Objectives: To evaluate the quality of end-of-life (EOL) care in nursing homes.

Design: Survey and semistructured interviews.

Setting: Jerusalem district nursing homes.

Participants: Staff members of 28 long-term care and skilled nursing facilities in the Jerusalem area in Israel of various ethnic, religious, and administrative affiliations (N = 207).

Measurements: Qualitative analysis of semistructured interviews and statistical analysis of questionnaires.

Results: Most staff members reported that EOL preferences were unknown for more than 90% of residents and that fewer than 10% had a healthcare proxy. Most staff members recalled conducting fewer than five EOL conversations over the past year with residents or family members and could recall fewer than five cases in which a resident was allowed to die in the nursing home. According to staff opinions the prevalence of tube feeding was estimated at greater than 10%, initiated because of aspiration, malnutrition, and understaffing, often against family’s preferences. More than 25% of staff members believed that pain management was inadequate. Knowledge about management of chronic pain was poor in half of nurses and nearly one-third of physicians. Most staff would rather not receive the treatments they administered to residents.

Conclusion: Nursing homes in Jerusalem lack competency for quality EOL care, and there are multiple psychological, training, and policy challenges to improvement.

Keywords: advance care planning; advance directives; advanced dementia; end of life; palliative care.