Ethical dilemmas for palliative care nurses: systematic review
Clinical Snapshot
PICO Framework
| P — Population | Nurses working in palliative care settings |
| I — Intervention | Exposure to ethical dilemmas in clinical practice (communication, decision-making, moral distress) |
| C — Comparator | No formal comparator; descriptive synthesis of qualitative and quantitative evidence |
| O — Outcomes | Nature, causes, and effects of ethical dilemmas encountered by palliative care nurses, including communication challenges, autonomy, dignity, and moral distress |
Bottom Line
This systematic review from Geng and colleagues attempts to synthesise the ethical dilemmas experienced by palliative care nurses, identifying three thematic domains: communication challenges (with patients and families), decision-making issues (autonomy and dignity), and moral distress. While the topic is clinically important and the thematic framework is coherent, the review has significant methodological limitations that constrain confidence in its findings. The absence of CINAHL from the search strategy is a critical omission for any nursing-focused review. No quality appraisal tool is reported, no protocol was registered, and the synthesis methodology is not described with sufficient transparency to permit replication or critical evaluation. The restriction to English-language publications and a six-year date range further limits comprehensiveness. With only 13 included studies and no GRADE-CERQual assessment, the certainty of synthesised findings is low. For Australian clinicians, the themes identified — particularly moral distress and communication dilemmas — resonate with domestic experience, but the review does not address context-specific issues such as voluntary assisted dying legislation. This review is best used as a conceptual orientation to the field and a prompt for institutional reflection, rather than as an evidence base for practice change. Higher-quality primary research and more rigorous synthesis are needed.
Key Findings
Effect Size: Not applicable — qualitative thematic synthesis; no quantitative effect sizes generated
Primary Outcome: Three thematic domains of ethical dilemmas for palliative care nurses: (1) ethical issues in communication — with patients (e.g., truth-telling, prognostic disclosure) and with families (e.g., conflicting wishes, surrogate decision-making); (2) ethical issues in decision-making — encompassing patient autonomy and dignity; (3) moral distress — arising from inability to act in accordance with ethical convictions
Nnt Or Sensitivity: Not applicable — descriptive qualitative synthesis; no diagnostic, therapeutic, or prognostic metrics calculated
Clinical Application
The thematic findings are broadly consistent with clinical experience and existing palliative care ethics literature. However, the absence of actionable recommendations, implementation frameworks, or context-specific guidance limits direct clinical translation. The review is more useful as an educational resource or for informing research priorities than as a basis for immediate practice change. Institutions could use the identified themes to structure ethics education programmes, clinical supervision frameworks, or moral distress debriefing protocols. In Australia, palliative care nursing operates within a framework shaped by the Palliative Care Australia Standards (2018), RACGP guidelines on end-of-life care, and state-based voluntary assisted dying (VAD) legislation — the latter representing a uniquely significant source of ethical dilemma not addressed in this review. The Nursing and Midwifery Board of Australia (NMBA) Code of Conduct emphasises nurses' ethical obligations in end-of-life contexts. Moral distress among Australian palliative care nurses has been documented in domestic literature, and the Australian Commission on Safety and Quality in Health Care has identified ethical communication as a priority domain. The PBS does not directly apply to this review's subject matter, though access to palliative medications and resource allocation decisions are relevant contextual factors. The TGA's scheduling of opioids and sedatives used in palliative care creates regulatory dimensions to ethical decision-making not captured by this review. Australian nurses considering VAD participation or conscientious objection face ethical dilemmas specific to the Australian legislative landscape that this review — with its restricted date range and English-only scope — may not fully capture. Registered nurses and enrolled nurses working in specialist palliative care units, hospice settings, aged care facilities, and general wards providing end-of-life care. Potentially applicable to nurse educators, clinical ethics consultants, and nursing managers responsible for workforce wellbeing and ethical culture.
Abstract
BACKGROUND: Nurses play a unique and critical role in palliative care, and it is noteworthy that nurses often encounter ethical dilemmas in this field. OBJECTIVE: This review aims to conduct a summarised synthesis of the latest research on the ethical considerations nurses faced in palliative care. METHODS: We conducted a rigorous systematic review of relevant existing studies published in high-quality English peer-reviewed journals from January 2017 to July 2023. We identified a total of 4492 articles (1029 in Web of Science, 1570 in PubMed and 1893 in Science Direct). Out of these, only 13 studies met the inclusion criteria. RESULTS: Following the thematic analysis, the ethical considerations reported in these 13 studies were grouped into three main themes and four subthemes: ethical issues in communication (ethical issues in communication with patients, ethical issues in communication with families), ethical issues in decision-making (autonomy, dignity) and moral distress in palliative care. CONCLUSION: This study elaborated on the ethical challenges faced by nurses in their communication with patients and families as well as decision-making and analysed the causes and effects of ethical distress, hoping to give a hand to ethical issues for nurses' work in palliative care.
References
- 1.Geng, S., Zhang, L., Zhang, Q., & Wu, Y. (2026). Ethical dilemmas for palliative care nurses: systematic review. BMJ Supportive & Palliative Care. https://doi.org/10.1136/spcare-2023-004742
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