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Review Article
This scoping review summarizes current evidence on the multilevel barriers and facilitators influencing ICU nurses' participation in end-of-life (EOL) decision-making, with the aim of clarifying the persistent gap between role recognition and actual involvement and informing strategies to enhance meaningful engagement in clinical practice.
Intensive care unit (ICU) nurses are widely regarded as essential contributors to end-of-life (EOL) decision-making, given their continuous bedside presence, close engagement with patients and families, and central role in interprofessional communication. However, a persistent gap remains between the conceptual recognition of this role and nurses' actual participation in formal decision-making. This scoping review summarizes current evidence on the barriers and facilitators shaping ICU nurses' participation in EOL decision-making and on the present state of their involvement in clinical practice. The review followed the Arksey and O'Malley framework and adhered to the PRISMA-ScR reporting guidelines. The Population–Concept–Context (PCC) framework guided eligibility criteria, study selection, and data extraction, and findings were synthesized using an inductive thematic synthesis approach. Eight English- and Chinese-language databases were systematically searched from inception to September 29, 2025. Studies were eligible if they reported on registered ICU nurses or on multidisciplinary teams from which nurse-specific data could be separately extracted. A total of 32 studies met the inclusion criteria, drawn from North America, Europe, Asia, Australia, and Latin America, and using cross-sectional, qualitative, and mixed methods designs; no interventional trials were identified. Findings were synthesized across four interrelated levels. Barriers included insufficient palliative care training, low confidence, and moral distress at the individual level; hierarchical power imbalance and ineffective communication at the team level; staffing shortages, heavy workload, and absent protocols at the organizational level; and legal uncertainty and cultural taboos surrounding death at the sociocultural level. Facilitators included clinical experience, role clarity, interprofessional collaboration, structured communication tools, institutional ethics support, and enabling legal frameworks. ICU nurses' participation in EOL decision-making is constrained by a mismatch between role recognition and actual involvement; coordinated multidimensional strategies and further interventional research are needed to enhance meaningful engagement.
With continuing advances in life-sustaining technologies and the acceleration of population aging, the proportion of dying patients in intensive care units (ICUs) has increased substantially. End-of-life decision-making (EOL decision-making) generally refers to key decisions made on behalf of patients who are unable to decide for themselves, including withholding or withdrawing life-sustaining treatment, transitioning to palliative care, and establishing do-not-resuscitate (DNR) orders. Among patients who die in the ICU, more than one-third are reported to undergo decisions involving the withdrawal of life-sustaining treatment1, and the quality of these decisions directly affects patients’ dignity at the end of life as well as bereavement outcomes among family members. International guidelines emphasize that multidisciplinary collaboration is essential to ensuring high-quality EOL decision-making2. As the professionals who have the closest and most sustained contact with patients, ICU nurses play an indispensable role in this process. Nevertheless, a substantial gap remains between conceptual recognition and actual clinical practice. Despite existing guideline recommendations, nurses continue to face multiple challenges, including unclear role positioning, organizational cultural barriers, and inadequate systemic support2,3. Previous studies have further shown a declining frequency of nurse involvement in EOL decision discussions, suggesting a persistent gap between policy advocacy and implementation in practice4.
At present, the evidence in this field remains fragmented, and a systematic synthesis of the barriers to and facilitators of ICU nurses’ participation in EOL decision-making is still lacking. A scoping review is particularly suitable for mapping complex and heterogeneous bodies of evidence of this kind. Therefore, this study aimed to use a scoping review approach to systematically describe the current practice of ICU nurses’ participation in EOL decision-making and to identify the multilevel factors influencing their effective involvement, thereby providing evidence to inform improvements in clinical practice and the development of targeted interventions.
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This scoping review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and followed the Arksey and O’Malley framework. A completed PRISMA-ScR checklist is provided as Supplementary File 1. No formal protocol was registered prior to conducting this review.
Research Questions
Based on a preliminary review of the literature, this scoping review examined the current state of ICU nurses’ participation in end-of-life (EOL) decision-making and identified the barriers and facilitators that influence their effective involvement in the decision-making process.
Inclusion and Exclusion Criteria
The inclusion and exclusion criteria were developed in accordance with the Population–Concept–Context (PCC) framework, a standard structuring approach for scoping reviews that defines eligibility along three dimensions: the target population, the phenomenon of interest, and the setting in which it occurs. The inclusion criteria were as follows: (1) the population comprised registered ICU nurses, or multidisciplinary teams involving ICU nurses from whom nurse-specific data could be extracted separately; (2) the concept focused on barriers to and/or facilitators of ICU nurses’ participation in EOL decision-making; (3) the context involved acute and critical care settings, including intensive care departments, general ICUs, and specialty ICUs. The exclusion criteria were as follows: (1) studies focusing only on general clinical nursing, decision outcomes, or patient preferences without directly addressing nurses’ participation in EOL decision-making; (2) studies conducted in pediatric ICUs or non-ICU settings; (3) studies for which the full text was unavailable or that provided seriously insufficient methodological information; (4) publications that were not in Chinese or English, as well as reviews, conference abstracts, or guideline documents.
Literature Search
A literature search was performed in September 2025 in eight major databases: PubMed, Embase, Web of Science, CINAHL, PsycINFO, China National Knowledge Infrastructure (CNKI), Wanfang Data, and the Chinese Biomedical Literature Database. The search strategy was designed with reference to the PCC framework and using some preliminary searching and team discussion. The strategy was devised using PubMed as an example: a combination of Medical Subject Headings (MeSH) and free-text terms were used.
("Intensive Care Units"[Mesh] OR ICU[Ti/Ab] OR "intensive care"[Ti/Ab] OR "critical care"[Ti/Ab]) AND ("Nurses"[Mesh] OR nurs[Ti/Ab]) AND ("end-of-life decision"[Ti/Ab] OR "end-of-life care"[Ti/Ab] OR "palliative care"[Ti/Ab] OR "Do Not Resuscitate"[Ti/Ab] OR DNR[Ti/Ab] OR "withholding treatment"[Ti/Ab] OR "withdrawing treatment"[Ti/Ab]) AND (participation[Ti/Ab] OR involvement[Ti/Ab] OR role[Ti/Ab] OR engagement[Ti/Ab]) AND (barrier[Ti/Ab] OR obstacle[Ti/Ab] OR challenge[Ti/Ab] OR facilitator[Ti/Ab] OR enabler[Ti/Ab] OR support[Ti/Ab])
For the other English language databases, equivalent subject headings and free-text terms were used. Specific search strategies were used for the Chinese databases (CNKI, Wanfang, and SinoMed) with the appropriate Chinese keywords. The search covered all records from database inception to September 29, 2025.
Study Selection and Data Extraction
All retrieved records were imported into EndNote, and duplicates were removed. Two reviewers who had received training in systematic review methodology independently screened titles and abstracts according to the predefined inclusion and exclusion criteria. Full texts were then obtained for studies that passed the initial screening, and the same two reviewers independently conducted full-text screening. Any disagreements arising during the screening process were resolved through discussion with a third reviewer until consensus was reached. For the studies ultimately included, the two reviewers independently extracted descriptive information on study objectives, research questions, geographic settings, participants, sample size, methods of data collection and analysis, and major findings.
To analyze and synthesize findings from the included studies, we used an inductive thematic synthesis approach because the aim of this scoping review was to identify and map barriers and facilitators of ICU nurses’ participation in EOL decision-making. This approach is commonly used in scoping reviews to synthesize qualitative and quantitative evidence into descriptive themes. The research team reviewed each included study and extracted reported barriers and facilitators from qualitative findings, author interpretations, and survey results. Through iterative discussion, these factors were grouped into categories and subsequently organized into four inductively derived thematic levels: individual, interpersonal/team, organizational/system, and social/cultural. The PCC framework guided eligibility criteria, study selection, and data extraction. Nursing Empowerment Theory was not used to guide data synthesis but was applied in the Discussion as an explanatory lens for interpreting how multilevel barriers and facilitators influence nurses’ participation in EOL decision-making.
Literature Search and Study Selection
The initial database search yielded 4,873 potentially relevant records. After removal of duplicate records, 3,660 records remained for screening, and 32 studies were ultimately included in the review. The reference lists of the aforementioned articles were retrieved to identify additional studies that might meet the inclusion criteria. A total of 26 articles were identified using this method; however, after repeating the aforementioned screening process, all were excluded. The study selection process is presented in Figure 1.
Characteristics of the Included Studies
Among the 32 studies included in this review, 10 were conducted in North America5,6,7,8,9,10,11,12,13,14, 8 in Asia3,15,16,17,18,19,20,21, 7 in Europe4,22,23,24,25,26,27, 3 in Australia28,29,30, and 2 in South America 31,32, while 2 were multinational studies 33,34. Thirteen studies reported quantitative data using cross-sectional survey designs3,6,7,10,12,14,16,17,18,19,20,21,25. In addition, 1 was a quantitative multicenter observational study34, 1 was a quantitative descriptive comparative study4, 16 were qualitative studies5,8,9,13,15,22,23,24,26,27,28,29,30,31,32,33, and 1 employed a mixed-methods design11. Seventeen studies reported data from nurses only, whereas the remaining 15 included data from physicians, other healthcare professionals, or family members. The characteristics and main findings of the included studies are summarized in Table 1. Supplementary Table 1 provides detailed nurse-specific data extracted from the 15 mixed-sample studies, including study composition, nurse sample sizes, extraction sources, extraction methods, and nurse-specific findings.
Nurses commonly identified themselves as patient advocates, supporters of family members, and information coordinators within the healthcare team, largely because their close and continuous contact with patients and families enables them to obtain key information regarding patients' preferences and family dynamics9,33. However, a gap exists between this recognized role and actual practice. For instance, a US-based multicenter study conducted more than a decade ago reported that only 31% of nurses stated they frequently attended family meetings, whereas as many as 89% wished to be involved10. More recent evidence from two studies published in 2024 and 2025 indicates that nurses' formal involvement in EOL decision-making remains limited across diverse settings29,34.
In the absence of sufficient participation in formal decision-making mechanisms, nurses' involvement largely depends on informal channels of communication. Nurses primarily influence the decision-making process by continuously providing physicians with patient assessments, conveying family members’ emotions and concerns, and expressing their worries about treatment plans during routine handovers8,30. When nurses perceive treatment to be approaching futility, they may adopt a seeding strategy, whereby they repeatedly provide physicians with relevant patient- and family-related information to gradually prompt re-evaluation of treatment goals27. This indirect influence is consistent with evidence that nurses often function as the eyes and ears of the patient, using their continuous bedside presence to shape the information on which physicians base their decisions9. The reliance on such informal strategies may be further reinforced when institutions lack written guidelines or protocols defining nurses’ responsibilities and speaking rights in EOL decision-making18, or when the incorporation of nurses’ views depends primarily on the individual style and attitude of the attending physician rather than on a stable and equitable process32.
Nurses’ participation in EOL decision-making also varies across regional and cultural contexts. Studies from Australia, New Zealand, and the Nordic countries suggest that interprofessional collaboration may be relatively well established in some settings, with clearer nursing roles and more visible participation in EOL decision-making29,34. In contrast, studies from some Asian, Latin American, and Middle Eastern contexts indicate that medical decision-making may be more physician-led, and nurses’ participation may remain less formalized, with nurses more often contributing through implementation, information sharing, or indirect communication rather than acting as explicit co-decision-makers21,25.
Barriers to and Facilitators of ICU Nurses’ Participation in EOL Decision-Making
Barriers
Individual level:
Nurses generally lack professional training in palliative and EOL care, resulting in limited competence in symptom management and psychological support for terminally ill patients10,31. EOL decision-making carries moral implications for all stakeholders, and assuming responsibility for such decisions often generates a substantial subjective burden9. The discontinuation of medical treatment, which may accelerate death, can expose ICU professionals to distress, trauma, compassion fatigue, and even post‑traumatic stress, thereby intensifying moral suffering25. In addition, many nurses perceive EOL decision-making as a purely medical matter and believe that their role is limited to implementing medical orders rather than participating in decision formulation32.
Interpersonal and team level:
Physicians generally dominate the decision-making process, often overlooking nurses‘ perspectives30. In some cases, inconsistent decisions made by different physicians may leave nurses uncertain about how to respond22. In many ICUs, nurses are expected merely to carry out decisions rather than participate in making them25. When nurses voice dissenting opinions, they may encounter exclusion or disregard from the team9.
Organizational and system level:
Nursing shortages and excessive workload make it difficult for nurses to devote sufficient time to decision-related discussions23. Time constraints may also prevent nurses from fully participating in lengthy family meetings and team discussions30. In ICU ethical decision-making, the lack of specific procedures or practical guidelines undermines the clarity and inclusiveness of the process and substantially reduces the effectiveness of information sharing and communication16,21.
Social and cultural level:
Marked differences exist across countries and regions in the legal regulation and cultural acceptance of EOL decision-making34. Such inconsistency may cause confusion for nurses in practice. Healthcare professionals are often reluctant to discuss and document EOL decisions clearly because of concerns about legal consequences25, a concern that is especially pronounced in regions with a high incidence of medical litigation. In some traditional cultural and religious contexts, discussions of death are regarded as taboo, and various forms of treatment limitation are opposed3,19. The time required to make EOL decisions depends largely on family members’ acceptance of the patient‘s impending death30. When family members are unwilling to accept a poor prognosis, they may demand life‑sustaining interventions that conflict with the patient’s wishes and may even threaten legal action to prevent the discontinuation of care6.
Facilitators
Individual level:
The accumulation of professional experience significantly enhances nurses‘ willingness and ability to participate in decision-making. Nurses with many years of ICU experience are better able to recognize when patients are approaching the end of life and are more likely to initiate or participate in discussions based on their clinical judgment4,29,31. Nurses who can communicate with empathy and clarity with both family members and physicians are more likely to be accepted into the decision-making process; this requires the ability to deliver bad news, explain the limitations of medical treatment, and help families come to terms with reality28,29. In addition, the ability to regulate one’s emotions and mitigate the distress caused by moral dilemmas helps nurses to participate in decision-making in a sustained and rational manner8,16. Many nurses regard safeguarding the patient‘s best interests and avoiding non‑beneficial treatment as core ethical responsibilities, motivating them to challenge what they perceive as futile treatment and to ensure that patients’ wishes are respected7,13.
Interpersonal and team level:
Nurses' continuous observations of patients and families are highly valuable in informing physicians' decisions8. In multidisciplinary teams, physicians’ respect for and uptake of nurses‘ opinions can significantly enhance nurses’ sense of involvement4,13. The avoidance of non‑beneficial treatment constitutes a shared core mission and value orientation for both ICU nurses and physicians9. Clear team expectations regarding nurses‘ roles in decision-making can reduce role ambiguity and conflict, while explicit authorization enhances the legitimacy of nurses’ initiation of discussions16,29. Regular and structured team meetings provide nurses with formal opportunities to express concerns and share information, and they are preferable to decision‑making conducted only during shift handovers or via telephone, as they ensure that all relevant nursing staff are included in the process24,28.
Organizational and system level:
Standardized decision-making procedures and guidelines, such as palliative care protocols and advance directive templates, can provide nurses with clear guidance for action and reduce legal and ethical uncertainty3,12,19. Institutional mechanisms such as ethics committee support, psychological counseling, and debriefing for moral distress were reported as facilitators in some studies14. Continuous education and skills training in ethical decision-making, difficult conversations, and bereavement support can directly improve nurses‘ competence and confidence10. In addition, ICUs with adequate nurse staffing and reasonable scheduling are more likely to provide nurses with the time and space needed to attend family meetings and team discussions23,31.
Social and cultural level:
In regions with clear legal frameworks and legal protections for healthcare professionals, nurses face fewer legal risks and are more willing to participate in decision-making25. Public death education and media advocacy may gradually reduce societal avoidance of death3. In societies where open discussion of death and advanced care planning are more widely accepted, ICU nurses encounter significantly fewer barriers to participation in EOL decision-making24.
Persistent participation gap and individual-level factors
In an ideal patient-centered care model, institutional arrangements such as advance directives and surrogate decision-maker designation are intended to safeguard patient autonomy. As the healthcare professionals who maintain the closest contact with patients, nurses should serve as key advocates and coordinators of patients’ wishes. This review found that, across global ICU practice, a pattern of high role recognition but low actual participation is common, with only a minority of nurses formally involved in family meetings or EOL decision-making processes10,34. The existing literature suggests that nurses’ influence on EOL decision-making still depends largely on informal, indirect, and often invisible forms of participation, with their primary contributions lying in the communication of information and transmission of preferences among physicians, patients, and family members3,4.
The reviewed evidence consistently points to individual-level deficiencies, particularly insufficient palliative care knowledge and role ambiguity, which, while not causally proven, are plausibly associated with reduced confidence and enthusiasm for EOL participation3,4,10. Conversely, accumulated clinical experience, emotional regulation skills, and a strong sense of ethical responsibility enable some nurses to initiate or engage in decision-making more effectively4,7,13,29,31. This pattern suggests that individual-level barriers, knowledge, and experience are not merely internal traits but rather determine how nurses perceive their professional identity within the EOL context. Notably, moral distress, which is an emotional response to perceived powerlessness, may further undermine nurses’ confidence to participate in EOL decision-making35,36,37. Future interventions should focus on both technical training and affirming nurses' professional role, helping them reframe EOL participation as a core professional competency.
Team-level barriers and communication dynamics
At the team level, several studies included in this review suggest that hierarchical team structures, physician-dominated decision-making, and institutional ambiguity may limit nurses’ formal participation in EOL decision-making4,15,19,21,31,32. However, these findings should not be interpreted as homogeneous characteristics of broad geographic regions, because healthcare systems, legal frameworks, and nursing roles differ substantially across countries and institutions. Studies from China reported that hierarchical power structures limited nurses’ initiative15,18. Studies from Turkey and Jordan identified power imbalances and institutional shortcomings that confined nurses to a passive position19,21. Brazilian studies further indicated that cultural norms and hierarchical dynamics may restrict nurses’ autonomy in EOL decision-making31,32. The frequency with which nurses are mentioned in decision-making does not necessarily reflect the extent of their substantive involvement, highlighting a gap between formal recognition and meaningful participation. Importantly, physician dominance in decision-making and the tendency to view nurses as implementers rather than partners may lead to underestimation of nurses’ actual contributions, especially when data rely primarily on physician-reported perspectives4,38. High role recognition but low participatory authority cannot be explained solely by hierarchical tradition. Rather, it may also reflect differences in how participation is understood within interprofessional teams. Physicians may view nurse involvement primarily as information provision, whereas nurses may regard meaningful participation as co-deliberation, shared accountability, and the ability to raise concerns during decision formulation. Without clearly defined team procedures, role ambiguity may continue to limit nurses’ involvement in formal EOL decision-making. The variation in nurse participation reported even in healthcare systems with established collaborative cultures further suggests that improving team-based EOL decision-making requires explicit procedural rules and institutionalized opportunities for nursing input, rather than reliance on individual physician preferences alone34.
Organizational and system-level support for meaningful participation
This review indicates that barriers to nurse involvement arise from multiple interconnected factors. Structural deficiencies, such as the lack of clear guidelines, protected discussion time, and formal opportunities to speak, may limit nurses’ participation in EOL decision-making and contribute to moral distress and emotional exhaustion. Ultimately, this predicament may not only result in patients receiving non-beneficial treatments that prolong the dying process39, but may also aggravate the deep-seated moral distress experienced by ICU nurses35,36,37. To interpret how these multilevel barriers and facilitators interact to perpetuate the participation gap, we drew on Nursing Empowerment Theory as an explanatory lens rather than as an a priori coding framework. This theory provides a useful lens for understanding why role recognition alone may be insufficient without structural support, institutional authorization, and formal opportunities for participation in EOL decision-making. The findings highlight that organizational support must extend beyond mere rhetoric to tangible structural provisions. This includes establishing clear protocols for EOL care, securing dedicated time for family meetings, and ensuring adequate nurse-to-patient ratios to allow for meaningful engagement23,31. Institutional mechanisms, such as ethics consultation services and psychological debriefing for moral distress, are also critical supports that buffer the emotional toll on staff14. While educational programs are necessary to build competence10, they are insufficient on their own. Training must be embedded within a supportive infrastructure. In systems with robust institutional backing, nurses are better positioned to translate their clinical expertise into decision-making influence. Conversely, in settings where organizational support remains ambiguous or lacking, even highly motivated and skilled nurses face insurmountable structural barriers.
Sociocultural context, informal strategies, and future directions
The seeding strategy deserves particular attention because it reflects both adaptive resourcefulness and structural exclusion27. On the one hand, it shows that nurses actively use their continuous bedside observations and relationships with families to safeguard patients’ interests when they perceive ongoing treatment as non-beneficia19,27,30. In this sense, seeding may function as an ethically motivated strategy through which nurses attempt to prompt reconsideration of treatment goals27. On the other hand, the need to rely on repeated, indirect, and informal persuasion also indicates that nurses may lack legitimate and stable channels to express concerns within formal EOL decision-making structures18,30,32. Therefore, seeding may reflect both nurses’ efforts to advocate for patients and the limited opportunities available for formal participation in EOL decision-making10,18,32,34.
At the broadest level, social and cultural factors shape the legal and normative environment within which ICU nurses operate. Marked differences across countries in legal regulation, cultural acceptance of EOL decisions, and religious traditions create confusion and risk aversion among nurses 3,19,25,34. In regions with clear legal frameworks and protections for healthcare professionals, nurses face fewer legal risks and are more willing to participate 25. Conversely, in societies where death discussion is taboo or where families may threaten legal action to demand life-sustaining interventions, nurses encounter substantial sociocultural barriers6,19. The social and cultural level often acts as the context shaping both barriers and facilitators at all other levels. Legal ambiguity, such as unclear definitions of nurses’ liability when participating in WLST, can override even strong team collaboration and individual competence40. Conversely, national policies that explicitly recognize nurses as legitimate participants in EOL decision-making create top-down permission. Importantly, cultural taboos are not immutable; they shift with public discourse and interprofessional advocacy. Therefore, interventions aimed at the sociocultural level, such as hospital-wide advance care planning campaigns or media engagement, should be seen as long-term efforts that complement immediate organizational and team-level solutions41.
The findings of this scoping review should be interpreted in light of several limitations. First, although this review examined ICU nurses’ participation in EOL decision-making and its influencing factors, it did not conduct stratified analyses across different regional and cultural contexts. Given the substantial differences in cultural values, policies, and practices between regions, particularly between Asian and Western settings, the transferability of the findings may be limited, and region-specific barriers may not be fully captured. Second, no interventional studies or randomized controlled trials met the inclusion criteria. The evidence base consisted primarily of qualitative studies and cross-sectional surveys, preventing evaluation of the effectiveness of strategies to improve nurse participation. Third, only Chinese- and English-language publications were included, and grey literature was not systematically searched, which may have introduced language bias and excluded relevant studies. Fourth, there is no unified framework for classifying nurses’ participation in EOL decision-making, and variations in role definitions and participation measures across studies may have affected the comparability of findings. Fifth, consistent with the nature of a scoping review, we did not conduct formal quality appraisal or risk-of-bias assessment, nor did we weight findings according to study design, sample size, or methodological rigor. Consequently, findings from smaller or less rigorous studies may have been represented equally alongside those from larger studies. Future systematic reviews incorporating formal quality appraisal and, where appropriate, meta-analysis are needed to validate these findings. Future research should also expand regional coverage, employ more diverse study designs, and develop standardized assessment tools.
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This review systematically mapped the multilevel factors influencing ICU nurses’ participation in EOL decision-making. The available evidence indicates that, globally, ICU nurses commonly face a paradox characterized by high role recognition but low practical involvement. The relevant barriers span the individual, interpersonal, organizational, and sociocultural levels, and these factors interact across levels to create a complex mechanism that continuously constrains nurses’ participation. At the same time, the facilita...
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The authors declare that they have no competing interests.
This study was supported by Wuxi Association for Science and Technology Soft Science Research Project(KX-25-C145).
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