End-of-life (EOL) care in acute healthcare settings often lacks clear, compassionate communication between the healthcare team and the patient’s family. Despite being at the bedside and closely connected to the patient, nurses are frequently underutilized in goals-of-care discussions and ethical decision-making processes. This leads to communication breakdowns, emotional distress for families, and moral distress for nurses. The concern is that without structured nurse involvement, care may not align with the patient’s values and may result in unnecessary suffering

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🔹 Who is directly affected?

• Patients who may not be able to voice their wishes during critical illness.

• Family members who must make urgent decisions without adequate guidance.

• Nurses who experience moral and emotional distress when excluded from conversations or asked to carry out decisions that conflict with their professional judgment.

• Healthcare teams who may struggle with interdisciplinary communication and unclear roles.

  
  

🔹 How does the issue occur?

The issue occurs when nurses are left out of formal communication channels, such as family meetings or ethics consultations. It can also arise from a lack of formal training in end-of-life communication, unclear expectations, or hierarchical dynamics that discourage nurse input. As a result, critical conversations may happen without the insights of the person who knows the patient best — the bedside nurse.

🔹 Where does it occur?

This issue most often arises in acute care settings, including:

• Intensive Care Units (ICU)

• Progressive care or step-down units

• Emergency departments

• Neurology and cardiac units
  These are high-stakes environments where rapid decisions must be made about life-sustaining treatments.

  
  

🔹 When does it occur?

It typically occurs when a patient experiences rapid clinical deterioration or when decisions about continuing or withdrawing aggressive interventions must be made. These moments often happen unexpectedly, leaving families unprepared to navigate emotionally charged decisions in a limited timeframe.

🔹 Why is it a concern?

When nurses are not involved in end-of-life care conversations:

• Families may feel unsupported and confused.

• Patients may receive treatment inconsistent with their values.

• Nurses experience moral distress from witnessing suffering they believe could have been prevented.

• Ethical standards and quality of care may decline.

• Team communication and collaboration can break down.

Nurse involvement is essential to ensure that end-of-life care is compassionate, ethically sound, and truly patient-centered.

In many acute care settings, nurses provide essential bedside care and symptom management during end-of-life (EOL) situations. They are often the first to recognize changes in a patient's condition and may initiate conversations with physicians about goals of care. Some nurses advocate for patients by relaying family concerns, clarifying treatment options, and offering emotional support to both patients and families. Experienced nurses may also participate in interdisciplinary team discussions when institutional protocols support nurse involvement (Alanazi et al., 2024).

🔹 What is the nurse not doing related to the issue?

Despite their proximity to the patient, nurses are often excluded from formal decision-making processes, such as ethics consultations or family conferences. Many nurses do not receive structured training in EOL communication or ethical decision-making, leading to uncertainty and hesitation in their role. Some may avoid engaging in deeper conversations about prognosis or goals of care due to fear of overstepping boundaries, lack of confidence, or institutional hierarchy (Palmyrd et al., 2023).

🔹 How is the nurse’s current participation improving the issue?

When nurses are involved in EOL discussions, they improve communication between families and providers, clarify treatment goals, and ensure that care aligns with the patient’s values (Palmyrd et al., 2023). Their presence helps humanize the healthcare experience and provides much-needed emotional and psychological support to families. This leads to better-informed decisions, reduced family distress, and smoother palliative or comfort-focused care transitions.

🔹 How is the nurse’s current participation (or lack thereof) exacerbating the issue?

When nurses are not empowered or trained to participate in EOL communication, critical information may be overlooked or delayed, contributing to poor decision-making and emotional strain for families (Alanazi et al., 2024). Nurses may experience moral distress when they are expected to carry out care plans that conflict with their ethical beliefs or understanding of the patient’s wishes (Ibrahim et al, 2024).

The review emphasizes that many nurses feel ethically torn when witnessing or participating in care they believe is not in the patient’s best interest. It also points to the need for stronger interdisciplinary collaboration and institutional support to include nurses more meaningfully in these conversations. The study concludes that equipping nurses with ethical frameworks and communication skills is essential to improving the quality of EOL care (Alanazi et al., 2024).

✅ Key Themes:

• Moral distress

• Unclear roles in decision-making

• Need for ethical and communication training

The study revealed a strong connection between ethical understanding and advocacy. Nurses with more training in ethical decision-making reported better quality of care, improved communication, and reduced emotional fatigue. It concludes that ongoing ethics education is crucial for nurses to act confidently and compassionately in EOL care situations (Ibrahim et al, 2024).

✅ Key Themes:

• Ethical knowledge improves advocacy

• Emotional impact of ethical uncertainty

• Importance of continuous training

Conversely, the study found that nurses who were empowered to speak with families, clarify clinical goals, and advocate for patient values helped reduce emotional trauma and improved decision-making outcomes. The authors recommend that nurse inclusion be standardized in EOL protocols, particularly in intensive care settings (Palmyrd et al., 2023).

✅ Key Themes:

• Nurse exclusion leads to moral distress

• Communication improves family outcomes

• Standardizing nurse participation is essential

There are several barriers that limit nurse participation in end-of-life (EOL) communication and ethical decision-making. These include:

• Lack of formal training in ethical frameworks and goals-of-care communication

• Hierarchical structures that limit nurse participation in interdisciplinary discussions

• Emotional burden and fear of saying the wrong thing or overstepping one’s role

• Time constraints in high-acuity environments, where urgent clinical tasks take precedence

• Inconsistent institutional policies that fail to clarify the nurse’s role in EOL decision-making

These barriers prevent nurses from confidently and consistently engaging in ethically sound and emotionally supportive conversations (Alanazi et al., 2024; Palmyrd et al., 2024)

🔹 If the nurse is not participating, or the participation is limited, explain why.

Nurse participation is often limited due to a combination of factors:

• Ethical uncertainty: Many nurses are unsure how to navigate the complex moral dimensions of end-of-life decisions without adequate training (Ibrahim et al, 2024).

• Professional boundaries: Nurses may feel it's the physician’s role to lead such conversations and fear crossing into a domain traditionally viewed as medical decision-making (Palmyrd et al., 2023).

• Emotional toll: The high emotional intensity of EOL discussions can be overwhelming, especially for newer or unsupported nurses, leading to withdrawal or avoidance (Alanazi et al., 2024).

• Lack of support systems: Without ethics consult teams, palliative care training, or institutional encouragement, many nurses simply do not feel equipped or empowered to speak up (Ibrahim et al, 2024).

  
  

🔹 Consider ethical, legal, financial, and social implications.

• Ethical: Nurses may experience moral distress when care plans conflict with the patient's best interests or known wishes, especially if they are not empowered to intervene (Alanazi et al., 2024).

• Legal: Fear of liability or perceived overstepping of scope of practice may prevent nurses from engaging in critical discussions. Clarity on legal protections and role expectations is lacking in many facilities.

• Financial: Institutions may prioritize revenue-generating, aggressive treatments over palliative options, unintentionally discouraging EOL discussions (Palmryd et al., 2023).

• Social: Cultural differences, language barriers, and family dynamics can complicate communication and may require specialized training that not all nurses receive (Ibrahim et al., 2024).

To promote greater nurse participation in end-of-life (EOL) care, healthcare organizations should provide structured training on goals-of-care conversations, ethical decision-making, and family-centered communication. This training should begin in orientation and continue through regular professional development. Programs that incorporate simulation, role-playing, and interdisciplinary workshops help nurses build the confidence and communication skills needed to engage meaningfully with patients and families (Alanazi et al., 2024; Ibrahim et al, 2024).

🔹 Recommendation 2: Establish clearly defined roles for nurses in EOL decision-making processes

Hospitals and acute care units should create clear protocols that outline the nurse’s role during interdisciplinary family meetings, ethics consults, and advance care planning. Nurses should be expected—and empowered—to provide input based on their firsthand knowledge of the patient’s condition, values, and goals. When nurses are formally recognized as contributors to decision-making, team communication improves and moral distress decreases (Palmryd et al., 2023; Alanazi et al., 2024).

🔹 Recommendation 3: Provide emotional and institutional support systems to reduce moral distress

Healthcare systems must support nurses emotionally and structurally to sustain their involvement in ethically complex EOL care. This can include access to debriefing after complex cases, mentorship programs, and inclusion in unit-level ethics rounds. Supporting nurses' emotional well-being improves their job satisfaction and strengthens their ability to advocate for patients with clarity and compassion (Palmryd et al., 2023; Ibrahim et al, 2024).

One of the most impactful concepts I learned during my time at Sentara College of Health Sciences was leadership through advocacy. In both clinical and classroom settings, we were taught that nurses are not just caregivers — we are advocates who lead from the bedside. This concept became especially real during my Neuro ICU rotation, where I saw firsthand how nurses can influence the direction of end-of-life care simply by speaking up on behalf of their patients.

This foundation in leadership has prepared me to confidently participate in ethical discussions, communicate with families during times of crisis, and represent the patient’s voice when they can no longer speak for themselves. As I transition into professional practice, I am committed to being the kind of nurse who leads with both clinical expertise and compassionate advocacy.

🔹 Curricular Concept 2: Ethical and Culturally Competent Care

Another vital concept was the integration of ethics and cultural competence into patient care. At SCOHS, we learned how to navigate moral dilemmas, respect patient autonomy, and honor cultural values at every stage of life — especially at the end of life. Through simulations, case studies, and clinical application, I developed the skills to assess not just a patient’s physical condition but their spiritual, emotional, and cultural needs as well.

This has prepared me to lead with sensitivity and integrity in diverse clinical environments. In end-of-life situations, where ethical and cultural concerns are heightened, I now feel equipped to foster inclusive, respectful care that aligns with each patient's unique values and beliefs.

🔚 Final Reflection:

Together, these concepts have shaped me into a nurse who is ready to lead in both formal and informal roles. Whether I am advocating during a family conference or offering quiet support at the bedside, I understand the weight of the nurse’s role in end-of-life care — and I am prepared to carry that responsibility with confidence, compassion, and clarity.

Ibrahim, A. M., Zaghamir, D. E. F., Ramadan Abdel-Aziz, H., Elalem, O. M., Al-yafeai, T. M., Sultan, H. M. S., Sliman, A. M. A., Elsaid, R. A. A., Aboelola, T. H., & Mersal, F. A. (2024). Ethical issues in palliative care: nursing and quality of life. BMC Nursing, 23(1). https://doi.org/10.1186/s12912-024-02530-7

Palmryd, L., Åsa Rejnö, Alvariza, A., & Tove Godskesen. (2024). Critical care nurses’ experiences of ethical challenges in end-of-life care. Nursing Ethics, 32(2). https://doi.org/10.1177/09697330241252975

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