In this cross-sectional study we found that German participants estimated that 20.5% of residents die in the hospital in contrast to the Dutch estimation of 5.9%. In German nursing homes ACP is offered less often and significantly fewer wishes for emergency situations of residents were known than in Dutch nursing homes. GPs were considered less well trained for end-of-life care in Germany. The most important measures to improve end-of-life care were comparable in both countries.

In our study, we found a lower in-hospital death of German nursing home residents with 20.5% compared to previous German studies. There, almost 30% of residents died in the hospital [5, 8, 16]. One study was comparable in methodology but already older, suggesting that there might be a decline in in-hospital deaths of German nursing home residents [16]. For Dutch nursing homes, our 5.9% of in-hospital deaths are in line with the previously reported 6% of residents who die in the hospital [10]. Worldwide numbers for in-hospital death of nursing home residents range from 5.9%-77.1%, showing that the Netherlands has one of the lowest percentages of hospitalization at the end-of-life [5]. German in-hospital deaths in the aforementioned study were around 30%, so above the worldwide median of 22.6% [5]. In our study, German in-hospital deaths were comparable to the worldwide median.

These differences in hospitalization in the two neighbouring countries could be due to structural differences in nursing home care. In Germany usually, several GPs are responsible for the medical care of nursing home residents. It has been shown, that on average 8.6 different GPs are responsible for one nursing home [24]. In Dutch type 1 nursing homes, which are the majority of facilities, ECPs are responsible. These are medical specialists with a specific focus on elder care medicine enabling them to do more diagnosis in the nursing home, which could prevent some hospital transports. Furthermore, ACP is part of their training [20, 23, 25].

ACP is a valuable tool to decrease hospitalization at the end-of-life [12]. In our study, 39.2% of German nursing homes offered ACP, which is comparable, but a bit less than seen in previous studies [17]. Of the Dutch nursing homes, 75.0% offered ACP. These results are in line with previous literature, describing percentages of persons with advance directives (4.9% and 33%) and PTOs (82%). In the Netherlands, ACP is usually integrated into nursing home care, resulting in a high proportion of residents with dementia having a comfort care goal before death [26].

In German nursing homes significantly fewer wishes for emergency situations were known, ranging from 44.7%- 55.8%. This result is consistent with a previous study, which found that 46% of nursing home residents received ACP in their last months of life [17]. However, the authors suspect a high degree of positive self-selection bias among facilities, making it difficult to generalize to all German nursing homes [17]. We also cannot exclude such selection bias. In around 60–70% of Dutch nursing homes, depending on the situation (e.g. CPR), wishes for residents’ emergency situations were known. This is in line with earlier studies where almost all residents (9 out of 10 residents with dementia) had a comfort care goal at the end of their life and 82% had a PTO [9, 19]. The proportion of Dutch residents with a do-not-hospitalize order increases significantly between nursing home admission and death, from 28 to 76% [27].

These differences could also be due to structural and additionally due to organisational differences in nursing home care between the two countries. In the Netherlands, the health of the residents is regularly discussed in multidisciplinary meetings. Furthermore, there are multiple contact moments between the resident’s relatives and nursing home staff, ensuring frequent medical evaluation and considering the residents and relatives will. These are documented in a treatment plan (PTOs or ADs) [9, 10, 19, 26]. In another study it was been shown, that Dutch ECPs have more contextual knowledge and knowledge of the quality of life of their patients, enabling them to treat based on what they perceived was in the best interest of their patients [28].

German nursing home residents, on the other hand, are usually able to keep their previous GP. Since GPs often have been responsible for their medical care for years, it could be assumed that they potentially know wishes regarding end-of-life care of their patients. However, addressing this issue does not seem to be a frequent part of everyday medical practice.

German participants were less likely than Dutch respondents to rate the overall quality of end-of-life care as rather good, and GPs in Germany were considered significantly less well trained for end-of-life care than Dutch physicians. When comparing to existing literature, the German overall rating of end-of-life care is slightly higher than in a previously conducted study (end-of-life care rated as rather good by 64.6%) and perceived training of GPs was in line with a previous study [16]. For the Netherlands, no comparable studies have been published. These different satisfaction levels could be due to the fact that Dutch ECPs have more training in end-of-life care [23, 25]. Cultural differences may also play a role. In the Netherlands, in contrast to Germany, there is more discussion on quality of life versus life-sustaining treatments [9]. It is more common in Dutch nursing homes to refuse potentially distressing life-sustaining treatments. It has been shown that for almost half of the nursing home residents (42.3%) it was decided not to start potentially life-prolonging treatment, and for more than half of the residents (53.7%) this treatment was discontinued [9]. Different attitudes towards the end of life are evident, for example, in the availability of euthanasia in the Netherlands as opposed to Germany [29].

In general, the suggested measures to improve end-of-life care in our study were mostly comparable between Germany and the Netherlands, differing only in the most common response. Reflecting that while in Germany staff shortage might have a big impact on end-of-life care, this is not the most pressing issue in Dutch nursing homes.

Respondents from both countries also indicated that better qualification of nursing staff would be a feasible measure to improve end-of-life care. This was also reflected in a previous German and Dutch study [16, 30]. Overall, due to the little amount of suggested measures to improve end-of-life care of Dutch respondents, limited conclusion can be drawn from this and further specific studies are needed to shed light on how to improve end-of-life care.

A strength of our study is, that to our knowledge, this is the first study directly comparing nursing home care in German and Dutch nursing homes with a large and nationwide sample. This makes it possible to directly compare the perspectives of end-of-life care in the two countries. Another strength of this study is, that we offered to answer the questionnaire online and on paper to minimize differences in both countries regarding digitalization.

However, one limitation is that the response from the Netherlands was nearly half than of Germany, possibly affecting generalizability and comparability of these results. One reason could be that in Dutch nursing homes it was often not possible to identify nursing staff managers through manual search to address the questionnaire directly to them. A similarly low Dutch response was described in a previous study, surveying nursing homes in six European countries [31]. Nursing staff managers and facility managers mostly filled out the questionnaire, possibly giving answers that would present their facility more positively. Additionally, the given answers most likely represent the subjective opinion of the person answering the questions. Furthermore, this study merely asked if ACP was offered and did not specify if residents had formal advanced directives, expressed ACP informally, or policy was actually carried out by the treating physician (PTOs). This makes it more difficult to compare to existing literature. However, we asked respondents to estimate how many residents had known wishes for care in emergency situations. This makes it possible to compare known wishes for both countries, irrespective of the existence of a written document.

We found that in Dutch nursing homes, fewer residents were expected to die in the hospital, more nursing homes offered ACP, more residents’ wishes for emergency situations were known, GPs/ECPs were perceived as better trained in end-of-life care, and significantly more participants rated end-of-life care as rather good than in German nursing homes. These differences could be due to structural differences (ECPs available 24/7 in Dutch nursing homes) and cultural differences (more discussion on quality of life versus life-sustaining treatments and euthanasia being available in the Netherlands). Due to these differences, country-specific approaches are necessary. Overall, more and better-qualified nursing staff and better integration of palliative care would improve the quality of end-of-life care. Future studies are needed to shed light on the specific processes regarding end-of-life care and multidisciplinary collaboration to improve end-of-life care in both countries.