End‐of‐Life Care Experiences, Attitudes and Perceptions of Intensive Care Clinicians in Middle Eastern Countries: A Systematic Integrative Review

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BACKGROUND: End-of-life care (EoLC) in Intensive Care Units (ICUs) in Middle Eastern (ME) countries is influenced by cultural and legal constraints, creating unique ethical dilemmas and challenges for clinicians. Ethical debates surround the acceptability of withholding and withdrawing treatments that sustain patients' lives. AIM: To collate and synthesise existing evidence on the EoLC experiences, attitudes and perspectives of ICU clinicians in Middle Eastern countries. STUDY DESIGN: A systematic integrative review was conducted. Searches were completed in AMED, CINAHL, EMBASE, Medline, PubMed and Google Scholar for studies published between 2012 and 2024. Quantitative results were translated into textual data and, along with the qualitative findings, were analysed using the thematic synthesis approach. RESULTS: Twenty-seven studies met the inclusion criteria: 16 quantitative, 10 qualitative and one mixed methods. Five themes were developed: (1) Challenges in EoLC decision-making in ICUs; (2) Cultural and ethical issues impacting the delivery of EoLC; (3) The need for comprehensive EoLC guidelines; (4) EoLC education and training for ICU clinicians; and (5) holistic support systems for ICU clinicians. CONCLUSIONS: Challenges in providing EoLC in Middle Eastern ICUs concern communication, problematic interactions with families and decision-making. Cultural and ethical issues are also found to affect EoLC delivery, pointing to the importance of comprehensive and clear guidelines. Future research could explore EoLC from the perspective of a wider range of stakeholders in Middle Eastern countries and determine how international best practices can be adjusted to Middle Eastern ICUs to enhance EoLC provision. RELEVANCE TO CLINICAL PRACTICE: To enhance EoLC in Middle Eastern ICUs, clinicians need to undergo training on communication skills, cultural sensitivity and family involvement strategies. Organisational support is required to better guide communication with families and palliative care decisions.

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