First-Hand Recommendations for Nursing Management to Support Nurses Involved in the Process of Hastened Death: A Systematic Review of the Qualitative Evidence

Aim . Te aim of this review was to support nursing management in creating frameworks for the care of people requesting hastened death, based on the best available evidence on the experiences of nurses. Background . Te legalisation of hastened death presents nurses with a complex set of ethical and moral risks. Te largely unregulated role of nurses in the politics of hastened death can lead to moral distress and burnout. Evaluation . A systematic database search was conducted in CINAHL, LIVIVO, Medline, OVID, and Web of Science. Te meta-aggregative approach was used to synthesise the fndings. Quality appraisal was done using criteria of the Joanna Briggs Institute. Key Issues . Sixteen studies from four diferent countries were included. Interview data were from 200 nurses. Meta-aggregation resulted in ten synthesised fndings including the need for guidelines; time resources; a supporting team; and professional, social, and personal skills. Conclusions . A working environment with clear guidelines, sufcient resources, structured professional adjustment programmes, and educational measures is supportive for nurses. Implications for Nursing Management . Nursing management should create a professional strategy, guidelines, promote good team culture, implement education, and training activities.


Introduction
Te legalisation of hastened death has confronted nurses with complex ethical and moral challenges in determining their own level of involvement in this new task.Nurses may already encounter problems when caring for geriatric people.It has been argued that the fear of hastening death by increasing the dose of morphine raises ethical issues [1].Uncoordinated voluntary abstention from food and drink can also be a source of moral distress [2].Especially chronically ill people sufering from cancer, neurological diseases (mostly motor neuron diseases), or end-organ failure (mostly heart failure and lung disease) express the wish for hastened death.Tey fear a loss of autonomy and control, sufer from unbearable physical symptoms or fear a sufering from them in the future (e.g., pain and nausea), or they have had negative experiences with death and dying in the past [3].Furthermore, old age, feeling lonely, and socioeconomic hardship are linked to the wish of hastened death [4].Good end-of-life care is important for nurses to prevent distressing events [5].Regarding hastened death, two approaches can be distinguished: (a) voluntary active euthanasia, i.e., the lethal drug is administered by a physician or, as in Canada, also by a nurse practitioner; (b) assisted suicide, i.e., the lethal drug is prescribed by a physician and the person who wishes to die takes the drug independently [6].Te preparation of the lethal medication can be done by a healthcare professional.Dying is recognised as a discursively constructed process in which medical-physical, psychological, emotional, social, and spiritual support is necessary [7].From this perspective, caring for people who wish hastened death is less a monoprofessional and more a multiprofessional matter.Terefore, the voices of all professional groups, such as physicians, nurses, social workers, and chaplains, should be heard in making the appropriate decisions [8,9].However, hastened death is primarily seen as the responsibility of physicians and the role of other professionals is rarely addressed [7,10].

Background
Te well-being of nurses is essential for integrated and effcient health service delivery.When nurses are unable to provide care in accordance with their own values, this can lead to psychological and moral distress and lower quality of care.Staf retention is negatively afected [11,12].Moral distress is often related to poor communication between the nurse and the interprofessional team, and the inability to fulfl a person's last wishes [1].To reduce the burden, nurse managers need to recognise and understand the problems and create a supportive environment [13].A scoping review of the role of nurses in hastened death has shown that nurses perform various tasks across the process continuum, from initial care and accompaniment, to assessing the person's condition, assistance in dying, debriefng, coordination, and documentation.However, depending on the country, their role is not always defned in the current legislation, which may lead them to practice outside the legal framework [14].Te unregulated role of nurses in hastened death policies jeopardises the safety of nurses (and patients) and may contribute to moral distress and burnout [15].Apart from the professional regulations, there is also a lack of qualifed training for nurses on the topic of hastened death [8,16,17].Systematic instructions are required to protect nurses, facilitate a safe working environment, and prevent morally questionable incidents.It is therefore necessary to defne which tasks fall within the responsibility of nurses and how they must be prepared [18].Tis systematic review of qualitative studies aims to support nursing management in creating a framework for the care of people requesting hastened death, based on the best available evidence on the experiences of nurses.On that basis, appropriate structures can be implemented, and education and training schedules can be designed.Te authors of this review are physicians, nurse, and anthropologist collaborating in a palliative care research group.In order not to bias the results of the review, the authors refected on their personal attitudes to the topic in advance and discussed them regularly within the team.Te study was guided by the questions "What experiences do nurses report who have cared for people requesting hastened death?What do nurse managers need to consider when designing a supportive environment for nurses?"

Methods
Te meta-aggregative approach of the Joanna Briggs Institute (JBI) was adopted, rooted in the philosophy of pragmatism [19].It is assumed that the goal of research is practical utility and that the new knowledge serves as a support for practical action [20].Te identifed studies were subjected to a quality check in order to obtain reliable results [21].As these are recommendations for concrete actions, they are presented in an if-then structure [19].Te review was registered on the PROSPERO platform (CRD42022322736).Te guidelines "Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ)" were followed for reporting [22].

Inclusion and Exclusion
Criteria.All types of qualitative studies were included if the study participants were nurses with experience in caring for people who wished hastened death, and if the article was peer-reviewed.We did not set a time limit on the publication date that could be included, but hastened death had to be legal at the time the study was conducted.Studies were excluded if they reported on nurses' attitudes towards hastened death or if participants were conscientious objectors.Due to limited resources for translation, articles had to be published in English or German.For further information, please see Supplementary Material Table 1.

Search Strategy.
A comprehensive literature search was conducted from July 2021 to December 2021 and updated in April 2022.Databases searched included CINAHL, LIVIVO, Medline via PubMed, OVID, and Web of Science.Te PICo mnemonic was used to defne the criteria population "nurses," phenomenon of interest "experiences," and context "care of people requesting hastened death" [21].In addition, search terms were used that related to the study design.Te search terms were combined with Boolean operators, and truncation was applied where appropriate (see Supplementary Material Table 2).Citation tracking was performed in the reference lists of the included articles and in the identifed systematic reviews.

Study Screening Methods.
Te identifed records were imported into the literature management programme Citavi (© Swiss Academic Software GmbH) and duplicates were removed.After the screening of the title and abstract, which was carried out by one researcher, the remaining full texts were checked for eligibility by two independent researchers.Discrepancies were discussed with a member of the research team.Before a fnal decision on inclusion was made, the quality of the studies was assessed.

Quality Appraisal.
Te quality appraisal was carried out using the JBI Critical Appraisal Checklist for Qualitative Research [23].To provide confdence in the results, the ConQual approach was used for scoring.Te score is composed of the dependability and credibility ratings.If the dependability score is 4 or 5, the study score remains high.If the rating is 2 or 3, the study is downgraded by one level, and if the rating is 0 or 1, the study is downgraded by two levels.To assess credibility, the fndings of the studies (= level 1 fndings) are graded as "unequivocal," meaning that the fnding is beyond doubt, "equivocal," meaning that the fnding is not entirely clear, or "unsupported," meaning that no supporting data could be found in the study results.If the synthesised fnding (= level 3 fnding) contains only  [25] to be categorised and synthesised.Categories (� level 2 fndings) were developed based on at least two level 1 fndings that were similar in meaning.Two or more similar level 2 fndings were combined to form level 3 fndings [21].Te synthesis process was carried out through consensus discussions within the review team.For this purpose, the results were summarised in a table, reviewed and discussed within the team for conclusiveness, selectivity, and delimitability.

Study Selection Results. Te Preferred Reporting Items
for Systematic Reviews and Meta-Analysis (PRISMA) fowchart [26] in Figure 1 shows that 1402 studies were identifed via databases.A total of 818 duplicates were removed and 537 records were excluded after title and abstract screening.Te full texts of 47 studies were screened for eligibility.A total of 16 studies met the inclusion criteria.

Study Characteristics.
Te 16 studies were conducted in Belgium (n = 5), Canada (n = 9), Switzerland (n = 1), and Te Netherlands (n = 1).Tey were published between 1998 and 2021 and used diferent methodological approaches: Grounded Teory (n = 6), interpretive description (n = 3), narrative enquiry (n = 2), in-depth qualitative enquiry (n = 1), qualitative description (n = 1), qualitative interview (n = 1), and qualitative unspecifed enquiry (n = 2).A total of 200 nurses were interviewed, with interviews with 104 nurses analysed in more than one study.Te methods of analysis used were thematic analysis (n = 6), grounded theory (n = 4), interpretive descriptive method (n = 3), constant comparative method (n = 2), and deductive categorisation (n = 1).Tree studies examined nurses' involvement in hastened death.Tree other studies aimed to determine the experiences of nurses in caring for people requesting hastened death.One study each examined the meaning of sufering, communication, moral experiences, and the experience of support in relation to hastened death.
One study each looked at the care of people requesting hastened death in the context of palliative care and in the context of care for older people.Two studies each examined the role of nurses and the implications for nursing practise.Te characteristics of the studies with references are summarised in Table 2.

Quality Appraisal Results (Findings/Credibility).
No distinction was made between voluntary active euthanasia and assisted suicide.Results from nurses who were legal providers or conscientious objectors were excluded.In some studies, the phenomenon of interest also included the experiences of other health professionals.Terefore, level 1 fndings that were not supported by a direct quote from a nurse were rated equivocal.A total of 310 unequivocal and 124 equivocal fndings were included and 40 unsupported fndings were excluded.Many of the unsupported fndings could also be found as supported fndings in other studies and were therefore included in the synthesis in this way, such as overwhelming feelings, highly professional care, and importance of communication.However, there were also unsupported fndings that had only been made in individual studies and could therefore not be included in the synthesis.Tis concerned, for example, statements about spatial diffculties when people did not want to carry out assisted suicide at home [40] or about informing the team about a person's expressed wish to die without having asked the person's permission beforehand [38].Te synthesised fndings are considered valid, as the ConQual scores of six of them are classifed as "moderate" and the ConQual scores of four as "high" (see Table 3).

Review Findings.
Te meta-aggregation produced ten synthesised fndings.Tese comprise two, three, or four categories, respectively (see Supplementary Material Table 3).

Synthesised Finding 1: If Nurses Are to Provide Good
Care, Tey Need Sufcient Time Resources.Problems related to lack of resources comprise three categories: "care for patients requesting hastened death is time consuming," "nurses face time restrictions," and "time constraints may have consequences."Nurses report a negative impact on the care of people requesting hastened death caused by a lack of resources, especially time (A4, A10, and A13), because "time is of essence for a good experience of the process" (A6, p. 44).It is important for nurses to provide good care (A6 and A8), but caring for people who wish hastened death is time consuming and can be at the expense of caring for others (A9 and A10).Nurses need time to connect with the person to build a relationship and better understand the request (A1, A13, and A15): Te man came to the hospital for his euthanasia, and you don't know him, and he only came for his euthanasia.(. ..)We weren't involved in any way, and I felt horrible about it, like, he comes over to die, and we haven't had any conversation with him, we didn't know him.(A1, p. 499)

Synthesised Finding 2: If Nurses Are to Provide Good
Care, Tey Need a Supporting Team.Te importance of a well-functioning team is described in three categories: "being part of a team and cooperation within a team is essential," "debriefngs are helpful to overcome uncertainty," and "senior nurses and managers play an important role for functioning teams."Team culture is critical to how nurses experience hastened death and whether or not they feel judged by team members (A11).Te quality of collaboration within the interprofessional team determines the quality of the process (A1, A2, A6, A7, and A13).It is the responsibility of senior nurses to promote good group dynamics (A8), as diferent attitudes among team members can cause problems (A9 and A11).While conscientious objectors may feel excluded from caring for people requesting hastened death Note: Y � yes; N � no; U � unclear; dependability scores derived from Q2, 3, 4, 6, and 7. JBI critical appraisal checklist for qualitative research [23].Q1: Is there congruity between the stated philosophical perspective and the research methodology?Q2: Is there congruity between the research methodology and the research question or objectives?Q3: Is there congruity between the research methodology and the methods used to collect data?Q4: Is there congruity between the research methodology and the representation and analysis of data?Q5: Is there congruity between the research methodology and the interpretation of results?Q6: Is there a statement locating the researcher culturally or theoretically?Q7: Is the infuence of the researcher on the research, and vice versa, addressed?Q8: Are participants, and their voices, adequately represented?Q9: Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?Q10: Do the conclusions drawn in the research report fow from the analysis, or interpretation, of the data? 4 Journal of Nursing Management Journal of Nursing Management 6 Journal of Nursing Management (A15), supporters may see resistance from their colleagues as a barrier to good care.Supporters may also feel isolated from the team, especially if managers appear to be among the objectors (A11).But team members learn to respect diferent attitudes (A16) and even often opposing views of palliative care nurses and hastened death supporters can develop positively (A13).When well-functioning teams have formed, it can be difcult for newcomers to be included and gain experience (A13).It is considered important to be part of a team and be able to help and support each other (A2, A12-A14).Senior nurses try "to be there as a pillar for the team, someone they can rely on" (A7, p. 3376).In doing so, they feel responsible for both the nurses and the physicians (A8).Formal debriefngs, either at the individual or team level, are considered helpful (A9 and A16).Informal conversations cannot replace these formal debriefngs (A11), although a "conversation in the corridor" (A16, p. 504) can be a source of support (A11 and A16).However, nurses may also feel unsupported in conversation, which can be accompanied by insensitive behaviour (A11).Nurse managers need to facilitate communication and support teams to create new forms of rituals: "We needed some sort of ceremony around it because it felt so weird because there wasn't any preamble or post anything" (A15, p. 7).

Synthesised Finding 3: If Nurses Are to Provide Good
Care, Tey Need Clear Guidelines and Policies.Tis fnding reports on the need for a clear defnition of responsibilities and processes.It includes two categories: "the caring process is complex, needs good organisation and develops over time" and "clear guidelines and policies help to reduce uncertainty."Te care process for people requesting hastened death has been described as complex and dynamic (A5, A7, A8, and A13).It can be compromised by inadequate teamwork and the care system (A4 and A13).Accurate planning, good organisation, and early identifcation of potential problems are crucial for high process quality (A5, A7, A8, and A15).Te lack of clear guidelines can lead to uncertainty and make nurses uncomfortable (A1, A2, A4, A5, A13, and A15).Ten, they may even be unsure whether they are allowed to talk about hastened death (A15).Moreover, "introducing the topic (. ..) might be misinterpreted as an invitation to request for it" (A10, p. 450).Practical aids, e.g., care protocols and checklists, proved helpful (A5, A15, and A13).Over time, the process evolves, and care becomes easier.Te team moves forward and feels prepared for future requests (A5-A7, A10, A13, and A14).

Synthesised Finding 4: If Nurses Are to Provide Good
Care, Tey Need Professional Skills.Tere is a need for qualifed nurses with high professional expertise, comprising three categories: "caring for persons requesting hastened death is not routine nursing care and may lead to professional satisfaction," "nurses must learn to distinguish between professional role and personal views," and "there is a need for further training."A high demand for professional nursing skills has been described, ranging from understanding sufering to postmortem activities (A2, A12, and A15).Care for people who wish hastened death is considered part of holistic care (A2, A4, A7, A15, and A16), where nurses need to provide the best possible care (A1, A5-A8, A13, and A16) to achieve "the most patient-centered death possible" (A15, p. 7).If hastened death is a new feld, nurses may face the challenge of generating new knowledge by themselves (A15).Tis can be seen as an opportunity to change routine nursing practice (A1, A2, A5, A12, A14, and A15).It may also lead to a change in the understanding and scope of nursing (A4, A14, and A16).Although it is not always easy, nurses try to separate their personal views from their professional role (A5, A6, A13, and A15):  A14).An exit strategy should be in place in case they change their mind (A15).Sometimes it can be difcult for nurses to fully understand the request (A1, A5, A6, and A16).As people often use vague terms (A16), nurses need to thoroughly assess individual values and expectations (A7, A15, and A16).It is necessary to refect on the possible reasons for the wish to die (A7 and A15): When we have a patient who says, loud and clearly: "want euthanasia!Don't bring me all the twaddle of palliative care.I want euthanasia!"Even then, we [. ..] say: "Okay, we want to have these conversations with you.We want to listen.(. ..)Just to make sure that it is your wish to die instead of merely wanting to be rid of physical pain" (A7, pp.3375-3376).
If nurses are open minded, alert, and attentive, the request should not come as a surprise (A8).Nurses emphasise the importance of communication with all members of the interprofessional team (A1, A2, and A7).It is important that the team is well informed (A5, A7, and A16), that each team member has the opportunity to contribute to the discussion and that they actively listen to each other (A7 and A8).Nurses should be actively involved in decision-making because of their close relationship to the person wishing to die-but this is not always the case (A6, A8, and A16): "(. ..) we sometimes have the feeling that the doctor decides fully independently (from the nursing team).(. ..)Tis is such a pity, because we do build up a diferent sort of relationship with the patient than the physician does" (A6, p. 44).
When talking to people requesting hastened death and families, it is important to create a communicational atmosphere, to take time to listen attentively and to address issues that are not related to hastened death.Nurses need to learn what words are appropriate and how to address a request (A1, A5, A7, A9, A10, and A15): "If you miscommunicate and impair your relationship with your patient, they may not trust you with this kind of sensitive information.We should have clinicians practice with simulated patients, and experts in communication can give feedback" (A9, p. 192).Troughout the process, nurses should "simply be there" (A7, p. 3375) for the person and family (A7 and A12) and, at the time of action, support "anyone who needs it (patient, family, colleagues, physician)" (A8, p. 2415).To "create closure in time and space" (A5, p. 270), nurses say goodbye to the dying person, take care of the family, and stay in contact with the family beyond that, e.g., by attending the funeral (A5, A8, A9, A15, and A16).

Synthesised Finding 7: If Nurses Are to Provide Good
Care, Tey Need to Change Teir Perspective.Nurses need to rethink their current perspective: "the experience of a hastened death may difer from that of a natural death," "nurses understanding of the value of life may difer from that of the person requesting hastened death," and "nurses may be insecure about the request."Nurses need to refect on their own attitudes towards hastened death.Tis can be particularly challenging if their understanding of the value of life difers from that of people requesting hastened death (A1 and A2).With increasing experience, nurses' view of dying may change (A3).As a planned phenomenon (A1, A3, and A12), this form of death is often experienced as more peaceful and deliberate than natural death (A6) and sometimes has a celebratory character (A2 and A12).It may seem unreal how quickly death occurs (A15 and A16): Te process is so incredibly smooth and peaceful that there's no trauma involved in watching it happen.[. ..]Te patient literally says yeah, I feel. . .and they're asleep.And then the stuf that ends their life happens while they're sound asleep.It's really incredibly peaceful.I think the whole thing takes something like fve minutes, and they're asleep after the frst 30 seconds.(A12) When patients die, nurses can be emotionally afected on a personal level (A4).While most nurses perceive hastened death and natural death as similar, others state that the natural death of people they have known for a long time can be even more difcult (A8 and A11).For some, hastened death is a violent form of death (A4) and a negative experience, especially when relatives cannot accept the person's decision (A10).Tey are aware of a potential misuse (A3, A9, and A16).

Synthesised Finding 8: If Nurses Are to Provide Good
Care, Tey Must Act as Mediators.Nurses are torn between two or more parties, such as ". ..between the person requesting hastened death and the family" and ". ..between the person requesting hastened death and the interprofessional team."When disagreements arise between family and the person requesting hastened death, nurses act as mediators, trying to make peace and resolve tensions (A7, A8, and A10).In the interprofessional team, nurses try to evoke an understanding of the person's decision (A7 and A12).While the request should be discussed between the person and physician (A16), nurses act as translators to ensure that both parties understand each other correctly (A7).Difculties can arise when physicians do not stick to agreements and nurses are not allowed to answer questions from the person requesting hastened death (A6): So that (the palliative sedation) in itself went well and all, but it has not been the patient's wish.We were not acting in a correct manner.Te request had been uttered before.(. ..)And then it becomes difcult, because the doctor comes and goes, but as a nurse you provide 24h-care.(A6, pp.44-45) 4.5.9.Synthesised Finding 9: If Nurses Are to Provide Good Care, Tey Need to Know that Tere Will be Emotional Ups and Downs.Several emotional challenges that can be associated with this task, such as "caring for persons requesting hastened death is emotionally demanding and may come along with positive and negative feelings," "nurses need help when deciding for or against participating in hastened death," and "nurses must develop coping strategies."Nurses feel a great sense of responsibility and describe caring for people requesting hastened death as demanding, intense, upsetting, and exhausting (A1, A4, A6, A10, and A14-A16).Caregiving can be associated with feelings of sadness, distress, and frustration (A1, A2, A9, and A14) and with a "yet unknown emotional impact over time of aiding in assisted deaths" (A3, p. 273).Some nurses think about it for several weeks after a hastened death (A4) and feel they can never get used to it (A6).Coping strategies such as a task-oriented approach, physical activities, and talking with the partner can be helpful (A3, A6, and A14).Some nurses also report a mixture of conficting emotions and surprisingly positive feelings (A1, A2, and A6).Tey experience working in this feld as a personal growth process (A5) and describe it as satisfying.Tey feel happy and grateful to be able to help (A2-A4, A6, A12, and A14).Tey also feel it is an honour and privilege to share this intimate moment with someone (A1 and A2) from whom they receive gratitude (A3 and A14): Te patients always say that they're grateful that their sufering is going to be over and the family members, whether they agree with the care option or not, because a lot of family members think this is awful, even after the assisted death has happened, the family members usually say, I'm happy that their sufering's over.(A14, p. 3879) 4.5.10.Synthesised Finding 10: If Nurses Are to Provide Good Care, Tey Need to Know that Hastened Death Will Afect Palliative Care.Hastened death may impact providing and receiving of palliative care.Te aspects were pointed out: "nurses must be aware that hastened death is a diferent approach to natural death," "nurses struggle with structural shortcomings," and "nurses observe conficts between palliative care and hastened death."Nurses report that the legalisation of hastened death could have a negative impact on palliative care.On the one hand, they fear that people believe that palliative care will accelerate death (A9 and A13).On the other hand, they observe that dying naturally is less accepted and people insist on a quick death (A1 and A6).While waiting for hastened death, it can be difcult for nurses to maintain the eligibility of the person and pain and symptom control (A10 and A13).Some nurses are certain that palliative care could have provided good solutions in many cases, but people are unwilling to compromise or have difculty accessing palliative care services (A13 and A15).It is problematic when the media focuses more on hastened death (A9) and resources are shifted from palliative care to this form of dying (A10).

Discussion
Tis review summarises the fndings of 16 studies on nurses' experiences of caring for people requesting hastened death.Te legalisation of hastened death confronts nurses with a complex set of ethical and moral risks.Te review has shown that nurses need to know what they are allowed to do, they need to have the appropriate skills and sufcient time.Although a person's wish is followed, caring for persons requesting hastened death is described as ethically challenging due to its high complexity.Of particular concern are the potential long-term personal and professional efects on nurses' emotions and moral values, which may afect their ability to work.Nurse managers need to create a supporting environment to prevent nurses from moral distress and burnout, including providing opportunities for moral deliberation and supervision.
Guidelines clearly outlining nursing competencies in relation to hastened death are therefore necessary [8,16].Te WHO [18] stresses the importance of competency frameworks that are fully applied in nursing practice and that nurses are involved in the development of these guidelines.Te nursing process for people requesting hastened death begins with the request and does not end with the death of the person, but still includes the care of the grieving relatives.Nurses need to be recognised as an essential part of the decision-making process by law and by the interprofessional team.If this is the case, they can understand and accept why a hastened death is being carried out [16].
Caring for people requesting hastened death is emotionally demanding and challenges personal values and beliefs.Te well-being of nurses requires structures where formal and informal psychosocial and spiritual support is available [6,18,43].Debriefng provides an opportunity to talk openly about difcult situations and allows nurses to refect on their experiences.Educational needs can be identifed.Tis improves the process and can protect professionals from burnout [44,45].Time is essential to build relationships with the person who wishes to die and the family, and not having enough time can be perceived as a moral failure [6].Terefore, safe stafng is necessary [18], i.e., there must be enough nurses on duty at all times [46].Senior nurses need leadership skills to ensure a good team culture in well-functioning interprofessional teams.

Journal of Nursing Management
Diferent attitudes within the team must be accepted [43] and should not cause confict [47].Nurses need support when they have to decide whether to participate in hastened death or not.Teir decision must be accepted without condemnation.All team members need to be aware that there may be diferent reasons for the decision and that attitude towards participation can change.New nurses need to be welcomed by the established team to enable them to gain experience themselves.Tis process can be supported by a buddy system that promotes both onboarding and knowledge sharing.In a buddy system, an experienced nurse accompanies the new nurse through the frst weeks on the ward.If new team members have fxed reference persons, they can familiarise themselves with the unit culture more quickly and feel comfortable [48].
Te review has shown that specifc education for all nurses should be introduced.Preparation for "this new type of death" [49] (p.227) is essential, and nurses need to learn to refect on their own attitudes towards (assisted) dying and death.Training should be provided by experienced nurses [18].As these are rare in this feld, the development of online programmes, such as Massive Open Online Courses (MOOCs), should be considered.Tereby, nurses could beneft from the knowledge of experts, regardless of location [50].
Studies in this review emphasise the importance of communication skills.As in previous studies, it was found that nurses need to learn how to respond to a request and how to determine if hastened death is really what the person wants [43,51].Simulation training to practice communication is advisable [18,52].Te research-based theatre method could be used to increase empathy and promote interprofessional collaboration.Nurses would have the opportunity to put themselves in diferent roles to better understand the feelings of the person afected.Tey would also be able to refect on their own role in the nursing process and the challenges they may face when caring for these people [53].Similarly, training in palliative and end-of-life care should be provided.Nurses need to learn to explore and address untreated sufering [16,43] and be competent in managing pain and symptoms at the end-of-life.

Limitations.
Tere are diferent legal regimes for hastened death in diferent countries.Tey difer in the location where the dying process is carried out (e.g., at home, in the hospital, and in a special facility), in access requirements, and in who may provide assistance in dying and in what way.However, we were unable to make any distinctions here, with the exception that we excluded quotes from nurse providers.Little information was provided about the demographic characteristics of nurses, such as ethnicity and religious afliation that might infuence their decisionmaking and experiences.Te 16 articles were from nine studies conducted in four countries.Although hastened death is legal in several countries and states of the United States of America (USA), no other suitable studies were found.Tis may be due to the fact that in most of these countries, the law has only recently been enforced.In the US-studies, the results of interviews with diferent health professionals were published together, and the quotes of nurses were either too few or the experiences of nurses were not delineated.It must therefore be assumed that the scope of experience is limited.

Conclusions
Care of people requesting hastened death can be challenging for nurses.A supportive environment can be helpful to avoid moral distress and burnout.In most countries, the care of people requesting hastened death is a new feld in nursing practice.As society changes, this feld will also change, experience and knowledge will increase.In the words of one nurse: "It's like living grounded theory.We're making it up as we go along" [40] (p.8).Continued research on this topic is essential to inform policy makers, professional associations, and nurses in management and practice.

Implications for Nursing Management
To avoid moral distress and burnout of nurses when caring for people requesting hastened death, they need a supportive environment.Terefore, nurse managers should create frameworks in terms of (1) establishing guidelines that address the role of nurses in hastened death, (2) create a professional strategy in responding to requests for hastened death, (3) providing sufcient (time) resources, (4) establishing regular debriefngs, (5) promoting a good team culture, (6) introducing a structured professional adjustment programme for new members of the nursing team, and (7) integrating the topic of hastened death into education and training.

Table 1 :
Appraisal of study quality and assessment of dependability.
‡ High: the synthesised fnding contains only unequivocal fndings.Downgrade 1 level: the synthesised fnding contains a mixture of unequivocal and equivocal fndings.