Meaning-Making in Home-Based End-of-Life Care: A Qualitative Study of Wives’ Experiences after the Loss of Their Husbands to Cancer

Meaning-Making in Home-Based End-of-Life Care: A Qualitative Study of Wives’ Experiences after the Loss of Their Husbands to Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Meaning-Making in Home-Based End-of-Life Care: A Qualitative Study of Wives’ Experiences after the Loss of Their Husbands to Cancer Mari Karikawa, Hisae Nakatani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8482686/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Caring for a spouse with cancer during the end of life at home is an emotionally demanding experience that can have lasting effects on bereaved partners. For some spouses, this caregiving period becomes a source of meaning, personal growth, and relational reconstruction after loss. However, existing research has not fully explored the creative processes that unfold over time after loss, particularly how spouses derive positive meaning from caring for a husband with cancer at home or how they rebuild relationships. This study investigated how spouses who had provided home care for a partner with cancer, and who had interpreted the end-of-life caregiving experience positively six months to two years after bereavement, subsequently understood and reinterpreted that experience two years later. Methods Using a qualitative longitudinal design, we conducted a second interview (approximately four years after bereavement) with spouses who participated in the first interview (six months to two years post-bereavement) and provided renewed consent. Data obtained through semi-structured interviews were transcribed verbatim and analyzed by conducting sequential comparative analysis. Results The analysis yielded five themes: “the enduring bond of the married couple,” “the importance of family members who spent time together until the end,” “the meaning attached to caring for the husband in the terminal phase,” “confronting life without the husband” and “reflection on one’s way of life”. Wives who had initially attributed positive meaning to their caregiving experience gradually reconfigured their relationship with their husband, shifting from viewing it as a “concluded past” to a “relationship that continues in the present.” Conclusions The meaning-making process surrounding care for a dying spouse did not remain fixed after bereavement; it evolved as a dynamic, ongoing reinterpretation. The findings indicate that positive meaning-making after loss deepens over time and is accompanied by relational growth. Through end-of-life care support, visiting nurses can understand how spouses “make meaning of their marital relationship” and provide opportunities for narrative exchanges that lead to post-bereavement re-meaning. bereaved spouses patients with terminal cancer qualitative longitudinal study spousal caregiving meaning-making Figures Figure 1 Background In Japan, over 380,000 people are diagnosed with cancer and die each year [ 1 ]. Since 1981, cancer has been the leading cause of death nationwide; as the population ages, the number of deaths is expected to continue to increase. Inpatient care for patients with cancer is becoming increasingly difficult, and the treatment and care environment for terminally ill patients with cancer is shifting from hospitals to home-based care. Japan’s Ministry of Health, Labour and Welfare has identified strengthening the coordination between medical and nursing care systems and enhancing home-based medical care as key policy measures [ 2 ], and institutional reforms aligned with these goals have been implemented. Home-based palliative care places significant responsibilities on family caregivers [ 3 ]. Assuming the role of a family caregiver can constitute a negative life event and potentially disrupt many aspects of the caregiver’s existence [ 4 ]. Feelings of helplessness and guilt experienced by family caregivers owing to their perceived inability to help the patient with cancer [ 5 ], alongside caregiving burdens [ 6 ], lead to depressive symptoms. Psychological distress among family caregivers of terminally ill patients with cancer persists even after the patient’s death. Among the family members of patients with cancer receiving hospice home care, over 50% exhibited clinically significant depressive symptoms 1 year after bereavement [ 7 ]. Longitudinal post-bereavement studies have focused primarily on changes in depressive symptoms and grief intensity, demonstrating diverse patterns of grief reduction and resilience over time [ 8 , 9 ]. Many of these studies viewed grief primarily through pathological and recovery-oriented lenses, focusing on reducing depression and psychological distress. These studies did not adequately address the dynamic processes that occur over time after bereavement, such as the construction of positive meaning and relationship reorganization. Neimeyer [ 10 ] proposed the concept of “meaning reconstruction” to address how individuals who experience bereavement accept and understand their loss. The concept describes a dynamic process in which an individual reorganizes their life narrative through loss and reconstructs the meaning of events temporally [ 11 , 12 ]. Based on this perspective, psychological adaptation after bereavement is reframed not as the “disappearance of grief” but as the “reconstruction of meaning.” Furthermore, recent grief research has focused on the concept of “continuing bonds,” where individuals maintain connections with the deceased even after loss [ 13 ]. This framework proposes understanding loss not as an “end” but as a “transformation of relationships” [ 14 ]. Moreover, in Japan, many bereaved family members describe a continued sense of the deceased’s presence in daily life and a tangible feeling that the relationship endures even after death [ 15 ]. Many of these theoretical frameworks focus on reconstituting meaning and continuing bonds triggered by bereavement. However, only a few longitudinal studies have clarified the subsequent changes in the meaning formed through the temporal and relational process of the “caregiving experience” prior to bereavement. Spouses who have lost a partner to cancer experience depressive symptoms at rates two to three times higher than those of other family members [ 16 ]. Studies focusing on wives who lost their husbands to cancer report markedly higher levels of physical and psychological symptoms—including depression, insomnia, fatigue, and loss of appetite—than those of other family members [ 17 , 18 ]. They also tended to experience prolonged grief and loneliness after bereavement [ 7 , 18 ]. However, the experiences of wives who cared for their spouses at home until death are narrated within a temporal continuum encompassing “caregiving,” “bereavement,” and “life after loss.” Within this narrative, the “pride of having fully supported her husband as a wife” and the “sense of loss from losing her husband” are intricately intertwined with the loss of the “role consciousness of the wife supporting the family” that is cultivated in the Japanese culture. We believe that understanding the change in meaning within this context—not merely as a psychological recovery process but also as relational growth and a reconfiguration of role consciousness rooted in cultural values—can improve our understanding of loss within Japan’s cultural context. This longitudinal study, therefore, aimed to clarify the process of reconfiguring the meaning of the end-of-life care experience over time, focusing on wives who had positively reframed their caregiving experience after providing home-based care for a spouse with cancer and were between six months and two years after the loss. Methods Sample and Recruitment This study’s first survey [ 19 ] involved interviews with 13 individuals (two men and 11 women) who had cared for and witnessed the death of their spouse with cancer at home. Based on the qualitative analysis results of the first set of interviews, participants were classified according to the degree of “positive meaning-making” regarding their caregiving experience. Those who struggled to accept the death of their spouse and could not find positive meaning in the caregiving process were excluded from the follow-up study. Participants who accepted the death of their spouse and expressed gratitude or a sense of fulfillment in the relationship were defined as having positive meaning-making (n = 11; two men, nine women). In the second interview, theoretical sampling was conducted to focus on such meaning-making’s gendered aspects. Of the nine wives, five agreed to participate, excluding those who declined because of poor health or the psychological burden of re-experiencing grief (Fig. 1 ). [Figure 1 here] Data collection Semi-structured interviews were conducted with the research participants in their homes to ensure privacy. The first interview with 13 participants, conducted six months to two years after bereavement, included the following items: 1) the condition of the patient receiving home care and the caregiving situation; 2) the participant’s daily life during caregiving; 3) the participant’s feelings and thoughts during patient care; and 4) their reflections on the meaning and value of their home caregiving experience. Subsequently, we conducted a second interview of spouses from among the five participants who had attributed positive meaning to their end-of-life care experience during the first interview and agreed to further interviews. Data were collected using an interview guide developed from the categories identified in the initial interviews [ 19 ]. The guide used open-ended questions intended to elicit detailed narratives and encourage participants to introduce new perspectives. At the outset of each interview, participants were prompted to recall statements from their first interview, and the discussion then focused on differences between their earlier reflections and their current perspectives. Supplementary Table 1 provides detailed information on the interviews. The interview content was recorded with the permission of the research participants. The second interview was conducted between May and August 2015, two years after the first interview. A two-year interval was selected to capture later-phase changes in bereaved spouses’ meaning-making in terms of their caregiving experience. Meaning reconstruction theory [ 10 ] and the continuing bonds framework [ 13 ] suggest that integrating loss into one’s life narrative progresses over an extended period. In addition, longitudinal bereavement studies have reported that significant psychological and relational changes often occur between 18 and 48 months post-loss [ 8 , 20 ]. Therefore, a two-year interval was deemed appropriate for capturing these developmental processes while minimizing recall burden for participants. Each interview lasted approximately one–two hours, and each participant was interviewed once. Analysis To clarify how the meanings ascribed to caregiving and end-of-life experience change over time, we conducted an initial set of interviews with wives who had provided home-based end-of-life care for their husbands, at six months to two years after bereavement [ 19 ]. Approximately two years later, we conducted a second set of interviews with the same participants. This interval was chosen to capture a period in which initial grief responses generally subside and deeper processes of meaning reconstruction are thought to occur [ 10 ]. By comparing the two sets of narratives, we examined longitudinally how the wives’ understandings of their caregiving and bereavement experiences changed and deepened temporally. This study was based on the qualitative longitudinal research (QLR) framework to elucidate the “changes in meaning over time” [ 21 ]. We explored the reconfiguration of meaning within individual narratives from the dual perspectives of “change” and “continuity,” which are QLR’s defining characteristics. Data were collected through semi-structured interviews conducted in Japanese, and verbatim transcripts were created. In the first interview, the participants’ narratives were examined closely. Open coding was performed by focusing on the essential meaning of participants’ experiences. The relationships between codes were organized to extract subthemes and themes. The second interview explored how participants’ states of mind and meaning-making had shifted since the first interview and built on the themes identified in the initial analysis. Transcripts from the second interview were similarly subjected to open coding to organize newly emerging meanings and changes. Finally, themes from the first and second interviews were compared to provide an integrated interpretation of the persistent elements and the changes in meaning over time. Thereafter, we created a longitudinal comparison matrix contrasting the themes in the first and second interviews to identify patterns of continuity and change in the narratives. Through this process, we identified newly emerging meanings or meanings that persisted temporally, extracting the process of “meaning reconstruction” across both time points. Theoretically, this comparative analysis positioned the process of narrative reconstruction over time by referring to Gillies and Neimeyer's [ 11 ] theory of meaning reconstitution and Park’s [ 12 ] concept of integrative re-meaning. The authors independently conducted coding to ensure the reliability of the analysis. After theme extraction, the researchers held repeated discussions to reach a consensus. Throughout the analysis, the researchers ensured reliability and validity through ongoing supervision provided by two community and home nursing specialists. Furthermore, bilingual researchers verified translations to preserve cultural and linguistic nuances. Ethical Considerations We asked the managers of the visiting nursing stations who had assisted with a previous study to contact former participants and invite them to take part in the present study. The researchers explained the study’s purpose and ethical considerations to the managers both verbally and in writing. The managers then contacted potential research participants as a part of bereavement support, asking for their consent to send them a document outlining the study’s purpose and ethical considerations. After receiving consent, the researchers sent the materials to those individuals. If they agreed to receive a full explanation of the study, the researchers arranged a meeting with them subsequently. During the meetings, the study purpose and ethical considerations were explained both verbally and in writing. The study was conducted after consent for participation was obtained. This study was approved by the Ethics Review Committee of Kobe City College of Nursing. Results Sample The study participants included five wives who had cared for their husbands with cancer and experienced bereavement at home. Participants were between their 30s and 70s. The period from the diagnosis of a terminal illness to patient death was 20–180 days. The duration of home care was 20–90 days. The time that elapsed between bereavement and the first interview was 12–24 months. The second interview was conducted two years after the first (Table 1 ). Table 1 Overview of the study participants Research Participants Relationship with the Patient Age Diagnosis Period from the diagnosis of a terminal illness to death Period requiring care Period from bereavement to first interview Period from bereavement to second interview A Wife 70s Lung cancer 4 months 3 months 19 months 38 months B Wife 30s Brain tumor 2.5 months 1.5 months 13 months 33 months C Wife 70s Liver cancer, oropharyngeal cancer 6 months 2 months 21 months 41 months D Wife 50s Bile duct cancer 5 months 1 month 24 months 46 months E Wife 60s Stomach cancer, prostate cancer 20 days 20 days 12 months 31 months [Table 1 here] The six themes identified in the first interview centered on marital relationships, relationships with family and others, caregiving experiences, self-existence, and views on life and death. In the second interview, themes such as the enduring bond of the married couple, the importance of family members who spent time together until the end, the meaning attached to caring for the husband in the terminal phase, confronting life without the husband, and reflection on one's way of life were extracted. These results indicated continuity in many of the major themes extracted at both time points. However, over time, the focus shifted from external relationships to the participant’s inner world (Table 2 ). Below, for each theme, we present narratives from the second interview and relate them to the first interview’s results. Table 2 Comparison of key themes at two time points Primary themes in the first interview (6–24 months after bereavement) Key themes in the second interview (approximately 2 years later) Characteristics of longitudinal relationships and changes The profound significance of existing as a couple The Enduring Bond of the Married Couple The meaning of being a couple was reconfigured over time as a shared existence that continued to be lived together, deepening into an inner bond. Awareness of an unshakable family relationship The Importance of Family Members Who Spent Time Together Until the End Narratives about family bonds are consistent, shifting from family as a source of support to family as a foundation for self-identity. The significance of those around them (Did not appear as an independent theme in the second round) Although the significance of surrounding support was mentioned, it weakened as a primary theme, shifting focus to the inner world of family and spouses. Realizing the ideal end The Meaning Attached to Caring for one’s Husband in the Terminal Phase Although satisfied with having achieved an ideal farewell, the participant felt self-reproach, such as whether they had done enough for their husband. The participant was reframing the caregiving experience itself as proof of love and growth. (Did not emerge as an independent theme in the first session) Confronting Life Without One’s Husband Although not seen as an independent theme in the first session, in the second session, by sharing the caregiving experience with others, the participant retained the husband’s presence in the heart and developed a new challenge: how to live life without the husband. Confidence in one’s existence Deepening views on life and death Reflection on One’s Way of Life Over time, meaning frameworks concerning self and life–death issues deepened to the point that the participants used them to reconstruct their lives and integrated them into their way of living. Note: This table presents the results of a longitudinal qualitative analysis of 13 spouses who cared for patients with cancer until the death of the patients (including five participants in the second follow-up). Each theme was generated according to the narratives of all participants at each time point, and the relationships between the two time points were organized through content analysis and re-examination of the narratives. [Table 2 here] The Enduring Bond of the Married Couple In this theme, the wife remained content with the peaceful daily life shared with the husband until death, even with the husband’s diminished abilities and increased care needs. Even after the husband’s death, the spouse felt the presence of the husband and remained conscious of their marital bond. In the second interview, participants spoke of their bond with their husbands not as something “lost” but as something “still present in their lives.” This theme represents how the “profound meaning of existing as a couple” identified in the first interview was reconfigured over time into a continuing marital bond that persisted while changing its form. Two subthemes emerged from this: “a sense of fulfillment in the final days of daily life spent consciously as a couple” and “ the sense of remaining connected to one's husband .” A Sense of Fulfillment in the Final Days of Daily Life Spent Consciously as a Couple This subtheme indicates that the wives felt satisfied in maintaining a relationship in which they could exchange jokes until the very end and in the ability to share time and space without feeling self-conscious. These wives found joy in preserving their lives together until the end, even while being conscious of their husbands’ imminent death. One wife shared the following: When I went out shopping, he worried about me. When he was asleep, I felt reassured and would quietly go check on him. If he was awake, we'd have tea together. I truly feel so glad I was able to be at home. (Ms. A) The Sense of Remaining Connected to One's Husband The wives cherished memories of their husbands’ final days, feeling their presence close even after death, as they continued with their lives. One wife stated as follows: In the end, it's the living who matter. So, if you can make the departed person your anchor in your heart, I think that's what it means to live together. (Ms. B) The Importance of Family Members Who Spent Time Together Until the End This theme reflects the family’s shared experience of caring for a husband whose health was steadily declining and supporting him at home until the end of life. It also shows that continuing to share this experience as a family provides an opportunity to reaffirm the value of their bonds and their collective sense of identity. This theme yielded two subthemes: “ the sense of unity with family members who shared one’s husband's final moments ” and “ the family connection alive in everyday life .” The Sense of Unity with Family Members Who Shared One’s Husband's Final Moments Wives described the time spent caring for their husbands and their families as a precious period of shared life. Being united in supporting the husband until death deepened family bonds, and this shared experience continued to serve as a lasting emotional connection. One wife shared the following: Since my children and grandchildren could visit only for a few days, I don't think we ever had this much time together as a family. So, I suppose the greatest advantage of caring for him at home is that everyone could support my husband with the same heartfelt feelings and that the months we spent together would remain as something profound in our hearts afterward. (Ms. D) The Family Connection Alive in Everyday Life The wives continued to feel connected to their husbands through their ongoing relationships with family members. The bonds formed while caring together for the dying husband remained present in their lives and emotions long after bereavement. For wives, this served not only as an emotional connection but also as support in their future lives. One wife shared the following: My husband relied heavily on our son. I think it was good that it wasn’t just me alone; my son and I cared for him together until the end. Even now, my son comes to my house every night. He lights incense for his father and spends 10 or 15 minutes talking to him about work, just like he did before he passed away. My son’s presence means so much to me. I rely on him for everything. Just having him there, that presence, is what matters. (Ms. C) The Meaning Attached to Caring for One’s Husband in the Terminal Phase This theme captured the care that the wives provided during their husbands’ final days and illustrated how they derived meaning in supporting them at home with help from others. In the second interview, some participants expressed regret about conversations they wished they had had and offered a more reflective reassessment of their caregiving experience. This theme comprised three subthemes: “ pride in supporting him as his wife until the end ,” “ gratitude for the help provided by professionals ,” and “ regrets about how to spend the last moments with one’s terminally ill husband.” Pride in Supporting Him as His Wife Until the End Wives felt pride in having supported their husbands throughout their lives. They spoke of providing the care they believed their husbands desired—providing support in whatever they wished to do and staying close to observe the slightest change in their condition—and witnessing their husbands’ peaceful death. Two wives shared the following: Of course, being woken up in the middle of the night was somewhat difficult. When my husband said, “I’m hungry,” at night, I made everything right here (in the kitchen). Had he been in the hospital, even if he hadn't called my name, if he had said “I want some water” in the middle of the night, I'd have had to call a nurse. All those things were possible because it was me and because we were here (at home). I slept right here (in the living room) with him. I could see his face all the time, and I truly believe that was absolutely best for my husband. Maybe it's just my own self-satisfaction.” (Ms. A) At the time, I was desperate, but after he passed away, I felt, “Ah, I'm so glad.” Back then, when I watched professionals change his diapers, I thought, “Oh, this is how you change a diaper.” But I never considered leaving him alone to do something else. I felt I had to stay by his side the whole time. (Ms. C) Gratitude for the Help Provided by Professionals Even with the imminent death of their husbands, the wives felt a deep sense of gratitude for the presence of doctors and nurses who allowed them to peacefully approach end-of-life care and fostered relationships that allowed open communication. One wife shared the following: Seeing my husband chatting with the doctor about daily hobbies and events, I thought he looked so happy. Even when he was bathing, the nurse would wash his back while they talked about all sorts of things. I was glad he could do that, and I felt happy. (Mr. A) Regrets About How to Spend the Last Moments with One’s Terminally Ill Husband The wives felt regret because they were aware of their husbands’ imminent death but avoided discussing it or expressing their true feelings regarding this situation. Additionally, they regretted being overly harsh with their husbands during end-of-life care because of feeling overwhelmed and experienced self-reproach about whether they provided sufficient support. For example, 33 months after the husband’s death, Ms. B regretted not having shared their mutual wishes about how they would spend their final days. Ms. B said: I really didn’t want to talk about death. I didn’t want to face it myself, and I didn’t want my husband to sense that either. As he approached death, maybe he had more wishes about what he wanted, but I never created that kind of atmosphere at all. In a way, I think I blocked it off myself. (Ms. B) Confronting Life Without One’s Husband This theme captured how the women navigated daily life without the husbands who had once supported them and how they confronted the emotions that surfaced in that absence. The subthemes were “ the sadness of life without one’s husband ” and “ sorting out one’s feelings. ” This theme did not exist independently in the first interview. However, by reflecting on life with their husbands and recounting their caregiving experience, the theme gained meaning based on a broader view of life. The Sadness of Life without One’s Husband Wives recalled their husbands’ presence, sometimes feeling a surge of loneliness, regretting that they could not spend the rest of their time together, and experiencing a sense of sadness. One wife shared the following: I suppose you do get used to life without him, but you never get used to the loneliness. Being alone, that loneliness never changes, no matter how much time passes. I often think, “If only he were here.” (Ms. D) Sorting Out One’s Feelings By sharing their caregiving experiences with others, the wives could objectively reflect on their feelings. Moreover, they found that people acknowledging that their loved one died at home helped them manage their feelings. One wife stated the following: By talking about how I felt when I was caring for my husband, I feel like I could make better sense of my emotions. When I think back to what I said in the first interview, I realize that’s how I truly felt at the time. Comparing that to how I feel now, I see there’s a bit of a difference. It makes me realize that going through that experience shaped who I am today. (Participant B) Reflection on One’s Way of Life This theme reflects the participants’ deepening thoughts about life and death elicited by providing end-of-life care to their husbands. This led to reflection on how to conduct their future lives. It comprised three subthemes: “ living with the legacy of one’s husband’s final kindness and wishes in one’s heart ,” “contributing to others by applying end-of-life care experience ,” and “ the view of life and death learned from one’s husband's final moments of life. ” This theme extended two themes from the first interview-“confidence in one’s existence” and “deepening views on life and death”—to explore a broader perspective on life and self-understanding. The participants gave meaning to these reflections by stepping back and viewing their lives from a wider vantage point. Living with the Legacy of One’s Husband’s Final Kindness and Wishes in One’s Heart Two wives stated: My husband, in his terminal phase, was conscious of his impending death. He reflected on the life his wife would live after he was gone, leaving behind letters, words, and memories that became her life sustenance. He wrote (in a letter before passing) that since I was always a cheerful person who could make lots of friends, I should go out into the world. That made me think, “Oh, right.” I believe I should find and do enjoyable things from now on. My husband wrote that I should do just that. (Ms. C) Contributing to Others by Applying End-of-Life Care Experience By caring for their husbands, the wives shared their caregiving experiences with others and helped them meet their needs. These actions allowed them to utilize their past caregiving knowledge to assist others. Two of the wives shared the following: Elderly members still come to church in good health. Of course, as they age, they come with canes, but even when they take their Bibles to their seats, I don’t mean to say I’m nursing them, but I’ll hold their cane for them and say, “Take my hand,” and walk with them. It might be an exaggeration to call it sincerity, but perhaps because I was nursing him, it just comes naturally. (Ms. A) Having my sister and her husband by my side as we cared for my husband in his final days gave me great strength. That’s why, if any of my other siblings ever need help, I’ll be there in a flash. (Ms. E) The View of Life and Death Learned from One’s Husband's Final Moments of Life Wives who witnessed their husbands’ final moments while providing care described searching for ways to live without burdening their families, pursuing fulfillment in their own lives, and recognizing the preciousness of life. Simultaneously, they began to contemplate their own deaths. Experiencing death as closely as life prompted them to re-examine their views on both. The wives shared as follows: My husband said he would insert his own feeding tube and seemed convinced it was necessary, but watching him, I wonder if it’s really needed. I want him to stay with me. But I don’t think it’s necessary to extend someone’s life that far. If I ever need a feeding tube, I won’t have one inserted. I think if I can’t eat, it’s fine to just let things take their natural course. (Ms. C) Dying at home isn’t a death filled with suffering and agony; it’s a peaceful way to go. That’s why I want to live my ordinary life at home, growing weaker little by little. (Ms. D) Toward the end, I laid our grandchild next to my husband, and I slept beside them. We were exhausted too, and while we dozed off, he passed away. So, I think he left peacefully. He absolutely hated the idea of being bedridden forever. That’s why I think it was a death with dignity. He said he didn’t want to live if it meant losing his dignity. (Ms. D) Discussion This study examined how the spouses of cancer patients who had positively reframed their end-of-life care experiences six–24 months after bereavement reconceptualized those experiences two years later. The results revealed five themes: the enduring bond of the married couple, the importance of family members who spent time together until the end, the meaning attached to caring for one’s husband in the terminal phase, confronting life without one’s husband, and reflection on one’s way of life. Although these themes largely aligned with findings from the initial interview from six months to two years post-bereavement, confronting life without one’s husband emerged as a new theme. Additionally, within the meaning attached to caring for the husband in the terminal phase, a new subtheme, “regrets about how to spend the last moments with my terminally ill husband ,” was derived. These findings suggest that the process of assigning meaning to end-of-life care experiences is not static but rather a dynamic psychological process that is reconfigured over time. Below, we discuss how a wife who had initially viewed home-based end-of-life care for her husband in a positive light re-evaluated that experience two years later, and we examine the characteristics and significance of that shift. Reconstructing Meaning Over Time In this study, the initial interviews already revealed narratives oriented toward the future. Through the experience of caring for their husbands at home until the end of life, the wives came to recognize their own value and role, articulated as a “conviction in one’s own significance.” Even in the early period after bereavement, the wives had begun to ascribe meaning to their caregiving experiences within the broader context of their lives, reflecting on “how to live going forward” and, in some cases, taking concrete actions. These findings suggest that meaning-making and personal growth do not necessarily arise only with the passage of time after bereavement but may begin to take shape relatively early. By contrast, the second interview was characterized not by the emergence of this future orientation, but by a more panoramic and integrated reconfiguration of meaning. With greater temporal distance, the wives revisited their husbands’ final days from a broader perspective and reinterpreted their husbands’ thoughts regarding the lives they left behind as sources of meaning that sustained their own present existence. Moreover, the aspirations expressed in the first interview—such as “wanting to be useful to others” and “wanting to make use of my experience”—were repositioned as more realistic and sustainable life choices. While this positive meaning-making was maintained, additional narratives emerged over time that reflected a more distanced and reflective appraisal of the end-of-life caregiving process. In this context, participants began to voice feelings of regret and self-reproach, including statements such as “I distanced myself when faced with my husband’s death” and “I did not have enough emotional capacity to be considerate.” This pattern accords with Neimeyer’s (2001) model of meaning reconstruction and with Park’s (2010) concept of “integrative meaning-making” within posttraumatic growth (PTG). Whereas the first interview primarily reflected meaning generation, in which meaning and value were directly derived from the caregiving experience, the second interview illustrated a shift toward meaning integration, whereby these meanings were repositioned within the broader temporal trajectory of the participants’ lives. Importantly, the expressions of “regret” and “self-blame” observed in the second interview should not be interpreted as indicators of grief relapse or maladjustment. Rather, they appear to reflect a mature process in which participants, while maintaining a positive appraisal of their caregiving, became able to move beyond idealization or self-protective narratives and engage in a more realistic and holistic reassessment of their experiences. The coexistence of ambivalent emotions—such as confidence in having supported their husbands to the best of their ability alongside a wish that they could have done more—can thus be understood as a hallmark of advanced meaning reconstruction, deepening the personal significance of the loss and integrating it into the self-narrative. Accordingly, the contribution of this study’s longitudinal findings lies not in determining whether participants began to contemplate their future lives, but in elucidating how an already present future orientation was reinterpreted, deepened, and stabilized within the self-narrative over time. These findings illuminate a process of maturation shaped by relationality and temporal distance among Japanese women who provided home-based end-of-life care for their spouses within a gendered cultural context. Reconstruction of Lasting Spousal Bonds and Connections The theme of “the profound significance of existing as a couple” revealed in the first interview was reconfigured in the second interview as “the enduring bond of the married couple.” This theme contained two subthemes: “a sense of fulfillment in the final days of daily life spent consciously as a couple” and “ the sense of remaining connected to one's husband. ” The first subtheme involved the participant recounting the daily life spent at home with the husband during the terminal phase of the illness as “proof of having lived as a couple,” positively affirming the value of that time even after his death. Meanwhile, the second subtheme featured narratives expressing the feeling of “still living with my husband” even after the husband’s death, framing the relationship as a transformation, not a loss. This aligns with the concept of “continuing bonds” proposed by Klass et al. [ 13 ], illustrating a psychological process in which the relationship is not severed by bereavement but maintained and deepened in a new form. The theme of “the enduring bond of the married couple” corresponds to the final stage of the meaning reconstruction model proposed by Gillies and Neimeyer [ 11 ], which involves integrating the experience of loss into personal narrative. Moreover, given that Japanese wives positively accept the responsibility of caring for their husbands, with an internalized sense of duty to support them [ 22 ], the persistence of this bond may be understood as a culturally embedded meaning structure closely intertwined with gender role perceptions. Confronting Life Without a Husband and Deepening the Relationship The second interview revealed a new theme: confronting life without one’s husband. This psychological process emerged only with the passage of time after bereavement. This theme encompasses two subthemes: “the sadness of life without one’s husband” and “sorting out one’s feelings.” Within the “the sadness of life without one’s husband” subtheme, many participants described a persistent sense of loneliness, even as they became more accustomed to the husband’s absence. This indicates that grief is not a linear recovery process but a sustained one oscillating between loss and connection [ 23 ]. Additionally, this “sadness” is a form of “continuing bonds” [ 12 ] and can be understood as an internal relationship of “continuing to live with one’s husband.” Conversely, the subtheme of “sorting out one’s feelings” described the process of deepening self-understanding through communication with others. This “processing through narration” reflects the tendency in East Asian cultures to “organize emotions through relationships” [ 24 ]. This represents the reconfiguration of emotions mediated through relationality rather than introspection confined within the individual. Furthermore, while expressing gratitude for the help received from professionals, the wives reframed receiving support not as “weakness” but as “relational solidarity in shared caregiving.” This relational interpretation reflects the cultural characteristic of Japanese women to “organize emotions within relationships” [ 24 ]. Through their narratives, the wives redefined “the self that had cared for their husband,” finding new roles and meaning in life without the husband. This redefinition involved more than recovering from loss; it marked a process of rebuilding life on the foundation of the years lived with their husband, aligning with the “changed philosophy of life” dimension of posttraumatic growth (PTG) [ 25 ]. From Sustained Bonds to Relational Growth The themes of the enduring bond of the married couple and confronting life without the husband both aligned with the concept of continuing bonds [ 13 ], illustrating how the relationship with the husband persists in altered forms after death and deepens internally over time. Furthermore, although the wives positively framed the experience of caring for their husbands at the end of life as “pride in having supported their husbands,” they re-evaluated this meaning and re-articulated it within their post-bereavement lives, reconstructing a “self that continues to live with their husbands.” This can be understood as a narrative reorganization process within Neimeyer’s [ 10 ]) “meaning reconstruction.” Therefore, wives achieved relational growth through loss, not only growing as individuals but also developing their personalities through relationships with others and the deceased, under the cultural characteristic of shaping oneself through relationships. This aligns with the concept of “posttraumatic growth” [ 25 ] in PTG theory and corresponds with the Japanese cultural value of “forming the self within relationships” [ 24 ]. Practical Implications: From the Perspective of Long-Term, Relational Support by Visiting Nurses This study’s findings indicate that wives who cared for their husbands with cancer at home until death experienced a reconstruction of their relationship with their spouse. They felt a sense of fulfillment in having supported their husbands until the end of life, yet they also carried lingering regret that “perhaps more could have been done.” This psychological process does not occur at the point of death but unfolds after bereavement. However, Japan’s medical and long-term care reimbursement frameworks restrict billable services to care delivered to the patient. As a result, bereavement follow-up for family members is not reimbursed, leaving its provision entirely to the organizational policies and capacities of individual home-visit nursing agencies. It is, therefore, important to recognize the practical value of the interactions that occur before death and during bereavement visits immediately afterward. The Importance of “Relational Support” Before Death The subtheme “ Gratitude for the help provided by professionals ” indicates that families re-evaluated receiving support not as a weakness but as a “sense of solidarity in shared end-of-life care.” When visiting nurses acknowledge caregivers’ efforts while clearly conveying a collaborative stance of “supporting together now,” it becomes a major factor in forming a positive meaning for surviving family members. Moreover, it is essential to consciously create an environment that values everyday interactions and expressions of affection between spouses, respecting their relationship and supporting the final moments as “time spent together as a couple.” Supporting these “small daily moments” during the end-of-life period—sharing tea, talking casually, or simply spending quiet time together—helps the surviving spouse feel fulfilled in having remained present until the end. These moments also lay the groundwork for deeper self-understanding after bereavement. Providing a “Visiting Space for Sharing Stories” during Bereavement In a nationwide survey, approximately 80% of Japan’s home-visit nursing stations conducted bereavement visits after end-of-life care, including visits offered when deemed necessary [ 26 ]. Although typically a single, brief encounter, this study suggests that this visit holds considerable significance for surviving spouses. Positioning such visits not primarily as an attempt to heal the bereaved family’s grief but as an “opportunity to organize one’s thoughts through talking” is important. As seen in the participants’ narratives, experiences such as “talking to someone helps me make sense of things” and “comparing my current self to my past self helps me feel my present existence” are deeply connected to the Japanese cultural characteristic of regulating emotions through third-party relationships [ 24 ]. Visiting nurses can play a role in promoting relational meaning-making by listening to the bereaved family’s narrative without interrupting. Limitations This study has several limitations. First, all participants in the second interview were women, and the sample size was small (five individuals). Therefore, the changes in meaning construction demonstrated here represent an aspect rooted in the cultural and gendered backgrounds of female spouses. This makes it difficult to generalize the results. Future research should include comparative analyses from diverse perspectives, such as male spouses and other family members, to clarify gender differences and the influence of family relationships on meaning-making after bereavement. Second, this study longitudinally examined changes in meaning-making over approximately four years, based on the first interview conducted six months to two years after bereavement and the second interview conducted approximately two years later. However, the length of time since bereavement varied among the participants, and the study was limited to comparisons between two time points. This imposes limitations on capturing the meaning reconstruction process in greater detail. Future research should employ multiwave tracking and incorporate a life story perspective to more comprehensively examine how loss experiences are integrated over time. Third, this study was limited to wives who positively reinterpreted their end-of-life care experiences during the first interview. Consequently, it does not sufficiently reflect the experiences of bereaved family members who negatively perceive caregiving or end-of-life care or those who struggle with reinterpretation. To understand the diverse aspects of grief, future research should study bereaved family members who cannot form positive reinterpretations and families experiencing conflict. This will enable a more multifaceted exploration of support approaches. Conclusions This study aimed to elucidate how wives who had previously derived positive meaning from caring for and witnessing the death of their husbands with cancer reinterpreted these experiences over time. The findings revealed that they continued to perceive an enduring bond with their husbands and reaffirmed the significance of their relationship as family members who shared the final phase of life. They also engaged in an ongoing process of reviewing and re-evaluating their caregiving experiences, thereby reconstructing the meaning of end-of-life care. Through third-party conversations, they organized their emotions, confronted life without their husbands, and deepened their personal understanding of life and death. While many themes overlapped with those identified during the first interview (six months to two years post-bereavement), the present study newly identified the theme of “confronting life without one’s husband,” as well as an additional subtheme within “the meaning attached to caring for one’s husband in the terminal phase,” specifically “regrets about how to spend the last moments with one’s terminally ill husband.” These findings indicate that the meaning-making of caregiving and bereavement experiences is not static; rather, it is a dynamic psychological process that is continuously reconstructed over time following spousal loss. Abbreviations PTG Posttraumatic growth QLR Qualitative longitudinal research Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Kobe City College of Nursing (Ethics Approval No. 2014-1-39-2). Our study strictly adhered to the ethical principles outlined in the Declaration of Helsinki and ensured compliance with all pertinent guidelines and regulations. All individuals involved in the study provided informed consent before participation. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This study was supported by JSPS KAKENHI (grant number: JP 26893235). Author Contribution MK: Writing—original draft, writing—review and editing, formal analysis, data curation. HN: Methodology, Formal analysis, Conceptualization, Supervision. All authors have read and approved the final version of the manuscript. Acknowledgement We sincerely appreciate the participation of all bereaved families in this study as well as the time they dedicated to it. We would also like to thank professor M Oeki for providing valuable advice throughout the analysis process. Data Availability The data used in this study are available from the corresponding author upon request. References Ministry of Health, Labour and Welfare. 2023. https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei18/index.html . Accessed 29 Oct 2025. Ministry of Health, Labour and Welfare. 2016. http//www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000106421.html . Accessed 30 Oct 2025. Knighting K, O’Brien MR, Roe B, Gandy R, Lloyd-Williams M, Nolan M, et al. Development of the Carers’ Alert Thermometer (CAT) to identify family carers struggling with caring for someone dying at home: a mixed method consensus study. BMC Palliat Care. 2015;14:22. org/10.1186/s12904-015-0010-6 . 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J Palliat Med. 2013;16:745–51. org/10.1089/jpm.2012.0450 . Bonanno GA, Wortman CB, Lehman DR, Tweed RG, Haring M, Sonnega J, et al. Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss. J Pers Soc Psychol. 2002;83:1150–64. org/10.1037//0022-3514.83.5.1150 . Bonanno GA, Wortman CB, Nesse RM. Prospective patterns of resilience and maladjustment during widowhood. Psychol Aging. 2004;19:260–71. org/10.1037/0882-7974.19.2.260 . Neimeyer RA, editor. Meaning reconstruction and the experience of loss. Washington, DC: American Psychological Association; 2001. Gillies J, Neimeyer RA. Loss, grief, and the search for significance: toward a model of meaning reconstruction in bereavement. J Constr Psychol. 2006;19:31–65. Park CL. Making sense of the meaning literature: an integrative review of meaning making and its effects on adjustment to stressful life events. Psychol Bull. 2010;136:257–301. org/10.1037/a0018301 . Klass D, Silverman PR, Nickman SL, editors. Continuing bonds: new understandings of grief. New York: Taylor & Francis; 1996. Rosenblatt PC. Grief across cultures: a review and research agenda. In: Stroebe MS, Hansson RO, Schut H, Stroebe W, editors. Handbook of bereavement research and practice: Advances in theory and intervention. editors. Washington, DC: American Psychological Association; 2008. pp. 207–22. Asai M, Akizuki N, Fujimori M, Matsui Y, Itoh K, Ikeda M, Hayashi R, Kinoshita T, Ohtsu A, Nagai K, Kinoshita H, Uchitomi Y. Psychological states and coping strategies after bereavement among spouses of cancer patients: a quantitative study in Japan. Support Care Cancer. 2012;20(12):3189–203. 10.1007/s00520-012-1456-1 . Song JI, Shin DW, Choi J-Y, Kang J, Baek Y‐J M, H‐N, et al. Quality of life and mental health in the bereaved family members of patients with terminal cancer. Psychooncol. 2012;21:1158–66. Nielsen MK, Neergaard MA, Jensen AB, Bro F, Guldin MB. Do we need to change our understanding of anticipatory grief in caregivers? A systematic review of caregiver studies during end-of-life caregiving and bereavement. Clin Psychol Rev. 2016;44:75–93. 10.1016/j.cpr.2016.01.002 . Kuo SC, Chou WC, Chen JS, Chang WC, Chiang MC, Hou MM, et al. Longitudinal changes in and modifiable predictors of the prevalence of severe depressive symptoms for family caregivers of terminally ill cancer patients over the first two years of bereavement. J Palliat Med. 2017;20:15–22. org/10.1089/jpm.2016.0116 . Karikawa M. Zaitaku de gan kanja o mitotta haigūsha ga shibetsu go ni toraeru kaigo taiken to sono imizuke ni kansuru kenkyū (Study of end-of-life care experiences and those experiences’ meaning as perceived by the spouse after the death of a cancer patient who was cared for at home). Fam Nurs Res. 2017;23:39–51. [in Japanese]. Holland JM, Thompson KL, Rozalski V, Lichtenthal WG. Bereavement-related regret trajectories among widowed older adults. J Gerontol B Psychol Sci Soc Sci. 2014;69(1):40–7. 10.1093/geronb/gbt050 . Epub 2013 Jun 13. Murray SA, Kendall M, Carduff E, Worth A, Harris FM, Lloyd A, et al. Use of serial qualitative interviews to understand patients’ evolving experiences and needs. BMJ. 2009;339:b3702. Sugiura K, Ito M, Kutsumi M, Mikami H. Gender differences in spousal caregiving in Japan. J Gerontol B Psychol Sci Soc Sci. 2009;64:147–56. 10.1093/geronb/gbn005 . Stroebe MS, Schut H. Meaning making in the dual process model of coping with bereavement. In: Neimeyer RA, editor. Meaning reconstruction and the experience of loss. Washington, DC: American Psychological Association; 2001. pp. 55–73. Markus HR, Kitayama S. Culture and the self: Implications for cognition, emotion, and motivation. Psychol Rev. 1991;98:224–53. 10.1037/0033-295X.98.2.224 . Tedeschi RG, Calhoun LG. Posttraumatic growth: conceptual foundations and empirical evidence. Psychol Inq. 2004;15:1–18. Kudo T, Furuse M. Hōmon kango sutēshon ni okeru izoku kea ni kansuru zenkoku chōsa(A nationwide survey on bereavement care at home-visit nursing stations)Palliat. Care Res. 2016;11:128–36. 10.2512/jspm.11.128 . [in Japanese]. Additional Declarations No competing interests reported. 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Cancer","fulltext":[{"header":"Background","content":"\u003cp\u003eIn Japan, over 380,000 people are diagnosed with cancer and die each year [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Since 1981, cancer has been the leading cause of death nationwide; as the population ages, the number of deaths is expected to continue to increase. Inpatient care for patients with cancer is becoming increasingly difficult, and the treatment and care environment for terminally ill patients with cancer is shifting from hospitals to home-based care. Japan\u0026rsquo;s Ministry of Health, Labour and Welfare has identified strengthening the coordination between medical and nursing care systems and enhancing home-based medical care as key policy measures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and institutional reforms aligned with these goals have been implemented.\u003c/p\u003e \u003cp\u003eHome-based palliative care places significant responsibilities on family caregivers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Assuming the role of a family caregiver can constitute a negative life event and potentially disrupt many aspects of the caregiver\u0026rsquo;s existence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Feelings of helplessness and guilt experienced by family caregivers owing to their perceived inability to help the patient with cancer [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], alongside caregiving burdens [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], lead to depressive symptoms. Psychological distress among family caregivers of terminally ill patients with cancer persists even after the patient\u0026rsquo;s death. Among the family members of patients with cancer receiving hospice home care, over 50% exhibited clinically significant depressive symptoms 1 year after bereavement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLongitudinal post-bereavement studies have focused primarily on changes in depressive symptoms and grief intensity, demonstrating diverse patterns of grief reduction and resilience over time [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Many of these studies viewed grief primarily through pathological and recovery-oriented lenses, focusing on reducing depression and psychological distress. These studies did not adequately address the dynamic processes that occur over time after bereavement, such as the construction of positive meaning and relationship reorganization.\u003c/p\u003e \u003cp\u003eNeimeyer [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] proposed the concept of \u0026ldquo;meaning reconstruction\u0026rdquo; to address how individuals who experience bereavement accept and understand their loss. The concept describes a dynamic process in which an individual reorganizes their life narrative through loss and reconstructs the meaning of events temporally [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Based on this perspective, psychological adaptation after bereavement is reframed not as the \u0026ldquo;disappearance of grief\u0026rdquo; but as the \u0026ldquo;reconstruction of meaning.\u0026rdquo; Furthermore, recent grief research has focused on the concept of \u0026ldquo;continuing bonds,\u0026rdquo; where individuals maintain connections with the deceased even after loss [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This framework proposes understanding loss not as an \u0026ldquo;end\u0026rdquo; but as a \u0026ldquo;transformation of relationships\u0026rdquo; [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, in Japan, many bereaved family members describe a continued sense of the deceased\u0026rsquo;s presence in daily life and a tangible feeling that the relationship endures even after death [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany of these theoretical frameworks focus on reconstituting meaning and continuing bonds triggered by bereavement. However, only a few longitudinal studies have clarified the subsequent changes in the meaning formed through the temporal and relational process of the \u0026ldquo;caregiving experience\u0026rdquo; prior to bereavement.\u003c/p\u003e \u003cp\u003eSpouses who have lost a partner to cancer experience depressive symptoms at rates two to three times higher than those of other family members [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Studies focusing on wives who lost their husbands to cancer report markedly higher levels of physical and psychological symptoms\u0026mdash;including depression, insomnia, fatigue, and loss of appetite\u0026mdash;than those of other family members [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. They also tended to experience prolonged grief and loneliness after bereavement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the experiences of wives who cared for their spouses at home until death are narrated within a temporal continuum encompassing \u0026ldquo;caregiving,\u0026rdquo; \u0026ldquo;bereavement,\u0026rdquo; and \u0026ldquo;life after loss.\u0026rdquo; Within this narrative, the \u0026ldquo;pride of having fully supported her husband as a wife\u0026rdquo; and the \u0026ldquo;sense of loss from losing her husband\u0026rdquo; are intricately intertwined with the loss of the \u0026ldquo;role consciousness of the wife supporting the family\u0026rdquo; that is cultivated in the Japanese culture. We believe that understanding the change in meaning within this context\u0026mdash;not merely as a psychological recovery process but also as relational growth and a reconfiguration of role consciousness rooted in cultural values\u0026mdash;can improve our understanding of loss within Japan\u0026rsquo;s cultural context.\u003c/p\u003e \u003cp\u003eThis longitudinal study, therefore, aimed to clarify the process of reconfiguring the meaning of the end-of-life care experience over time, focusing on wives who had positively reframed their caregiving experience after providing home-based care for a spouse with cancer and were between six months and two years after the loss.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample and Recruitment\u003c/h2\u003e \u003cp\u003eThis study\u0026rsquo;s first survey [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] involved interviews with 13 individuals (two men and 11 women) who had cared for and witnessed the death of their spouse with cancer at home. Based on the qualitative analysis results of the first set of interviews, participants were classified according to the degree of \u0026ldquo;positive meaning-making\u0026rdquo; regarding their caregiving experience. Those who struggled to accept the death of their spouse and could not find positive meaning in the caregiving process were excluded from the follow-up study. Participants who accepted the death of their spouse and expressed gratitude or a sense of fulfillment in the relationship were defined as having positive meaning-making (n\u0026thinsp;=\u0026thinsp;11; two men, nine women).\u003c/p\u003e \u003cp\u003eIn the second interview, theoretical sampling was conducted to focus on such meaning-making\u0026rsquo;s gendered aspects. Of the nine wives, five agreed to participate, excluding those who declined because of poor health or the psychological burden of re-experiencing grief (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e[Figure\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews were conducted with the research participants in their homes to ensure privacy. The first interview with 13 participants, conducted six months to two years after bereavement, included the following items: 1) the condition of the patient receiving home care and the caregiving situation; 2) the participant\u0026rsquo;s daily life during caregiving; 3) the participant\u0026rsquo;s feelings and thoughts during patient care; and 4) their reflections on the meaning and value of their home caregiving experience.\u003c/p\u003e \u003cp\u003e Subsequently, we conducted a second interview of spouses from among the five participants who had attributed positive meaning to their end-of-life care experience during the first interview and agreed to further interviews. Data were collected using an interview guide developed from the categories identified in the initial interviews [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The guide used open-ended questions intended to elicit detailed narratives and encourage participants to introduce new perspectives. At the outset of each interview, participants were prompted to recall statements from their first interview, and the discussion then focused on differences between their earlier reflections and their current perspectives. Supplementary Table\u0026nbsp;1 provides detailed information on the interviews. The interview content was recorded with the permission of the research participants. The second interview was conducted between May and August 2015, two years after the first interview. A two-year interval was selected to capture later-phase changes in bereaved spouses\u0026rsquo; meaning-making in terms of their caregiving experience.\u003c/p\u003e \u003cp\u003eMeaning reconstruction theory [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and the continuing bonds framework [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] suggest that integrating loss into one\u0026rsquo;s life narrative progresses over an extended period. In addition, longitudinal bereavement studies have reported that significant psychological and relational changes often occur between 18 and 48 months post-loss [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, a two-year interval was deemed appropriate for capturing these developmental processes while minimizing recall burden for participants. Each interview lasted approximately one\u0026ndash;two hours, and each participant was interviewed once.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eTo clarify how the meanings ascribed to caregiving and end-of-life experience change over time, we conducted an initial set of interviews with wives who had provided home-based end-of-life care for their husbands, at six months to two years after bereavement [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Approximately two years later, we conducted a second set of interviews with the same participants. This interval was chosen to capture a period in which initial grief responses generally subside and deeper processes of meaning reconstruction are thought to occur [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. By comparing the two sets of narratives, we examined longitudinally how the wives\u0026rsquo; understandings of their caregiving and bereavement experiences changed and deepened temporally.\u003c/p\u003e \u003cp\u003eThis study was based on the qualitative longitudinal research (QLR) framework to elucidate the \u0026ldquo;changes in meaning over time\u0026rdquo; [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. We explored the reconfiguration of meaning within individual narratives from the dual perspectives of \u0026ldquo;change\u0026rdquo; and \u0026ldquo;continuity,\u0026rdquo; which are QLR\u0026rsquo;s defining characteristics.\u003c/p\u003e \u003cp\u003eData were collected through semi-structured interviews conducted in Japanese, and verbatim transcripts were created. In the first interview, the participants\u0026rsquo; narratives were examined closely. Open coding was performed by focusing on the essential meaning of participants\u0026rsquo; experiences. The relationships between codes were organized to extract subthemes and themes. The second interview explored how participants\u0026rsquo; states of mind and meaning-making had shifted since the first interview and built on the themes identified in the initial analysis. Transcripts from the second interview were similarly subjected to open coding to organize newly emerging meanings and changes. Finally, themes from the first and second interviews were compared to provide an integrated interpretation of the persistent elements and the changes in meaning over time.\u003c/p\u003e \u003cp\u003eThereafter, we created a longitudinal comparison matrix contrasting the themes in the first and second interviews to identify patterns of continuity and change in the narratives. Through this process, we identified newly emerging meanings or meanings that persisted temporally, extracting the process of \u0026ldquo;meaning reconstruction\u0026rdquo; across both time points. Theoretically, this comparative analysis positioned the process of narrative reconstruction over time by referring to Gillies and Neimeyer's [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] theory of meaning reconstitution and Park\u0026rsquo;s [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] concept of integrative re-meaning.\u003c/p\u003e \u003cp\u003eThe authors independently conducted coding to ensure the reliability of the analysis. After theme extraction, the researchers held repeated discussions to reach a consensus. Throughout the analysis, the researchers ensured reliability and validity through ongoing supervision provided by two community and home nursing specialists. Furthermore, bilingual researchers verified translations to preserve cultural and linguistic nuances.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eWe asked the managers of the visiting nursing stations who had assisted with a previous study to contact former participants and invite them to take part in the present study. The researchers explained the study\u0026rsquo;s purpose and ethical considerations to the managers both verbally and in writing. The managers then contacted potential research participants as a part of bereavement support, asking for their consent to send them a document outlining the study\u0026rsquo;s purpose and ethical considerations. After receiving consent, the researchers sent the materials to those individuals. If they agreed to receive a full explanation of the study, the researchers arranged a meeting with them subsequently. During the meetings, the study purpose and ethical considerations were explained both verbally and in writing. The study was conducted after consent for participation was obtained. This study was approved by the Ethics Review Committee of Kobe City College of Nursing.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSample\u003c/h2\u003e \u003cp\u003eThe study participants included five wives who had cared for their husbands with cancer and experienced bereavement at home. Participants were between their 30s and 70s. The period from the diagnosis of a terminal illness to patient death was 20\u0026ndash;180 days. The duration of home care was 20\u0026ndash;90 days. The time that elapsed between bereavement and the first interview was 12\u0026ndash;24 months. The second interview was conducted two years after the first (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of the study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch Participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelationship with the Patient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeriod from the diagnosis of a terminal illness to death\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePeriod requiring care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePeriod from bereavement to first interview\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePeriod from bereavement to second interview\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLung cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e38 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBrain tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.5 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e33 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLiver cancer, oropharyngeal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e41 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBile duct cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e46 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStomach cancer, prostate cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e31 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003eThe six themes identified in the first interview centered on marital relationships, relationships with family and others, caregiving experiences, self-existence, and views on life and death. In the second interview, themes such as the enduring bond of the married couple, the importance of family members who spent time together until the end, the meaning attached to caring for the husband in the terminal phase, confronting life without the husband, and reflection on one's way of life were extracted. These results indicated continuity in many of the major themes extracted at both time points. However, over time, the focus shifted from external relationships to the participant\u0026rsquo;s inner world (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Below, for each theme, we present narratives from the second interview and relate them to the first interview\u0026rsquo;s results.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of key themes at two time points\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary themes in the first interview (6\u0026ndash;24 months after bereavement)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKey themes in the second interview (approximately 2 years later)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCharacteristics of longitudinal relationships and changes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe profound significance of existing as a couple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Enduring Bond of the Married Couple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe meaning of being a couple was reconfigured over time as a shared existence that continued to be lived together, deepening into an inner bond.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of an unshakable family relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Importance of Family Members Who Spent Time Together Until the End\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNarratives about family bonds are consistent, shifting from family as a source of support to family as a foundation for self-identity.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe significance of those around them\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Did not appear as an independent theme in the second round)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlthough the significance of surrounding support was mentioned, it weakened as a primary theme, shifting focus to the inner world of family and spouses.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRealizing the ideal end\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe Meaning Attached to Caring for one\u0026rsquo;s Husband in the Terminal Phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlthough satisfied with having achieved an ideal farewell, the participant felt self-reproach, such as whether they had done enough for their husband. The participant was reframing the caregiving experience itself as proof of love and growth.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Did not emerge as an independent theme in the first session)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfronting Life Without One\u0026rsquo;s Husband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlthough not seen as an independent theme in the first session, in the second session, by sharing the caregiving experience with others, the participant retained the husband\u0026rsquo;s presence in the heart and developed a new challenge: how to live life without the husband.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConfidence in one\u0026rsquo;s existence\u003c/p\u003e \u003cp\u003eDeepening views on life and death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReflection on One\u0026rsquo;s Way of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOver time, meaning frameworks concerning self and life\u0026ndash;death issues deepened to the point that the participants used them to reconstruct their lives and integrated them into their way of living.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: This table presents the results of a longitudinal qualitative analysis of 13 spouses who cared for patients with cancer until the death of the patients (including five participants in the second follow-up).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEach theme was generated according to the narratives of all participants at each time point, and the relationships between the two time points were organized through content analysis and re-examination of the narratives.\u003c/p\u003e \u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe Enduring Bond of the Married Couple\u003c/h3\u003e\n\u003cp\u003eIn this theme, the wife remained content with the peaceful daily life shared with the husband until death, even with the husband\u0026rsquo;s diminished abilities and increased care needs. Even after the husband\u0026rsquo;s death, the spouse felt the presence of the husband and remained conscious of their marital bond. In the second interview, participants spoke of their bond with their husbands not as something \u0026ldquo;lost\u0026rdquo; but as something \u0026ldquo;still present in their lives.\u0026rdquo; This theme represents how the \u0026ldquo;profound meaning of existing as a couple\u0026rdquo; identified in the first interview was reconfigured over time into a continuing marital bond that persisted while changing its form.\u003c/p\u003e \u003cp\u003eTwo subthemes emerged from this: \u003cem\u003e\u0026ldquo;a sense of fulfillment in the final days of daily life spent consciously as a couple\u0026rdquo;\u003c/em\u003e and \u0026ldquo;\u003cem\u003ethe sense of remaining connected to one's husband\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cem\u003eA Sense of Fulfillment in the Final Days of Daily Life Spent Consciously as a Couple\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis subtheme indicates that the wives felt satisfied in maintaining a relationship in which they could exchange jokes until the very end and in the ability to share time and space without feeling self-conscious. These wives found joy in preserving their lives together until the end, even while being conscious of their husbands\u0026rsquo; imminent death. One wife shared the following:\u003c/p\u003e \u003cp\u003eWhen I went out shopping, he worried about me. When he was asleep, I felt reassured and would quietly go check on him. If he was awake, we'd have tea together. I truly feel so glad I was able to be at home. (Ms. A)\u003c/p\u003e\n\u003ch3\u003eThe Sense of Remaining Connected to One's Husband\u003c/h3\u003e\n\u003cp\u003eThe wives cherished memories of their husbands\u0026rsquo; final days, feeling their presence close even after death, as they continued with their lives. One wife stated as follows:\u003c/p\u003e \u003cp\u003eIn the end, it's the living who matter. So, if you can make the departed person your anchor in your heart, I think that's what it means to live together. (Ms. B)\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThe Importance of Family Members Who Spent Time Together Until the End\u003c/h2\u003e \u003cp\u003eThis theme reflects the family\u0026rsquo;s shared experience of caring for a husband whose health was steadily declining and supporting him at home until the end of life. It also shows that continuing to share this experience as a family provides an opportunity to reaffirm the value of their bonds and their collective sense of identity. This theme yielded two subthemes: \u0026ldquo;\u003cem\u003ethe sense of unity with family members who shared one\u0026rsquo;s husband's final moments\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003ethe family connection alive in everyday life\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eThe Sense of Unity with Family Members Who Shared One\u0026rsquo;s Husband's Final Moments\u003c/h2\u003e \u003cp\u003eWives described the time spent caring for their husbands and their families as a precious period of shared life. Being united in supporting the husband until death deepened family bonds, and this shared experience continued to serve as a lasting emotional connection. One wife shared the following:\u003c/p\u003e \u003cp\u003eSince my children and grandchildren could visit only for a few days, I don't think we ever had this much time together as a family. So, I suppose the greatest advantage of caring for him at home is that everyone could support my husband with the same heartfelt feelings and that the months we spent together would remain as something profound in our hearts afterward. (Ms. D)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThe Family Connection Alive in Everyday Life\u003c/h2\u003e \u003cp\u003eThe wives continued to feel connected to their husbands through their ongoing relationships with family members. The bonds formed while caring together for the dying husband remained present in their lives and emotions long after bereavement. For wives, this served not only as an emotional connection but also as support in their future lives. One wife shared the following:\u003c/p\u003e \u003cp\u003eMy husband relied heavily on our son. I think it was good that it wasn\u0026rsquo;t just me alone; my son and I cared for him together until the end. Even now, my son comes to my house every night. He lights incense for his father and spends 10 or 15 minutes talking to him about work, just like he did before he passed away. My son\u0026rsquo;s presence means so much to me. I rely on him for everything. Just having him there, that presence, is what matters. (Ms. C)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eThe Meaning Attached to Caring for One\u0026rsquo;s Husband in the Terminal Phase\u003c/h2\u003e \u003cp\u003eThis theme captured the care that the wives provided during their husbands\u0026rsquo; final days and illustrated how they derived meaning in supporting them at home with help from others. In the second interview, some participants expressed regret about conversations they wished they had had and offered a more reflective reassessment of their caregiving experience.\u003c/p\u003e \u003cp\u003eThis theme comprised three subthemes: \u0026ldquo;\u003cem\u003epride in supporting him as his wife until the end\u003c/em\u003e,\u0026rdquo; \u0026ldquo;\u003cem\u003egratitude for the help provided by professionals\u003c/em\u003e,\u0026rdquo; and \u0026ldquo;\u003cem\u003eregrets about how to spend the last moments with one\u0026rsquo;s terminally ill husband.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePride in Supporting Him as His Wife Until the End\u003c/h2\u003e \u003cp\u003eWives felt pride in having supported their husbands throughout their lives. They spoke of providing the care they believed their husbands desired\u0026mdash;providing support in whatever they wished to do and staying close to observe the slightest change in their condition\u0026mdash;and witnessing their husbands\u0026rsquo; peaceful death. Two wives shared the following:\u003c/p\u003e \u003cp\u003eOf course, being woken up in the middle of the night was somewhat difficult. When my husband said, \u0026ldquo;I\u0026rsquo;m hungry,\u0026rdquo; at night, I made everything right here (in the kitchen). Had he been in the hospital, even if he hadn't called my name, if he had said \u0026ldquo;I want some water\u0026rdquo; in the middle of the night, I'd have had to call a nurse. All those things were possible because it was me and because we were here (at home). I slept right here (in the living room) with him. I could see his face all the time, and I truly believe that was absolutely best for my husband. Maybe it's just my own self-satisfaction.\u0026rdquo; (Ms. A)\u003c/p\u003e \u003cp\u003eAt the time, I was desperate, but after he passed away, I felt, \u0026ldquo;Ah, I'm so glad.\u0026rdquo; Back then, when I watched professionals change his diapers, I thought, \u0026ldquo;Oh, this is how you change a diaper.\u0026rdquo; But I never considered leaving him alone to do something else. I felt I had to stay by his side the whole time. (Ms. C)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eGratitude for the Help Provided by Professionals\u003c/h2\u003e \u003cp\u003eEven with the imminent death of their husbands, the wives felt a deep sense of gratitude for the presence of doctors and nurses who allowed them to peacefully approach end-of-life care and fostered relationships that allowed open communication. One wife shared the following:\u003c/p\u003e \u003cp\u003eSeeing my husband chatting with the doctor about daily hobbies and events, I thought he looked so happy. Even when he was bathing, the nurse would wash his back while they talked about all sorts of things. I was glad he could do that, and I felt happy. (Mr. A)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eRegrets About How to Spend the Last Moments with One\u0026rsquo;s Terminally Ill Husband\u003c/h2\u003e \u003cp\u003eThe wives felt regret because they were aware of their husbands\u0026rsquo; imminent death but avoided discussing it or expressing their true feelings regarding this situation. Additionally, they regretted being overly harsh with their husbands during end-of-life care because of feeling overwhelmed and experienced self-reproach about whether they provided sufficient support.\u003c/p\u003e \u003cp\u003eFor example, 33 months after the husband\u0026rsquo;s death, Ms. B regretted not having shared their mutual wishes about how they would spend their final days. Ms. B said:\u003c/p\u003e \u003cp\u003eI really didn\u0026rsquo;t want to talk about death. I didn\u0026rsquo;t want to face it myself, and I didn\u0026rsquo;t want my husband to sense that either. As he approached death, maybe he had more wishes about what he wanted, but I never created that kind of atmosphere at all. In a way, I think I blocked it off myself. (Ms. B)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eConfronting Life Without One\u0026rsquo;s Husband\u003c/h2\u003e \u003cp\u003eThis theme captured how the women navigated daily life without the husbands who had once supported them and how they confronted the emotions that surfaced in that absence. The subthemes were \u0026ldquo;\u003cem\u003ethe sadness of life without one\u0026rsquo;s husband\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003esorting out one\u0026rsquo;s feelings.\u003c/em\u003e\u0026rdquo; This theme did not exist independently in the first interview. However, by reflecting on life with their husbands and recounting their caregiving experience, the theme gained meaning based on a broader view of life.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eThe Sadness of Life without One\u0026rsquo;s Husband\u003c/h2\u003e \u003cp\u003eWives recalled their husbands\u0026rsquo; presence, sometimes feeling a surge of loneliness, regretting that they could not spend the rest of their time together, and experiencing a sense of sadness. One wife shared the following:\u003c/p\u003e \u003cp\u003eI suppose you do get used to life without him, but you never get used to the loneliness. Being alone, that loneliness never changes, no matter how much time passes. I often think, \u0026ldquo;If only he were here.\u0026rdquo; (Ms. D)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSorting Out One\u0026rsquo;s Feelings\u003c/h2\u003e \u003cp\u003eBy sharing their caregiving experiences with others, the wives could objectively reflect on their feelings. Moreover, they found that people acknowledging that their loved one died at home helped them manage their feelings. One wife stated the following:\u003c/p\u003e \u003cp\u003eBy talking about how I felt when I was caring for my husband, I feel like I could make better sense of my emotions. When I think back to what I said in the first interview, I realize that\u0026rsquo;s how I truly felt at the time. Comparing that to how I feel now, I see there\u0026rsquo;s a bit of a difference. It makes me realize that going through that experience shaped who I am today. (Participant B)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eReflection on One\u0026rsquo;s Way of Life\u003c/h2\u003e \u003cp\u003eThis theme reflects the participants\u0026rsquo; deepening thoughts about life and death elicited by providing end-of-life care to their husbands. This led to reflection on how to conduct their future lives. It comprised three subthemes: \u0026ldquo;\u003cem\u003eliving with the legacy of one\u0026rsquo;s husband\u0026rsquo;s final kindness and wishes in one\u0026rsquo;s heart\u003c/em\u003e,\u0026rdquo; \u003cem\u003e\u0026ldquo;contributing to others by applying end-of-life care experience\u003c/em\u003e,\u0026rdquo; and \u0026ldquo;\u003cem\u003ethe view of life and death learned from one\u0026rsquo;s husband's final moments of life.\u003c/em\u003e\u0026rdquo; This theme extended two themes from the first interview-\u0026ldquo;confidence in one\u0026rsquo;s existence\u0026rdquo; and \u0026ldquo;deepening views on life and death\u0026rdquo;\u0026mdash;to explore a broader perspective on life and self-understanding. The participants gave meaning to these reflections by stepping back and viewing their lives from a wider vantage point.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLiving with the Legacy of One\u0026rsquo;s Husband\u0026rsquo;s Final Kindness and Wishes in One\u0026rsquo;s Heart\u003c/h2\u003e \u003cp\u003eTwo wives stated:\u003c/p\u003e \u003cp\u003eMy husband, in his terminal phase, was conscious of his impending death. He reflected on the life his wife would live after he was gone, leaving behind letters, words, and memories that became her life sustenance.\u003c/p\u003e \u003cp\u003eHe wrote (in a letter before passing) that since I was always a cheerful person who could make lots of friends, I should go out into the world. That made me think, \u0026ldquo;Oh, right.\u0026rdquo; I believe I should find and do enjoyable things from now on. My husband wrote that I should do just that. (Ms. C)\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eContributing to Others by Applying End-of-Life Care Experience\u003c/h2\u003e \u003cp\u003eBy caring for their husbands, the wives shared their caregiving experiences with others and helped them meet their needs. These actions allowed them to utilize their past caregiving knowledge to assist others. Two of the wives shared the following:\u003c/p\u003e \u003cp\u003eElderly members still come to church in good health. Of course, as they age, they come with canes, but even when they take their Bibles to their seats, I don\u0026rsquo;t mean to say I\u0026rsquo;m nursing them, but I\u0026rsquo;ll hold their cane for them and say, \u0026ldquo;Take my hand,\u0026rdquo; and walk with them. It might be an exaggeration to call it sincerity, but perhaps because I was nursing him, it just comes naturally. (Ms. A)\u003c/p\u003e \u003cp\u003eHaving my sister and her husband by my side as we cared for my husband in his final days gave me great strength. That\u0026rsquo;s why, if any of my other siblings ever need help, I\u0026rsquo;ll be there in a flash. (Ms. E)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eThe View of Life and Death Learned from One\u0026rsquo;s Husband's Final Moments of Life\u003c/h2\u003e \u003cp\u003eWives who witnessed their husbands\u0026rsquo; final moments while providing care described searching for ways to live without burdening their families, pursuing fulfillment in their own lives, and recognizing the preciousness of life. Simultaneously, they began to contemplate their own deaths. Experiencing death as closely as life prompted them to re-examine their views on both. The wives shared as follows:\u003c/p\u003e \u003cp\u003eMy husband said he would insert his own feeding tube and seemed convinced it was necessary, but watching him, I wonder if it\u0026rsquo;s really needed. I want him to stay with me. But I don\u0026rsquo;t think it\u0026rsquo;s necessary to extend someone\u0026rsquo;s life that far. If I ever need a feeding tube, I won\u0026rsquo;t have one inserted. I think if I can\u0026rsquo;t eat, it\u0026rsquo;s fine to just let things take their natural course. (Ms. C)\u003c/p\u003e \u003cp\u003eDying at home isn\u0026rsquo;t a death filled with suffering and agony; it\u0026rsquo;s a peaceful way to go. That\u0026rsquo;s why I want to live my ordinary life at home, growing weaker little by little. (Ms. D)\u003c/p\u003e \u003cp\u003eToward the end, I laid our grandchild next to my husband, and I slept beside them. We were exhausted too, and while we dozed off, he passed away. So, I think he left peacefully. He absolutely hated the idea of being bedridden forever. That\u0026rsquo;s why I think it was a death with dignity. He said he didn\u0026rsquo;t want to live if it meant losing his dignity. (Ms. D)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined how the spouses of cancer patients who had positively reframed their end-of-life care experiences six\u0026ndash;24 months after bereavement reconceptualized those experiences two years later. The results revealed five themes: the enduring bond of the married couple, the importance of family members who spent time together until the end, the meaning attached to caring for one\u0026rsquo;s husband in the terminal phase, confronting life without one\u0026rsquo;s husband, and reflection on one\u0026rsquo;s way of life. Although these themes largely aligned with findings from the initial interview from six months to two years post-bereavement, confronting life without one\u0026rsquo;s husband emerged as a new theme. Additionally, within the meaning attached to caring for the husband in the terminal phase, a new subtheme, \u003cem\u003e\u0026ldquo;regrets about how to spend the last moments with my terminally ill husband\u003c/em\u003e,\u0026rdquo; was derived. These findings suggest that the process of assigning meaning to end-of-life care experiences is not static but rather a dynamic psychological process that is reconfigured over time.\u003c/p\u003e \u003cp\u003eBelow, we discuss how a wife who had initially viewed home-based end-of-life care for her husband in a positive light re-evaluated that experience two years later, and we examine the characteristics and significance of that shift.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eReconstructing Meaning Over Time\u003c/h2\u003e \u003cp\u003eIn this study, the initial interviews already revealed narratives oriented toward the future. Through the experience of caring for their husbands at home until the end of life, the wives came to recognize their own value and role, articulated as a \u0026ldquo;conviction in one\u0026rsquo;s own significance.\u0026rdquo; Even in the early period after bereavement, the wives had begun to ascribe meaning to their caregiving experiences within the broader context of their lives, reflecting on \u0026ldquo;how to live going forward\u0026rdquo; and, in some cases, taking concrete actions. These findings suggest that meaning-making and personal growth do not necessarily arise only with the passage of time after bereavement but may begin to take shape relatively early.\u003c/p\u003e \u003cp\u003eBy contrast, the second interview was characterized not by the emergence of this future orientation, but by a more panoramic and integrated reconfiguration of meaning. With greater temporal distance, the wives revisited their husbands\u0026rsquo; final days from a broader perspective and reinterpreted their husbands\u0026rsquo; thoughts regarding the lives they left behind as sources of meaning that sustained their own present existence. Moreover, the aspirations expressed in the first interview\u0026mdash;such as \u0026ldquo;wanting to be useful to others\u0026rdquo; and \u0026ldquo;wanting to make use of my experience\u0026rdquo;\u0026mdash;were repositioned as more realistic and sustainable life choices.\u003c/p\u003e \u003cp\u003e While this positive meaning-making was maintained, additional narratives emerged over time that reflected a more distanced and reflective appraisal of the end-of-life caregiving process. In this context, participants began to voice feelings of regret and self-reproach, including statements such as \u0026ldquo;I distanced myself when faced with my husband\u0026rsquo;s death\u0026rdquo; and \u0026ldquo;I did not have enough emotional capacity to be considerate.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThis pattern accords with Neimeyer\u0026rsquo;s (2001) model of meaning reconstruction and with Park\u0026rsquo;s (2010) concept of \u0026ldquo;integrative meaning-making\u0026rdquo; within posttraumatic growth (PTG). Whereas the first interview primarily reflected meaning generation, in which meaning and value were directly derived from the caregiving experience, the second interview illustrated a shift toward meaning integration, whereby these meanings were repositioned within the broader temporal trajectory of the participants\u0026rsquo; lives. Importantly, the expressions of \u0026ldquo;regret\u0026rdquo; and \u0026ldquo;self-blame\u0026rdquo; observed in the second interview should not be interpreted as indicators of grief relapse or maladjustment. Rather, they appear to reflect a mature process in which participants, while maintaining a positive appraisal of their caregiving, became able to move beyond idealization or self-protective narratives and engage in a more realistic and holistic reassessment of their experiences. The coexistence of ambivalent emotions\u0026mdash;such as confidence in having supported their husbands to the best of their ability alongside a wish that they could have done more\u0026mdash;can thus be understood as a hallmark of advanced meaning reconstruction, deepening the personal significance of the loss and integrating it into the self-narrative.\u003c/p\u003e \u003cp\u003eAccordingly, the contribution of this study\u0026rsquo;s longitudinal findings lies not in determining whether participants began to contemplate their future lives, but in elucidating how an already present future orientation was reinterpreted, deepened, and stabilized within the self-narrative over time. These findings illuminate a process of maturation shaped by relationality and temporal distance among Japanese women who provided home-based end-of-life care for their spouses within a gendered cultural context.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eReconstruction of Lasting Spousal Bonds and Connections\u003c/h2\u003e \u003cp\u003eThe theme of \u0026ldquo;the profound significance of existing as a couple\u0026rdquo; revealed in the first interview was reconfigured in the second interview as \u0026ldquo;the enduring bond of the married couple.\u0026rdquo; This theme contained two subthemes: \u003cem\u003e\u0026ldquo;a sense of fulfillment in the final days of daily life spent consciously as a couple\u0026rdquo;\u003c/em\u003e and \u0026ldquo;\u003cem\u003ethe sense of remaining connected to one's husband.\u003c/em\u003e\u0026rdquo; The first subtheme involved the participant recounting the daily life spent at home with the husband during the terminal phase of the illness as \u0026ldquo;proof of having lived as a couple,\u0026rdquo; positively affirming the value of that time even after his death. Meanwhile, the second subtheme featured narratives expressing the feeling of \u0026ldquo;still living with my husband\u0026rdquo; even after the husband\u0026rsquo;s death, framing the relationship as a transformation, not a loss. This aligns with the concept of \u0026ldquo;continuing bonds\u0026rdquo; proposed by Klass et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], illustrating a psychological process in which the relationship is not severed by bereavement but maintained and deepened in a new form. The theme of \u0026ldquo;the enduring bond of the married couple\u0026rdquo; corresponds to the final stage of the meaning reconstruction model proposed by Gillies and Neimeyer [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which involves integrating the experience of loss into personal narrative. Moreover, given that Japanese wives positively accept the responsibility of caring for their husbands, with an internalized sense of duty to support them [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], the persistence of this bond may be understood as a culturally embedded meaning structure closely intertwined with gender role perceptions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eConfronting Life Without a Husband and Deepening the Relationship\u003c/h2\u003e \u003cp\u003eThe second interview revealed a new theme: confronting life without one\u0026rsquo;s husband. This psychological process emerged only with the passage of time after bereavement. This theme encompasses two subthemes: \u0026ldquo;the sadness of life without one\u0026rsquo;s husband\u0026rdquo; and \u0026ldquo;sorting out one\u0026rsquo;s feelings.\u0026rdquo; Within the \u0026ldquo;the sadness of life without one\u0026rsquo;s husband\u0026rdquo; subtheme, many participants described a persistent sense of loneliness, even as they became more accustomed to the husband\u0026rsquo;s absence. This indicates that grief is not a linear recovery process but a sustained one oscillating between loss and connection [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Additionally, this \u0026ldquo;sadness\u0026rdquo; is a form of \u0026ldquo;continuing bonds\u0026rdquo; [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and can be understood as an internal relationship of \u0026ldquo;continuing to live with one\u0026rsquo;s husband.\u0026rdquo; Conversely, the subtheme of \u0026ldquo;sorting out one\u0026rsquo;s feelings\u0026rdquo; described the process of deepening self-understanding through communication with others. This \u0026ldquo;processing through narration\u0026rdquo; reflects the tendency in East Asian cultures to \u0026ldquo;organize emotions through relationships\u0026rdquo; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This represents the reconfiguration of emotions mediated through relationality rather than introspection confined within the individual. Furthermore, while expressing gratitude for the help received from professionals, the wives reframed receiving support not as \u0026ldquo;weakness\u0026rdquo; but as \u0026ldquo;relational solidarity in shared caregiving.\u0026rdquo; This relational interpretation reflects the cultural characteristic of Japanese women to \u0026ldquo;organize emotions within relationships\u0026rdquo; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThrough their narratives, the wives redefined \u0026ldquo;the self that had cared for their husband,\u0026rdquo; finding new roles and meaning in life without the husband. This redefinition involved more than recovering from loss; it marked a process of rebuilding life on the foundation of the years lived with their husband, aligning with the \u0026ldquo;changed philosophy of life\u0026rdquo; dimension of posttraumatic growth (PTG) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eFrom Sustained Bonds to Relational Growth\u003c/h2\u003e \u003cp\u003eThe themes of the enduring bond of the married couple and confronting life without the husband both aligned with the concept of continuing bonds [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], illustrating how the relationship with the husband persists in altered forms after death and deepens internally over time. Furthermore, although the wives positively framed the experience of caring for their husbands at the end of life as \u0026ldquo;pride in having supported their husbands,\u0026rdquo; they re-evaluated this meaning and re-articulated it within their post-bereavement lives, reconstructing a \u0026ldquo;self that continues to live with their husbands.\u0026rdquo; This can be understood as a narrative reorganization process within Neimeyer\u0026rsquo;s [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]) \u0026ldquo;meaning reconstruction.\u0026rdquo;\u003c/p\u003e \u003cp\u003eTherefore, wives achieved relational growth through loss, not only growing as individuals but also developing their personalities through relationships with others and the deceased, under the cultural characteristic of shaping oneself through relationships. This aligns with the concept of \u0026ldquo;posttraumatic growth\u0026rdquo; [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] in PTG theory and corresponds with the Japanese cultural value of \u0026ldquo;forming the self within relationships\u0026rdquo; [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePractical Implications: From the Perspective of Long-Term, Relational Support by Visiting Nurses\u003c/h3\u003e\n\u003cp\u003eThis study\u0026rsquo;s findings indicate that wives who cared for their husbands with cancer at home until death experienced a reconstruction of their relationship with their spouse. They felt a sense of fulfillment in having supported their husbands until the end of life, yet they also carried lingering regret that \u0026ldquo;perhaps more could have been done.\u0026rdquo; This psychological process does not occur at the point of death but unfolds after bereavement. However, Japan\u0026rsquo;s medical and long-term care reimbursement frameworks restrict billable services to care delivered to the patient. As a result, bereavement follow-up for family members is not reimbursed, leaving its provision entirely to the organizational policies and capacities of individual home-visit nursing agencies. It is, therefore, important to recognize the practical value of the interactions that occur before death and during bereavement visits immediately afterward.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eThe Importance of \u0026ldquo;Relational Support\u0026rdquo; Before Death\u003c/h2\u003e \u003cp\u003eThe subtheme \u0026ldquo;\u003cem\u003eGratitude for the help provided by professionals\u003c/em\u003e\u0026rdquo; indicates that families re-evaluated receiving support not as a weakness but as a \u0026ldquo;sense of solidarity in shared end-of-life care.\u0026rdquo; When visiting nurses acknowledge caregivers\u0026rsquo; efforts while clearly conveying a collaborative stance of \u0026ldquo;supporting together now,\u0026rdquo; it becomes a major factor in forming a positive meaning for surviving family members. Moreover, it is essential to consciously create an environment that values everyday interactions and expressions of affection between spouses, respecting their relationship and supporting the final moments as \u0026ldquo;time spent together as a couple.\u0026rdquo; Supporting these \u0026ldquo;small daily moments\u0026rdquo; during the end-of-life period\u0026mdash;sharing tea, talking casually, or simply spending quiet time together\u0026mdash;helps the surviving spouse feel fulfilled in having remained present until the end. These moments also lay the groundwork for deeper self-understanding after bereavement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eProviding a \u0026ldquo;Visiting Space for Sharing Stories\u0026rdquo; during Bereavement\u003c/h2\u003e \u003cp\u003eIn a nationwide survey, approximately 80% of Japan\u0026rsquo;s home-visit nursing stations conducted bereavement visits after end-of-life care, including visits offered when deemed necessary [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Although typically a single, brief encounter, this study suggests that this visit holds considerable significance for surviving spouses. Positioning such visits not primarily as an attempt to heal the bereaved family\u0026rsquo;s grief but as an \u0026ldquo;opportunity to organize one\u0026rsquo;s thoughts through talking\u0026rdquo; is important. As seen in the participants\u0026rsquo; narratives, experiences such as \u0026ldquo;talking to someone helps me make sense of things\u0026rdquo; and \u0026ldquo;comparing my current self to my past self helps me feel my present existence\u0026rdquo; are deeply connected to the Japanese cultural characteristic of regulating emotions through third-party relationships [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Visiting nurses can play a role in promoting relational meaning-making by listening to the bereaved family\u0026rsquo;s narrative without interrupting.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, all participants in the second interview were women, and the sample size was small (five individuals). Therefore, the changes in meaning construction demonstrated here represent an aspect rooted in the cultural and gendered backgrounds of female spouses. This makes it difficult to generalize the results. Future research should include comparative analyses from diverse perspectives, such as male spouses and other family members, to clarify gender differences and the influence of family relationships on meaning-making after bereavement.\u003c/p\u003e \u003cp\u003eSecond, this study longitudinally examined changes in meaning-making over approximately four years, based on the first interview conducted six months to two years after bereavement and the second interview conducted approximately two years later. However, the length of time since bereavement varied among the participants, and the study was limited to comparisons between two time points. This imposes limitations on capturing the meaning reconstruction process in greater detail. Future research should employ multiwave tracking and incorporate a life story perspective to more comprehensively examine how loss experiences are integrated over time. Third, this study was limited to wives who positively reinterpreted their end-of-life care experiences during the first interview. Consequently, it does not sufficiently reflect the experiences of bereaved family members who negatively perceive caregiving or end-of-life care or those who struggle with reinterpretation. To understand the diverse aspects of grief, future research should study bereaved family members who cannot form positive reinterpretations and families experiencing conflict. This will enable a more multifaceted exploration of support approaches.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study aimed to elucidate how wives who had previously derived positive meaning from caring for and witnessing the death of their husbands with cancer reinterpreted these experiences over time. The findings revealed that they continued to perceive an enduring bond with their husbands and reaffirmed the significance of their relationship as family members who shared the final phase of life. They also engaged in an ongoing process of reviewing and re-evaluating their caregiving experiences, thereby reconstructing the meaning of end-of-life care. Through third-party conversations, they organized their emotions, confronted life without their husbands, and deepened their personal understanding of life and death.\u003c/p\u003e \u003cp\u003eWhile many themes overlapped with those identified during the first interview (six months to two years post-bereavement), the present study newly identified the theme of \u003cem\u003e\u0026ldquo;confronting life without one\u0026rsquo;s husband,\u0026rdquo;\u003c/em\u003e as well as an additional subtheme within \u003cem\u003e\u0026ldquo;the meaning attached to caring for one\u0026rsquo;s husband in the terminal phase,\u0026rdquo;\u003c/em\u003e specifically \u003cem\u003e\u0026ldquo;regrets about how to spend the last moments with one\u0026rsquo;s terminally ill husband.\u0026rdquo;\u003c/em\u003e These findings indicate that the meaning-making of caregiving and bereavement experiences is not static; rather, it is a dynamic psychological process that is continuously reconstructed over time following spousal loss.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePosttraumatic growth\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQLR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQualitative longitudinal research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis study was approved by the Ethics Committee of Kobe City College of Nursing (Ethics Approval No. 2014-1-39-2). Our study strictly adhered to the ethical principles outlined in the Declaration of Helsinki and ensured compliance with all pertinent guidelines and regulations. All individuals involved in the study provided informed consent before participation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by JSPS KAKENHI (grant number: JP 26893235).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMK: Writing\u0026mdash;original draft, writing\u0026mdash;review and editing, formal analysis, data curation. HN: Methodology, Formal analysis, Conceptualization, Supervision. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely appreciate the participation of all bereaved families in this study as well as the time they dedicated to it. We would also like to thank professor M Oeki for providing valuable advice throughout the analysis process.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used in this study are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei18/index.html\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei18/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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[in Japanese].\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"bereaved spouses, patients with terminal cancer, qualitative longitudinal study, spousal caregiving, meaning-making","lastPublishedDoi":"10.21203/rs.3.rs-8482686/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8482686/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCaring for a spouse with cancer during the end of life at home is an emotionally demanding experience that can have lasting effects on bereaved partners. For some spouses, this caregiving period becomes a source of meaning, personal growth, and relational reconstruction after loss. However, existing research has not fully explored the creative processes that unfold over time after loss, particularly how spouses derive positive meaning from caring for a husband with cancer at home or how they rebuild relationships. This study investigated how spouses who had provided home care for a partner with cancer, and who had interpreted the end-of-life caregiving experience positively six months to two years after bereavement, subsequently understood and reinterpreted that experience two years later.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing a qualitative longitudinal design, we conducted a second interview (approximately four years after bereavement) with spouses who participated in the first interview (six months to two years post-bereavement) and provided renewed consent. Data obtained through semi-structured interviews were transcribed verbatim and analyzed by conducting sequential comparative analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis yielded five themes: \u0026ldquo;the enduring bond of the married couple,\u0026rdquo; \u0026ldquo;the importance of family members who spent time together until the end,\u0026rdquo; \u0026ldquo;the meaning attached to caring for the husband in the terminal phase,\u0026rdquo; \u0026ldquo;confronting life without the husband\u0026rdquo; and \u0026ldquo;reflection on one\u0026rsquo;s way of life\u0026rdquo;. Wives who had initially attributed positive meaning to their caregiving experience gradually reconfigured their relationship with their husband, shifting from viewing it as a \u0026ldquo;concluded past\u0026rdquo; to a \u0026ldquo;relationship that continues in the present.\u0026rdquo;\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe meaning-making process surrounding care for a dying spouse did not remain fixed after bereavement; it evolved as a dynamic, ongoing reinterpretation. The findings indicate that positive meaning-making after loss deepens over time and is accompanied by relational growth. Through end-of-life care support, visiting nurses can understand how spouses \u0026ldquo;make meaning of their marital relationship\u0026rdquo; and provide opportunities for narrative exchanges that lead to post-bereavement re-meaning.\u003c/p\u003e","manuscriptTitle":"Meaning-Making in Home-Based End-of-Life Care: A Qualitative Study of Wives’ Experiences after the Loss of Their Husbands to Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-14 20:12:01","doi":"10.21203/rs.3.rs-8482686/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-17T08:09:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T03:25:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T18:13:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326155985275265520445068632819668713763","date":"2026-01-20T06:55:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268571432797512913608162692251301269499","date":"2026-01-19T21:55:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266416818319125664166869009267950301554","date":"2026-01-19T08:47:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-12T10:16:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-12T07:48:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-10T07:17:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2026-01-10T07:10:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a448dce-9aa0-416a-95c8-ce57d6abcb12","owner":[],"postedDate":"January 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T11:40:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-14 20:12:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8482686","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8482686","identity":"rs-8482686","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}