Background Non-invasive advanced respiratory support (NARS), such as CPAP or BiPap/NIV, is prevalent within modern practice and extensively used in the care of patients with COVID-19. Despite this there is little guidance on how best to care for patients dying whilst using, or having recently used, NARS. This study aimed to explore end of life practice around NARS and evaluate the impact this care had on staff.

Methods A qualitative study of 21 multidisciplinary team members (from palliative care, acute and respiratory medicine) drawing on a social constructionist perspective using thematic analysis of semi-structured interviews from a single acute UK NHS Trust.

Results practice around the provision of NARS to critically unwell COVID-19 patients was viewed as extremely challenging and most discussed the harmful impacts of this. Five distinct themes were developed: ill prepared and unsupported, actions of a moral dimension, loss of professional autonomy, duty and factors that may protect staff from harm.

Findings are resonant with moral injury theory. Injurious events included staff feeling they had acted in a way that caused harm (e.g. giving high burden treatment), failed to prevent harm (e.g. were unable to relieve suffering) or had been let down by seniors or the Trust.

Conclusions The impact on staff was profound. This study adds to the literature outlining the impact of the COVID-19 pandemic on psychological well-being of healthcare workers by identifying how this impact is caused. Although many of the issues described by participants are likely immutable components of healthcare in a pandemic there were several important protective factors (experience, providing a peaceful death and self-preservation behaviours) that may provide modelling for future education and support services to help prevent moral injury – or aide in its recovery.