Barriers and facilitators to explore palliative care implementation in the ICU from tripartite perspectives: a qualitative systematic review and meta-aggregation

Abstract

Objective

To synthesise qualitative studies on the experiences and perceptions of palliative care in the intensive care unit (ICU) among healthcare providers, patients and families.

Design

Meta-aggregation.

Methods

Published and unpublished literature from January 2025 was retrieved from MEDLINE (via PubMed), EMBASE, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, PsycINFO, Google Scholar and four Chinese databases (CNKI, WANGFANG DATA, Vip and Sinomed). The qualitative research population includes ICU healthcare providers, patients or their families. The Phenomenon of Interest (I) was to uncover the barriers and facilitators that influenced the implementation of palliative care in the ICU by collecting the perceptions of ICU healthcare providers, patients and family members about palliative care. Two reviewers independently screened, appraised and extracted data using Joanna Briggs Institute (JBI) tools; findings were graded as unequivocal, credible or not supported. Meta-aggregation followed the JBI three-step procedure.

Results

The review incorporated 31 articles, yielding 534 findings with credibility ratings of ‘unequivocal’ or ‘credible’. The findings were categorised into 10 themes and summarised into 5 key findings: (1) emotional management, (2) communication, (3) models of care, (4) environmental factors and resource availability and (5) education.

Conclusion

The deployment of palliative care in the ICU is affected by elements concerning emotional management, communication practices, care models, resource allocation and staff training. Recommendations include enhancing multidisciplinary teamwork, improving emotional support and communication, optimising resource allocation and providing targeted training for healthcare professionals. Future research should focus on refining palliative care strategies tailored to different clinical environments.

PROSPERO registration number

CRD42025642572.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Tripartite perspective: integrates views of healthcare providers, patients and families for comprehensive insights.

• Extensive search strategy: covers multiple international and Chinese databases, ensuring broad literature coverage.

• Optimising care delivery: provides insights into improving palliative care across diverse resource settings and cultural contexts.

• Cultural applicability: findings may not fully apply to all cultures in the world.

Introduction

Palliative care is a strategy focusing on the needs of the patient that prioritises symptom management, pain relief and psychological and spiritual support for individuals with serious illnesses.¹ This model places an intense emphasis on respecting the preferences of patients, providing holistic care, along with striving to enhance overall quality of life.² As healthcare paradigms have evolved, palliative care has emerged as an indispensable component of modern medical practice, particularly in the context of irreversible diseases, offering a more compassionate and humane way of addressing patients’ needs.³

Palliative care is administered across diverse settings, and the challenges associated with its delivery differ between these environments. In comparison to general wards, intensive care unit (ICU) patients are often in life-threatening conditions, requiring palliative care to manage physical symptoms as well as their psychological and emotional demands.^{4 5} The high-pressure, fast-paced nature of the ICU further elevates the demands of providing palliative care, necessitating that healthcare providers possess enhanced professionalism and communication skills.⁶ Moreover, the employment of ICU palliative care is affected by elements including resource allocation and the emotional state of the families of patients.^{7 8}

Identifying the factors which facilitate and impede the employment of ICU palliative care is crucial for optimising nursing practice, enhancing patient satisfaction and improving health outcomes. However, the present application of palliative care in the ICU is not yet optimal. Research indicated that ICUs face significant challenges in integrating palliative care effectively, with issues of inadequate communication, insufficient training and the absence of clear policies contributing to inadequate outcomes.^{5 7} Given these challenges, it is essential to incorporate perspectives from healthcare providers, patients and relative families to identify both the enabling and obstructing factors within the ICU environment.⁵ A comprehensive analysis of these factors can provide insights for the efficacy of carrying out the ICU palliative care, thereby informing future research and clinical practice.⁵

Although numerous experts have employed quantitative studies and comprehensive reviews to promote palliative care implementation in ICU,⁹,¹¹ these studies have primarily focused on interventions and treatment outcomes. However, these research methods are unable to fully capture cognitive differences. Consequently, qualitative data are crucial in elucidating the experiences and demands of healthcare providers, patients, along with families in palliative care. Additionally, although there have been some systematic evaluations to elaborate on the factors associated with palliative care in the ICU, the analyses have not been comprehensive. For example, Aslakson et al’s findings were limited to traditional clinical indicators (length of stay, risk of death) and did not elaborate on the emotional, communication and cultural factors of the study population.¹² Meddick-Dyson et al’s study, while confirming that clinical resources and teamwork are key factors in the implementation of palliative care in the ICU, was based on a healthcare provider’s viewpoint and lacked an in-depth explanation of the patient’s and family’s experience.¹³ A more balanced and accurate awareness of the challenges and supporters to effective palliative care in the ICU would be achieved by capturing the diverse experiences and needs of all involved.

Therefore, this study implemented a qualitative meta-aggregation to conduct a comprehensive assessment and analysis of the difficulties and supporters to the efficient application of ICU palliative care based on diverse healthcare providers, patients and families. The research is projected to aid in advancing ICU palliative care, ultimately aiming to enhance life quality of patients.

Methods

Purposes and design

The purpose of the current investigation is to summarise the elements that impede and enhance the adoption of ICU palliative care. Through the integration of studies reported globally, it provides valuable insights to strengthen the effective employment of palliative care. The study protocol is registered with PROSPERO (CRD42025642572).¹⁴ The Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Enhancing Transparency in Reporting of Qualitative Research Reviews guidelines were applied in this study.¹⁵ These frameworks incorporate the in-depth viewpoints and practice of healthcare providers, patients and families regarding ICU palliative care. Based on the fact that the study’s findings do not relate to health outcomes, it was not registered with any review registry.

Search strategy

Published articles were retrieved based on databases of MEDLINE (via PubMed), EMBASE, CINAHL, Cochrane Library, Scopus, Web of Science, PsycINFO, Google Scholar and four Chinese databases (CNKI, Sinomed, VIP and WANGFANG DATA) in January 2025. Details of the remaining research strategies and their corresponding search results can be found in online supplemental appendix 1. Additionally, the bibliographies of eligible studies were hand-searched to supplement electronic database retrieval.

Selection criteria

The study’s inclusion criteria for this study were established according to the PICo framework, which consists of Participants (P), the Phenomenon of Interest (I) and the Context (Co).¹⁶ The participants (P) included healthcare providers, patients and families. Healthcare providers eligible for inclusion were those with more than 1-year experience working in an ICU or undergoing completed relevant internship training, regardless of the specific duration of their job or internship. Patients eligible for the study were those who were receiving, or expressing a desire to receive, palliative care or related interventions within the ICU, including, but not limited to, palliative care and life-extending treatments. Family members were defined as the patient’s immediate family or primary caregiver, such as a spouse, parent, child or primary guardian. For the Phenomenon of Interest (I), the study focused on the facilitators and challenges to palliative care as perceived by ICU healthcare providers, patients and families. The Context (Co) referred to studies conducted in the ICU. Only full-text qualitative studies in English and Chinese were considered for inclusion. Quantitative studies, reviews, conference abstracts and commentary articles were excluded. To ensure the comprehensiveness of the research, no time limitations were imposed on the studies included in this review.

Study screening and selection

Two researchers independently screened the literature by importing the retrieved articles from various databases into EndNote X9 reference management software. Duplicate titles were removed both automatically by the software and manually. The studies underwent a systematic examination of the abstracts and full texts to assess their alignment with predefined inclusion and exclusion criteria. Two reviewers independently evaluated titles/abstracts against PICo criteria; any record failing any PICo element was labelled ‘inconsistent’ and excluded. Discrepancies among reviewers were resolved through consensus-based deliberations, with unresolved issues escalated to third-party adjudication for final determination.

Quality appraisal

Two independent researchers evaluated the literature quality based on the qualitative research quality assessment criteria developed by JBI.¹⁷ The criteria consist of 10 items, each evaluated as ‘yes’, ‘no’ or ‘unclear’. Studies fulfilling all inclusion criteria were categorised as grade A, those partially satisfying the requirements were defined as grade B, and those that did not reach any criteria were assigned grade C. Only literature with grades other than C was included in this study, with studies receiving at least seven B ratings with a ‘yes’ response being included.

Data fetch

Two investigators independently conducted data fetch from eligible articles, following the qualitative data extraction form developed by the Centre for Evidence-Based Health Care at the Joanna Briggs Institute (JBI)¹⁷ in Australia. The form included key details such as the basic traits of the study and main discoveries, containing the first author, region, year of publication, recruitment and participant information, methods of data analysis and the phenomenon of interest.

Data synthesis

First, two researchers analysed the included studies and extracted the relevant content. The findings were graded based on the consistency level between the results and the supporting data, categorised as ‘unequivocal’ (findings are supported by solid evidence), ‘credible’ (supported by illustrations but with some uncertainty) or ‘not supported’ (lack of evidence support, such as ‘findings’ not corroborated by interviews).¹⁸ After dual-independent grading, 15 findings that lacked supporting data were excluded, thereby enhancing the reliability of the remaining 534 findings that entered meta-aggregation. Second, the two researchers reviewed the clear or reliable findings, along with their supporting examples and grouped similar findings into different categories. Finally, the aggregated results were further summarised and organised based on these categories.

Confidence of the synthesised findings

The quality of the aggregated results was assessed using the ConQual method, which assumes an initial high quality, with the final grade determined through downgrading based on reliability and credibility.¹⁹ Reliability was assessed based on items 2, 3, 4, 6 and 7 from the quality criteria of literature. No downgrade was applied if items 4 and 5 were rated ‘yes’; one level down if items 2 and 3 were rated ‘yes’; and two levels down if items 0 and 1 were rated ‘yes’. For the credibility assessment, if the combined results contained only ‘unequivocal’ findings, it maintained the original rating. The presence of ‘unequivocal’ and ‘credible’ findings triggered a one-level downgrade. Only ‘credible’ evidence warranted a two-level downgrade. Results containing ‘not supported’ evidence were subjected to a three-level downgrade, whereas exclusively ‘not supported’ findings incurred a four-level penalty. This hierarchical demotion system ensured methodological rigour in evidence quality assessment. Specific scoring details are respectively shown in tables1 2.

Table 1. Reliability scoring criteria.

Item	5	4	3	2	1	0
(2) Congruity between the research methodology and the research question or objectives	Y	Y	Y	Y	Y	N/U
(3) Congruity between the research methodology and the methods used to collect data	Y	Y	Y	Y	N/U	N/U
(4) Congruity between the research methodology and the representation and analysis of data	Y	Y	Y	N/U	N/U	N/U
(6) Locating the researcher culturally or theoretically	Y	Y	N/U	N/U	N/U	N/U
(7) Influence of the researcher on the research, and vice versa, is addressed	Y	N/U	N/U	N/U	N/U	N/U
Scoring criteria	0-level downgrade	0-level downgrade	1-level downgrade	1-level downgrade	2-level downgrade	2-level downgrade

‘0/1/2-level down-grade’ requires any 4–5/2–3/0–1 entries to be met (not limited to example combinations).

N/U, no/unclear (Joanna Briggs Institute quality appraisal); Y, yes.

Table 2. Credibility scoring criteria.

Composition of integrated findings	Download
All findings rated ‘Unequivocal’	0-level downgrade
Mix of ‘Unequivocal’ and ‘Credible’ findings	1-level downgrade
All findings rated ‘Credible’	2-level downgrade
Any ‘Not supported’ findings present alongside other ratings	3-level downgrade
All findings rated ‘Not supported’	4-level downgrade

Ethics statements

Ethical approval was not required because this study is a secondary analysis of publicly available literature and did not involve the collection of new data from human participants.

Patient and public involvement statement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Results

Literature search

The process of literature inclusion and exclusion is illustrated by figure 1. A preliminary search of both domestic and international databases, as well as grey literature, identified 4298 studies. After removing 1598 duplicates through both automated and manual processes, 2212 studies were excluded because titles/abstracts did not match inclusion criteria (PICo) ([1] population not ICU patients/families/staff; [2] intervention unrelated to palliative care; [3] study design not qualitative; [4] language other than English/Chinese; [5] conference abstract or review). An additional 432 conference abstracts were excluded, and the remaining studies underwent full-text re-screening. Ultimately, 31 studies were approved for permitting into the final analysis.

Figure 1. Flowchart of the review procedure.

Quality appraisal

Online supplemental appendix 2 presents quality assessment outcomes of the selected literature (34 articles in total). Among 31 articles,⁴,⁸²⁰ 9 were rated ‘Yes’ for both questions six and seven, 2 were rated ‘Unclear’ for question nine, and the remaining studies were rated ‘Yes’ for all other questions. The most frequently failed items were: item (6) (locating the researcher culturally or theoretically), which was marked ‘No’ in 22 studies (71%) and item (7) (influence of the researcher on the research, and vice versa), which also received a ‘No’ in 22 studies (71%). All other JBI items were rated ‘Yes’ in ≥90 % of studies. The remaining three articles were excluded due to low quality.⁴⁶,⁴⁸

Study traits

A total of 31 qualitative investigations carried out from 2007 to 2024 are ultimately analysed. The systematic review reveals all selected studies from multiple countries employed non-quantitative research methodologies. Participants primarily include healthcare providers working or practicing in the ICU, patients receiving treatment in the ICU and their accompanying family members, totalling 529 participants. Further supporting information is available in online supplemental appendix 3.

Meta-aggregation result

Among 549 original findings, 534 were retained for meta-aggregation: 523 were rated unequivocal (eg, Xie et al⁵ quoted a physician stating to emphasise lack of hospice training ‘Palliative care has not been discussed in either pre-employment training or academic conferences that focus on severe cases. Maybe patients with cancer are more suitable for palliative care than those who are critically ill’.) and 16 were rated credible (eg, Ozga et al⁷ reported ‘Noncompliance with the ICU employment standards [E2, E8, E9, E17, E13, E14, E16, E17, E18, E19, E20, E23, E24]’ was a barrier, because no participant explicitly described which standards were missed or how). 15 findings were excluded as unsupported due to insufficient evidence, primarily because they lacked direct participant data (eg, Nelson et al’s study²⁷ identified ‘Some [specialists] don’t think it’s in their scope or purview to have to have those conversations’, yet provided no direct interview excerpts to substantiate this claim).

The remaining 534 original findings were categorised into 10 groups, which were condensed into 5 key findings as shown in table 3 for the composite findings. These five final findings are presented in terms of both barriers and facilitators, with each factor described from the viewpoints of healthcare providers, patients and families. Further supporting information is available in online supplemental appendix 4.

Table 3. The synthesised findings.

Synthesised findings	Categories	Description of category	Number
Emotional management: psychological factors in palliative care	Emotional fatigue, fear, difficulty in accepting reality (barriers)	Emotional burnout of healthcare providers, patient isolation and fear and family emotionalism hinder communication	86 (84U, 2C)
	Emotional support mechanisms, counselling, emotional fulfilment (facilitators)	Hospitals establish emotional management mechanisms to provide emotional support to healthcare providers and psychological counselling to help patients and families reduce anxiety and stabilise their moods	15 (15U)
Communication: the key to realising patients’ wishes	Lack of understanding, cultural differences, lack of communication skills and medical information (barriers)	Healthcare providers’ reluctance, patients’ inability to communicate and family dissatisfaction with lack of medical information hinder effective communication	43 (41U 2C)
	Positive communication, determining appropriate treatment, developing the right mindset (facilitators)	Healthcare providers’ willingness to communicate and respect for patient preferences fosters trust, while patients express their desire to avoid pain and families benefit from receiving correct information to support decision-making	94 (94U)
Models of care: teamwork and a targeted approach	Lack of consensus, insufficient autonomy, variable disease progression, adherence to curative treatment (barriers)	Lack of uniform protocols on treatment modalities among multidisciplinary team members, nurses’ dependence on doctors without treatment rights, unpredictable alteration in the condition of patients and family reluctance to discontinue life-sustaining therapy	32 (32U)
	Need for team collaboration, nurse leadership, individualised treatment plans (facilitators)	The establishment of multidisciplinary teams creates a dedicated palliative care unit, empowering nurses to lead more targeted care and develop treatment plans based on patients’ and families’ preferences through family meetings	141 (141U)
Environmental factors and resource availability: the basis for palliative implementation	Noisy environment, lack of resources, poor policies (barriers)	Palliative care in the ICU is hindered by personnel shortages, limited resources, overcrowded environments and inadequate government policies	34 (24U 10C)
	Guidelines and development of visiting rights, dignified environment, follow-up care (facilitators)	Guidelines help regulate hospice care implementation, extend visiting rights and provide follow-up care, creating a calming environment that respects and upholds patients’ rights	29 (29U)
Education: long-term safeguards for palliative implementation	Cognitive bias, lack of planning, lack of systematic training (barriers)	Misconceptions about palliative care among healthcare providers, lack of detailed planning when implementing palliative care and insufficient training related to palliative care	46 (44U 2C)
	Experience, importance of training (facilitators)	Healthcare providers seek to increase their experience and improve their skills through training	14 (14U)

C, Credible; ICU, intensive care unit; U, Unequivocal.

Synthesised finding 1: emotional management – psychological factors in palliative care

The synthesis of results 1 underscores the pivotal role of emotional management in palliative care, highlighting both the challenges and facilitators involved. 13 studies revealed that healthcare providers often experience emotional exhaustion and psychological stress, due to prolonged exposure to high-pressure situations, particularly when caring for patients and grieving families.721 28 29 33,37 41 42 44 45 Additionally, six studies identified that patients often feel emotionally drained and fearful as their illness progresses and curative treatments are no longer effective.^{4 25 28 38 41 43} Furthermore, four studies reported that families often find it tough to face the truth of a patient’s imminent death.^{20 31 38 39} On a positive note, Mediani et al’s research suggested that the implementation of emotional support mechanisms can aid healthcare providers in coping with these emotional challenges, thereby significantly alleviating their psychological stress.²⁸ Moreover, four studies emphasised that palliative care provides healthcare providers with a sense of emotional fulfilment.^{28 36 43 44} In addition to offering psychological counselling, healthcare providers contribute to help patients and their families alleviate emotional distress. Four studies indicated that families, after receiving support from healthcare providers, were able to gradually stabilise their emotions and engage more actively in care decisions.^{20 24 31 38}

Synthesised finding 2: communication – the key to realising patients’ wishes

The synthesised results 2 highlight that communication is crucial for ensuring patients’ wishes are realised in palliative care, involving interactions between healthcare providers, patients and families. Barriers to effective communication were identified in 3.2% of studies, where healthcare providers were unaware of patients’ wishes and unable to resolve emotional conflicts with families.³² Additionally, 25.81% of studies noted that staff were hesitant to discuss the patient’s condition due to cultural differences or concerns about burdening patients and families, such as the ‘traditional filial piety’ of China and the ‘religious culture’ of countries such as Jordan.^{6 7 22 27 30 37 42} Two studies further highlighted that ICU patients often lacked the ability to communicate,^{25 31} while Mediani et al’s research pointed out that some awake patients were distressed by unintended remarks from healthcare providers.²⁸ Regarding family members, two studies found that they perceived a lack of communication with healthcare providers.^{24 31} Six studies indicated that families frequently felt inadequately informed or confused about the patient’s condition, which led to frustration and anger.^{7 24 31 32 38 45} Three studies revealed that family members were dissatisfied with the way individual healthcare providers communicated, resulting in a loss of trust in palliative care.^{24 31 38} Despite these barriers, positive aspects were also evident: 12.9% of studies found that healthcare providers respected and incorporated patients’ wishes,^{8 24 29 32} while 41.94% demonstrated that staff were willing to engage in open communication with families to build trust and reduce conflicts.68 22 23 25 27 32 34 35 41,^{43 45} For patients, three studies indicated that they valued the opportunity to communicate with healthcare providers, expressing their preference for pain-free palliative care.^{4 5 29} For families, five studies found that they desired more communication with healthcare providers to better understand the patient’s progress.^{20 24 31 38 39} Furthermore, 19.35% of studies reported that families came to appreciate the significance of palliative care through communication and believed it provided comfort to patients during their last moments of life.^{4 24 31 38 39} These efforts are essential in ensuring the effective implementation of palliative care.

Synthesised finding 3: models of care – teamwork and a targeted approach

The third synthesised finding emphasised that the care model is a vital element in palliative care, particularly the balance between teamwork and individualised support. In terms of challenges, seven studies reported a lack of consensus among multidisciplinary teams, which hindered the effective implementation of care plans.^{22 23 26 27 29 32 35} Additionally, 9.68% of studies highlighted that nurses lacked the autonomy to fully participate in nursing decisions, limiting their role in patient care.^{29 32 34 35 41 45} From the patient’s perspective, five studies noted that ICU patients, being highly variable and unpredictable, were often unable to communicate their feelings, which posed challenges to the delivery of palliative care.^{5 23 29 35 44} On the family side, 9.68% of studies observed that families frequently insisted on curative treatments and were reluctant to transition to palliative care.^{5 6 41} In terms of facilitators, 67.74% of studies found that healthcare providers who had greater autonomy were more proactive in implementing palliative care.56 8 20 21 23 25 28,^{30 32 35} Additionally, 38.71% of studies indicated that multidisciplinary teams were effective in promoting palliative care.⁵,721 22 26 27 29 34 36 37 43 Two studies underscored the importance of leading nurses in identifying and implementing palliative care more efficiently and accurately.^{6 27} Furthermore, two studies found that healthcare providers helped patients and corresponding families gain a proper acknowledgement of palliative care, often through family meetings.^{30 36} Finally, two studies highlighted that families expressed a wish for spending more time attending to patients.^{31 38}

Synthesised finding 4: environmental factors and resource availability – the basis for palliative implementation

This finding highlighted that the environment equally influences the implementation of palliative care. 12 studies indicated that healthcare providers believed that factors such as staff shortages, limited resources, inadequate space and noisy, crowded environments all hindered the efficient employment of palliative care in the ICU.⁵,⁸²⁶ Additionally, 12.9% of studies noted the absence of government policies specifically addressing palliative care.^{7 30 33 42} Gutierrez’s study also mentioned the inconvenience caused by the lack of adequate policies in some settings.³⁸ However, 9.68% of studies reported that certain countries, such as India, have palliative care laws and guidelines in place.^{8 21 33} The healthcare providers in Iyer et al’s study suggested that ICU visitation rights should be liberalised to improve patient and family well-being.⁸ Two studies recommended that hospitals create more conducive environmental conditions to support palliative care.^{28 30} From the patient perspective, three studies found that patients expressed a desire to be accompanied by family members in the ICU to alleviate anxiety,^{4 25 38} while four studies highlighted that patients wanted the ICU environment to preserve their dignity,^{4 5 38 44} such as by drawing curtains during treatment. For family members, three studies noted that they would appreciate follow-up care from the ICU staff,^{7 38 39} as this could provide a buffer and help them prepare for the difficult news.

Synthesised finding 5: education – long-term safeguards for palliative implementation

Education functions in the effective delivery of hospice care by enhancing healthcare providers’ professional skills, ensuring higher-quality care and fostering greater patient and family support and understanding. In terms of challenges, 38.71% of studies highlighted misconceptions about palliative care, particularly the conflict between the ICU environment and the traditional focus on curing disease.^{6 8 20 22 23 27 29 32 33 42 45} Brook’s study (a) noted that healthcare providers often lacked the practice of developing comprehensive care plans.²² Six studies reported that healthcare providers did not receive systematic training on the philosophy and practices of palliative care.⁵,^{737 41 42} However, six studies suggested that experience could help healthcare providers shift their perspectives on palliative care, enabling them to handle complex care situations more effectively.^{6 21 23 35 44 45} Two studies emphasised the significance of delivering palliative care training for healthcare providers, as it can significantly improve the implementation of palliative care.^{22 27}

ConQual summary

Table 4 presents the ConQual summary based on the synthesised findings, which outlines the dependability, credibility and overall ConQual scores for various aspects of palliative care. Overall, the dependability is moderate, while the credibility tends to range from moderate to high. However, the ConQual scores are generally low, particularly in areas related to emotional management, communication, environment and resources and education. This indicates that, while the findings are generally dependable, the strength of the evidence, in terms of quality, may be insufficient.

Table 4. ConQual summary.

Synthesised findings	Dependability	Credibility	ConQual score
Emotional management: psychological factors in palliative care	M (downgrade 1 level)	M (downgrade 1 level)	L
Communication: the key to realising patients’ wishes	M (downgrade 1 level)	M (downgrade 1 level)	L
Models of care: teamwork and targeted approach	M (downgrade 1 level)	H	M
Environmental factors and resource availability: the basis for palliative implementation	M (downgrade 1 level)	M (downgrade 1 level)	L
Education: long-term safeguards for palliative implementation	M (downgrade 1 level)	M (downgrade 1 level)	L

H, high; L, low; M, moderate.

Discussion

The study identified five key aspects that affect the employment of ICU palliative care. Difficulties include emotional and communication challenges, insufficient teamwork, limited resources and inadequate educational support, all of which contribute to distress and misconceptions among healthcare providers, patients and families. However, by addressing these challenges with targeted interventions, facilitators such as emotional support, information sharing, teamwork, personalised care, optimal resource allocation and systematic training can be strengthened. These improvements can enhance both the palliative care quality and the emotional well-being of healthcare providers, patients and families.

Consistent with Brighton’s (2016) findings,⁴⁹ this study also identifies poor conversation between doctors and patients as a significant obstruction for ICU palliative care. A recent systematic review by Park et al⁵⁰ catalogued technology-driven communication interventions for ICU families, yet it centred on video calls and clinician training without examining how family cultural expectations or emotional states shape these interactions. So it is necessary to supplement and solve communication problems between healthcare providers, patients and their families by integrating the perspectives of the three groups. The intense environment of the ICU makes it difficult for healthcare providers to interact effectively with patients and families.²⁶,^{2830 33 35} The investigation highlights the significance of interactive communication, where both patients and families can actively engage with healthcare providers,^{5 38} and doctors encourage family meetings.^{6 8 22} Such practices help alleviate communication barriers and promote the caring quality. By involving families, healthcare providers can gain a clearer understanding of patients’ needs and adjust care plans to align with palliative goals.^{27 31} While some families may be hesitant to consider hospice care for various reasons, the study suggests that appropriate communication from healthcare providers can help both patients and families recognise palliative care values and consider forgoing curative treatments.^{4 24 31 38 39 51}

Although previous investigations have determined the consequence of multidisciplinary teamwork in palliative care, most have predominantly focused on the healthcare providers’ perspective,⁵²,⁵⁴ limiting the comprehensive evaluation of teamwork. This study reveals the essential role of multidisciplinary teamwork in ICU palliative care, highlighting the necessity of interaction and collaboration among healthcare providers. Additionally, actively listening to the voices of patients and their relatives can enhance the development of multidisciplinary teams in clinical practice.^{7 37} The findings emphasise the need for effective communication and collaboration among team members, offering both practical guidance and theoretical support for future implementation. Furthermore, this study reveals that, despite the acknowledged importance of multidisciplinary teamwork and communication, existing models often exclude patients and families, with decision-making typically dominated by healthcare providers—especially doctors. For example, a systematic review by Michalsen et al⁵⁵ comprehensively examined the functioning of multidisciplinary teams in the ICU setting; however, the review focused primarily on interprofessional collaboration between clinicians and neglected the critical role of patient and family involvement in the decision-making process. This ‘paternalistic’ approach limits their involvement in care decisions. Combining the voices of patients and families with those of clinicians, thereby replacing the traditional paternalistic paradigm with a truly collaborative model is necessary, and palliative care decisions need to be made jointly by all stakeholders. Future practice should focus on creating a more inclusive model, enabling patients, families and even nurses who lack autonomy to actively participate, thereby shifting from a ‘paternalistic’ to a ‘collaborative’ approach in decision-making. Additionally, a feedback mechanism should be integrated into the care plan to regularly collect and incorporate the opinions of patients and families, ensuring the team’s care plan aligns with their shared expectations.⁸ Hospitals could also consider selecting patient and family representatives to join the multidisciplinary team, providing healthcare providers with a deeper understanding of patients’ preferences and needs, and optimising palliative care implementation.⁵⁶

Given the scarce empirical data on the prevalence and manifestations of emotional distress within therapeutic alliances during palliative care, coupled with insufficient evidence on when such distress occurs, this study systematically investigates and validates the epidemiology of this phenomenon from three critical dimensions.^{20 36} The findings reveal that healthcare providers experience emotional distress during the implementation of palliative care, and that the emotional responses of patients and their relatives significantly influence the effectiveness of the care process.^{7 37 42 44} While a systematic review by Pereira et al (2021)⁵⁷ confirmed the high prevalence of emotional distress among palliative care providers, it did not explore practical management strategies. To address these emotional challenges, the study suggests that hospitals establish mechanisms for targeted emotional management to support healthcare providers’ emotional well-being.²⁸ Additionally, Doherty’s study indicates that family meetings, along with the compassion and empathy demonstrated by healthcare providers, can help alleviate emotional distress among patients and their families.⁵⁸

In contrast to previous research,⁵⁹ which suggested that hospitals are generally able to provide sufficient material resources to conduct the implementation of palliative care, this investigation finds that some departments face funding shortages.⁸ This discrepancy may be attributed to variations in the allocation of palliative resources across hospitals and regions, as well as differences in how hospital management prioritises palliative care. Therefore, optimising the allocation of resources for palliative care is crucial, particularly through the guidance of policies and social support mechanisms.⁶⁰ Additionally, this study highlights that economic factors and unequal resource distribution are key barriers preventing some families from accessing palliative care.³⁸ While some studies have addressed the issue of resource allocation,^{61 62} few have examined how to optimise this allocation within different economic contexts. Future research should explore how to guarantee equitable acquisition to quality palliative care for all families through rational resource distribution and innovative financing models, tailored to diverse economic contexts.⁶³

Education and training serve as an important element in the implementation of hospice care; however, fewer studies have systematically examined their impact on palliative care within the ICU setting. This study observes that ICU medical staff are eager to learn about hospice care and seek to enhance their competence and experience through education and training.^{6 23 27 35} To address the issue of some medical staff not recognising the value of hospice-related training, Saft’s study suggests improving the relevance and practicality of hospice training by incorporating tools that align with the specific needs of the ICU environment. This approach would enhance the applicability and operational effectiveness of the training content.⁶⁴ Additionally, Anderson’s study highlights that increasing the interactivity of training can enable medical staff to personally experience and understand the value of palliative care, thus fostering greater recognition and participation.⁶⁵

To our knowledge, this study represents the first comprehensive examination of ICU palliative care integrating multidimensional perspectives of healthcare providers, patients and families. By incorporating the views of these three groups, the study reveals critical determinants shaping palliative care in the ICU and proposes actionable strategies for its enhancement. Additionally, it provides novel insights into optimising care, particularly in dimensions of emotional support, communication and resource allocation, offering a valuable foundation for future research.

Merit and demerit of this study

A bright spot of this investigation, in comparison to previous systematic reviews, lies in its concentration on the tripartite dimension of healthcare workers, patients and families in the ICU, offering a multidimensional exploration of their viewpoints and experiences of palliative care. By integrating these perspectives, the study not only identifies multidimensional factors affecting the implementation of palliative care but also emphasises critical issues related to emotional management and communication, providing novel insights for future nursing practice. Furthermore, the study ensured rigour and objectivity in incorporating the views of different groups through frequent team discussions and thorough analyses of the original research. However, several limitations of this study need to be recognised. First, the findings may not be fully applicable to Asian cultures since most studies were carried out in Western countries, particularly in relation to cultural differences, communication styles and care models. Second, although we incorporated the perspectives of healthcare providers, patients and family members, studies that include all three groups remain scarce, meaning that the unique views of some patients and family members may not have been fully captured. Lastly, the ConQual score for this study was moderate. While this score reflects the study quality, the variability of study quality may have influenced the reliability of the final results.

Conclusions

This study examined the challenges and facilitators to the implementation of ICU palliative care by analysing the perspectives of healthcare providers, patients and families. The results reveal that the effectiveness of palliative care is influenced by factors such as emotional management, communication styles, care models, resource allocation and education and training. These factors collectively determine the success of palliative care initiatives. Based on these insights, it is recommended to strengthen collaboration within multidisciplinary teams, prioritise emotional support and effective communication, optimise resource allocation and enhance palliative care training for healthcare providers. Future research should further investigate how to optimise the administration of palliative care across different environments and cultural contexts, with the aim of promoting its broader application.

Data availability statement

No data are available.