The Search On DataBases YIELDED A Total of 3122 Records. Subsequently, These Records WERE Imported Into Rayyan for Deduplication and Screening, and 1395 Entries Were Removed. The title and Abstracts of the Remaining 1727 Reviews WEERE Independently Reviewed by Two Authors, Excluding 1459 ReviewsUnrelted to the Review's Eligibility Criteria. The Remaint 268 Search ReCords Underwent A Full-Text Screening Process, With An AdDityal Exclusion of 2222 8 Reviews Not Meeting the Inclusion Criteria. Consequently, 40 Papers Remained for the Final Analysis and Synthesis.Text Screening Were Excluded Based on Settings Other than Peri-Intensive Care Setting, Meaning Care Before, During and after Icu Admission (N = 81), Reviews That Wee NOT Done SystemAtically, Meaning Reviews Without A Search Strategy or Synthesis (n = 48), Language Other than English (n = 12), Population Other than Adults (n = 13), not focused on end-of-life or palliant cares (n = 74). On process is Illustrated as a Prisma Flow Diagramin Fig. 1.

The Characteristics of the Systems Incorpoled Into the Analysis Are Provided In Table 1. P in supportmentary file 5, and a description of each systematic review in the umbrella review is provementary file 6. SUPPLEMANTARY FILE 7 Provides a View of the Country of Origin of Systematic Reviews, and Fig. 2 Provides a Year-Wise Distribution of Public EWS.

The Quality of Each Systematic Review Included in The Synthesis Was Evaluated USING An 11-ITEM JBI Critical Appraisal Checklist [32] Entary File 8. Of the Included Reviews, 28 (22 Systematic and Six Scoping Reviews) WERE High Quality.Eleven Reviews (NINE SYSTEMATIC and TWO Scoping Review). Eir Methodology Quality. MobileInclusion Criteria (Q2) and Search Strategy (Q3). Thirty-Five Reviews Had Search at Least Three DataBases (Q4). WS [41,42,43,44,45,46,47] DIDNot have a critical appraisal (q5). TheRe Wee Eight Scoping Reviews [48,49,50,52,53,54,55]. Opping Reviews, TWO Reviews [52, 54]Assessed the method of the inforting itms for overViews (Prior) Checklist is provided in SUPPLEM Entary File 9. Table 2 Provides information on Palliative and End-OF-LIFE CARE PRACTIES in Icus and their Outcomes.Visually Represented in Fig. 3.

In a Few Systematic Reviews [41, 45, 46, 56,57,58], Prognostification and Prognostic Communication Were Described As A Palliative Care Practice with ICU. It. It. It EncompaSset icu Physicians with Proficience in Prognostic Estimates [45, 56], CreatingA Trigger-Based Palliative Care Referral System Based on Predictive Estimates [41, 57] And using Program Scales [56]. HE ICU Physician to Intuitively Recognise A Patient Who Might Benefit from Palliant Care in the Early Phase of ICUManagement [45, 56]. Palliative care integration in iCus Enabled ICU PHYSICIANS to Readily ReCogNISE END-OFE PALLIATIVE CARLAEDS [57]. While Communicating with Surrogates, ICU Physicians used numerical prognostic estimates, Diagrams and Radiography to Predict Outcomesand survival [56]. Predictive estimates in medical and surgical ICUs to trigger palliative care referral relied on age, comorbidities, length of ICU stay, days on mechanical ventilation and presence of cancer and chronic illnesses leading to end-stage organ impairment [41,57].

Involvement of Experienced Clinicians in Program and USINOSTIC Scales ImproVICAL PRINICAL PRINICAL PRINICAL PRINICAL PRINICAL PRINICAL PRINICAL PRINICION Gnostication, They Could Quickly Recognite the Need For Palliant Care [56] and the end-of-life phase [58], Which Facilities SharedDecision-Making [45, 56], Enhanced Access to Palliative Care [58], Reduced icu Stay, and Improved Family SatisFaRe [41]. On Icians' Lack of UNDERSTANDINGINGINGINOSTISTIS IMPEDED TIMELY Referrals to Palliative Care[46] And Left Families DISSATISFIED with the Communication They Received [41]. FURTHERMORE, a WANT of Prognostic Skills Results Receiving InappaPP Ropriate Care in the ICU, Leading to Family DisAppointments [58].

Communication as a Palliative Care Practice in ICU SETTINGS WAS Described in Most SystemAtic Reviews 2,63,64,65,66,67,68]. It embodies conductucting faamily Meetings [42, 45, 46, 49, 57, 65, 68], having service Illness Conversation ATION TOOLSfor Communication [34, 41, 61, 65]..

Family Meetings are effective when it is scheduled elely [48], Proactively [44] And within 72 H OF ICU Admission [66]. Family-reportred conferences [49, 57, 57 , 64, 68] And Family Countelling Interventions [49,51] In iCus can be nurse or social-work-sele, and they can attacmunication facilitators, which cored be an alternative to physician meetings [67]. IENTS and their Families with Complete and Timely Information During the Meetings in the ICUCan IMPROVE Shared Decision-MAKING OPPORTUNIES [61, 63]. It can Result in Reduced Anxiety and Psychology Distress [45, 56]. Family Meetings In iCus OVIDE BETTER FAMIY-CENTRED Support [68] and Caregiver Satisfaction [45, 65, 68] And Foster Agreement BetWeen ICU PROVIDERS and Families [48]. Failure to do so can lead to conflicTs Regarding Program and Patient Management [61], and families. Dislike Poor Communication, Incomplete Information, and Short Engagement During Family Meetings [45].

For Serious Illness Conversations to Be Beneficial, They Must Be Timely [61] and Culturally Sensitive [60]. Ions with Patients and Families Should Be Trained in Communication Skills, Planning and Scheduling These Meetings, And PREFERABLY, TheyCan use nurses and social worker as liaison support [48, 57]. Serious Illness Conversations DeCreased ICU Deaths and the Average LENGTH in the iCus [44, 48, 48, 48 , 66]. However, Serious Illness Conversations that Wee Not Open and Clear ResultIn Families Feeling Unprepared for the Death of their Loved One [61]. It Led to Negative Feelings About the deth of their loved one, Provoking Anxiety, Anger A nd distress [61]..Culturally Diverse Families [60] Impeded the Conversations. Lack of Cultural Competency and Inability to Handle RequestsClosure of Information LED to Needless Prolongation of Life-Sustaining Treatments and Health-Related Suffering [60].

The ICU Teams USed Printed Family Information Leaflets [68], Information Brochures and Booklets [41, 57], ResusCity Documents [34] And Others Like The (Psychological Assessment and Communication Evaluation) and the Value Communication Tool [65] to Aid ConversationsIn the iCus. The place too Led to Higher SatisFaction with the assessment and Treatment of Symptoms, While The value Tool Resultd Frequent Family , Increased Nurse Participation, And Better Documentation of Treatment Goals.a plan of care [48]. Communication aids IMPROVED DOCUMENTATION of END-OF-LIFE CARE, Decision-MAKING, and Resource Utilisation [34]. -Team Communication [52], Effectively Conveyed Intents of Care to the OtherMembers of the Team [34] and Enabled Nurses to Communicate Effectively in the ICU [59].

MOST SYSTEMATIC Reviews Included in the Umbrella Review DiscusSed the Practice of DeCision-Making Processs in the ICU Setting [43,44,45,46,47, 55, 55 , 56,57, 59, 62,63,64,65, 67, 67, 69, 70]. The decision-mailing process involution multidisCipLinary Teams Engaging in Inter-Team Discussions BeFore Elicing The GoAls of the Care on with the family [51, 56], a process of collaborative decision-mAKING Between ICU Teams and Families [45, 46, 59, 62,63,64, 70], and using decision-making aids [34, 63, 65, 69].

Disagreements among Healthcare Provident Regarding GOALS of Care Weequently Observation [50], Resulting in Needless and Prolonged Intensive International [56 ]. AdDitionally, Conflices and Disagreements Between Physicians and Family Members Regarding Goals of Care Posed Barrier to Integrating A Pall joint e approachin the iCus [56]. FURTHERMORE, Insuffility Clarity and Inadequate Assessment by HealthCare PROVIDERTED in Ill-Informanced defering-mak ING, Which Has Been Linked to A Reduction in Overall Family SatisFACTION [42]. TheReFore, Inter-Team Discussions OnProgNOSIS, FUTILITY, Benefits Versus Harm and Future Management [51, 56] WERE Helpful, Reducing Decision-Making ConflicTs [55].

According to review findings, Family Meetings in an Icu setting are effective when the connections are Led by a team propages [63]. Involv EMENT of a Senior Physician [54], Skills in Crisis Communication [46], Clarity of Prognosis [46]. Decision-Making in the iCus. Involving Families During Comprehensive Care Planning [44, 56], Discussing Treatment Options, and Estimating Survival Time During Family Meetings Reduced Decisional Conflict, Shortened icu Stays, and Aligned Family ND Physician Preferences-Making Leads to Conflict [46]. Moreover, nurses often feel left out during family meetings [56]..

Review Findings Support utining -aming Aids [34, 65], Written Documents [63], Educational VideoS [34], Video-Based Decision-SUPPPOLS and l descriptors [69]. It Bettered icu Physicians' Familiarity with Decision-Making[58], Promoted Shared Decision-Making, Reduced ICU Costs and Length of Stay and Instific Confidence among Family Members [65]Varanasi Investment. uring decision-mailing [55] And Helped Families to Make DeCisions consisted with Physician Prognosis [4666]..

MOST SYSTEMATIC Reviews Included in this Umbrella Review Described Findings to Suggest Care Planning as a Vital Practure in Critical Ill Patients In iCus [34 , 43,44,45, 47, 51, 53,54,55,56,57, 61,62, 63,64, 66,67,68,69,70,71,72,73,74]. It Involved having a consensus-based anticipator care plan [43, 51, 54, 56, 66, 66] and Making APalliative Care Referral [34, 56, 66, 68, 71].. d in the area are in the icu setting than in Others.

The Consensus-Based Anticipator Care Plan Involution The Family's UndersTanding of the Care Process, Discussion and Documentation of the Nature of Care d ResusCitation Preferences [55, 69]. The Presence of Do-Not-ATEMPT-ResusCitation (DNAR) Orders in theIcu has become a widly accepted contemporary plactice S May Be Necessary If Deemed Non-BeneFical or Potentially Inappropriant [53, 54, 57,61, 62, 71,72,73,74]. The Results of this Review Review Reinforce The Notion that Patients with Low-Performance Status and Multiple Medical Comorbidities Should Be Con Con Con Con SIDERED for Anticipator Care Planning When Determing the Extent of Life-Sustaining Treatments [74] And that Needless Life-ProLonging Therapies Should Be Discontinued [64]. Dnar Orders often Result from Collaborative GOAL-SHARED DECISIONG BEE Tween HealthCare PROVIDERS, Patients, ORROGATES and Are An Integral Component of Care Planning [44, 57]Moreover, incorpoating dnar orders in the ICU is often considerd a hallmark of high-Quality care in critical care settings [44, 74].

Lack of Care Planing OFTEN Leaves Families Unprepared for DeCision-Making, Resulting in Conflicting Treatment Intents and a Focus On Life P when of Information, Misconceptions, and HealthCare Provident's' SUPPORT or ENCORAGEMENT Can Also Hinder Care Planning [55]. It is not uncommon for families to exceInse of guilt, and the abandonment when disicipticipator care, some clinicians consi Der withholding and withdrawing as ethically distribution, which might hinder tartables in the ICU [54].

Review Findings Support Proactively [67] Involving Palliative and Supporting Care Services as part of the ICU Care Planning iSciplinary support for discCentric Care, Shortens ICU Stays, and Boosts Family SatisFact [54, 56, 66, 68]. Patients with Advanced Cancer WHO DIDN'TE Receive Palliative Care Caretation More lively to require mechanical venntification [75], and one reviewCare is Seldom Considered in BURNS ICUS [76].

This Review has IDentified vital prACTITITITATITATITING PALLIATIVE and END-OF-LIFE CARE ICUS [34, 41, 42, 44,45,46,47, 49, 53, 56,57,58,59, 61,62,63,64,65,66, 68, 71, 73, 75, 77,78,79]. It Includes having Institutional Guidelines and Policies on Treatment ],,,Symptom Management and Psychosocial Support [54, 57, 61, 62], withholding or Withdrawal of Life-Sustaining Treatments [68], Optimising Artification and hydration [68], after deth care and bereavement support [44, 49, 51, 54, 61, 66, 77] And Training ICU PROVIDIDERS in Palliative Care [41, 51, 56, 57, 59, 64].

In the context of end-of-life care in iCus, Ethical Considerations Play a Cruction Role [47, 53], and institutional policies on timential innet by Ethical Frameworks [47]. Healthcare Professionals Should Seek Clinical Ethics Consultation When Faced Faced Faced Faced Faced FacedWith Complex DECISION-MAKING [34, 41, 44, 65, 66, 68]. Legal Considerations Are Also Integral; Physicians Must STAY Informed of Contextual Details [58, 6 3].OFTEN STEMS FROM A POOR UNDERSTANDINGING of Legal Provisions [58]. Legal Concerns Notbly Influent Physicians' DeCisions to issue or eorder [58]. Without Adequate Knowledge of Ethical and Legal isSues Surrowing End-OF-LIFE DeCisions, The Delivery of Palliative Care in iCus May Be Impeded by UNCERTAINTY [58]. the lack of spiecific propocols for end-of-life care with, 79] Impedes Care. Moreover, A Systematic Review Has Raised Doubt Over The Reliality and Interpretability of Clinical Signs Use in Determing Future AN D END-OF-LIFE PHASE, Leading to SCEPTICISM TOCHARDS SUCH GuidelinesOR Residentance to Adhering to These Guidelines Can Hinder PROVIDIDING OPTIMAL END-OFE CARE ICUS [56].

Effective Pain and Symptom Management During During End-Life Care Is Essential to Quality Care [54, 57, 61, 62]. ICU PROVIDERS Shoulder Training Idated Scales for Symptom Assessment and Administering Opiates to Manage Symptoms [71, 73]The Absence of Palliative Care and Pain Management Protocols within the Context of End-LIFE CARE ICUS Can Impede the Care PROCESS [73]. Dequate Guidance On Managing Symptoms Such as Dyspnoea During Mechanical Ventilation withdrawal Can Cauces for Families[47] The Systematic Review Results UNDERSCORD The Importance of Upholding Patients' Dignity in the ICU by Honouring Their Preferences [45, 46, 59] and of fernalised care [45, 59]. Sharing written documentation with families regarding end-Of-Life Care [64] and Allowing Families to Be Present During During Treatment Limitations and the Dying Process Can Be Beneficial [45, 64, 77]. IRITUAL Support to Families [45, 57, 59, 75], ESTABLISHING ASpiritual support system within the icu [42, 64], and promoting communication to address space and existential distress [59] If valuable.

The Review Findings SUGGEST that Offering Care Immediatedly After Death and Bereavement SUPPORT Are Crucial Initiatives. G at the ICU Bedside Poses A Significant Challenge [61]. It was found that integrating the mortuary team into the multidisCipLinary Team CouldHelp Provideo after-Death Care [51]. Additively, Creating A Family Bereavement System [54, 66] and provement printend documents CE Letters, Brocures, Pamphlets, and Diaaries Weemed Valid [44, 45, 49, 77] The Review Findings Also Highlight The Importation of Recognising Post-TRAUMATIC Stress, Anxiety, and depression among family members [44, 49] AN d using value to screen for them [77].

The Findings of this Review Suggest that iCus Must have the capacity to provide end-life care. And Medical and Nursing Staff [41, 51, 56, 57, 59, 64]Initiatives to Education Nursing Staff on End-OF-LIFE CARE Interventions Have Improved their Abi Prive Quality Care [42, 57, 59]. USING CASE SCENAROS FOUND to Be Helpful [57]. In Contrast, The Absence ofEducation Initiatives has been found to limit their capacity to do so [56].

Eight Systematic Reviews [42, 49, 51, 53, 56, 57, 62, 64, 65] Discusted Formal and Information Amily Feedback as a Surrogate Marker of the CareProvided. The Bereaved Family Members Completed Care of the Dying Evaluation or Quality of Death QuestionNaires During A Survey Or Participott in A Qualitation ErView to Formall Assess End-OF-LIFE CARE in the iCus. Likewise, Informally, During Bereavement Support, Views of FamiliesOn the care process in the last days of life explored.

ENSURING FAMILY SATISFACTION With END-OF-LIFE CARE IS CRUCIAL in An Icu Setting [42, 56, 64]. Families perceived pose dying experiences Ed with Patient Comfort [62], The Presence of Family During the Dying PROCESS, the PeritionOf nursing Expertise, Support in Decision-Making, and Documentation of END-OF-LIFE WISHES [64]. Access to appropr assourcess, Including AINCY and Other Support Personnel, Bettent Satisfaction [60]. Family-CENTRD CARE and Physician-LED Conferences Also Contributed to Family SatisFactION sion-macking support [65, 67] Yielded Cost-Saving Advantages, Improving FamilySatisFaction. The United StatesAGEable Expense Associated with Medical Care in ICUS Exherbate Families' Financial and Emotional Stress [53]. ST of Treatment May Lead some to Question Its Necessity, FURTHER Compounding The Burden on Families [53].

Likewise, Limited Bed Availability, Space, High Occupance Levels, INSUFFICIENT MeANS of PROVIDIDIDINGIDING Comfort, and Lack of Privacy ImpaaCTED Y SatisFaction [79]. The Families unprepared for the unpredictability of the end-of-life process, unitedrTyty about the timing ofEvents, and SIGNS of Respiratory Distress Following the Removal of Mechanical Ventilation Led to DISSACTION [62]. D with Inconsistent and Contradictory Information PROVIDED by Physicians, Lack of Clarity, Holistic Assessment, and Poor Timing and Frequency Communication ation,Which Can Lead to UninFormed Decision-Making [42, 56]Kolkata Stocks. Moreover, unwelcoming and uncomfortable icu waioms, lack of private spanication, and int Xible VISITING HORS Can Also Contribute to DISSATISFACTION [42, 52, 80].

Various Methods, SUCH As Surveys, Scoring Systems, and Interview-Based Studies, have ben userd to Assess? LES, Good Death Inventory, Quality of Death and Dying (QODD), Family SatisFactionICU (FS-ICU) and Evaluation of Experiences of withdrawal Tool WERE SOME OF The Scales and Tools Used to Evaluate the Care of the Dying from the Perspect of the F Amily [64]. However, USING Quantitative Instruments for Assession Services May Not Fully CaptureThe Intricacies of Care, and Evaluations May Be Influiced by the Biases of the Self-SELECTIP PARTICIPATING in these Assessments [51].New Delhi Investment