How we die is complicated. Health and medical sciences and advances in clinical care have had a dramatic impact on Australians’ lives.
Complex chronic illnesses are being treated successfully, and lives are prolonged. At the same time, the end-of-life has become increasingly complex and often protracted.
Australians are living longer than ever, with median age at death now 80 years for men and 85 for women.1 This ageing population experiences more prolonged periods of illness, often marked by disability, dementia, and multimorbidity. Despite the predictability of decline, only 12% of Australians have an advance care plan in place.2 Recognition that someone is dying often occurs within the final 48 hours of life, when opportunities for meaningful discussion, preparation, and comfort may be lost.2
This presents a challenge to the nursing and midwifery professions: To step forward as both advocates and leaders in improving communication and care at the end-of-life.
The uncomfortable silence around death
The culture of modern healthcare often revolves around recovery, restoration, and cure. Nurses and midwives enter their professions to alleviate suffering, promote healing, and support families. But when restoration of health is no longer possible, many clinicians find themselves in unfamiliar territory. The shift from active treatment to end-of-life care may feel like failure, especially in high-pressure hospital environments where “doing everything” is frequently equated with good care.3 Moving to end-of-life care is often slow or doesn’t happen at all.
The absence of quality end-of-life care can be isolating for patients, families and healthcare teams at a time when individuals and families most need clarity, reassurance, and the chance to say goodbye.3
Research shows that offering to discuss end-of-life issues does not cause harm. On the contrary, these conversations often bring relief. Many patients want to talk about their fears, their hopes, their regrets, and what matters most in their final days. Families want to understand what to expect and how best to support their loved ones.3 We need to listen.
A skill, not just an instinct
Many nurses and midwives lack confidence in knowing when or how to initiate end-of-life conversations.4 Yet, these are not conversations that require perfection. They require presence. A listening ear. The willingness to sit with uncertainty, emotion, and the unknown.
Communication at end-of-life is a skill that can be developed. Frameworks such as the SPICT5 can help identify when a patient may be nearing end-of-life. Prompts such as “What worries you most about your illness?” or “What would you like to do with the time you have left?” are powerful words to open conversations. The ABCD model – Attitudes, Beliefs, Compassion, and Dialogue6 – reminds clinicians that their mindset is just as important as their words.
Leadership from every role
It is a common misconception that end-of-life discussions are the domain of senior doctors or palliative care teams. Nurses and midwives are uniquely placed to lead these conversations at the bedside. They hear the patient’s fears, hopes, and wishes.
Leadership here does not mean issuing directives. It means modelling openness and curiosity, asking thoughtful questions, supporting colleagues, and advocating for dignity and clarity in care planning. It means recognising end-of-life care not as a separate specialty but as a core responsibility of healthcare, regardless of setting or title.
Building a culture of psychological safety
Advocating for patients at end-of-life is needed, and nurses are in a prime position to do so. One of the greatest barriers to end-of-life communication is the fear of speaking up. Nurses and midwives may be concerned about overstepping roles, challenging hierarchies, or appearing negative. This hesitancy can be especially strong in interprofessional teams shaped by seniority, discipline, and authority.
To overcome this, nurses and workplaces can cultivate psychological safety, the shared belief that it is safe to ask questions, raise concerns, and admit uncertainty without fear of humiliation or blame. In such environments, all staff can frame differences of opinion as learning opportunities rather than threats.7
Self-care is not optional
It is vital to acknowledge that providing care at the end-of-life can be emotionally taxing. Providing care to the dying and supporting those who are newly bereaved is important work that demands care of ourselves.3 Nurses and midwives must be encouraged to reflect on their own needs, seek support, and engage in meaningful self-care. Asking “Who supports me?” and “What helps me stay well?” are not indulgent questions, they are essential.
A call to reflect and reframe
As our population ages and demands grow for quality and safe end-of-life care, nurses and midwives have an opportunity to reframe death not as a failure, but as a phase of life deserving of the same attention, compassion, and professionalism as any other.
Are we prepared to speak, listen, advocate and lead? Or will we allow silence to persist where conversation is most needed?
The answer lies not in policy documents or medical charts, but in the courage to act, one conversation at a time.
References
1 Australian Institute of Health and Welfare (AIHW). 2025. Deaths in Australia. https://www.aihw.gov.au/reports/life-expectancy-deaths/deaths-in-australia/contents/life-expectancy
2 Mitchell I, Lacey J, Anstey M, Corbett C, Douglas C, Drummond C, Hensley M, Mills A, Scott C, Slee JA, Weil J, Scholz B, Burke B, and D’Este C. Understanding end-of-life care in Australian hospitals. Aust Health Rev. 2021 Jun 2:540-547. doi:10.1071/AH20223
3 Bloomer MJ, Ranse K, Butler A et al. A National Position Statement on adult end-of-life care in critical care. Aust Crit Care 2021;35:480–7. doi: 10.1016/j.aucc.2021.06.006
4 Croxon L, Deravin L, Anderson J. Dealing with end-of-life – new graduated nurse experiences. J Clin Nurs. 2018;27(1–2):337–44. doi: 10.1111/jocn.13907
5 The University of Edinburgh. Supportive and palliative care indicators tool (SPICT). 2016. www.spict.org.uk
6 Chochinov H. Dignity and the essence of medicine: The A, B, C, and D of dignity conserving care. Br Med J. 2007 Jul;335(7612):184-187. doi: 10.1136/bmj.39244.650926.47
7 Edmondson AC, Higgins M, Singer S, et al. Understanding Psychological Safety in Health Care and Education Organizations: A Comparative Perspective. Research in Human Development. 2016;13(1):65-83. https://doi.org/10.1080/15427609.2016.1141280
Authors:
Associate Professor Kim Devery, Project Lead, End-of-Life Essentials project and Dr Caroline Phelan, Co-Lead.
