Measuring attitudes toward death and dying among adult intensive care unit staff: A systematic review of assessment tools

PURPOSE: Attitudes toward death and dying are central to intensive care unit (ICU) culture, influencing communication, ethical decision-making, moral distress and professional identity. Yet how these attitudes are measured in adult ICU clinicians, and the robustness of available instruments, remains unclear. We systematically reviewed tools used to assess attitudes toward death and dying in adult ICU staff. METHODS: This systematic review followed PRISMA 2020 guidance and was registered on PROSPERO (CRD420250527706). Medline, PsycINFO, CINAHL and Scopus were searched from January 1980 to December 2024. Original peer-reviewed studies using named quantitative instruments in adult ICU clinicians were included. Study selection was undertaken independently by three reviewers. Measurement properties were appraised using COSMIN criteria, and methodological quality using the Mixed Methods Appraisal Tool (MMAT). Given substantial heterogeneity in constructs and outcomes, findings were synthesised narratively. RESULTS: Fourteen studies reporting eleven primary instruments were included, predominantly involving ICU nurses and cross-sectional designs. Instruments addressed diverse constructs, including caring attitudes, perceived barriers to end-of-life care, ethical sensitivity, organisational values and treatment decision-making. Several tools demonstrated acceptable internal consistency and construct validity. Overall methodological quality was moderate to high, although sampling representativeness and non-response bias were frequently unclear. CONCLUSIONS: Current instruments provide fragmented and conceptually divergent assessments of ICU clinicians' attitudes toward death and dying. Limited cross-cultural validation and poor evidence of responsiveness constrain their usefulness for evaluating interventions or supporting improvement. More coherent, implementation-ready measurement tools are needed to strengthen end-of-life culture in intensive care.