The moral dilemma of ICU nurses in end-of-life care: A meta-synthesis

Despite advancements in critical care medicine, moral challenges in end-of-life care persist. Approximately 80% of ICU deaths occur after decisions are made to limit or withdraw life-sustaining treatments. ICU nurses frequently experience moral dilemma when their professional judgment conflicts with clinical realities or institutional constraints. This meta-synthesis systematically integrated qualitative evidence to explore ICU nurses' experiences, alongside the sources and impacts of this dilemma. We conducted a comprehensive search of PubMed, Web of Science, Embase, CINAHL, CNKI, and Wanfang databases from inception to May 2025, ultimately including six qualitative studies from six countries. The analysis identified three core themes: (1) Sources of moral dilemmas; (2) Impacts of moral dilemmas on nurses; (3) Coping with moral dilemmas. The sources of moral dilemmas comprise five sub-themes: (1)Conflict between futile treatment and dignity preservation; (2) Infringement of patients' right to informed consent and autonomy; (3) Lack of nursing voice in clinical decision-making; (4) Insufficient family involvement in end-of-life care; and (5) Inadequate organizational support. The impact of moral dilemmas includes two sub-themes: (1) Distress experience and emotional exhaustion and (2) Professional burnout. These findings highlight the critical importance of recognizing that ICU nurses operate within a complex moral environment shaped by interwoven institutional structures, cultural norms, and relational dynamics. Therefore, providing effective support requires the implementation of systematic interventions, which should encompass comprehensive moral training, strong interdisciplinary collaboration, and the formulation of organizational policies that clearly prioritize nurses' autonomy and the maintenance of patients' dignity. This review highlights the urgent need to foster supportive moral environments globally to alleviate moral dilemma and improve the quality of end-of-life care in ICUs.