Care of the dying patient in austere environments: a systematic review

Deployed end-of-life care represents an area of increasing importance amidst near-peer conflicts where air superiority is no longer guaranteed. This complex intersection of medical ethics and battlefield realities is an area where current doctrine is lacking. This leaves soldiers and military clinicians vulnerable to moral injury, without a clear decision-making framework. This systematic review explores the existing literature surrounding end-of-life care, euthanasia, reverse triage and end-of-life decision-making in austere environments.

A systematic search of MEDLINE, CINAHL, Embase and Web of Science databases (inception October 2024) was performed using exhaustive terms, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. The search was limited to English-language publications in peer-reviewed journals. Citation searching of included articles' references was also conducted to identify peer-reviewed publications and applicable grey literature. Papers were reviewed by a minimum of two reviewers to determine inclusion. Each study was assessed for quality and bias.

A total of 32 studies were included. Internal factor analysis was structured using the Training, Equipment, People, Infrastructure, Doctrine, Clinical, Organisation, Information, and Logistics framework. Of the framework headings, training was most frequently referenced, resulting in a focus on the practical changes that should be made to the training of our service personnel in preparation for expectant casualty care delivery.

End-of-life care in the deployed space is an ethical and operational necessity. With the current move from Battlefield Advanced Trauma Life Support to Tactical Combat Casualty Care within the British military and the resulting review of protocols, there is an urgent need to harmonise doctrinal frameworks across NATO. Developing prolonged casualty care training for medical service personnel and the surrounding logistics and leadership will ensure that dignity and comfort at the end of life is not neglected in the fog of war.