 family caregivers and 25 healthcare providers), and data saturation was achieved for each group. Secondly, whilst reporting data from distinct participant groups, such as patients, is plausible, presenting the viewpoints of all three parties concurrently allowed us to make comparisons of experiences and perceptions from multiple perspectives. This might result in a balanced and thoughtful data analysis, as well as a more profound comprehension of and response to the research questions.

There are also some limitations to this study. Firstly, patients and family caregivers who were unable to express themselves clearly were excluded from the interviews, for example, those who had severe auditory or cognitive impairment. They may have different perspectives and special needs regarding end-of-life communication. Secondly, all the healthcare providers included had at least five years’ experience of working with patients with advanced illnesses. Experiences and perceptions from providers with less work experience may not be represented in this study and need further exploration. Moreover, the participants were from two hospitals in one city, although the two hospitals receive patients from all over the country. Given the imbalance in end-of-life care resources and development in different cities in China (Lu et al., 2024), the transferability of our findings may be limited. These findings' direct applicability and transferability to other countries and regions, including those with similar cultural backgrounds, may be limited due to the potential influence of local political, legal, and healthcare systems on end-of-life communication. Nevertheless, these findings have implications for promoting effective end-of-life communication in societies with similar cultural backgrounds. Social professionals (e.g., palliative care social workers) were not included, though their role warrants future exploration (see Russell & Quaack, 2021).
5.2 Recommendations for further research
Non-verbal cues are worth exploring in culturally sensitive healthcare communication, particularly in end-of-life scenarios. Comparative studies across different cultures could identify specific non-verbal signals that are effective and appropriate, providing valuable insights for healthcare providers working in diverse environments. Compiling detailed case studies with clear background information and application scenarios can offer practical guidance and enrich the existing knowledge base. Multifocal interventions based on personal factors need to be developed to improve end-of-life communication in hospitals.
5.3 Implications for policy and practice
A better policy environment is needed to accommodate open end-of-life communication by revisiting the protective medical measures for patients with advanced illnesses. Establishing a systematic end-of-life communication and quality evaluation system is crucial to encourage and standardise effective communication practices among providers. Moreover, enhancing education and training programs for healthcare professionals is essential to equip them with the necessary skills to manage the emotional and psychological aspects of end-of-life care and navigate family dynamics and disagreements. In practice, healthcare providers are expected to be proactively involved in end-of-life communication, including promoting the truth-telling process. Knowledge about patient- and family-related factors is necessary for healthcare providers to select appropriate end-of-life communication strategies. While this study focuses on patients with advanced, life-limiting illnesses, end-of-life communication may also apply to older adults with terminal decline, though this population was not explicitly examined.