Table 3 Summary of the included qualitative studies

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.