Introduction
Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Tunisia, United Arab Emirates, Palestine, and Yemen. |
Research question
Methods
Study eligibility criteria
Information sources and search strategy
Study selection process
Data extraction
First author/ year Country Objective | Population and Setting | Design and sample | Measurement tool | Findings | Conclusions |
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Mani (2017) Country: Saudi Arabia Objective: To explore nurses’ perceptions of obstacles to the provision of end-of-life care in the intensive care unit (ICU) in Saudi Arabia. | Conducted in a 936 bed specialist hospital in Riyadh between March and April 2015 There were 129 adult ICU beds in 6 specialist ICUs, including medical, hematological, oncological, surgical, and cardiac. All nurses working in ICU were eligible for the study. | Quantitative cross-sectional design Convenience sample of 77 ICU nurses | NSCCNR-EOLC Questionnaire Measures reported intensity and frequency of 29 obstacle items on a Likert scale ranging from 0–5. Intensity: 0 = least intense; 5 = most intense. Frequency: 0 = never occurs; 5 = always occurs. Open-ended questions: additional information on obstacles; aspects of care they would change; other comments. | Response rate was 62% (87/140). 10 incomplete responses were excluded. The mean score for each intensity items was calculated. Scores ranged from 1.27 to 4.26. The four highest obstacle intensity items were related to family issues, including Families not accepting what the physician is telling them about the patient’s poor prognosis. (4.26), The nurse having to deal with angry family members. (4.13) and family and friends who continually call the nurse wanting an update on the patient’s condition rather than calling the designated family member for information (4.06). These obstacles were also ranked in the top six for frequency | The major barriers were related to communication with and caring for patients’ families. Patient’s family, physicians with different opinions, cultural differences and language barriers were also highlighted. Nurses also reported the need for educational awareness and involvement of family in end-of-life care and futile care. |
Almansour (2019) Country: Jordan Objective: To determine perceptions of Jordanian critical care staff about intensity and frequency of obstacles and facilitators to end-of-life care. | Conducted in two teaching hospitals and in five critical care units. The hospitals have western style health care. Critical care staff were eligible if they were involved in providing care for dying patients and employed in the units at the time of the study. | Quantitative Cross -sectional design Convenience sample of 104 ICU staff (76 nurses + 28 physicians) for Obstacles survey 76 ICU nurses for facilitators survey | NSCCNR-EoLC Questionnaire The first section uses a 5-point Likert scale to measure perceptions of intensity of 29 obstacles to EOL care ranging from 0 (not an obstacle) to 5 (an extremely large obstacle) and the frequency of their occurrence, ranging from 0 (never occurs) to 5 (always occurs). The second section uses a 5-point Likert scale to access perceptions about the intensity of 24 facilitators to EOL care, ranging from 0 (not a help) to 5 (extremely large) and the frequency of occurrence, ranging from 0 (never occurs) to 5 (always occurs). | The overall response rate was 72.7% (n = 104/143). 76 nurses (69.1%) and 28 physicians (84.5%) responded. Nurses and physicians perceived that the most intense obstacle to EOL care was: “family members not understanding what life-saving measures really mean” (Nurses: M = 4.12; Physicians: M = 3.92), then “clinicians who are evasive and avoid having conversations with family members” (Nurses: M = 3.71; Physicians: M = 3.46). The most intense facilitator to EOL care perceived by nurses was “having family members accept that the patient is dying” (M = 4.12). | Nurses and physicians agreed that the highest scoring obstacles were related to family members and the poor design of critical care units. Other highly scoring obstacles related to clinicians’ behaviours, characteristics and attitudes. Nurses perceived the highest scoring facilitator was related to family members and then the physicians practice/agreement about the care. |
Attia (2013) Egypt Questions: Which barriers to providing EOL care to critically ill patients do critical care nurses perceive as the most intense? Which supportive behaviors to providing EOL care to critically ill patients do critical care nurses perceive of great help? | The study was conducted in four ICUs at Mansoura University Hospitals, Egypt, namely the oncology ICU, the coronary care unit, the hepatic ICU, and the surgical ICU. | Quantitative Cross-sectional design Convenience sample of 70 ICU nurses | The instrument adapted from NSCCNR-EOLC and translated into Arabic. 25 barrier items and 19 possible help behaviors. A 4-point Likert-type scale ranging from 1 = not a barriers/help to 4 = a great barrier/help. | Response rate 100%. The response to each items in the survey was calculated in percentage. The top items reported as severe barriers were associated with issues related to the ICU environment such as nurses’ heavy workload (81.4%), the poor ICU design (67.1%), and the liberal unit visiting hours (51.4%). Some items were related to patients’ family such as family members who do not understand the meaning of life-saving measures (65.7%) and family who continually call the nurse for updated information on the patient’s condition (62.9%). The highest supportive behaviors were nurses’ support involved good communication between physicians and nurses caring for the dying patient (94.3%), nurses drawing on their own previous experiences (82.9%), and supporting each other after the death of their patients (75.7%) | Barriers to providing EOL care were mainly related to intensive care environment, family members, followed by nurses’ knowledge and skills, physicians’ attitudes and treatment policy. However, the highest possible help to providing EOL care were nurses’ support and family-centered care, and families’ support. |
Author/ Year Country Objective | Population and setting | Design and sample | Findings | Conclusions |
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Al Mutair (2020) Saudi Arabi Objective: To identify the needs, beliefs, and practices of Muslim family members during end-of-life care for a family member in the intensive care unit (ICU) in Saudi Arabia. | Conducted in the ICU of a 320-bed tertiary referral hospital in Dahran city in Saudi Arabia. The ICU has 36 beds including 14 neonatal beds, four adult post-cardiac surgery beds, eight coronary care beds, and 10 general adult ICU beds. However, only family members of adult patients were interviewed. | Qualitative a phenomenological study In-depth interviews conducted with 10 Family members of dying patient in ICU between September 2016 and March 2017. | The four major themes were: (a) the spirituality of death, (b) family’s need for information, (c) being there for enough time, and (d) having good space at bedside. | Participants placed high value on religious practices such as prayer, and appreciated when these practices could be accommodated in the ICU. They also detailed their need for frequent communication about the patient condition. |
O’Neill (2017) Bahrain Objective: To explore nurses’ care practices at the end of life, with the objective of describing and identifying end of life care practices that nurses contribute to, with an emphasis on culture, religious experiences and professional identity. | It was conducted in the two ICUs of two hospitals that are the main providers of acute care. | Qualitative -Grounded theory Semi-structured in-depth interviews with 10 ICU nurses (five from each ICU). | A core category, Death Avoidance Talk, emerged. This was supported by two major categories: (1) order-oriented (medically directed) care: nurses were consulted by medical staff but not involved in decisions; and (2) signalling death and shifting the focus of care to family members. The organisation was hierarchical, with nurses deferring to doctors in end-of-life discussions with families. Yet medical staff were reluctant to speak plainly about death with families. Consequently, communication was unclear, treatments prolonged, and death sometimes unexpected by families. Nevertheless, there were feelings of respect and compassion towards the families. | Despite the avoidance of death talk and nurses’ lack of professional autonomy, they created awareness that death was imminent to family members and ensured that end of life care was given in a culturally sensitive manner and aligned to Islamic values. Of all the nurses interviewed, none had received any specialist education in ethics or palliative care. Specialist education and training is needed. |
Abu-El-Noor (2016) Palestine Objective: to examine how Palestinian nurses working in intensive care units (ICUs) understand spirituality and the provision of spiritual care at the end of life. | It was conducted at the two major hospitals in Gaza Strip, Palestine. The first hospital had 740 beds, of which 12 were ICU beds, and 24 ICU nurses. The second hospital had 240 beds including 12 ICU beds and a total of 18 ICU nurses. Gaza Strip has five ICUs with a total of 39 beds and 89 ICU nurses. | Qualitative Semi-structured in-depth interviews 13 ICU nurses | The following themes were identified: meaning of spirituality and spiritual care, identifying spiritual needs, and taking actions to meet spiritual needs. Spirituality was mostly thought of as expressing Islamic religious needs and practices. Spiritual needs were identified by talking with family members (and sometimes patients) and by assessing how close patients were to death. Actions included shifting the goals of care to comforting; allowing more visiting; reciting the Quran; enabling prayer. | Most of the spiritual care provided was based on religious beliefs and practices, thus illustrating the importance of the role of religion in providing healthcare. Nurses used both communication and observation to identify spiritual needs of patients and provide relevant spiritual care. It was recommended to increase the emphasis on the provision of spiritual care for all patients. |
Borhani (2014) Iran Objective: to explore intensive care nurses’ perspectives of the end-of-life care in an Islamic context in South-east of Iran | It was conducted in three ICUs at an Iranian teaching hospital affiliated to Kerman University. | Qualitative semi-structured interview 12 ICU nurses | Four major categories emerged from analysis of the interviews: commitment to care, awareness of dying patients, caring relationships, and dealing with barriers and ethical issues. The ICU nurses emphasis on creating a spiritual caring environment to enable patients, families and even nurses to achieve a spiritual comfort. Physical care of dying patients may not be useful in their cure but is a prerequisite of spiritual care causing families and nurses to become satisfied. Nursing thinking is restoration and resuscitation, and futile care is prohibited in nursing on the care of people in any conditions and times. Care is never futile, but medical interventions sometimes are. | The first category commitment to care, was emphasized and appeared dominant in all interviews. It was concluded that emphasis on creating a spiritual caring environment is needed to enable patients, families and even nurses to achieve a spiritual comfort. |
Hamdan Alshehri (2021) Saudi Arabia Objective: to explore the association of organisational structures when integrating palliative care in intensive care units. | The data were collected by conducting interviews between April and July 2019, at four Ministry of Health hospitals in Riyadh, Saudi Arabia; in two tertiary referral specialist hospitals and two secondary general hospitals. | Qualitative descriptive/ in-depth interviews 15 managers and 36 health care professionals working in intensive care | Three themes were identified: Do not resuscitate policy as a gateway to palliative care, facilitating family members to enable participation and support and barriers for palliative care in intensive care unit as a result of intensive care organisation. Both managers and health care professionals working closely with patients in ICU pointed to the organisational structures as a major block in integrating a palliative care approach into intensive care situations. The lack of palliative care policy in intensive care opened up spaces in which moral dilemmas were confronted including do not resuscitate policies and practices and especially those dilemmas related to personal beliefs influenced by religion and culture. This may create barriers for the integration of palliative care in ICU. | The findings indicate the need for specific palliative care policies and implementation strategies tailored according to practice needs. |
Alasiry (2012) Saudi Arabia Objective: to explore the nurses’ experiences of providing palliative care for critically ill patients in an intensive care unit in Saudi Arabia. | intensive care unit in Saudi Arabia, it included Medical- Surgical ICU and long-term ICU. | Qualitative, semi-structured interview with 9 ICU nurses | The study highlights the important aspects of palliative care e.g. symptoms control, communication, team work and family support Six themes were identified: Care in the ICU is challenging; Collaborative work to achieve patient’s needs; Caring as a holistic approach; experiencing language as a support; experiencing language as a barrier; and Family-patient centered care and support. The majority of nurses in the study are non-Arabic speakers and they found that language is a barrier to communicate with a patient and family. However, different protocols was available to standardized care to deal with different symptoms, in addition to having competencies that keep them updated to achieve maximum patient care. | Communication was a barrier when non-Arabic speaking nurses provide palliative care for critically ill patients and their families. Therefore, the patient and family’s involvement and the spiritual care appears insufficient in this ICU. |
Study assessment process
Data synthesis
Results
Study selection
Study characteristics
Methodological quality
Author/ year | 1 Were the criteria for inclusion in the sample clearly defined? | 2 Were the study subjects and the setting described in detail? | 3 Was the exposure measured in a valid and reliable way? | 4 Were objective, standard criteria used for measurement of the condition? | 5 Were confounding factors identified? | 6 Were strategies to deal with confounding factors stated? | 7 Were the outcomes measured in a valid and reliable way? | 8 Was appropriate statistical analysis used? | Score |
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[46] | Yes | Yes | Yes | Not clear | NA | NA | Yes | Yes | 5 |
[47] | Yes | Yes | Yes | Not clear | NA | NA | Yes | Yes | 5 |
[48] | Yes | Yes | Yes | Not clear | NA | NA | Yes | Yes . | 5 |
Author/ year | 1 Is there congruity between the stated philosophical perspective and the research methodology? | 2 Is there congruity between the research methodology and the research question or objectives? | 3 Is there congruity between the research methodology and the methods used to collect data? | 4 Is there congruity between the research methodology and the representation and analysis of data? | 5 Is there congruity between the research methodology and the interpretation of results? | 6 Is there a statement locating the researcher culturally or theoretically? | 7 Is the influence of the researcher on the research, and vice- versa, addressed? | 8 Are participants, and their voices, adequately represented? | 9 Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body? | 10 Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data? | Score |
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[40] | Yes | Yes | Yes | Yes . | Yes | Yes . | No | Yes | Yes | Yes | 9 |
[41] | Yes | Yes | Yes | Yes | Yes | not clear . | No | Yes | Yes | Yes . | 8 |
[42] | Yes | Yes | Yes | Yes | Yes | not clear . | No | Yes | Yes | Yes | 8 |
[43] | Yes | Yes | Yes | Yes | Yes | Not clear | No | Yes | Yes | Yes | 8 |
[44] | Yes | Yes | Yes | Yes | Yes | Yes | Not clear | Yes | Yes | Yes | 8 |
[45] | Yes | Yes | Yes | Yes | Yes | Not clear | Not clear | Yes | Yes | Yes | 8 |
Main objectives of the studies
Study populations
Cultural context
End-of-life care challenges and supportive behaviours
Organisational structure and management
(Mis)understanding of end-of life care
Spirituality and religious practices for the dying
Communication about EOL care
Impact of the ICU environment
Discussion
Strengths and limitations
Conclusion and recommendations
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Organisations should agree and make available suitable policies and guidance to provide a supportive framework for EOL care and reduce uncertainty and ambiguity for ICU staff.
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ICU staff should have access to appropriate education and training to promote interprofessional collaboration, and effective engagement with patients and their families in relation to EOL care.
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Where possible a named family member should be identified as the key communicator for the family and a member of ICU staff be similarly identified, with the aim of understanding the needs and perspectives of family members, avoiding misunderstanding, and effectively communicating goals of care, changes in prognosis, and reasons for treatment decisions.
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The value of spiritual and religious care should be recognized by ICU staff and end-of-life care delivered in a culturally sensitive manner and, where appropriate to the patient and family, aligned to Islamic and Arabic values.
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Where ICU staff are not confident in local languages, the organisation should make interpreters available to facilitate discussion of EOL decisions with the patient and family.
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The limitations of the ICU environment should be considered when the patient is nearing the end of life, with consideration given to longer and more flexible visiting hours, and providing privacy at the patient’s bedside.