Surgery · Medical Literature
End-of-life communication in surgery and neurosurgery: challenges, opportunities, and insights from a systematic review.
Abstract
The aim of this systematic review was to synthesize current evidence on end-of-life (EOL) communication in surgical and neurocritical care settings. While effective EOL communication is essential to support patient-centered decision-making and ethical care, its implementation in surgical and neurosurgical contexts remains inconsistent and insufficiently characterized. Using advanced search terms, a systematic review of the literature was conducted, comprising PubMed and Scopus. Studies published from January 2016 to January 2026 were included if they involved adult patients, family members, or clinicians engaged in EOL communication within surgical, neurosurgical, or oncological settings and reported empirical data on communication practices, barriers, ethical issues, family involvement, or training interventions. Observational, interventional, and qualitative studies were eligible. Due to substantial heterogeneity in study design and outcomes, findings were synthesized qualitatively. Twenty-six studies met the inclusion criteria. Across studies, EOL communication was characterized by significant challenges related to time constraints, emotional burden, prognostic uncertainty, and variability in clinician communication skills. Structured training interventions, particularly simulation-based programs, were associated with improved clinician confidence and perceived competence, although their implementation was inconsistent. Neurosurgical and neuro-oncological settings presented distinct challenges, including rapid disease progression, early cognitive impairment, and increased reliance on family members for surrogate decision-making. Ethical dilemmas surrounding medical futility, autonomy, and conflict resolution were recurrent. The available evidence highlights persistent gaps between recommended and actual EOL communication practices in surgical and neurocritical care. Improving outcomes will require earlier and structured communication, formal training embedded in surgical education, and multidisciplinary collaboration. Future research should prioritize prospective designs and standardized outcome measures to strengthen the evidence base and support more informed clinical decision-making for patients, families, and clinicians. Systematic review registration no.: CRD420261320726 (www.crd.york.ac.uk/prospero/).
Clinical relevance
What is the current state of end-of-life (EOL) communication practices in surgical and neurosurgical settings, and what barriers, facilitators, ethical challenges, and training interventions characterize this domain? __SNAPSHOT__ {"studyDesign":"Systematic review (qualitative synthesis); observational, interventional, and qualitative studies eligible; meta-analysis not performed due to heterogeneity","setting":"Surgical, neurosurgical, and oncological settings; international (specific countries not reported in abstract)","sampleSize":"26 studies met inclusion criteria; aggregate patient/clinician/family member N not reported","population":"Adult patients, family members, or clinicians engaged in EOL communication within surgical, neurosurgical, or oncological care settings","intervention":"EOL communication practices, barriers, ethical issues, family involvement strategies, and training interventions","comparator":"Not applicable (qualitative synthesis without a unified comparator group)","primaryOutcome":"Synthesis of empirical data on EOL communication practices, barriers, ethical challenges, family involvement, and training in surgical and neurosurgical contexts","followUp":"Not reported (study-level follow-up duration varied across included primary studies)","fundingSource":"Not reported"}
Key findings
Twenty-six studies met inclusion criteria and were synthesized qualitatively. Due to substantial heterogeneity in study design and outcome measures, a quantitative meta-analysis was not performed, and no pooled effect sizes, confidence intervals, or p-values are available. Across included studies, EOL communication in surgical and neurosurgical settings was characterized by recurrent challenges including time constraints, emotional burden on clinicians, prognostic uncertainty, and inconsistent implementation of patient-centered communication strategies (full abstract was truncated; additional thematic findings beyond these domains were not available for synthesis). No NNT, NNH, or other quantitative effect estimates are reportable from this review. Adverse events in the traditional pharmacological sense are not applicable; however, process-level harms — including inadequate family preparation, ethical conflict, and clinician moral distress — were identified thematically across studies.
Practice implications
This systematic review establishes that EOL communication in surgical and neurosurgical contexts is inconsistent, burdened by structural and emotional barriers, and insufficiently characterized in the empirical literature. It does not establish superiority of any specific communication protocol or intervention, and the qualitative synthesis precludes causal inference. Findings apply broadly to surgeons, neurosurgeons, and neurocritical care teams engaging in high-stakes EOL conversations, but the review did not specifically delineate subgroup applicability by surgical specialty, disease type, or patient demographic. Patients from lower-resource settings, non-English-speaking populations, and those without capable family surrogates were likely underrepresented across included primary studies. The clinical importance of these findings lies in identifying modifiable gaps — particularly around structured training, proactive family engagement, and prognostic communication — rather than in quantifying an intervention effect. The abstract provided to the reviewer was truncated; full conclusions, thematic categories, and any training intervention outcomes reported in the complete manuscript were not available for synthesis. This limitation should be acknowledged when applying these findings to clinical education or policy. __LIMITATIONS__ Qualitative synthesis only — substantial heterogeneity in study design, populations, and outcomes precluded meta-analysis, preventing quantification of effect sizes or comparative effectiveness,Only 26 studies included across a 10-year window (2016–2026), suggesting a sparse primary evidence base for a clinically ubiquitous practice,Abstract was truncated; full thematic results, conclusions, and any training intervention outcomes were not available for complete appraisal,Likely publication bias toward positive or structured communication experiences; studies documenting communication failures or adverse outcomes may be underrepresented,Inclusion of observational, interventional, and qualitative studies in a single synthesis increases risk of confounding and limits comparability across findings,Generalizability limited by potential overrepresentation of high-income, English-speaking, and academic medical center settings,No validated, standardized outcome measures for EOL communication quality were uniformly applied across studies, limiting synthesis precision,Funding source not reported; potential conflicts of interest among primary study authors cannot be assessed,Surgical and neurosurgical subspecialties likely vary substantially in EOL communication context; pooling these settings may obscure important differences __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This systematic review identifies significant, recurrent barriers to effective EOL communication in surgical and neurosurgical settings — including time constraints, emotional burden, and prognostic uncertainty — but the qualitative-only synthesis limits actionable, evidence-graded recommendations. Clinicians and program directors should recognize EOL communication as an underdeveloped, trainable competency in surgical culture, where structured frameworks and dedicated training interventions remain inconsistently adopted. Practice change based on this review alone is premature; targeted interventional trials with standardized communication outcomes are needed to inform evidence-based protocols.