When Dying Patients Fall Silent: How Nurses Navigate Decision‐Making in the Last Days of Life—A Qualitative Study

AIM: To explore nurses' perspectives on decision-making processes and influencing factors when caring for unresponsive dying patients in the last days of life. DESIGN: A qualitative interpretive study. METHODS: Using purposive recruitment and informal peer referral, twenty-one nurses from a specialist palliative care service in a metropolitan city in Australia were interviewed between July 2024 and January 2025. Data were analysed using reflexive thematic analysis. Decision-making theory was used as an interpretive lens. FINDINGS: Two themes were generated: 'The patient as an absent presence' and 'Enacting agency through embodied cognition and relational attunement', together with five interconnected subthemes. The analysis highlighted the importance of knowing the patient's cues and wishes. The data linked nurses' decision-making to both relational and communication processes, particularly in the context of family engagement and the care needs of the unresponsive dying patient. Other influences included uncertainty and the nurse's own professional practice. CONCLUSION: Nurses' decision-making when caring for the unresponsive dying patient is complex. Decision-making evolves through the nurse's intentionality in assessment, communication skills, accommodation of uncertainty, and through implicit ethical and moral agency. Recognising the vulnerability of unresponsive dying patients is essential to supporting person-centred care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: This research contributes valuable new insights into decision-making by nurses caring for a largely under-researched vulnerable population. Strengthening nurses' decision-making may support more timely recognition of care needs, improve assessment and management of distress or discomfort, promote person-centred care, and enhance communication with families when patients are in the final days of life. IMPACT: This study explored nurse decision-making among a vulnerable population of unresponsive dying patients. Creating relationships with the patient and their family through effective communication, informed and influenced nurses' decision-making. Patients die in many different health care settings. This research foregrounds the need for enhanced nurse decision-making when caring for unresponsive dying patients and their families. REPORTING METHOD: The research team adhered to the Standards for Reporting Qualitative Research (SRQR). PATIENT OR PUBLIC CONTRIBUTION: This study did not include patient or public involvement in its design, conduct, or reporting.