End-of-life care for forensic psychiatric patients: Ethical, legal, and systemic challenges in integrating palliative approaches

End-of-life (EOL) care for patients with serious mental illness (SMI) in forensic mental health settings remains a critical yet underexplored area of healthcare. Individuals with SMI experience significant health disparities, including reduced life expectancy due to preventable chronic illnesses. These challenges are compounded in forensic settings by legal constraints, systemic neglect, and limited access to palliative care services. This narrative review examines the unique barriers to EOL care in forensic psychiatric institutions. Key issues explored include diagnostic overshadowing, restricted patient autonomy, and the absence of integrated palliative care models. Additionally, ethical and legal dilemmas, such as involuntary treatment and advance care planning (ACP), are analysed in the context of forensic mental health. Best practices for improving EOL care in forensic psychiatric settings include the integration of multidisciplinary palliative care teams, trauma-informed approaches, and the development of hospice and alternative care models. Policy and systemic recommendations highlight the need for early palliative care consultations, legal reforms that balance patient rights with public safety, and enhanced staff training in EOL care competencies. Despite these proposed interventions, significant gaps remain in research, particularly in evaluating the effectiveness of palliative interventions in forensic settings. Addressing these gaps is crucial to ensuring forensic psychiatric patients receive compassionate, dignified, and ethically sound EOL care.