Introduction
A In recent decades, due to scientific and technological advances and improved socio-economic conditions, the growth of the aging population has intensified. Therefore, for various reasons, including chronic diseases, the elderly may need specialized and emotional care. In 2017, 29% of people in need of care were elderly people over 60. In this situation, family caregivers play a vital role; In addition to providing physical and health care, they provide emotional support and help older patients cope better with the stresses and limitations of end-of-life. However, caregivers, who are mostly female, often face a variety of pressures. This study aimed to investigate the lived experience of informal female caregivers of older patients in Iran to provide a deeper understanding of this phenomenon and provide the basis for effective policymaking for this group.

Methods & Materials
This study was conducted in Tehran, Iran, from March 2023 to November 2024. The study population consists of informal female caregivers of the elderly at the end stage of life (wife, daughter, or daughter-in-law). Participants were selected through purposive sampling. Inclusion criteria were age ≥18 years, caring for an elderly person in the final stages of life (due to chronic disease or severe inability to care for themselves) for at least 3 months, and at least 2 months having passed since the elderly person’s death. Exclusion criteria were receiving payment for providing care or unwillingness to participate in or continue participation in the study. Caregivers of different ages and education levels were selected. They underwent interviews. They were first asked: “Tell me about your experience of caring for an older patient. How was it? How did it go?” Then, based on their answers, we asked probing questions about three time points: before the death, at the time of death, and after the death of the elderly person. The interviews were recorded and transcribed. The collected data were analyzed using Colaizzi’s seven-step method. The trustworthiness of the data was assessed using Guba’s four criteria: Credibility, Transferability, Dependability, and Confirmability.

Results
This study involved 10 informal female caregivers aged 29-77 years and their elderly patients aged 60-93 years. Data analysis extracted 6 main themes and 28 subthemes (Table 1).



Before death experiences
Heaviness of the caregiving burden
This theme addresses the physical, psychological, and social pressures of caregiving. Insomnia, fatigue, seeing the elderly suffer, anxiety, financial difficulties, lack of equipment, and inattention from medical staff (during the COVID-19 pandemic) were the most important pressures. Caregiver No.5 said: “Imagine that he suddenly falls and cries. It hurts to see a person cry, especially if he is your father.”

Compassionate caregiving
Caregivers created a supportive atmosphere by being positive and hopeful, maintaining the elderly’s connections with loved ones, and ensuring a safe environment. The family’s cooperation and financial support also reduced the burden. Caregiver No.6 stated: “Manner and giving hope are very important... Hope keeps you alive.”

Psychosocial driving forces
This theme addresses the semantic, cognitive, and social resources that reinforce the caregiving role. These resources included gratitude, conscientiousness, compassion, religious/spiritual beliefs, external reinforcements, and coping strategies for grief. Caregiver No. 1 stated: “He had no one here. We stepped forward to take care of him... It’s our duty... It was God’s will.”

Gradual acceptance of an inevitable truth
Caregivers accepted death by observing the elderly’s increasing problems, the disappointment of doctors, and the experience of others’ death. The caregiver’s or the elderly person’s premonition of approaching death was also a facilitating factor. Caregiver No.10 said: “Dad was very ill that night. It was as if he was telling me this is the last night!”

At the time of death experiences
Being or not being
This theme refers to the experiences of caregivers during and immediately after the death of an elderly person. The presence of an experienced person, praying, and the use of last-minute opportunities with the elderly person were comforting. Sadness, regret, anger, and gratitude for the provision of good care were among the emotional responses. Breaking the news of death to distant relatives (during the COVID-19 pandemic) also seemed challenging. Caregiver No. 3 talked about giving the news of his father’s death to his brother (who was living outside Iran): “The kid broke down. He picked up his pieces so that he could see his father through video call and say farewell.”

After death experiences
Keep living after loss
Despite experiencing loneliness, longing, and illness, caregivers adapted to the loss by changing their environment, seeking solitude, working more, and imagining the presence of the elderly. The loss of the elderly gave caregivers a deeper understanding of themselves, others, life, and death, including surrender to divine will and sometimes a sense of emptiness. Feelings of contentment and pleasant nostalgia were also reported. Caregiver No.2 said: “I kept myself busy with work.... so, I could gradually get along with it.”

Conclusion
Based on the results of the present study, female family caregivers of the elderly at the end stage of life in Iran face a heavy burden of care, but despite this pressure, they try to provide a supportive and safe environment for the elderly. They also find motivation to follow this path by giving their care meaning through love and duty. Although some caregivers struggle with feelings of emptiness, depression, and longing after the death of their elderly person, these experiences can ultimately lead to a deeper understanding of life and death, greater respect for oneself and others, and a less important focus on material things.
It is recommended that effective planning be carried out to support family caregivers, such as identifying and registering caregivers’ profiles in relevant local systems. It is also necessary to consider short-term programs and services to quickly meet basic needs and teach caregiving and self-care skills, as well as long-term programs and services to create lasting, continuous effects on the health of family caregivers.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.RETECH.REC.1401.486). Before the interviews, necessary information about the study objectives, audio recording, and confidentiality of personal data was explained to the caregivers, and their written informed consent was obtained. They were free to leave the study at any time.

Funding
This study was funded by the Religion and Health Studies Center, Shahid Beheshti University of Medical Sciences.

Authors' contributions
The authors contributed equally to the preparation of the manuscript. All authors read and approved the final version of the manuscript for submission.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank all participants for their cooperation and time in this research. We also acknowledge the assistance of Dr. Mahnaz Khalafeh-Nilsaz, Dr. Rozina Rahman, Dr. Fereshteh Rezaei, Ms. Marzieh Karamkhani, and Dr. Mohammad Reza Lakpour and Dr. Ayub Nafei,  in this study.

References