Prevention and Resolution of Ethical Issues that Arise in End-of-Life Care in Low- and Middle-Income Countries (LMICs): A qualitative study in a University Teaching Hospital in Nigeria

Abstract Background End-of-life (EOL) care is a critical aspect of healthcare that raises ethical concerns for patients, providers, and families. Preventing and resolving these ethical issues is essential to ensure high-quality care. While Western contexts have established guidelines based on lived experiences in high-income countries, these are often applied in low- and middle-income countries (LMICs) such as Nigeria, since empirical data on lived experiences are almost nonexistent. However, cultural factors and available tools in LMICs strongly shape end-of-life (EOL) care practices. Understanding the local context is therefore essential for improving ethical decision-making. This study examines strategies used at one of Nigeria’s most developed Oncology and palliative care units to prevent or resolve ethical issues in EOL care within a teaching hospital. Methods This cross-sectional qualitative study was conducted over two months at the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria. In-depth and key informant interviews using semi-structured guides were used to investigate how ethical challenges faced by dying patients, families, and healthcare personnel were prevented or resolved. Ethical approval was secured, and written informed consent was obtained from all participants. Descriptive statistics were used to analyze demographic data, while qualitative content analysis of the interview data was performed using NVivo 12 software. Results The study found a complete absence of clinical ethics committees and the use of advance directives. Ethical issues were often resolved through collaborative discussions and actions with relevant stakeholders, as well as discussions between healthcare teams and families or patients, and by upholding patients' values, although some issues remained unresolved. Strategies to prevent ethical challenges included involving families in patient care, holding family meetings, and fostering strong patient-doctor relationships. However, some preventive measures previously reported in the literature were not used. Conclusion Family involvement and meetings, empathetic doctor–patient relationships, collaboration, discussions, and respect for patient and family preferences were identified as key strategies for preventing and resolving ethical issues in EOL care. Strengthening these existing methods is vital, as they remain reliable in the absence of other reported approaches. Exploring preventive pathways not yet implemented is also critical for comprehensive EOL care in Nigeria.