Types of studies and inclusion criteria

Original studies with qualitative, quantitative, and mixed approaches published between January 2018 and January 2024 were included. Results were limited to Spanish and English, as these contain the largest number of relevant scientific publications on the topic. Reviews and gray literature were not considered due to the lack of a rigorous peer-review process, which is essential to fulfill the objective of this review: to provide reliable evidence to serve as a basis for future research.

Only articles from primary sources that demonstrated the role of nursing staff in palliative sedation management, whether in the adult or pediatric population, were considered. The exclusion criteria applied were articles with restricted access, to ensure the availability and accessibility of the results; previous reviews or studies without primary data (e.g., expert opinions without empirical analysis); undergraduate theses; and studies focused exclusively on pregnant women, as they do not correspond to the focus of the present review.

Search strategy

The search was conducted in four databases recognized for their robustness in the biomedical field: MEDLINE (via PubMed), EMBASE, Web of Science, and Scopus. The search equation used was: (palliative sedation AND nursing AND palliative care AND attitude), applied in both English and Spanish.

The search period was limited to January 1, 2018, and January 1, 2024, yielding a total of 191 records. The previously defined inclusion and exclusion criteria were then applied to these records.

Selecting sources of evidence

Once the results were obtained, technological tools were used for reference management and article filtering. First, all records were uploaded to the Rayyan platform, which allowed for automatic elimination of duplicates. Subsequently, two researchers independently selected studies in three phases: title reading, abstract review, and full reading of the text. Any discrepancies were resolved by consensus.

To ensure methodological rigor, the report was prepared following the recommendations of the PRISMA Extension for Scoping Reviews (PRISMA-ScR). The results of the search and selection process will be presented in detail using the PRISMA-ScR flowchart (Figure 1). ¹²

Data extraction

Data extraction was performed independently by two researchers, who thoroughly reviewed each of the included articles. The Joanna Briggs Institute (JBI) critical appraisal tools were used to assess the methodological quality of the studies.^8,10 The level of evidence in the literature was assessed by administering the Oxford Centre for Evidence-Based Medicine (OCEBM) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) scales.

The information was organized using a matrix designed in Microsoft Excel, which included the following data: article title, authors, source or journal of publication, country, year, methodology, original language, level of evidence, population or participants, study context, results, emerging categories, and additional relevant information. This systematization allowed for structured organization and comparison of the findings. Additionally, the included articles were archived and managed through the Mendeley Data platform, which facilitated the storage, access, and traceability of sources.

Criteria of rigor and selection of articles

To ensure the quality and methodological rigor of the selection process, recognized international guidelines were applied. The COREQ checklist was used to evaluate 12 qualitative studies, while the STROBE checklist was applied to 3 observational studies. These tools allowed us to assess the transparency, internal consistency, and validity of the included studies, thus ensuring the robustness of the findings presented in this review.

Figure 1: Flowchart of the study inclusion process, prepared according to the PRISMA-ScR guidelines and adapted from the original format. ¹²  

Specific knowledge on the management of palliative sedation

The studies included in this review show that nursing professionals have varying levels of knowledge about palliative sedation, influenced by their training, experience, and the setting of care (hospital or home). In the hospital setting, nurses tend to report greater familiarity with standardized protocols, while in the home setting, they face uncertainty due to a lack of clear practice guidelines and resources.

In the hospital setting, studies such as Mengual et al. ¹³ found that primary care nurses in Spain have limited knowledge of palliative care and lack specific training in sedation, which limits their confidence in hospital management. Other authors, meanwhile, highlight that in hospital palliative care wards, nurses apply protocol-based practices, displaying positive attitudes toward sedation as a tool to relieve suffering, albeit with some reservations due to ethical considerations⁴ they point out that hospital specialists use low doses of sedative medications for comfort, reflecting a conservative attitude toward deep sedation. ⁽¹⁵

On the other hand, in the home setting, nurses are described as feeling like they are “flying blind” in home palliative care due to the lack of clear guidelines for its practice and the difficulty in adjusting the sedation dose, which generates attitudes of insecurity and frustration.¹⁴ Similarly, Grüne et al. ¹⁹⁾ note that in nursing homes and hospitals, nurses face logistical and communication challenges with physicians, but in the home setting, although there is a greater level of autonomy, there is less support and guidance.

Nursing expertise regarding palliative sedation management varies between hospital and home settings. In the hospital setting, nurses tend to follow standardized protocols, such as those developed by the European Association for Palliative Care, prioritizing the use of low doses of sedatives with midazolam to ensure patient comfort without inducing deep sedation.^15,27 These protocols are applied under strict criteria, such as refractory suffering and limited life expectancy, and usually have multidisciplinary support. ^4,20 In contrast, in the home setting, practices are more flexible due to logistical challenges such as a lack of resources and 24/7 availability. In this context, nurses adapt doses according to patient response, relying more on their clinical experience than on formal guidelines; a situation that leads them to rely more on their clinical judgment, which can increase stress and variability in practices.^15,19

Factors associated with nurses’ beliefs, values, and perceptions

The authors agree that nursing professionals’ beliefs, values, and perceptions about palliative sedation are shaped by cultural, ethical, and personal factors, with differences between hospital and home settings. Attitudes range from acceptance to reluctance, influenced by the perception of sedation as an act of care or as an intervention that accelerates death.

In the hospital setting, Vieille et al. ¹⁷ found that nursing staff perceived sedation as an ethical practice to alleviate suffering, although in some cases they associated it with moral dilemmas about the end of life, showing ambivalent attitudes between acceptance and rejection. Similarly, in a specialized hospital in Brazil, they expressed “psychological fantasies” about sedation, seeing it as an act of compassion, but also as an emotional burden for nursing staff during direct care with patients at the end of life. Other authors emphasize that they value patient participation in decision-making, which reinforces their acceptance of sedation as a collaborative process that improves their quality of life.^16,23

Some nurses, for their part, prefer not to be present during a patient’s final moments, especially in hospital settings. ¹³ One of the factors affecting nursing staff’s attitudes toward palliative sedation is the lack of institutional consensus on its use, even though nurses closely monitor patients, identify clinical needs, and communicate their observations to the medical team. ^14,17 For their part, Grüne et al. found that one of the main challenges for nursing staff is determining the right time to start sedation and establishing the correct dose, avoiding potential harm to the patient. Added to this is pressure from family members, who in some cases refuse sedation or demand increased doses, which can conflict with the patient’s actual clinical needs.¹⁹

In the home setting, some authors found that, in nursing homes and home environments, nurses avoid deep sedation for fear of “hastening death,” displaying attitudes of resistance based on personal values. They emphasized that in residences where older adults are located, ethical barriers and a lack of consensus with families can arise, generating negative perceptions toward sedation.^20,21) It was also evident that nurses experience distress when indications for palliative sedation are unclear, and although some advocate for its early use in patients who require it, their suggestions are not always taken into account, leading to frustration as the final decision rests with the attending physician.^21,22

Another recurring feeling expressed by nursing professionals, especially on weekends, is uncertainty. This occurs when the need to initiate palliative sedation arises, but medical personnel are unavailable to authorize it, even though the clinical indication has already been identified.^4,18,23 Furthermore, some studies highlight that the suffering observed in patients can generate feelings of sadness, anguish, or anxiety, especially when patients identify with them or project their own family members onto them, thus intensifying the emotional burden of their daily work.¹⁸ Furthermore, it has been documented that the initiation of SP can cause additional distress, as family members sometimes perceive that the effects of the medication take longer than expected and express their desire to accelerate the dying process, which generates emotional tension for both the team and the family. ^(22,23

Emotional impact and educational needs perceived by staff and families

The emotional impact of palliative sedation is significant for nursing professionals, and educational needs are a recurring demand both in hospital and home settings. Families also express a need for information and support, influencing staff attitudes.

In this regard, it is also evident from the hospital setting that nurses experience stress when administering sedation, especially when they perceive a lack of clarity in the instructions, displaying attitudes of exhaustion and a need for psychological support during direct contact with patients and their families. Likewise, nursing staff experience emotional impact, hopelessness, and uncertainty, demanding more training to handle ethical dilemmas, reflecting a proactive attitude toward the need for education.^18,22 Some studies highlight that hospital nurses view sedation as emotionally challenging, but necessary to improve patient suffering, and they request clear guidelines to improve their performance in daily activities.^19,26

At the same time, nursing staff’s experiences in hospital settings foster the development of skills for symptom management in patients at the end of life, as well as for emotional support for families, especially when faced with manifestations of distress and suffering. In contrast, nurses working in nursing homes report feeling overwhelmed by the high demand for palliative care and the frequent absence of medical staff, which makes timely decision-making difficult. Although some are authorized to prescribe medications, they decided not to do so due to the ethical dilemma posed by the possibility of accelerating the dying process, a situation that increased their emotional burden and sense of responsibility and uncertainty.^19,20

In the home setting, it is also evident that nurses report greater emotional stress due to the loneliness they feel when making decisions regarding medication administration, family pressure from experiencing the patient’s symptoms firsthand, and despair while the prescribed doses of medication take effect. ¹⁹ Some articles also observed vulnerability on the part of nurses when dealing with patient suffering, generating an urgent need for training not only for staff but also for families due to the emotional burden involved.^14,18,25

Finally, from the educational needs reported in the articles, those related to tools to evaluate symptoms objectively are included,¹⁵ training in communicating bad news and managing ethical conflicts with families. ^14,20 However, these findings underscore the importance of adapting clinical guidelines to the home setting and strengthening non-technical skills in both settings.¹⁸ As well as assessing the level of knowledge about medications used in palliative sedation among nursing professionals with and without postgraduate training.

Strikingly, greater conceptual and practical mastery was observed among professionals without specialized training, highlighting potential gaps in postgraduate programs. These findings underscore the need to strengthen training in palliative sedation, especially regarding the differentiation between palliative sedation and euthanasia, a fundamental aspect for professionals who have initial contact with patients and are responsible for administering medications. ⁽¹⁸

Considering the above, it can be said that, in the hospital, the emotional impact is partially mitigated by institutional support, while at home, direct exposure to family dynamics intensifies stress. Educational needs are common, but at home, emphasis is placed on communication with families, compared to the focus on protocols in the hospital.