Nurses’ experience of moral distress in the context of medical assistance in dying (MAiD): a systematic review

Abstract

Purpose: Moral distress poses a significant challenge in nursing, often arising in ethically complex situations and leading to negative outcomes such as mental and physical strain, burnout, staff turnover, and diminished care quality. As medical assistance in dying (MAiD) is an ethically contentious practice, it could be a major source of moral distress for nurses. This systematic review synthesizes international evidence on nurses’ experiences of moral distress in the context of MAiD and considers its relevance for the German healthcare system. The central question guiding this review is: What evidence exists on nurses’ experiences of moral distress related to MAiD? Methods: The review was pre-registered on PROSPERO and conducted in accordance with PRISMA guidelines. Peer-reviewed empirical studies in English were included, spanning all care settings. Databases searched were CINAHL, MEDLINE, and PsycINFO, supplemented by manual searches. Studies were screened using predefined criteria and assessed with Joanna Briggs Institute tools. A narrative synthesis resulted in a conceptual model outlining contributing factors to moral distress in MAiD. Results: From 3079 records, 25 studies (22 qualitative, 2 quantitative, 1 mixed-methods) from nine countries were included. Six interconnected themes were identified: (1) complex emotional reactions, (2) moral reasoning, (3) intrinsic factors, (4) situational factors, (5) relational factors, and (6) extrinsic factors. Conclusion: The findings underscore the complexity of moral distress in the MAiD context. Addressing this requires policy and educational strategies as well as the promotion of ethical dialogue and interdisciplinary support structures.