Real-world ethics in palliative care: a systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice

Guy Schofield*, Mariana Dittborn, Richard Huxtable, Emer Brangan, Lucy Ellen Selman

*Corresponding author for this work

Research output: Contribution to journalReview article (Academic Journal)peer-review

19 Citations (Scopus)
168 Downloads (Pure)


Background: Ethical issues arise daily in the delivery of palliative care. Despite much (largely theoretical) literature, evidence from specialist palliative care practitioners about day-to-day ethical challenges has not previously been synthesised. This evidence is crucial to inform education and adequately support staff.

Aim: To synthesise the evidence regarding the ethical challenges which specialist palliative care practitioners encounter during clinical practice.

Design: Systematic review with narrative synthesis (PROSPERO registration CRD42018105365). Quality was dual-assessed using the Mixed-Methods Appraisal Tool. Tabulation, textural description, concept mapping and thematic synthesis were used to develop and present the narrative.

Data Sources: Seven databases (MEDLINE, Philosopher’s Index, EMBASE, PsycINFO, LILACS, Web of Science, and CINAHL) were searched from inception to December 2019 without language limits. Eligible papers reported original research using inductive methods to describe practitioner-reported ethical challenges.

Results: 8074 records were screened. 13 studies from 9 countries were included. Challenges were organised into 6 themes: application of ethical principles; delivering clinical care; working with families; engaging with institutional structures and values; navigating societal values and expectations; philosophy of palliative care. Challenges related to specific scenarios/contexts rather than the application of general ethical principles, and occurred at all levels (bedside, institution, society, policy).

Conclusion: Palliative care practitioners encounter a broad range of contextual ethical challenges, many of which are not represented in palliative care ethics training resources, e.g. navigating institutional policies, resource allocation and inter-professional conflict. Findings have implications for supporting ethical practice and training practitioners. The lack of low- and middle- income country data needs addressing.
Original languageEnglish
Pages (from-to)1-20
Number of pages20
JournalPalliative Medicine
Early online date11 Dec 2020
Publication statusE-pub ahead of print - 11 Dec 2020


  • ethical challenges
  • systematic review
  • palliative care
  • empirical bioethics
  • clinical ethics
  • bioethics


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