Effective practices and transdisciplinary team-based approaches in home palliative care for terminal cancer patients: a qualitative descriptive study

BACKGROUND: In Japan, approximately 60% of patients with cancer prefer to spend their final days at home, yet only 11.8% die at home. Contributing factors include uneven distribution of community resources and difficulties in multidisciplinary collaboration. We aimed to qualitatively identify key practices in home-based palliative care that should be shared among professionals within a transdisciplinary team approach, which may offer solutions to these challenges. METHODS: Between November 2021 and March 2022, semi-structured interviews were conducted with 13 professionals—physicians, nurses, care managers, care workers, pharmacists, and medical social workers—affiliated with institutions that provide more than 12 cases of home-based end-of-life care annually. We used reflexive thematic analysis to code the data, extracted subcategories and main categories, and inductively developed the themes. RESULTS: We identified 625 codes, 66 subcategories, and nine categories, which were integrated into three themes. Theme 1 (Iterative Communication & Coordination) described repeated alignment of prognosis and care goals among teams, patients, and families, supported by real-time information sharing. It also illustrated how teams recalibrated care direction in response to subtle changes in patient conditions or family perspectives. Theme 2 (Family Readiness & Relational–Emotional Support) captured practices that strengthened caregivers’ psychological readiness and emotional stability by alleviating burden, responding sensitively to distress, and fostering meaningful connections. This theme also highlighted that caregiver needs fluctuate throughout the illness trajectory, requiring tailored and ongoing engagement from multiple professionals. Theme 3 (Proactive Preparedness & Resource Orchestration) encompassed anticipatory symptom management, coordination of financial/practical resources, and flexible cross-disciplinary role-sharing to ensure timely responses at home. Proactive preparation—such as securing medications, anticipating care gaps, and coordinating resources across institutions—played a crucial role in preventing crises and sustaining home care. Collectively, these integrated practices enabled resource-conscious, transdisciplinary support that contributed to the realisation of home deaths in resource-limited settings. CONCLUSIONS: These findings inform education and system design by clarifying how transdisciplinary teams integrate iterative communication, caregiver support, and proactive preparation to provide flexible, comprehensive care, even in resource-limited settings, thereby offering a foundation for developing transferable training frameworks and implementation strategies across diverse care contexts.