Barriers and Facilitators to Intensive Care Unit Nurses’ Participation in End-of-Life Decision-Making: A Scoping Review

Summary

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.

Abstract

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.

Introduction

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....