To our knowledge, this is the first study to systematically assess perspectives and factors influencing EOL practices among ICU physicians in Morocco. While most intensivists associated EOL care with dignity and palliative support, reluctance toward withdrawing LSTs, particularly mechanical ventilation, was notable. This reluctance reflects a complex interplay of cultural sensitivities, ethical uncertainties, and, most importantly, the legal ambiguity surrounding EOL care in Morocco. Although decision-making was generally collegial, physicians predominantly led the process, with limited input from nurses or patients. Family preferences frequently outweighed patient autonomy, reinforcing the paternalistic model that remains common in North African and Middle Eastern (MENA) healthcare systems [11, 12, 22]. While withholding LSTs was generally accepted, withdrawal remained controversial. Key decision drivers included age, comorbidities, prognosis, and suffering, whereas economic or logistical constraints played a minor role. Notably, 76% of respondents believed that Islamic teachings permit W/W futile treatments, indicating that religious frameworks may offer a basis for structured national guidelines. Practicing in public hospitals and belief in religious permissibility were the two factors independently associated with W/W decisions. Our findings mirror global trends showing that EOL practices vary according to legal, religious, and cultural contexts [3, 5, 6, 14].
This variability is also reflected in the frequency of W/W decisions reported by our respondents. During the survey period, 38% of Moroccan intensivists reported never making W/W decisions and 88% reported fewer than one decision per week—similar to patterns seen in South Asia and the Middle East, where EOL policies are often absent or ambiguous [4, 6]. While causality cannot be asserted, studies like Lobo et al. and Phua et al. suggest that the absence of formal frameworks significantly contributes to the underuse and underdocumentation of W/W decisions in low- and middle-income countries [4, 6]. In North Africa, Egyptian intensivists, for instance, reported facing moral, religious, and legal dilemmas, and a lack of institutional protocols [11]. These hesitations may also reflect deeply rooted beliefs in Moroccan society, where life is considered sacred and only God is seen as having the authority to end it—a view that shapes ethical discomfort with W/W decisions among both clinicians and families [16]. By contrast, European and North American ICUs more frequently report W/W decisions, supported by robust legal and ethical infrastructure [3,4,5]. Addressing these gaps through structured national policies that respect ethical and religious sensitivities could help harmonise practice and facilitate timely and appropriate EOL decision-making [14].
Given this context, the absence of a clear legal framework in Morocco warrants specific attention. In Muslim-majority countries like Morocco, the absence of a clear legal framework remains one of the most significant barriers to consistent, ethical EOL care. This legal vacuum contributes to physician hesitation, inconsistent documentation, and a tendency to favour withholding rather than withdrawing life-sustaining treatments (LSTs). Although Islamic teachings permit W/W of LSTs when treatment is deemed futile—a stance supported by various fatwas and bioethics councils [16, 17]—clinicians remain cautious in the absence of explicit national guidelines that incorporate these religious and ethical perspectives. Similar challenges have been documented in other Muslim-majority countries, where legal ambiguity often outweighs religious or sociocultural concerns [11, 12]. Establishing national laws and institutional protocols rooted in Islamic ethical principles could reduce uncertainty, protect clinicians, and promote more transparent and ethically sound EOL decision-making.
In parallel with these legal challenges, reluctance to withdraw LSTs among Moroccan intensivists reflects broader global discomfort with this practice. The ETHICUS study reported that withdrawal of LST was less common in Southern Europe than in Northern Europe [5]. Similar trends were observed in South Africa, where physicians favoured withholding over withdrawing treatments [8]. Many clinicians find withdrawing LSTs ethically and emotionally more challenging than withholding, despite ethical guidelines equating the two practices [24, 25].
Patient autonomy remains a challenge, as only 40% of intensivists considered the patient’s wishes in W/W decisions. Instead, decisions were driven more by clinical prognosis and family input. This mirrors findings from other LMICs, where shared decision-making remains underdeveloped and family-centered care predominates [26, 27]. The low prioritisation of patient autonomy raises important ethical concerns regarding shared decision-making and respect for patient preferences.
While Moroccan intensivists were willing to limit treatments like antibiotics, transfusions, or renal replacement therapy, there was hesitance to reduce fluids, oxygen or ventilatory support. This aligns with global findings (ETHICUS, ICON), where respiratory support was among the least likely therapies to be withdrawn [3, 5, 6, 15]. Moroccan intensivists reported that mechanical ventilation withdrawal was generally performed through gradual weaning rather than terminal extubation—a pattern seen globally where active withdrawal is viewed as more ethically challenging [6, 12, 29]. In Israel, legal distinctions between withholding and withdrawing reinforce similar reluctance [30]. In Egypt and Tunisia, where the majority of population is Muslim Sunni, physicians reported strong discomfort with ventilator withdrawal [11, 12]. These consistent patterns underscore the influence of Islamic values and legal uncertainty in shaping EOL practice.
Our findings reveal that EOL care in Morocco is primarily physician-led and family-focused, with limited nurse and patient engagement. This mirrors broader MENA trends, where family authority often supersedes individual autonomy [6, 17]. In a systematic review, Almalki et al. recently highlighted that in the MENA region—including Saudi Arabia, Bahrain, and Palestine, healthcare staff avoid open discussions about death, and nurses often lack autonomy to engage with families without physician approval. Instead, communication around EOL transitions is frequently indirect, with nurses relying on non-verbal cues to signal impending death rather than explicitly addressing it [31]. However, intra-regional variability exists. In Lebanon, Al-Jawish et al. reported nurse involvement in 78% of EOL decisions, and Ounaes et al. observed frequent nurse participation in Tunisia [12, 22]. These findings suggest that collaborative decision-making is feasible within Muslim-majority settings and could be encouraged more broadly [32]. As emphasized by the Durban World Congress Ethics Round Table IV, nurses play a vital role in ethical EOL care given their proximity to patients and families [33].
Beyond communication and team involvement, documentation practices also shape the quality and transparency of EOL care. In our survey, documentation rates were low (27%), and 94.5% of respondents reported no formal institutional protocols—similar to other LMICs [5, 9]. In contrast, European and North American ICUs maintain structured documentation to ensure transparency and accountability [13, 23]. The ETHICUS-2 study emphasized the role of institutional protocols in standardising EOL decision-making across different healthcare settings [3].
Finally, institutional context—including whether care is delivered in public or private settings—may also influence EOL practices. In fact, one of our most notable findings was that physicians in public hospitals were significantly more likely to engage in W/W decisions. This may reflect greater institutional support and reduced legal risk in public-sector settings, where decisions are often more collective. In contrast, private hospitals may involve stronger family pressure to continue aggressive care, driven by financial investment or insurance. Similar trends have been reported in trauma centers in North America, where withdrawal of LST was more common among publicly insured or uninsured patients [34], and in India, where end-of-life practices varied between public and private institutions [35]. These observations suggest that healthcare setting, economic factors, and family expectations significantly influence EOL decisions and should be considered when developing national policies.
This study has several limitations. As a survey-based study, findings rely on self-reported practices, which may not fully reflect actual clinical decision-making. Despite assurances of anonymity, social desirability bias could have influenced responses. Although the survey was distributed nationally, differences in institutional participation may have introduced sampling bias. The study also focused exclusively on physicians and did not include perspectives from patients, families, or nurses—limiting its scope. The gender imbalance in the sample (majority male) reflects the national ICU physician workforce but may limit insight into gender-based perspectives on EOL care. While the study was conducted in Morocco, findings may be relevant to other North African and Muslim-majority countries given shared legal, religious, and cultural features.
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