Barriers to healthcare professionals screening, recognizing, and managing delirium in the adult patients receiving specialist palliative care: a mixed-methods systematic review

Abstract

Background

Delirium frequently occurs in palliative care settings, yet its screening, identification, and management remain suboptimal in clinical practice. This review aims to elucidate the barriers preventing healthcare professionals from effectively screening, recognizing, and managing delirium in adult patients receiving specialist palliative care, with the goal of developing strategies to enhance clinical practice.

Methods

A mixed-methods systematic review was conducted (PROSPERO: CRD42024563666). Literature was sourced from PubMed, Web of Science, Embase, CINAHL, The Cochrane Library, and Clinical Trials databases from their inception to November 16, 2024, without language restrictions. Studies that were primary quantitative, qualitative, and mixed-methods research, and reported the barriers to healthcare professionals’ screening, recognition, and management of delirium in adult patients receiving specialist palliative care (including inpatient hospice/hospital care, consultation teams, and outpatient/community services) were included. Studies were excluded if they did not permit barrier factor extraction, had duplicate or incomplete data, or were case reports or conference abstracts. The Mixed Methods Appraisal Tool (MMAT) version 2018 was employed to evaluate the methodological quality of included studies. Data synthesis used the convergent-integrated JBI mixed-methods approach.

Results

21 articles that meet the selection criteria have been identified, with 11 quantitative, 8 qualitative and 2 mixed-methods, collectively involving 857 patients and 649 healthcare professionals. Four themes were identified from the includes studies: (1) Individual level: knowledge and understanding gaps among healthcare professionals; (2) Operational level: implementation challenges in clinical practice; (3) Organizational level: structural and resource deficiencies; (4) Contextual level: specific impacts of situational factors.

Conclusion

The systematic review uncovered a complex interplay of barriers spanning individual, operational, organizational, and contextual levels in palliative settings. To address these challenges, recommended strategies include developing targeted training programs, implementing standardized delirium assessment tools, improving guideline accessibility, and promoting interdisciplinary collaboration to enhance delirium screening and management in palliative care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-024-01634-w.

Introduction

Delirium is a complex neurocognitive syndrome characterized by acute disturbances in attention, cognition, and consciousness [1, 2]. A systematic review has revealed that the prevalence of delirium in palliative care settings widely, ranging from 4 to 88%, with approximately one-third of patients experiencing delirium during inpatient palliative treatment [3]. In the context of palliative care, delirium can significantly increase the risk of complications, higher symptom expression, impair communication between patients and caregivers [4–6]. Overall, these factors can profoundly affect a patient’s end-of-life experience and the bereavement experience of their loved ones. Consequently, it is crucial to systematically screen patients receiving palliative care for delirium risk, promptly identify cases, and effectively manage contributing factors.

Despite its significance, inadequate screening, identification, and management of delirium in adult patients receiving specialist palliative care remain formidable challenges in clinical practice, particularly as the management of delirium with treatment of underlying precipitating factors will vary according to the person’s goals of care. A survey from UK revealed that more than half of delirium cases in specialist palliative care units were neither recognized nor documented by the treating clinical team [7]. Furthermore, a survey of 335 palliative care physicians found that only 13% of palliative care teams used delirium assessment tools on first admission [8]. Understanding the factors that hinder healthcare professionals in screening, identifying, and managing delirium in patients receiving specialist palliative care is crucial for addressing these clinical practice issues.

While recent studies have begun to explore the challenges healthcare professionals face in identifying and managing delirium, significant gaps remain in the existing literature. Bianchi et al. [9] investigated the barriers faced by healthcare professionals in identifying and managing delirium in hospitalized elderly patients, their study was limited to older patients receiving end-of-life care, thus narrowing its scope. Featherstone et al. [10] comprehensively explored the experiences of patients, families, clinicians, and volunteers regarding delirium and its care within the palliative care context, highlighting how limited understanding severely impacts the capabilities of palliative care providers. However, their work was only a systematic evaluation of qualitative research on relevant issues.

Recognizing that obstacles can be effectively explored through qualitative and quantitative methods, and acknowledging these gaps in the literature, our study aimed to conduct a mixed-methods systematic review to comprehensively understand the barriers faced by healthcare professionals in screening, identifying, and managing delirium in adult patients receiving specialist palliative care, providing strategies for optimizing clinical practice in this critical area. Specifically, we aimed to answer the following question: What are the barriers encountered by healthcare professionals in screening, identifying, and managing delirium in adult patients receiving specialist palliative care?

Methods

To appraise and synthesize evidence of empirical studies, reporting the obstacles faced by healthcare professionals in screening, identifying, and managing delirium in adult patients receiving professional palliative treatment. The review was registered on the PROSPERO database for systematic reviews: CRD42024563666, and no separate protocol has been developed. The review followed the Joanna Briggs Institute (JBI) guidance for mixed-methods systematic reviews [11], and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and PRISMA-S extension [12, 13] (See Appendix 1 and Appendix 2).

Eligibility criteria

The inclusion criteria were as follows: (1) Primary quantitative, qualitative, and mixed-methods research, without language restrictions; (2) Studies focusing on barriers to healthcare professionals’ screening, recognition, and management of delirium in adult patients (≥ 18 years) receiving specialist palliative care; (3) Specialist palliative care services include inpatient care in a hospice or hospital palliative care unit, palliative care consultation teams and specialist outpatient and community services [14]. Exclusion criteria: (1) Literature that does not allow for the extraction of barrier factors; (2) When thesis/dissertation and journal articles from the same research team report identical content, the journal article is retained; (3) Literature with incomplete data that is inaccessible; (4) Case reports, conference abstracts, and duplicate publications.

Search strategy

We conducted a complete systematic literature search across five electronic databases and one clinical registration center: PubMed, Web of science (including Web of Science Core Collection, KCI-Korean Journal Database, MEDLINE, Preprint Citation Index, ProQuest™ Dissertations & Theses Citation Index, SciELO Citation Index), Embase, CINAHL, The Cochrane library, and Clinical Trials, from the index start date to November 16, 2024, without language limitations. In Web of Science and The Cochrane library searches, we added a document types filter based on exclusion criteria. Based on the research designs reported in previously published systematic reviews [9, 14, 15] and the objectives of this study, FQ and DYY developed a search strategy tailored for this study. THT then reviewed the search strategy using the Peer Review of Electronic Search Strategies (PRESS) [16]. Search terms included ‘delirium’, ‘palliative care’, ‘healthcare professionals’, ‘barriers’, ‘screening’, ‘recognition’ and ‘management’ along with related synonyms combined with MeSH terms, Boolean operators, and truncation. A comprehensive literature search was conducted for the first time on July 18, 2024, followed by a re-search and literature update using the same search strategy on November 16, 2024. We manually searched the references of identified studies for additional potential articles. The full search strategy and the number of search results for each database are presented in Appendix 3.

Study selection

EndNote X9 was used to exclude duplicate records and manage the included studies. Two researchers (FQ, DYY) selected studies independently using a two-step screening process consisting of title and abstract screening followed by full-text review to identify studies meeting the eligibility criteria. Disagreements were resolved by consensus or consultation with a third researcher (THT).

Data extraction

Two reviewers (FQ, DYY) independently performed data extraction using a pre-designed table in Microsoft Word. Extracted information included author, year of publication, study design, location, sample characteristics, delirium assessment methods, and barriers to screening, recognition, and management. Discrepancies were resolved through discussion or consultation with a third researcher (THT).

Quality appraisal

Two researchers (FQ, DYY) independently evaluated the quality assessment, and any differences were discussed or sought after by a third researcher (THT) until consensus was reached on all ratings. Quality was assessed using the Mixed- Methods Appraisal Tool (MMAT) version 2018 [17]. The MMAT is a reliable quality assessment tool that can appraise five of the most common study designs: qualitative research, randomized controlled trials, quantitative non-randomized studies, quantitative descriptive studies and mixed methods studies. Each criterion was rated as “yes”, “no” or “unclear”. A score of 1 was given to criteria rated as “yes”, and 0 was given to criteria rated as “no” or “unclear”. In accordance with the MMAT recommendations, the quality appraisal was reported using descriptive responses to for each MMAT standard to report quality assessments [17].

Data synthesis

Two researchers (FQ, DYY) independently conducted the data synthesis using a convergent JBI mixed-methods approach [11], with discrepancies resolved by a third reviewer (THT) and final themes validated by all authors. The synthesis process involved the following steps: (a) Quantitative data transformation: Quantitative results were converted into “qualitized data” through textual descriptions or narrative explanations to directly address the research questions; (b) Data integration: The qualitized data were combined with the qualitative data extracted from the included studies; (c) Thematic analysis: The integrated data were classified and aggregated based on semantic similarity to identify common themes and patterns; (d) Synthesis of findings: A comprehensive set of findings was generated by synthesizing the themes and patterns identified in the previous step.

Results

Study characteristics

The systematic search yielded 1235 results, with 177 duplicates removed. After screening 1059 titles and abstracts, 29 full-text articles were evaluated, resulting in 21 studies meeting the inclusion criteria for our analysis (Fig. 1). The 21 articles were conducted in five countries: the UK (n = 10) [7, 18–26], Australia (n = 7) [27–33], Canada (n = 2) [34, 35], the US (n = 1) [36], and Ireland (n = 1) [37]. In terms of research methodology, 8 studies employed qualitative approach [18–20, 27–30, 34], 11 used quantitative methods [7, 21, 23, 24, 26, 31–33, 35–37], and 2 adopted a mixed-methods design [22, 25]. The review analyzed 21 articles encompassing 857 adult patients receiving specialist palliative care and 649 healthcare professionals. The healthcare team comprised 373 nurses (57.5%), 174 physicians (26.8%), 48 healthcare assistants (7.4%), and other professionals including volunteers, physiotherapists, pharmacists, and allied health support staff (8.3%). Among the 16 studies targeting healthcare professionals, 7 focused specifically on the screening, identification, and management of delirium in adult patients receiving specialist palliative care from a nursing perspective [19, 27–29, 34–36], while 9 studies explored the viewpoints of multiple professional groups [7, 18, 20–23, 25, 30, 31]. The literature included in this review covers palliative care from various environments including inpatient, outpatient, home care, and community settings. Fourteen studies reported using specific delirium assessment tools [7, 19, 21–27, 29, 32, 33, 36, 37]. Table 1 shows the basic characteristics of included studies.

Fig. 1.

PRISMA flow- chart

Table 1.

Basic characteristics of included studies

Authors, year and country	Design	Participants (sample size)	Setting	Delirium assessment tool
Brajtman et al., 2006.Canada [34]	Qualitative	Nurses (N= 9)	In-patient and home palliative care	N/A
Ryan et al., 2009. Ireland [37]	Quantitative descriptive	Patients (N = 84)	In-patient palliative care	CAM
Sands et al., 2010. Australia [32]	Quantitative descriptive	Patients (N= 21)	In-patient palliative care	SQiD
Agar et al., 2012.Australia [27]	Qualitative	Nurses (N = 10)	In-patient palliative care	DSM-IV
Hosie et al., 2014. Australia [28]	Qualitative	Nurses (N = 30)	In-patient palliative care	N/A
Hosie et al., 2015. Australia [29]	Qualitative	Nurses (N= 21)	In-patient palliative care	Nu- DESC
Porteous et al., 2016. UK [21]	Survey	28 nurses, 19 physicians, 7 allied health professionals, 3 healthcare assistants, 2 chaplains, 1 pharmacist and 3 administrators (N = 63)	In-patient palliative care	short-CAM
Baird et al., 2017. UK [23]	Quantitative descriptive	2 nurses, 2 physicians, and 75 patients (N = 79)	In-patient palliative care	4AT; short-CAM
Waterfield et al., 2018. UK [18]	Qualitative	12 nurses and 6 healthcare assistants (N = 18)	In-patient palliative care	N/A
Harris et al., 2020. UK [19]	Qualitative	Nurses (N = 10)	Community palliative care	4AT
Sutherland et al., 2020. Canada [35]	Quantitative non-randomized	Nurses (N = 20)	In-patient palliative care	N/A
Hosie et al., 2021.Australia [31]	Survey	75 nurses, 66 physicians, and 1 pharmacist (N = 142)	Community, outpatient and inpatient palliative care	N/A
Sands et al., 2021. Australia [33]	Quantitative descriptive	Patients (N = 142)	In-patient palliative care	SQiD
Sinchak et al., 2021. US [36]	Quantitative non-randomized	Nurses (N = 10)	In-patient palliative care	Nu-DESC
Green et al.,2022. Australia [30]	Qualitative	17nurses, 6 physicians, 3 physiotherapists, 1 social worker and 1 pastoral care worker (N = 28)	In-patient palliative care	N/A
Arnold et al.,2022. UK [22]	Mixed-method	21 patients, 4 nurses and 3 physicians (N = 28)	In-patient palliative care	4AT; DSM-5
Woodhouse et al., 2022. UK [7]	Survey	68 physicians, 106 nurses, 22 healthcare assistants and 24 other allied health professionals (N = 220)	In-patient palliative care	4AT; CAM
Featherstone et al.,2023. UK [20]	Qualitative	9 healthcare assistants, 8 nurses, 6 physicians, 5 volunteers, 1occupational therapist, 1physiotherapist and 1 senior manager (N = 31)	In-patient palliative care	N/A
Arnold et al., 2024. UK [24]	Quantitative descriptive	Patients (N = 134)	In-patient palliative care	4AT
Jackson et al., 2024. UK [25]	Mixed-method	80 patients, 2 medical consultant, 4 physicians, 11 nurses, 8 healthcare assistant, and 1 allied health professional (N = 106)	In-patient palliative care	4AT; RASS-PAL
Jackson et al., 2024. UK [26]	Quantitative non-randomized	Patients (N = 300)	In-patient palliative care	4AT; RASS-PAL

Note: CAM: The Confusion Assessment Method; SQiD: Single Question in Delirium; DSM: Diagnostic and Statistical Manual of Mental Disorders; Nu-DESC: Nursing Delirium Screening Scale; 4AT: 4AT assessment test for delirium and cognitive impairment (assesses 4 items: Alertness, Orientation using AMT4, Attention, and Acute change or fluctuating course); RASS-PAL: Richmond Agitation Sedation Scale – Palliative Version

Quality of the included studies

Table 2 summarizes the methodological quality assessment for the included studies. There were 16 studies [18–20, 22–30, 32–34, 37] rated as extremely high-quality, meeting all the quality criteria for their study design. Two non-randomized studies [35, 36]encountered insufficient information in controlling for confounding factors, resulting in an “Can’t Tell” evaluation. Among the three included descriptive quantitative studies [7, 21, 31], potential biases mainly stemmed from reporting of sampling methods, proof of target population representativeness, and response rates, typically characterized by high-risk features or underreporting. Adhering to MMAT user guide instructions, no studies were excluded based on methodological quality concerns (See Table 2).

Table 2.

Quality appraisal of the included studies

Author, year	Screening		Qualitative studies					Non-randomized studies					Descriptive studies					Mixed methods studies
	S1	S2	1.1	1.2	1.3	1.4	1.5	3.1	3.2	3.3	3.4	3.5	4.1	4.2	4.3	4.4	4.5	5.1	5.2	5.3	5.4	5.5
Brajtman et al., 2006 [34]	√	√	√	√	√	√	√
Ryan et al., 2009 [37]	√	√											√	√	√	√	√
Sands et al., 2010 [32]	√	√											√	√	√	√	√
Agar et al., 2012 [27]	√	√	√	√	√	√	√
Hosie et al., 2014 [28]	√	√	√	√	√	√	√
Hosie et al., 2015 [29]	√	√	√	√	√	√	√
Porteous et al., 2016 [21]	√	√											U	√	√	U	√
Baird et al., 2017 [23]	√	√											√	√	√	√	√
Waterfield et al., 2018 [18]	√	√	√	√	√	√	√
Harris et al., 2020 [19]	√	√	√	√	√	√	√
Sutherland et al., 2020 [35]	√	√						√	√	√	U	√
Hosie et al., 2021 [31]	√	√											√	√	√	×	√
Sands et al., 2021 [33]	√	√											√	√	√	√	√
Sinchak et al., 2021 [36]	√	√						√	√	√	U	√
Green et al.,2022 [30]	√	√	√	√	√	√	√
Arnold et al.,2022 [22]	√	√	√	√	√	√	√						√	√	√	√	√	√	√	√	√	√
Woodhouse et al., 2022 [7]	√	√											√	U	√	U	√
Featherstone et al.,2023 [20]	√	√	√	√	√	√	√
Arnold et al., 2024 [24]	√	√											√	√	√	√	√
Jackson et al., 2024 [25]	√	√	√	√	√	√	√						√	√	√	√	√	√	√	√	√	√
Jackson et al., 2024 [26]	√	√						√	√	√	√	√

Note:√: Yes; ×: No; U: Can’t tell. The mixed methods appraisal tool (MMAT) version 2018 (Hong et al., 2018); S1, S2, 1.1, 1.2, 1.3, 1.4, 1.5, 3.1, 3.2, 3.3, 3.4, 3.5, 4.1, 4.2, 4.3, 4.4, 4.5, 5.1, 5.2, 5.3, 5.4, and 5.5 denote the quality assessment item under each study design

Synthesis of results

There was synergy in barriers identified from the included studies. Four themes were identified: (1) Individual level: knowledge and understanding gaps among healthcare professionals; (2) Operational level: implementation challenges in clinical practice; (3) Organizational level: structural and resource deficiencies; (4) Contextual level: specific impacts of situational factors. The themes and subthemes are presented in Table 3.

Table 3.

Themes across the included studies

Themes and subtheme	Qualitative studies	Quantitative studies	Mixed-methods studies
1.Individual level: knowledge and understanding gaps among healthcare professionals
Insufficient understanding of concept, symptoms and risk factors of delirium	Agar et al., 2012 [27]; Hosie et al., 2014 [28]; Hosie et al., 2015 [29]; Waterfield et al., 2018 [18]; Featherstone et al.,2023 [20]	Hosie et al., 2021 [31]; Sinchak et al., 2021 [36]	Arnold et al., 2022 [22]; Jackson et al., 2024 [25]
Lack of knowledge in delirium management	Hosie et al., 2014 [28]; Waterfield et al., 2018 [18]	Sutherland et al., 2020 [35]
2. Operational level: implementation challenges in clinical practice
Difficulties in applying assessment tools	Hosie et al., 2015 [29]; Harris et al., 2020 [19]	Porteous et al., 2016 [21]; Arnold et al., 2024 [24]; Ryan et al., 2009 [37]; Baird et al., 2017 [23]; Sands et al., 2021 [33]; Sands et al., 2010 [32]	Arnold et al., 2022 [22]; Jackson et al., 2024 [25]
Poor guideline implementation	Hosie et al., 2014 [28]; Hosie et al., 2015 [29];		Jackson et al., 2024 [25]
Communication challenges	Hosie et al., 2014 [28]; Waterfield et al., 2018 [18]; Green et al.,2022 [30];	Woodhouse et al., 2022 [7]
Restricted nursing environment	Brajtman et al., 2006 [34]; Harris et al., 2020 [19]
3. Organizational level: structural and resource deficiencies
Workload and time burden	Agar et al., 2012 [27]; Hosie et al., 2014 [28]; Waterfield et al., 2018 [18]; Harris et al., 2020 [19]; Green et al.,2022 [30]; Featherstone et al.,2023 [20]	Woodhouse et al., 2022 [7]; Hosie et al., 2021 [31]; Sinchak et al., 2021 [36]	Jackson et al., 2024 [25]
Inadequate professional development and training	Hosie et al., 2014 [28]; Hosie et al., 2015 [29]; Harris et al., 2020 [19]; Green et al.,2022 [30]; Brajtman et al., 2006 [34]	Woodhouse et al., 2022 [7]
Inadequate inter-professional collaboration	Agar et al., 2012 [27]; Hosie et al., 2014 [28]; Hosie et al., 2015 [29]; Green et al.,2022 [30]; Featherstone et al.,2023 [20]	Jackson et al., 2024 [26]
4. Contextual level: specific impacts of situational factors
Ethical dilemma in palliative care	Waterfield et al., 2018 [18]; Green et al.,2022 [30]		Arnold et al., 2022 [22]
Emotional burdens	Brajtman et al., 2006 [34]; Agar et al., 2012 [27]; Featherstone et al.,2023 [20]	Hosie et al., 2021 [31]	Jackson et al., 2024 [25]

Individual level: knowledge and understanding gaps among healthcare professionals

Our analyses revealed significant challenges in delirium knowledge and understanding among healthcare professionals. Insufficient understanding of concept, symptoms and risk factors of delirium were mentioned in 9 of the 21 studies (42.6%) [18, 20, 22, 25, 27–29, 31, 36]. Healthcare professionals, encompassing physicians, nurses, pharmacists, healthcare assistants, medical consultants, and allied health professionals, reported feeling that their knowledge and understanding of delirium symptoms and risk factors were limited or insufficient [18, 25, 28, 29, 31, 36]. This difficulty was also reflected in their description and recording of the condition, as struggling to define or explain what delirium actually means. Instead of using specific terms related to cognitive changes, most described ambiguous terminology (e.g., agitation or confusion) when documenting delirium [20, 22, 27]. Furthermore, three studies (14.3%) emphasized the lack of knowledge in delirium management among nurses and medical assistants, which affects clinical practice [18, 28, 35].

Operational level: implementation challenges in clinical practice

In the realm of clinical practice, particularly in screening, identifying, and managing delirium by healthcare professionals, four primary obstacles have emerged: difficulties in applying delirium assessment tools, poor guideline implementation, communication hurdles, and constrained nursing settings. Ten studies (47.6%) underscored the obstacles in utilizing delirium assessment tools within palliative care settings [19, 21–25, 29, 32, 33, 37]. Six studies conducted from the perspective of health care professionals showed that physicians, nurses, pharmacists, and other health care professionals faced a variety of difficulties in using assessment tools, including difficult to access delirium assessment tools [23], lack of clear guidance on frequency of use and indications [19, 29], and low familiarity with tool use [21, 22, 25]. Another 4 studies approached from the perspective of tool validation, revealing that finding the 4AT needs more evaluation in community settings [24], CAM is valid in palliative care but depends on proficiency [37], and SQiD, not a replacement, offers additional utility and benefits in delirium detection and care for cancer patients [32, 33]. This diversity of tools and contexts adds to the difficulties in selecting and implementing delirium appropriate assessment tools. Three studies (14.3%) noted that delirium guideline has poor clinical accessibility, and has not been well implemented to the identification and screening of delirium in palliative care [25, 28, 29]. Communication barriers with patients and their families, documented in four studies (19.0%), impeded delirium screening, assessment, prevention, and the formulation of care plans [7, 18, 28, 30]. Two studies (9.5%) highlighted the distinctive challenges posed by home-based palliative care settings, particularly the constraints of the care environment: restricted patient contact time diminishes nurses’ capacity to recognize delirium symptoms and their fluctuations, creates safety risks when treating isolated delirium patients, and complicates the maintenance of continuous care [19, 34].

Organizational level: structural and resource deficiencies

Our analyses revealed significant barriers at the systemic and organizational levels. Workload and time burdens were the most commonly reported issues, mentioned in 10 studies (47.6%) [7, 18–20, 25, 27, 28, 30, 31, 36], with healthcare professionals finding delirium management labor-intensive and having inadequate time for proper care due to escalating workloads. Six studies (28.6%) highlighted deficiencies in professional development and training [7, 19, 28–30, 34]. Physicians, nurses, healthcare assistants, and other allied health professionals have all expressed the need for delirium education in the context of palliative care [7, 19, 28, 29, 34]. Recommendations included enhanced on-site training, particularly for weekend, temporary, and new staff [30]. Six studies (28.6%) highlighted that insufficient interprofessional collaboration is a barrier [20, 26–30]. Specifically, nurses’ assessments often lacked recognition or follow-up from other team members [28, 29], and medical teams lacked consensus, sometimes impeding the effective implementation of intervention measures [20, 26, 27, 30].

Contextual level: specific impacts of situational factors

Situational factors play a crucial role in delirium management in palliative care, and this review primarily explores the ethical dilemmas and emotional burdens. Notably, three studies (14.3%) emphasized the ethical dilemmas in balancing effective delirium management with patient quality of life and wishes, directly influencing management strategy decisions [18, 22, 30]. Furthermore, five studies (23.8%) highlighted that emotional burdens have emerged as a significant challenge, as nurses, physicians, healthcare assistants, and other allied health professional declared witnessing the symptoms experienced by delirium patients causes psychological distress and exhaustion [20, 25, 27, 31, 34].

Discussion

This mixed-methods systematic review examined the barriers to delirium screening, recognizing, and management among healthcare professionals in specialist palliative care. Our findings showed that nurses constituted the majority of the healthcare professionals, and seven studies specifically focused on nursing perspectives. The significant focus on nursing perspectives may be attributed to nurses being in the best position to detect fluctuations in delirium symptoms [38, 39]. It is worth noting that effective delirium management requires an interprofessional collaborative approach [40]. Therefore, future research should further explore the interprofessional team perspective to better understand how different healthcare professionals collaborate in delirium management, which could potentially improve clinical practice of delirium in palliative care.

Our research underscored that insufficient understanding of concept, symptoms and risk factors of delirium among healthcare professionals is a major obstacle, which may impede the early identification and prevention of delirium [41]. Studies have shown that hypoactive delirium, the most prevalent subtype in palliative care, is particularly challenging to identify without validated screening tools due to its subtle symptoms [42, 43]. Palliative care patients often face multiple concurrent delirium risk factors due to advanced disease progression, multiple organ dysfunction, and frequent exposure to iatrogenic risk factors (such as opioids, anticholinergics, and invasive procedures) [41, 44, 45]. This complex clinical picture makes delirium identification and assessment particularly challenging in palliative care settings, suggesting that addressing knowledge gaps alone may be insufficient. Moreover, the identified knowledge gaps in delirium management among nurses and medical assistants raise concerns about the quality-of-care delivery, as these professionals play crucial roles in early detection and ongoing monitoring of delirium [46]. These challenges underscore the need for not only enhanced delirium education and training programs that specifically address these knowledge deficits but also standardized assessment tools and clinical guidelines.

However, our review identified difficulties in applying delirium screening tools in palliative care settings. Insufficient understanding of the use of delirium assessment tools by medical personnel may be one of the reasons [47]. Moreover, previous studies show diverse delirium assessment tools in palliative care, with none fully meeting all patients’ needs across institutions, making their use complex [48, 49]. Poor accessibility and implementation of guidelines was also mentioned in the results of this study, which further underscores the need for a systematic approach to addressing the challenges in delirium screening. To mitigate the identified difficulties, a comprehensive strategy encompassing multifaceted interventions is recommended. Firstly, further research is crucial to develop targeted training programs that enhance healthcare professionals’ theoretical knowledge and practical proficiency in using delirium assessment tools. Secondly, it is crucial to provide healthcare professionals with a standardized but flexible tool selection and implementation framework that recognizes the unique needs of different patients in various palliative care settings. Additionally, creating more user-friendly, concise, and practical documents improves the accessibility of guidelines to facilitate easier understanding and application by healthcare professionals.

Our research findings also reveal that communication challenges and limited nursing involvement in home-based palliative care impeded delirium management, primarily due to restricted patient interaction [50, 51]. Given caregivers’ vital role in delirium care [52–54], evidence suggests that caregiver education and delirium identification toolkits can enhance collaboration and improve management [55, 56]. While FAM-CAM enables family caregiver assessments, professional verification remains essential [57]. Telemedicine allows real-time evaluations, timely care, and immediate guidance [58]. Thus, integrating telemedicine with FAM-CAM offers a key direction for real-time evaluation and intervention in home-based delirium management.

Analysis revealed that deficiencies at the system and organizational levels were the primary obstacles, consistent with previous research [59]. Within this domain, workload and time burden, and inadequate professional development and training were mentioned. To address these issues, increasing the number of healthcare professionals may reduce workloads and time burdens, but not enough to improve professional practice [60]. Literature suggests that multidisciplinary collaboration can improve clinical practice and healthcare outcomes [61]. Nevertheless, this review also identified inadequacies in inter-professional cooperation, which may be due to a lack of role recognition [62]. To improve this situation, it is necessary to clarify the responsibilities and roles of healthcare professionals in effectively preventing and managing delirium in palliative care, and develop corresponding role responsibility matrices based on the guiding principles. Additionally, cross-disciplinary education should be integrated into training programs, as it can improve the coordination and teamwork skills of healthcare professionals [61].

While our results identified perceived ethical dilemmas in healthcare teams in balancing effective delirium management with patient quality of life and willingness, these situations do not necessarily pose ethical challenges, as most countries allow goals of care and treatment plans to be discussed with designated substitute decision-makers when patients have fluctuating or lack decision-making capacity [63]. Being the people most in contact with death and continuously exposed to negative emotions such as distress, healthcare professionals often face emotional burdens, which can affect decision-making [64]. Effective education for behavioral change requires targeting and tailoring to specific contexts [65]. Therefore, future delirium education and training programs should emphasize not only these established decision-making frameworks to help healthcare teams better navigate such situations, but also address the emotional implications of decision-making, offering clear guidance for healthcare professionals dealing with the complex situational factors in palliative care.

The strengths and limitations of this systematic review

This mixed-methods systematic review offers a more comprehensive understanding of barriers to delirium management in specialist palliative care than single-method approaches. It encompasses studies across various palliative care settings, and diverse clinical context enhances the findings’ representativeness and generalizability. This review also has some potential limitations. All studies were conducted in English, and most of the studies were conducted in the UK and Australia, which may limit universality. Converting quantitative data into qualitative format through the JBI method can be useful for comprehensive analysis of research results, but may introduce explanatory bias. Despite most studies meeting high methodological standards, limitations were observed in two non-randomized studies with insufficient information for confounding factor control and three descriptive studies with potential biases in sampling strategies, representativeness, and response rates. These gaps may affect the reliability of their findings, highlighting the need to enhance methodological rigor, including transparent sampling techniques, and enhanced reporting practices.

Conclusion

For healthcare professionals, screening, identifying, and managing delirium in adults receiving palliative care remains a significant challenge. The review identified potential barriers at individual, operational, organizational, and contextual levels that may impact practice effectiveness, and highlighted the need to further explore interdisciplinary team perspectives. These obstacles highlighted the urgency of strengthening delirium training programs in palliative care, with a focus on symptom recognition, risk management, standardized delirium assessment tools and ethical decision-making. Simultaneously, implementing standardized yet flexible delirium assessment tools that recognize the unique needs of different patient populations, improving guideline accessibility through user-friendly documentation, and promoting interdisciplinary collaboration are crucial steps forward. By developing role responsibility matrices and exploring innovative approaches like telemedicine as a complementary approach to existing assessment for community-based delirium management, healthcare institutions can potentially enhance the quality of delirium care in palliative settings.

Electronic supplementary material

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Abbreviations

Nu DESC

Nursing Delirium Screening Scale

CAM

The Confusion Assessment Method

PRESS

Review of Electronic Search Strategies

Author contributions

FQ & DYY: Literature retrieval, Literature screening, Data extraction, Visualization, Writing–original draft preparation. HHS: Methodology, Supervision, Validation–reviewing and editing. THT: Methodology, Supervision, Validation – reviewing and editing, Critical revision of intellectual content. DJB: Conceptualization, Project administration, Supervision, Validation–reviewing and editing, Final approval of manuscript. All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

A full table of all screened articles primarily included in this mixed-methods systematic review can be obtained from the corresponding author.

Declarations

Ethics approval and consent to participate

not applicable.

Consent for publication

not applicable.

Competing interests

The authors declare no competing interests.