Palliative and end-of-life care on the battlefield: a scoping review

Abstract Background Modern conflicts have brought about a paradigm shift in military medicine. In Prolonged Field Care, recommendations have so far focused on damage control and care aimed at ensuring survival. But, particularly in large scale combat operation, not all patients will survive, and despite the development of palliative care in the civilian sector, no extension of this approach has yet been envisaged for military medicine. This review aims to identify knowledge gaps in palliative and supportive care in combat situations. Methods We conducted a literature review in PubMed, CAIRN, Scopus and Embase, with the last search carried out on 31 December 2025, using triangulation at each stage of the screening process. Studies published since 1900 focusing on frontline palliative and end-of-life care for combatants were included. Results Of 3,629 unique records, 35 articles were included, ranging from World War II-era accounts to current prolonged field care guidelines. Pain management was the most extensively documented topic. Morphine, a historical mainstay, has been increasingly supplemented by oral transmucosal fentanyl citrate and ketamine. Ketamine was favored in austere settings for its hemodynamic stability and multi-route administration. Other analgesics, such as paracetamol and NSAIDs, were also briefly described. Regional anesthesia was recognized as an analgesic force multiplier, though never described in an explicitly palliative context. For expectant and dying casualties, a limited but consistent body of literature addressed opioid titration and palliative sedation, notably via continuous midazolam infusion. Diverse end-of-life-related symptoms were addressed, including nausea, dyspnea, secretions, and delirium. Non-pharmacological measures, such as thermal regulation, mouth care, disarming, and comfort items, were described as accessible across provider levels. Spiritual care and family communication, though addressed in few sources, emerged as important but under-formalized components. Overall, evidence specific to palliative and end-of-life battlefield care remains sparse and largely extrapolated from curative-care literature. Conclusion Pain management in combat is a well-researched field, but one that is rarely examined in the specific context of end-of-life care. Similarly, there is a notable gap in the literature regarding palliative care in a combat context. Where such topics are addressed, they are often simply a transposition of civilian data. The lack of training and doctrinal guidance prevents the proper integration of this specialized care, which aims to ensure dignity for dying combatants and to reflect the values upon which military medicine is founded. Clinical trial number The protocol was pre-registered on the Open Science Framework (OSF) on 8 December 2025 (DOI: 10.17605/OSF.IO/U9RSG). Take-home message As future conflicts threaten to bring mass casualties on a scale that counterinsurgency warfare never approached, this scoping review reveals that current guidance on palliative and expectant battlefield care remains fragmented. By synthesizing the existing evidence and identifying key gaps, this review lays the foundation for standardized protocols to help providers deliver ethical, compassionate care to dying combatants.