Intensive Care Med (2024) 50:1438–1458

https://doi.org/10.1007/s00134-024-07565-7

SYSTEMATIC REVIEW

Assessing palliative care practices

in intensive care units and interpreting them
using the lens of appropriate care concepts. An
umbrella review
Naveen Salins1 , Vijay Shree Dhyani2 , Mebin Mathew3 , Ashmitha Prasad3, Arathi Prahallada Rao4*
, Anuja Damani1, Krithika Rao1, Shreya Nair1, Vishal Shanbhag5, Shwethapriya Rao5, Shivakumar Iyer6,
Roop Gursahani7, Raj Kumar Mani8, Sushma Bhatnagar9 and Srinagesh Simha3

© 2024 The Author(s)

Abstract
Purpose: Intensive care units (ICUs) have significant palliative care needs but lack a reliable care framework. This
umbrella review addresses them by synthesising palliative care practices provided at end-of-life to critically ill patients
and their families before, during, and after ICU admission.
Methods: Seven databases were systematically searched for systematic reviews, and the umbrella review was con-
ducted according to the guidelines laid out by the Joanna Briggs Institute (JBI).
Results: Out of 3122 initial records identified, 40 systematic reviews were included in the synthesis. Six key themes
were generated that reflect the palliative and end-of-life care practices in the ICUs and their outcomes. Effective com-
munication and accurate prognostications enabled families to make informed decisions, cope with uncertainty, ease
distress, and shorten ICU stays. Inter-team discussions and agreement on a plan are essential before discussing care
goals. Recording care preferences prevents unnecessary end-of-life treatments. Exceptional end-of-life care should
include symptom management, family support, hydration and nutrition optimisation, avoidance of unhelpful treat-
ments, and bereavement support. Evaluating end-of-life care quality is critical and can be accomplished by seeking
family feedback or conducting a survey.
Conclusion: This umbrella review encapsulates current palliative care practices in ICUs, influencing patient and fam-
ily outcomes and providing insights into developing an appropriate care framework for critically ill patients needing
end-of-life care and their families.
Keywords: Critically ill patients, Intensive care, Supportive care, Palliative care, Overview of reviews

Introduction
Palliative and end-of-life care needs in intensive care
units (ICUs) worldwide are often overlooked despite
being prevalent among those admitted to these units [1–
5]. Research shows that about 88% of older individuals
*Correspondence: [email protected]
4 have at least one palliative care need [6], with neuro-ICU
Department of Health Policy, Prasanna School of Public Health, Manipal
Academy of Higher Education, Manipal, Karnataka 576104, India patients having exceptionally high rates of need at 62%
Full author information is available at the end of the article [7]. Families of these patients often feel unsupported,
 1439

with goals of care not being adequately discussed [7].

Many critical care settings have identified symptom Take‑home message:
management, comprehensive care planning, and family
This umbrella review provides a thorough overview of palliative and
support as crucial areas where palliative care is needed end-of-life care practices in an intensive care setting, drawing from
[8]. One helpful tool for identifying critically ill patients a synthesis of systematic and scoping reviews. It adds to the current
with potentially unmet palliative care needs is the body of knowledge and offers valuable perspectives for establishing
an effective and appropriate care framework for critically ill patients
electronic poor outcome screening (e-POS) score [9]. and their families facing end-of-life.
About one-third of patients with low e-POS scores die
within six months of ICU admission [9]. Despite these
pressing needs, there remains significant variation in sceptical about the quality and practicality of existing
palliative and end-of-life care practices in ICUs across guidelines [26]. Some feel that guidelines restrict treat-
different geographic contexts [10, 11]. ment options and interfere with the flexibility needed to
The symptom burden and psychosocial distress in ICUs provide individualised patient care. Most participants did
are high, and there is a lack of regular assessment for pain not see a significant difference between palliative care
and emotional needs [12]. Additionally, interdisciplinary principles and guidelines [26]. Therefore, this umbrella
family conferences are infrequent [13]. Palliative care review aims to use evidence from systematic reviews as
referral in ICUs is significantly less for patients with non- the foundation for developing an appropriate care frame-
cancer conditions compared to cancer [14]. Furthermore, work for palliative and end-of-life care practices in ICUs.
there is variability among clinicians involved in end-of- This framework could serve as a basis for future guideline
life communication tasks in ICUs, leading to different development.
outcomes depending on the clinician leading the
conversation [12]. It often leads to a lack of alignment Methods
in priorities or treatment goals between clinicians, The review question was
families, and patients [15]. The joint palliative care- “What palliative care practices are offered to critically
ICU multidisciplinary rounding model has been linked ill patients needing end of life care and their families
to a significant reduction in ICU and hospital length of before, during and after ICU admission?”
stay [16]. Additionally, among ICU patients requiring The review’s objectives were to assess the palliative care
extracoroporeal membrane oxygenation (ECMO) practices offered to patients with critical illness needing
support, a more extended ICU stay and treatment with end of life care and their families before, during and after
more life-sustaining measures was associated with fewer ICU admission. Additionally, the aim was to identify the
palliative care consult visits in the ICU [17]. factors that either facilitate or hinder the provision of
A scoping literature search revealed few published pal- such care in ICU setting. Furthermore, the review sought
liative and end-of-life care guidelines in ICU settings. to establish a correlation between palliative and end-
Various strategies have been used to create these guide- of-life care practices and patient and family outcomes.
lines, including participatory action research in Thai Finally, the review aimed to develop an appropriate care
paediatric ICUs [18], harmonisation of published clini- framework for palliative and end-of-life care practices in
cal practice guidelines [19], plain literature review [20], ICUs.
and consensus-based approaches through Delphi studies
in Japan [21], the USA [22], and India [23]. These guide- Protocol and registration
lines addressed components of palliative care in paediat- Umbrella reviews involve systematically analysing
ric ICUs [18], timely utilisation of palliative care in ICUs multiple systematic reviews on a specific research topic
[19], integrating national palliative care guidelines in [27]. They are conducted when several systematic reviews
ICU settings [20], medical decision-making on treatment are available on the topic, providing a comprehensive
limitation [21], critically ill surgical patients needing pal- overview of the various aspects of the phenomenon
liative care consults [22] and procedural guidelines on being explored. However, the validity of umbrella review
treatment limitation in Indian ICUs [23]. Like the Indian findings depends on the quality of the eligible systematic
consensus paper [23], European guidelines have recom- reviews. Biases in primary studies and systematic reviews
mended integrating palliative care in clinical acute and can be compounded and challenging to clarify [27]. This
emergency medicine, focusing on non-oncology condi- review adheres to the guidelines laid out by the Joanna
tions [24]. A cluster-randomised controlled study has Briggs Institute (JBI) for umbrella reviews [28]. It has
shown that these guidelines can improve end-of-life care also been registered with the International Prospective
and increase family satisfaction [25]. However, a survey Register of Systematic Reviews (PROSPERO), with the
study has revealed that many healthcare providers remain registration number CRD42023463718. Furthermore, a
1440

comprehensive methodology protocol for this review has criteria. Relevant citations from this initial screening
been published separately to provide detailed insights were retrieved in total. In the second stage, two reviewers
into the process [29]. examined the full texts to ensure they met the eligibility
criteria. Any disagreements on eligibility were resolved
Eligibility criteria through consensus between the reviewers or with the
The inclusion criteria for this umbrella review, outlined assistance of a senior reviewer (NS and VSD) if necessary.
in supplementary File 1, encompassed systematic and The Preferred Reporting Items for Systematic Reviews
scoping reviews focusing on adults receiving ICU and Meta-Analyses (PRISMA) flow chart [31] (Fig. 1)
treatment and their families. The included reviews illustrates the outcomes of the database search, screening
addressed diverse demographics, individuals of all process, and reasons for exclusions during the full-text
genders, ethnicities, and geographic locations, regardless review.
of the disease conditions. The scope of the umbrella
review extended to various critical care settings, Data extraction
including multidisciplinary or disease-specific ICUs, The findings of the selected reviews were extracted by
high-dependency units (HDUs), or areas within hospitals independent reviewers MM and AP. In the event of
designated explicitly for critical care. Furthermore, discrepancies, a discussion facilitated by NS and VSD
we focused on systematic reviews discussing hospital- led to a consensus. We created a customised JBI data
based specialist palliative and end-of-life care practices extraction template designed explicitly for umbrella
before, during and after ICU admissions, as detailed in reviews. We collaborated with subject expert NS to
supplementary File 2. The systematic reviews with or reduce errors and conducted a pilot exercise to adjust
without meta-analysis, qualitative systematic reviews, the data extraction form. The reviewers discussed the
scoping reviews, and mixed-method reviews were approach, testing specific items to ensure it aligned
included. However, reviews without any search strategy with the review objectives, and they retrieved relevant
or synthesis of findings, reviews exclusively involving data in sufficient detail. Data was systematically
paediatric and neonatal age groups, and reviews focusing extracted as sections. In the initial section on review
on formal or paid caregivers were excluded. Additionally, characteristics, we recorded author details, publication
reviews on acute care administered in a hospital ward year, review type, objectives, country, and setting. It
setting, homes, or facilities not classified as ICU or HDU was followed by a section on methodological attributes
settings were excluded. that covered eligibility criteria, reporting guidelines,
databases searched, timeframe, screening methods, data
Information sources and search strategy extraction, risk of bias, quality assessment tools, and
We conducted an extensive search of seven electronic review synthesis methods. The final findings section
databases, including the Cochrane Library, SCOPUS included information on the number of studies, quality
(Elsevier), Web of Science (Clarivate), EBSCO (CINAHL of evidence, quantitative and qualitative data on palliative
Complete), Medline (PubMed), EMBASE, and PsycINFO and end-of-life care practices, barriers and facilitators,
(Ovid), from their inception to November 30, 2023. No patient outcomes, Grades of Recommendation,
grey literature included in systematic or scoping reviews Assessment, Development, and Evaluation (GRADE)
covered in this overview was explicitly searched for. As assessment of the quality of evidence, review limitations,
provided in supplementary File 3, our search strategy conclusions, and funding.
utilised free-text and thesaurus terms specific to the
databases we explored, including MEDLINE, CINAHL,
EMBASE, and PsycINFO. We combined these terms Quality assessment
using Boolean operators (OR, AND) and did not impose Systematic and scoping reviews underwent an evaluation
any limitations on the search by specific dates or use for methodological quality by two independent review-
database-specific filters. The search conducted on ers (MM and AP) using the JBI critical appraisal check-
Medline (PubMed) can be found in supplementary File 4. list [32]. In cases where discrepancies arose between
the reviewers, they were resolved through discussion or
Study selection by seeking input from a third reviewer (NS and VSD).
After eliminating duplicate entries in the Rayyan soft- Data was collected for 11 specific items, and the quality
ware [30], the records underwent a thorough two-step of each included review was assessed using the JBI criti-
screening process. In the first stage, two reviewers cal appraisal checklist [32] for systematic reviews and
(MM and AP) independently evaluated each article’s research syntheses. Each review was evaluated based on
titles and abstracts based on predetermined eligibility specific criteria, with responses categorised as yes, no,
 1441

Fig. 1 PRISMA flow diagram

unclear, or not applicable. Each systematic review was Data synthesis and analysis
classified as high quality (10–11 points), moderate qual- The narrative synthesis method combined the qualitative
ity (7–9 points) and low quality (4–6 points) based on and quantitative reviews [35]. Initially, a preliminary
the classification provided by Neuyen et al. [33]. How- synthesis was created by providing a concise textual
ever, three items on the JBI checklist (items 5 and 6 on overview of the systematic reviews included in the
the appraisal of studies and item 9 on publication bias) umbrella review. This approach allowed the reviewers to
were not applicable for scoping reviews. To maintain uni- familiarise themselves with the data before conducting
formity in assessing the quality of reviews, the full score the analysis. The interconnections between the reviews
(1 point) was awarded to items that were not applicable were examined by organising the review findings into
in reviews. Moreover, we included all reviews regardless meaningful categories and themes [35]. To ensure the
of their quality. Most included reviews did not report the reliability of the synthesis, the reviews were critically
certainty of evidence (GRADE), except for one review appraised, as discussed before [28], and the synthesis
[34], and the GRADE quality score for each outcome was process was carefully considered.
low to very low. An overall assessment of the certainty The characteristics of this review are presented as a
of the evidence using GRADE was not feasible. The out- table, along with a narrative explanation and descriptive
comes of quality assessment are presented in the results
section and supplementary File 8.
1442

statistics. To focus on palliative and end-of-life care records underwent a full-text screening process, with
practices, a classification framework was developed based an additional exclusion of 228 reviews not meeting the
on previous guidelines from the Indian Society of Critical inclusion criteria. Consequently, 40 papers remained for
Care Medicine (ISCCM) [36, 37], and outcomes were the final analysis and synthesis. The reviews during full-
recorded for each practice. The purpose of identifying text screening were excluded based on settings other
these practices was to develop key search concepts than peri-intensive care setting, meaning care before,
that became search terms for the review. Factors that during and after ICU admission (n = 81), reviews that
impacted these practices, acting as both barriers and were not done systematically, meaning reviews without a
facilitators, were organised into themes and then into search strategy or synthesis (n = 48), language other than
overarching groups in line with a previously published English (n = 12), population other than adults (n = 13),
methodology [38]. The framework used in this synthesis not focused on end-of-life care or palliative care practices
is available in the protocol that informed this review (n = 74). The selection process is illustrated as a PRISMA
[29]. Palliative care practices in the ICU were identified flow diagram in Fig. 1.
by focusing on key drivers, including prognostication, The characteristics of the systematic reviews incorpo-
communication, decision-making, care planning, care rated into the analysis are provided in Table 1. The coun-
facilitation, and care evaluation [39]. These themes and tries included in the review are illustrated as a map in
several contributing categories informed this umbrella Supplementary File 5, and a description of each system-
review. Additionally, new categories were generated atic review included in the umbrella review is provided
during data synthesis, indicating that the synthesis was in supplementary File 6. Supplementary File 7 provides a
not limited to the framework developed for the review. view of the country of origin of systematic reviews, and
Fig. 2 provides a year-wise distribution of published sys-
Appropriate care concept tematic reviews.
According to an integrative review [40], the appropriate The quality of each systematic review included in the
care concept (ACC) encompasses five notions. The synthesis was evaluated using an 11-item JBI critical
care must be evidence-informed, delivered by a appraisal checklist [32] provided as supplementary File 8.
team with clinical expertise, and patient and family- Of the included reviews, 28 (22 systematic and six scop-
centred, enabling optimal utilisation of resources and ing reviews) were high quality. The remaining eleven
promoting equity. Evidence-based care focuses on reviews (nine systematic and two scoping reviews) were
achieving positive health outcomes and implementing of moderate quality. One review was of poor quality. The
evidence into practice. A skilled clinical team has the reviews have not been excluded based on their methodo-
necessary expertise and training to incorporate expert logical quality. Most of the reviews had a specific review
opinions into clinical decisions, allowing for customised question and objectives (Q1), defined inclusion criteria
treatment of individual patient cases. Patient and family- (Q2) and search strategy (Q3). Thirty-five reviews had
centred care entails offering responsive, coordinated searched at least three databases (Q4). Among the 40
care and promoting patient autonomy through open reviews, seven systematic reviews [41–47] did not have a
communication and shared decision-making. Resource critical appraisal (Q5). There were eight scoping reviews
management includes minimising wastage and avoiding [48–55]. Although quality assessment is not a require-
unnecessary interventions, ensuring efficient resource ment in scoping reviews, two reviews [52, 54] assessed
allocation, and reducing costs. Equity involves the the methodological rigour of the included studies. The
fair distribution of resources across settings to enable preferred reporting items for overviews of reviews
uniform health outcomes and non-discriminatory care. (PRIOR) checklist is provided in supplementary File 9.
The ACC lens was used to interpret the review findings Table 2 provides information on palliative and end-of-life
and develop an appropriate care framework for critically care practices in ICUs and their outcomes. It is visually
patients needing end of life [40]. represented in Fig. 3.

Results Prognostication
The search on databases yielded a total of 3122 records. In a few systematic reviews [41, 45, 46, 56–58], prognos-
Subsequently, these records were imported into Rayyan tication and prognostic communication were described as
for deduplication and screening, and 1395 duplicate a palliative care practice within the ICU. It encompassed
entries were removed. The title and abstracts of the ICU physicians with proficiency in prognostic estimates
remaining 1727 reviews were independently reviewed [45, 56], creating a trigger-based palliative care referral sys-
by two authors, excluding 1459 reviews unrelated to the tem based on predictive estimates [41, 57] and using prog-
review’s eligibility criteria. The remaining 268 search nostication scales [56]. Proficiency meant the ability of the
 1443

Table 1 Characteristics of the systematic reviews included in the umbrella review

Characteristics Number

Types of reviews
Systematic reviews 31 [34, 41–47, 56–75, 77–79]
Scoping reviews 8 [48–55]
Integrative reviews 1 [80]
Country of publication
United States 13
Australia 6
The Netherlands 3
United Kingdom 3
Canada 2
India 2
Portugal 1
Croatia 1
Sweden 1
China 1
Brazil 1
Spain 1
Belgium 1
Colombia 1
Italy 1
Japan 1
Indonesia 1
Number of databases searched
  ≥ 5 17
2–4 22
1 1
Type of databases searched
Medline PubMed 38
Medline Ovid 10
Embase 23
CINAHL 28
Cochrane Library 20
Scopus 9
PsycINFO 16
Google Scholar 4
Web of Science 16
ProQuest 2
Others 15
Types of quality assessment tools used
Critical appraisal skills program 6
JBI critical appraisal tool 1
Effective public health practice project 1
Hawker’s tool 1
Caldwell’s framework 2
Risk of bias for non-randomised studies—ROBINS 1
Appraisal of guidelines for research and evaluation II instrument—AGREE 1
Cochrane risk-of-bias 3
Newcastle–Ottawa Scale 2
Adapted checklist 9
1444

Table 1 (continued)
Characteristics Number

Not reported 13
Synthesis method described in systematic reviews
Narrative synthesis 17
Meta-analysis 2
Meta-synthesis 2
Thematic synthesis 6
Not described 13
Reporting guidelines
PRISMA 24
PRISMA-ScR 7
ENTREQ 1
Not reported 8
Number of primary studies included in the systematic reviews
1–10 studies 9
11–20 studies 11
21–30 studies 11
31–40 studies 4
41–50 studies 1
  > 50 studies 4
Quality of systematic reviews based on 11-item JBI critical appraisal checklist
High quality 28
Moderate quality 11
Poor quality 1

Number of Publicaons
9
8
8
7
7
Number of Publicaon

6 6
6
5
4
4
3
2 2 2 2
2
1
1
0 0 0
0
2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
Year of Publicaon
Fig. 2 Year-wise distribution of published systematic reviews. This figure illustrates the distribution of review publications by year, revealing a peak
in 2016 with eight publications, making up 21% of the total. This is followed by 2022 with seven publications, and 2019 and 2020 contribute six
publications. All the included reviews were published between 2011 and 2023

ICU physician to intuitively recognise a patient who might and palliative care needs [57]. While communicating with
benefit from palliative care in the early phase of ICU man- surrogates, ICU physicians used numerical prognostic
agement [45, 56]. Palliative care integration in ICUs ena- estimates, diagrams and radiographs to predict outcomes
bled ICU physicians to readily recognise end-of-life phase and survival [56]. Predictive estimates in medical and
Table 2 Palliative and end of life care practices in ICUs, their outcomes, facilitators and barriers
Practices Outcomes Facilitators Barriers

Prognostication
Physician competency in prognostic estimates Enabled patient and family support in decision- Having a specialist palliative care team Lack of clarity in prognosis was a common source
Senior clinician involved in prognostication making facilitated identifying palliative care needs of conflict in the ICU, and communication
and communication of prognosis Enabled recognising the end-of-life phase, Trigger systems based on predictive estimates without prognostic estimates was often not
Clinical prediction palliative care needs and prompt access to enabled palliative care consultation perceived well by the families
Prognostic clarity palliative care Reduction in ICU and hospital costs was Lack of understanding on how to assess patients’
Triggers for palliative care referral Identification of patients requiring a palliative facilitated by identifying triggers for palliative prognostication impacted palliative care referral
Prognostic scales and tools approach in the early stage of intensive care care referral Lack of prognostic familiarity led to patients
Trigger-based referral improved patient and Using prognostic tools and scales enabled receiving invasive and unhelpful treatment in
family satisfaction, decreased hospital and ICU objective decision-making ICUs
length of stay
Communication
Family meetings Decreased ICU deaths and length of stay Scheduling it early and within 72 h was helpful Families disliked poor communication skills,
Family-centred conferences Bettered family-centred support and comfort The nurse or social work-led communication incomplete information, and short family
Family counselling Improved family satisfaction, enabled facilitated emotional support meetings
Serious illness conversations documentation of end-of-life decisions and Involvement of family counsellors and liaison Communication that was not open and unclear
Physician training in communication, lowered hospital resource use support during family meetings was resulted in families feeling psychologically
especially serious illness conversations Enabled agreement between ICU providers and beneficial unprepared for the possibility of death
Timely and complete disclosure of information families Nurses/social workers as communication Delayed communication caused negative
Informing patients about their choices and Mitigated anxiety and emotional distress of facilitators made families to be at ease memories of the dying process and provoked
engaging them in decision-making families, improved emotional outcomes Printed information leaflets assisted serious anxiety, distress, and anger
Using communication tools Enabled families to have a plan of care illness conversation Doctors not at ease in talking to patients and
Informational brochures/booklets used as Bettered inter-team understanding of the care Do not resuscitation documents were often their families about limiting therapy and
communication aids considered a form of communication inability to engage culturally diverse families
hindered serious illness conversations
Lack of culturally appropriate practices around
disclosure of prognosis impeded consensus
for end-of-life care, potentially prolonging life-
sustaining treatment
Shift changes and the rotation of staff in the
ICU limited the ability to build rapport with
patients and families, leading to ineffective
communication
Not having access to support services in ICUs
and absence of guidance documents impeded
communication
Inability to navigate language, cultural
preferences and religious beliefs led to
inadequate disclosure of information about
prognosis
1445
 1446

Table 2 (continued)
Practices Outcomes Facilitators Barriers
Decision-making
Inter-disciplinary team consensus on patient Goals of care discussion facilitated patient and Weekly multidisciplinary review of ICU care Conflict and disagreements between family
management should precede goals of care family support in shared decision-making, enabled patients to receive appropriate care members and physicians concerning the goals
discussion decreased ICU length of stay and enabled Involving families during comprehensive of care were a barrier to the integration of a
Eliciting treatment preferences, discussing patients to receive treatment congruent with decision-making facilitated timely initiation of palliative approach
goals of care, expected survival, and patient and family preferences end-of-life care Disagreement between physicians and the ICU
developing strategies to overcome Using decision-making aids reduced ICU costs Anticipatory care planning and doctors’ team about the goals of care led to continued
decisional conflict and length of stay familiarity with end-of-life care fostered intensive care interventions
Decision-making aids Written and video-based decision aids bettered decision-making Non-involvement of families in decision‑making
Video-based decision support tools surrogate satisfaction in decision-making is a common source of conflict
Consultative approach by the palliative care Decision-making with anticipatory care The limited contribution of nurses in decision-
team planning principles lowered decision-making making was a barrier
Timely engagement of surrogates and conflict Uninformed and misguided decision-making
decision-makers wasassociated with a decrease in family
Applying anticipatory care planning principles satisfaction
Inadequate communication led to families
making choices not consistent with physician
recommendations
Care planning
Consensus among the treating team in Inter-team discussion improved documentation The number of DNAR orders and timing Lack of care planning often made the families
making end-of-life decisions of care plan, DNAR, understanding of care reflected the quality of care in the ICU unprepared for the decision-making process
Creating a comprehensive anticipatory care process, congruence with patient wishes, and DNAR documented as an outcome of goals of and usually led to conflicting intents and focus
plan a degree of confidence among ICU team care discussion was well-accepted on life preservation
Discussion and documentation of do not Anticipatory care plan bettered interdisciplinary Consultative model and ICU staff training Lack of information, misconceptions,
attempt resuscitation (DNAR) support for patient and family, decisional facilitated DNAR and decisions on limiting and healthcare providers’ support or
Poor performance status and multiple medical outcomes for patient-centred quality care life-sustaining treatments encouragement were barriers to care planning
comorbidities considered while deciding on Timely palliative care referral helped patient- Acknowledgement by the ICU providers that Families experienced a sense of guilt, distress and
life-sustaining treatments centred care, reduced ICU stay and improved treatment with no potential benefit must not abandonment while discussing an anticipatory
Implementing decision on withholding or family satisfaction be offered enabled end-of-life care planning care plan
withdrawing life-sustaining treatment and withdrawal of needless therapies Reluctance to forgo life-sustaining therapies
Initiating palliative care referral delayed comfort care
Having a clear plan for managing end-of-life Clinicians considered with-holding and
symptoms post-withdrawal of mechanical withdrawing decisions as being ethically
ventilation distinct
Lack of palliative care consultation in patients
with advanced cancer was associated with
increased use of invasive mechanical ventilation
Table 2 (continued)
Practices Outcomes Facilitators Barriers
Care facilitation
Ethical and legal considerations Enabled decision-making in the context Ethical frameworks underpinning institutional Lack of knowledge of ethical issues concerning
Clinical ethics consultation in complex- of artificial nutrition and hydration and policies on treatment limitation is usually end-of-life decisions and uncertainty about the
decision making withholding or withdrawal of life-sustaining implemented legal details hindered palliative care in ICUs
Physician aware of contextual legal treatments The presence of institutional guidelines Scepticisms about guidelines concerning the
considerations Education improved nursing interventions and and policies helped comprehensive care futility of care due to its unreliability or difficulty
Institutional guidelines and policies on end-of- care at end-of-life documentation leading to end-of-life care in interpreting clinical signs delayed palliative
life care provision in the ICUs care engagement in ICUs
ICU providers trained in palliative and end-of- Simulation-based training involving case Lack of awareness about guidelines or resistance
life care scenarios and continued medical and nursing to their implementation hindered end-of-life
Pain and symptom management at the end education enabled end-of-life care training for care in ICUs
of life ICU providers Restrictive ICU visitation policy hindered family
Accommodating patients’ religious and Training ICU providers in pain and symptom involvement in end-of-life care
cultural beliefs and providing spiritual control using validated scales and opiate Shortcomings in palliative care training impeded
assistance titration helped symptom management the ability of the ICU team to provide end-of-
Preserving dignity through respecting life care
preferences The lack of specific protocols for providing end-
Providing person-centred care of-life care within the ICUs hindered nurses
Written information to prepare families for the from providing care
dying process Inadequate step-down beds, lack of space, higher
Enabling family presence during treatment occupancy in the ICUs, scarcity of means to
limitation and dying process provide comfort, and lack of privacy hindered
Emotional and practical support to patients the ability to provide end-of-life care
and family Not having access to resources such as
Spiritual support to families, a spiritual chaplaincy and other support personnel
support system in ICUs and communication constrained end-of-life care in ICUs
to alleviate the spiritual and existential Lack of clear guidance for managing end-of-
suffering life symptoms, such as dyspnoea, during
Mortuary team integration into a multi- withdrawal of mechanical ventilation, hindered
disciplinary team care
Creating family bereavement support Lack of palliative care content in nationally
ICU dairy, condolence letters, brochures, developed guidelines for chronic, non-curable,
pamphlets, or other printed bereavement life-limiting diseases deterred palliative care in
information ICUs
Recognising symptoms of post-traumatic Limited access to private spaces for those who
stress disorder among families wanted to grieve away from the bedside
Using validated tools to screen for anxiety, impeded family experience
depression, and post-traumatic stress
disorder among families
1447
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Table 2 (continued)
Practices Outcomes Facilitators Barriers
Care evaluation
Scales and tools to score quality of dying and Indicated family satisfaction with end-of-life Perceived nursing skill, decision-making Quantitative instruments evaluating end-of-life
death care support, and documentation of patient care might not capture the care complexity,
Survey and qualitative studies on the quality wishes about end-of-life care were associated and these evaluations may be prone to bias as
of death with better quality of death users of such services might be a self-selecting
Informal family feedback on the quality of Family presence at the time of death was group
end-of-life care in the ICU associated with the feeling of good death Families unprepared for the unpredictability
Comforting physical environment, presence of the dying process or surprised by the
of family and nurses encouraging families to length of time to death were associated with
build positive memories of the dying person dissatisfaction
influenced the perception of a peaceful death The presence of signs of respiratory distress
following the removal of mechanical ventilation
was perceived by the family as poor quality of
dying
Families felt dissatisfied with the lack of clarity in
patient assessment
Inconsistent and contradictory information,
reduced time and frequency of physician
communication led to feelings of uninformed
and misguided decision-making
Families experienced moral distress and felt the
need for emotional support to reduce such
stress during introduction of palliative care in
the ICU
Unwelcoming and uncomfortable ICU waiting
rooms
The lack of private space for communication
contributed to the perception of diminished
care
 1449

Fig. 3 Synthesis of palliative and end of life care practices in the intensive care units

surgical ICUs to trigger palliative care referral relied on Involvement of experienced clinicians in prognosti-
age, comorbidities, length of ICU stay, days on mechani- cation and using prognostic scales improved clinical
cal ventilation and presence of cancer and chronic illnesses prediction, and when ICU physicians were proficient
leading to end-stage organ impairment [41, 57]. in prognostication, they could quickly recognise the
1450

need for palliative care [56] and the end-of-life phase cultural competency and inability to handle requests
[58], which facilitated shared decision-making [45, 56], for nondisclosure of information often led to needless
enhanced access to palliative care [58], reduced ICU prolongation of life-sustaining treatments and health-
stay, and improved family satisfaction with care [41]. On related suffering [60].
the other hand, physicians’ lack of understanding about The ICU teams used printed family information
prognostics impeded timely referrals to palliative care leaflets [68], information brochures and booklets [41,
[46] and left families dissatisfied with the communication 57], resuscitation documents [34] and others like the
they received [41]. Furthermore, a want of prognostic PACE (Psychological Assessment and Communication
skills resulted in patients receiving inappropriate care in Evaluation) and the VALUE communication tool
the ICU, leading to family disappointments [58]. [65] to aid conversations in the ICUs. The PACE tool
led to higher satisfaction with the assessment and
Communication treatment of symptoms, while the VALUE tool resulted
Communication as a palliative care practice in ICU in more frequent family updates, increased nurse
settings was described in most systematic reviews [34, participation, and better documentation of treatment
41, 42, 44–46, 48, 49, 53, 54, 56, 57, 59–68]. It embodies goals. These enabled families to be prepared and agree
conducting family meetings [42, 45, 46, 49, 57, 65, 68], on a plan of care [48]. Communication aids improved
having serious illness conversations [45, 53, 54, 56], and documentation of end-of-life care, decision-making, and
using information tools for communication [34, 41, 61, resource utilisation [34]. It facilitated better inter-team
65]. communication [52], effectively conveyed intentions of
Family meetings are effective when it is scheduled early care to the other members of the team [34] and enabled
[48], proactively [44] and within 72 h of ICU admission nurses to communicate effectively in the ICU [59].
[66]. Moreover, family-centred conferences [49, 57, 64,
68] and family counselling interventions [49, 51] in ICUs Decision‑making
can be nurse or social-work-led, and they can act as Most systematic reviews included in the umbrella review
communication facilitators, which could be an alternative discussed the practice of decision-making processes in
to physician meetings [67]. Providing patients and their the ICU setting [43–47, 51, 55–57, 59, 62–65, 67, 69, 70].
families with complete and timely information during The decision-making process involved multidisciplinary
these meetings in the ICU can improve shared decision- teams engaging in inter-team discussions before eliciting
making opportunities [61, 63]. It can result in reduced the goals of the care discussion with the family [51, 56],
anxiety and psychological distress [45, 56]. Family a process of collaborative decision-making between ICU
meetings in ICUs provide better family-centred support teams and families [45, 46, 59, 62–64, 70], and using
[68] and caregiver satisfaction [45, 65, 68] and foster decision-making aids [34, 63, 65, 69].
agreement between ICU providers and families [48]. Disagreements among healthcare providers regarding
Failure to do so can lead to conflicts regarding prognosis goals of care were frequently observed [50], resulting
and patient management [61], and families dislike poor in needless and prolonged intensive care interventions
communication, incomplete information, and short [56]. Additionally, conflicts and disagreements between
engagement during family meetings [45]. physicians and family members regarding goals of care
For serious illness conversations to be beneficial, they posed a significant barrier to integrating a palliative
must be timely [61] and culturally sensitive [60]. The ICU approach in the ICUs [56]. Furthermore, insufficient
physicians conducting serious illness conversations with clarity and inadequate assessment by healthcare
patients and families should be trained in communication providers resulted in ill-informed and misguided
skills, planning and scheduling these meetings, and decision-making, which has been linked to a reduction
preferably, they can use nurses and social workers as in overall family satisfaction [42]. Therefore, inter-team
liaison support [48, 57]. Serious illness conversations discussions on prognosis, futility, benefits versus harm
decreased ICU deaths and the average length of stay and future management [51, 56] were helpful, reducing
in the ICUs [44, 48, 66]. However, serious illness decision-making conflicts [55].
conversations that were not open and clear resulted in According to review findings, family meetings in an
families feeling unprepared for the death of their loved ICU setting are effective when the conversations are
ones [61]. It led to negative feelings about the death of led by a team proficient in communication skills [63].
their loved ones, provoking anxiety, anger and distress Involvement of a senior physician [54], skills in crisis
[61]. Physicians who were uncomfortable discussing communication [46], clarity of prognosis [46], timely
treatment limitations [54] or handling culturally diverse identification of next of kin or surrogates [65] and the
families [60] impeded these conversations. Lack of use of principles of advanced care planning [63] during
 1451

family meeting improved end-of-life decision-making Lack of care planning often leaves families unprepared
in the ICUs. Involving families during comprehensive for decision-making, resulting in conflicting treatment
care planning [44, 56], discussing treatment options, and intents and a focus on life preservation [42, 43]. Lack of
estimating survival time during family meetings reduced information, misconceptions, and healthcare providers’
decisional conflict, shortened ICU stays, and aligned support or encouragement can also hinder care planning
family and physician preferences [44, 45, 57, 63, 64, 67]. [55]. It is not uncommon for families to experience
However, neglecting family involvement in decision- a sense of guilt, distress, and abandonment when
making leads to conflict [46]. Moreover, nurses often feel discussing an anticipatory care plan [55]. Moreover,
left out during family meetings [56]. some clinicians consider withholding and withdrawing
Review findings support using decision-making aids as ethically distinct, which might hinder treatment
[34, 65], written documents [63], educational videos limitations in the ICU [54].
[34], video-based decision-support tools and verbal Review findings support proactively [67] involving
descriptors [69]. It bettered ICU physicians’ familiarity palliative and supportive care services as part of the
with decision-making [58], promoted shared decision- ICU care planning [34, 56, 66, 68, 71] as it betters
making, reduced ICU costs and length of stay and interdisciplinary support for decision-making [46, 51].
instilled confidence among family members [65]. It also It promotes patient-centric care, shortens ICU stays,
decreased disagreements during decision-making [55] and boosts family satisfaction [54, 56, 66, 68]. Patients
and helped families to make decisions consistent with with advanced cancer who didn’t receive palliative care
physician prognosis [46]. consultation were more likely to require mechanical
ventilation [75], and one review revealed that palliative
care is seldom considered in burns ICUs [76].
Care planning
Most systematic reviews included in this umbrella
Care facilitation
review described findings to suggest care planning as
a vital practice in critically ill patients in ICUs [34, 43– This review has identified vital practices facilitating
45, 47, 51, 53–57, 61–64, 66–74]. It involved having a palliative and end-of-life care in ICUs [34, 41, 42, 44–
consensus-based anticipatory care plan [43, 51, 54, 56, 47, 49, 51, 53, 54, 56–59, 61–66, 68, 71, 73, 75, 77–79].
63, 66] and making a palliative care referral [34, 56, 66, It includes having institutional guidelines and policies
68, 71]. There were more studies on care planning and on treatment limitation and end-of-life care [54, 56, 71],
facilitation in this review, corresponding to more primary symptom management and psychosocial support [54,
research conducted in these areas in the ICU setting than 57, 61, 62], withholding or withdrawal of life-sustaining
in others. treatments [68], optimising artificial nutrition and
The consensus-based anticipatory care plan involves hydration [68], after death care and bereavement support
eliciting the family’s understanding of the care process, [44, 49, 51, 54, 61, 66, 77] and training ICU providers in
discussion and documentation of the nature of care palliative care [41, 51, 56, 57, 59, 64].
and resuscitation preferences [55, 69]. The presence In the context of end-of-life care in ICUs, ethical
of Do-Not-Attempt-Resuscitation (DNAR) orders in considerations play a crucial role [47, 53], and
the ICU has become a widely accepted contemporary institutional policies on treatment limitations must be
practice [54, 55, 69, 72, 74]. It is commonly acknowledged underpinned by ethical frameworks [47]. Healthcare
that withholding or withdrawing life-sustaining therapies professionals should seek clinical ethics consultation
may be necessary if deemed non-beneficial or potentially when faced with complex decision-making [34, 41, 44, 65,
inappropriate [53, 54, 57, 61, 62, 71–74]. The results of 66, 68]. Legal considerations are also integral; physicians
this review reinforce the notion that patients with low- must stay informed of contextual legal details [58, 63].
performance status and multiple medical comorbidities The misconception that the law prohibits the withdrawal
should be considered for anticipatory care planning when of mechanical ventilation often stems from a poor
determining the extent of life-sustaining treatments understanding of legal provisions [58]. Legal concerns
[74] and that needless life-prolonging therapies should notably influenced physicians’ decisions to issue or
be discontinued [64]. DNAR orders often result from acquire a do-not-resuscitate order [58]. Without adequate
collaborative goal-setting and shared decision-making knowledge of ethical and legal issues surrounding end-of-
between healthcare providers, patients, or surrogates life decisions, the delivery of palliative care in ICUs may
and are an integral component of care planning [44, be impeded by uncertainty [58]. Institutional guidelines
57]. Moreover, incorporating DNAR orders in the ICU promote comprehensive care documentation [47, 54,
is often considered a hallmark of high-quality care in 56, 75], but the lack of specific protocols for end-of-life
critical care settings [44, 74]. care within ICUs [59, 79] impedes care. Moreover, a
1452

systematic review has raised doubt over the reliability Care evaluation
and interpretability of clinical signs used in determining Eight systematic reviews [42, 49, 51, 53, 56, 57, 62, 64, 65]
futility and end-of-life phase, leading to scepticism discussed formal and informal evaluations of end-of-life
towards such guidelines [71]. Furthermore, a lack of care in ICUs. Care was evaluated using family feedback
awareness or resistance to adhering to these guidelines as a surrogate marker of the care provided. The bereaved
can hinder providing optimal end-of-life care in ICUs family members completed care of the dying evaluation
[56]. or quality of death questionnaires during a survey or
Effective pain and symptom management during end- participated in a qualitative interview to formally assess
of-life care is essential to quality care [54, 57, 61, 62]. end-of-life care in the ICUs. Likewise, informally, during
ICU providers should receive training in using validated bereavement support, views of families on the care
scales for symptom assessment and administering provided in the last days of life were explored.
opiates to manage symptoms [71, 73]. The absence of Ensuring family satisfaction with end-of-life care is
palliative care and pain management protocols within crucial in an ICU setting [42, 56, 64]. Families perceived
the context of end-of-life care in ICUs can impede the positive dying experiences as being associated with
care process [73]. Additionally, inadequate guidance patient comfort [62], the presence of family during
on managing symptoms such as dyspnoea during the dying process, the perception of nursing expertise,
mechanical ventilation withdrawal can cause distress for support in decision-making, and documentation of
families [47]. The systematic review results underscored end-of-life wishes [64]. Moreover, access to appropriate
the importance of upholding patients’ dignity in the resources, including chaplaincy and other support
ICU by honouring their preferences [45, 46, 59, 61] personnel, bettered satisfaction [60]. Family-centred
and offering personalised care [45, 59]. Sharing written care and physician-led conferences also contributed
documentation with families regarding end-of-life care to family satisfaction [42, 49, 56, 57]. Implementing
[64] and allowing families to be present during treatment strategies to reduce the duration of ICU stays [53, 65]
limitations and the dying process can be beneficial and providing decision-making support [65, 67] yielded
[45, 64, 77]. Additionally, providing spiritual support cost-saving advantages, improving family satisfaction.
to families [45, 57, 59, 75], establishing a spiritual The unmanageable expenses associated with medical
support system within the ICU [42, 64], and promoting care in ICUs exacerbate families’ financial and emotional
communication to address spiritual and existential stress [53]. The perceived high cost of treatment may lead
distress [59] were valuable. some to question its necessity, further compounding the
The review findings suggest that offering care burden on families [53].
immediately after death and bereavement support are Likewise, limited bed availability, space, high
crucial initiatives. However, limited access to spaces for occupancy levels, insufficient means of providing
grieving at the ICU bedside poses a significant challenge comfort, and lack of privacy negatively impacted family
[61]. It was found that integrating the mortuary team satisfaction [79]. The families unprepared for the
into the multidisciplinary team could help provide unpredictability of the end-of-life process, uncertainty
after-death care [51]. Additionally, creating a family about the timing of events, and signs of respiratory
bereavement support system [54, 66] and providing distress following the removal of mechanical ventilation
printed bereavement documents such as condolence led to dissatisfaction [62]. Additionally, families
letters, brochures, pamphlets, and diaries were deemed were dissatisfied with inconsistent and contradictory
valid [44, 45, 49, 77]. The review findings also highlighted information provided by physicians, lack of clarity,
the importance of recognising post-traumatic stress, holistic assessment, and poor timing and frequency of
anxiety, and depression among bereaved family members physician communication, which can lead to uninformed
[44, 49] and using validated tools to screen for them [77]. decision-making [42, 56]. Moreover, unwelcoming and
The findings of this review suggest that ICUs must uncomfortable ICU waiting rooms, lack of private space
have the capacity to provide end-of-life care. One way for communication, and inflexible visiting hours can also
to enhance this capacity is by educating ICU providers contribute to dissatisfaction [42, 52, 80].
and medical and nursing staff [41, 51, 56, 57, 59, 64]. Various methods, such as surveys, scoring systems, and
Initiatives to educate nursing staff on end-of-life care interview-based studies, have been used to assess care
interventions have improved their ability to provide evaluation in ICUs [51, 64]. Care evaluation scales, good
quality care [42, 57, 59]. Simulated learning using case death inventory, quality of death and dying (QODD),
scenarios was found to be helpful [57]. In contrast, the family satisfaction ICU (FS-ICU) and Evaluation of
absence of education initiatives has been found to limit Experiences of Withdrawal Tool were some of the
their capacity to do so [56]. scales and tools used to evaluate the care of the dying
 1453

from the perspective of the family [64]. However, using is a critical care component for all ICU patients [88].
quantitative instruments for assessing services may not Furthermore, ICU providers should have expertise in
fully capture the intricacies of care, and evaluations may withholding or withdrawing unhelpful life-sustaining
be influenced by the biases of the self-selecting group measures, including deactivating devices at the end of life
participating in these assessments [51]. [89, 90].
The review has identified key features surrounding
Discussion patient and family-centredness in prognostication,
The lenses of appropriate care concept [40] discussed communication and decision-making. Incorrect
in the methods section was used to interpret the review predictions and disagreements over patient prognoses
findings. Care is appropriate when it is evidence-based, can lead to significant moral distress for ICU staff,
delivered by a professional team with the requisite potentially hindering the care provided to patients
expertise, with a patient and family focus, enabling and their families [76] and it is essential to convey
optimal usage of resources and promoting equity [40]. a truthful and accurate prognosis to prevent harm
Several palliative and end-of-life care practices and safeguard patients in the ICU [91]. The review
described in this review highlighted evidence-based supported the idea of timely, proactive, sensitive, and
approaches like prognostic estimates based on tools effective family-centred communication. It facilitated
and models informing decision-making. Evidence- families’ preparedness, support, and empowerment to
based practices like neuro-prognostication in cases of make informed decisions. Discussing uncertainty and
hypoxic brain injury [81] and prediction approaches like assessing family comprehension is crucial in achieving
the Acute Physiology and Chronic Health Evaluation, shared decision-making in clinician-family meetings
Simplified Acute Physiology Score, and Mortality regarding care goals for critically ill neurologic patients
Probability Models were valuable in ICU care [82]. [92]. The use of vague or hedge language by ICU
Evidence-based decision-making tools were helpful in physicians, such as probabilistic statements, emotional
randomised controlled trials involving Australian ICUs, expressions, metaphors, contingency statements,
where families reported feeling included in the decision- and unclear time references, often impeded effective
making process [83]. communication [93]. Intensive care nurses felt
The significance of physicians’ proficiency in prognostic undervalued in treatment decision-making processes,
estimates and clinical prediction and timely and effective and their lack of involvement often led to frustration
communication of prognosis to facilitate informed [94]. They believe their participation in decision-
decision-making and care planning could be an example making would lead to more frequent collaboration
of a team’s expertise. Implementing a structured process with specialist palliative care teams [94]. Additionally,
that fosters inter-team collaboration and shared decision- focusing solely on ICU interventions and physiology-
making by eliciting care goals was identified as a helpful centeredness may be perceived as incomplete [95].
practice in this review. A proficient team must facilitate It is also essential to find ways to communicate
a shared decision-making process through effective and understand the preferences of nonverbal and
exchange of information, thoughtful deliberation, and, consciously mechanically intubated patients in the ICU
ultimately, a treatment decision [84]. Facilitating paced to ensure their inclusion in the decision-making process
reflection, iterative thinking, and careful information [96]. The review findings recommend evaluating the
sharing effectively promoted shared decision-making provided care informally by gathering feedback from
[85]. Evidence from this review supports the view that families or formally through survey questionnaires
excellent care planning reflects team expertise. The and qualitative interviews. The euroQ2 initiative
findings mirror a study conducted in the United States, assessed end-of-life care quality using the euro-QODD
where comprehensive care planning in ICUs involves questionnaire in Danish and Dutch families [97]. The
ethics consultations, family education, proactive effective management of treatment limitations and the
involvement of a palliative care team, goals-of-care level of participation in the decision-making process
discussions, and advance care planning [57]. However, were found to be the primary factors affecting family
it should account for contextual factors, disease stages, satisfaction with care [97]. Additionally, integrating
potential treatments, possible outcomes, medications, palliative care into ICUs has been linked to improved
and management of complications [86]. Moreover, review emotional well-being, post-traumatic stress, and
findings recommend that ICU teams must have expertise bereavement support [12].
in managing end of life symptoms, as most patients in The family-clinician Shared Decision-Making
intensive care units experience distressing symptoms, model in China increased family satisfaction, reduced
particularly delirium [87]. Regardless of prognosis, it patients’ ICU stay and optimally utilised ICU resources
1454

[98]. Several practices discussed in this review have and documentation of care preferences, especially resus-
described optimal resource utilisation as an outcome citation preferences, are vital practices that avoid unnec-
leading to equity. Anticipatory care planning often essary and inappropriate care at the end of life. Excellent
leads to decreased ICU admissions and reduced ICU end-of-life care must include symptom management, sup-
length of stay [99]. Quality predictors like the absence port for families, optimisation of hydration and nutrition,
of cardiopulmonary resuscitation in the last eight hours and withholding and withdrawing unhelpful treatment.
of life could be one of the indicators of ICU resource Additionally, it should extend to care and support families
utilisation [100]. immediately following death and during the bereavement
The current published guidelines and position period. Evaluating the quality of end-of-life care is essential
statements on palliative and end of life care in ICUs and can be done informally through family feedback or a
[18–24] are developed as consensus-based approaches survey study. Evidence regarding practices related to pallia-
through Delphi studies and often underpinned by plain tive care provision in the ICU is more extensively developed
narrative reviews. This umbrella review has synthesised than preparation for this care, which involves prognostica-
palliative care practices in ICUs, their outcomes, tion, communication, and decision-making. This umbrella
facilitators, and barriers from forty systematic reviews review has comprehensively synthesised the current pallia-
across the globe and might serve as a potential resource tive care practices observed in ICUs, examining their impact
for future guidelines development. on patient and family outcomes. It is a novel approach, con-
tributes to existing knowledge and offers valuable insights
Strengths and limitations for developing an appropriate care framework for critically
This review offers a comprehensive guide to the palliative ill patients facing end-of-life and their families.
and end-of-life practices in an intensive care setting. Supplementary Information
The findings are based on synthesising systematic and The online version contains supplementary material available at https://​doi.​
scoping reviews using rigorous and transparent methods org/​10.​1007/​s00134-​024-​07565-7.
by JBI guidelines [28]. The reporting adheres to PRIOR
guidelines [101], but it should be noted that excluding Author details
1
non-English and grey literature, including policy Department of Palliative Medicine and Supportive Care, Kasturba Medical
College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka
documents, might be a limitation. The methodological 576104, India. 2 Kasturba Medical College, Manipal, Karnataka 576104, India.
challenges identified in some of the included reviews may 3
Karunashraya Bangalore Hospice Trust, Bangalore, India. 4 Department
have been transferred to this umbrella review during the of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher
Education, Manipal, Karnataka 576104, India. 5 Department of Critical Care
synthesis process, potentially presenting a limitation. It Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher
should be noted that most scoping reviews included in Education, Manipal, Karnataka 576104, India. 6 Department of Critical Care
this umbrella review did not assess the methodological Medicine, Bharati Vidyapeeth University Medical College, Pune, India. 7 P D
Hinduja Hospital, Mahim, Mumbai, India. 8 Yashoda Super Speciality Hospitals,
quality of primary studies in their review. Furthermore, Ghaziabad, India. 9 Oncoanaesthesia and Palliative Medicine, Institute Rotary
the limited representation of systematic reviews from low Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.
and middle-income countries may be a limitation, as the
Author contributions
evidence synthesised in this review may not accurately NS: Guarantor of the overview, Conceptualisation, formal analysis,
represent international practice. As it is overview of methodology, supervision, writing—original draft, writing—review & editing,
reviews, there might be overlap of primary studies and funding acquisition. VSD: Conceptualization, data curation, formal analysis,
methodology, writing—review & editing. MM: Data curation, formal analysis,
between reviews and findings may be amplified due to writing—review & editing. AP: Data curation, formal analysis, writing—
repetition. review & editing. AR: Conceptualisation and writing—review & editing,
Corresponding author. AD: Writing—review & editing. KR: Writing—review
& editing. SN: Writing—review & editing. VS: Writing—review & editing. SR:
Conclusion Writing—review & editing. Shivakumar Iyer: Writing—review & editing. RG:
ICU physicians must be skilled in prognostication and com- Writing—review & editing. RKM: Writing—review & editing. SB: Writing—
review & editing. SS: Writing—review & editing.
munication to enable families to make effective and timely
decisions. Family communication should be scheduled pro- Funding
actively and early, emphasising open, effective, and cultur- Open access funding provided by Manipal Academy of Higher Education,
Manipal. The study is funded by The End of Life Care in India Taskforce (ELICIT).
ally sensitive communication. This approach helps families
to cope better with uncertainty, reduces distress, and short- Data availability
ens ICU stays. Before eliciting goals of care and making All available data for this review is already provided as supplementary files.
decisions, inter-team discussion and consensus building are Declarations
essential. This approach aligns care with patient and fam-
ily preferences, fosters collaboration, and reduces conflicts. Conflicts of interest
The Authors declare no competing interest.
Decision-making tools and aids can be helpful. Discussion
 1455

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