End of life in the ICU: A scoping review of factors associated with moral distress in critical care nurses

Abstract

BACKGROUND: Moral distress is common among critical care nurses providing end-of-life (EOL) care, yet contributing factors are not fully synthesized. PURPOSE: To summarize the literature on factors influencing moral distress in adult ICU nurses delivering EOL care. METHODS: A scoping review of moral distress in adult ICU nurses providing EOL care, published 1984 to 2025, was conducted across five databases. Data on study design and findings were extracted and thematically analyzed. Study quality was assessed using the Mixed Methods Appraisal Tool. DISCUSSION: Moral distress among ICU nurses in EOL care stems from structural, interpersonal, and organizational factors. Key themes include hierarchical power that silences nurses, emotionally charged nurse-family relationships, systemic barriers, and the role of professional development and empowerment in building resilience. The findings suggest shifting focus from individual resilience to organizational and interprofessional strategies targeting root causes. Literature highlights interprofessional discord over nonbeneficial care, inconsistent palliative care integration, and the importance of professional growth in managing moral distress. CONCLUSION: Multi-level factors drive moral distress. Structured training, clear protocols, and supportive policies are essential to support nurses and optimize EOL care.