Environmental sustainability in palliative care: a narrative review

Introduction

Climate change is considered the greatest threat to human health of the 21st century (1). Extreme weather events such as floods, storms, heat waves, and wildfires can lead to bodily injury, heat stroke, respiratory and cardiovascular diseases, and psychological distress (2). These events also impact societal determinants of health disrupting infrastructure for health care delivery, sanitation and food systems and frequently leads to displacement (3). For example, in 2025 unusually heavy rains and glacial lake overflows led to flooding in Pakistan displacing 2.5 million people. Roads and bridges were destroyed, Pakistan’s ‘bread basket’ was submerged in water leading to rising food prices, water borne diseases spiked and at least 1000 lives were lost (4). The effects of climate change disproportionately affect vulnerable populations (5), including palliative patients with advanced illness and high care needs. Additionally, the demand for palliative care is expected to rise as climate change increases heat-related illnesses, and water-, food-, and vector-borne disease and exacerbates noncommunicable diseases (6).

Paradoxically, the healthcare sector contributes significantly to climate change, accounting for approximately 4.4% of global greenhouse gas (GHG) emissions (7,8). On a global scale, if the healthcare sector were considered an independent nation, it would rank as the fifth largest emitter of GHGs (9). Specific to end of life care, data from Statistics Canada indicate that adults in their final year of life account for approximately 5,855,566 hospital bed-days annually, representing an estimated carbon footprint of 177,424 to 263,500 tonnes of CO₂ equivalents (tCO₂e) each year (10,11). At a more localized level, a hospice in the Southwest of England reported an annual carbon footprint of approximately 420 tCO₂e, comparable to the average annual footprint of 42 individuals in the United Kingdom (UK) (12). The carbon emissions of the healthcare sector reveal a fundamental ethical tension: while healthcare is grounded in the principle of non-maleficence, the provision of care contributes to environmental degradation and, consequently, harm to planetary and human health (13).

In response to the healthcare sector’s responsibility to reduce its emissions, a coalition of 50 countries pledged to develop health systems that are both climate-resilient and low-carbon. In 2020, the National Health Service (NHS) of the UK became the first health system to commit to achieve net-zero emissions by 2040. Choosing Wisely Canada, a national initiative that collaborates with medical specialties to develop recommendations regarding commonly overused tests and treatments that offer limited clinical value published 41 climate-conscious clinical recommendations in 2024 (14). While the Canadian Society of Palliative Care Physicians has contributed to Choosing Wisely recommendations in the past, they were not represented in these specific climate conscious recommendations. This gap in published guidance on sustainability in palliative care highlighted the need for investigation in this area. The aim of this narrative review was to examine the published literature describing the ecologic impact of palliative medicine and identify any sustainability initiatives emerging in the field. We present this article in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-146/rc).

Methods

A literature search was conducted to identify palliative medicine concerns related to environmental and climate issues, up to March 2026. Planetary health and palliative care keywords and indexed headings were both used, including concepts of ‘carbon emissions’, ‘climate change’, ‘sustainability’, ‘palliative’ topics, ‘end of life’, and ‘terminal care’. The search focused on peer reviewed literature via a wide range of scholarly databases, but did not extend to public opinion in the form of blogs, videos, reels, social media or other popular public platforms. Medline, Embase, CINAHL, UBC Summon, GreenFile, Health Business Elite, and TRIP Medical databases were searched without limiting by date or study type.

Table 1 summarizes the literature search strategy, inclusion/exclusion criteria and selection process. Publications that discussed carbon emissions, waste, or ecologic impacts of palliative medicine were included. Articles that discussed practices outside of the scope of palliative medicine, or discussed sustainability in a manner not relevant to planetary health (ex. economic sustainability) were excluded.

Titles and abstracts of all retrieved records were reviewed independently by two researchers (F.H. and S.L.) in June 2025 and March 2026. Full-text articles meeting inclusion criteria were then independently assessed. Additional sources referenced in eligible articles were also included if inclusion criteria were met. Discrepancies arising at any stage of the process (identification, screening, eligibility, or inclusion) were resolved through discussion between both researchers until consensus was reached. Due to the scant literature in this space, the methodological quality of the included studies was not assessed. Data regarding the carbon footprint, ecologic impact and waste associated with palliative medicine was coded in an iterative process by a single researcher (F.H.). The findings were grouped into major themes and summarized narratively by two researchers (F.H. and S.L.) to highlight opportunities for clinicians to provide environmentally sustainable palliative care.

Results

A total of 176 articles were identified, plus two from reference lists of the full text articles. After removing duplicates and screening titles and abstracts, 18 articles met inclusion/exclusion criteria. After full text review, an additional 10 articles were excluded. Most excluded articles were either not relevant to health care/palliative medicine or environmental sustainability. Three articles explored the current and anticipated impact of climate change on palliative patients and the capacity of health care providers to provide palliative care. These were excluded as they were not directly relevant to the research question. The two articles identified in the reference lists of full text articles were included. The eight articles included in this narrative review were all published in peer-reviewed academic journals and are summarized in Table 2. Major themes identified were in relation to pharmaceuticals, investigations and procedures, and intensity of care at the end of life.

Pharmaceuticals

In Canada, pharmaceuticals and their associated supply chains account for an estimated 21% of healthcare-related GHG emissions (11). GHGs are emitted at every step of the supply chain, from production to transport, to patient use and disposal. In addition to GHG emissions, pharmaceuticals contribute to environmental degradation from copious water use and contamination of water systems from human excretion and inappropriate disposal practices (11). Deprescribing and conservative prescribing align with best clinical practice but also decrease the ecologic impact of medical care and may represent one of the most immediate and effective strategies for promoting environmental sustainability in healthcare (11,15).

Within palliative care populations, polypharmacy is common, particularly in the last year of life. Some of these medications are indicated for primary or secondary prevention of comorbid illnesses which are no longer clinically relevant. Up to 20% of medications prescribed near end of life are considered inappropriate, including antithrombotics, statins, antihypertensives, and proton pump inhibitors (11). In Canada, approximately 0.75% of the population dies annually, with 90% of these deaths resulting from chronic illness. A 10% reduction in polypharmacy within this group could prevent an estimated 488,700 tCO₂e emissions (11). These emissions are roughly equivalent to the annual emissions of 214 509 North American households (16). Specific to medical oncology, avoiding administering systemic anticancer therapy in the final month of life represents an opportunity to decrease the ecologic impact of systemic agents at a population level while adhering to principles of avoiding overly aggressive care near the end of life (17).

Decreasing pharmaceutical waste and ensuring proper disposal of unused medications is another mechanism to decrease the ecologic impact of palliative care. A hospice in California piloted a mail-back program for unused medications in 2009. Nursing staff received education on the environmental impact of pharmaceutical waste, and patient and families were subsequently given brochures about the program. The pilot successfully diverted 119 pounds of pharmaceutical waste from the environment over a six-month period (18). Similarly, two hospices in the UK introduced a medication reuse program for dispensed but unused medications aimed at reducing waste and mitigating medication shortages, resulting in cost savings ranging from £300 to £15,500 (19). Additional initiatives to minimize pharmaceutical waste include vial sharing and split-fill dispensing (17). Split-fill dispensing refers to the practice of dispensing partial medication quantities, particularly for high-cost or high-toxicity drugs, to allow early discontinuation in cases of intolerance or lack of efficacy, thereby reducing unused medication and limiting environmental contamination. These interventions demonstrate practical opportunities to reduce pharmaceutical waste while maintaining the safety and effectiveness of patient treatment.

Procedures and investigations

Reducing low-value procedures and investigations, particularly when incongruent with a patient’s goals of care, has the ability to minimize harm and improve patient quality of life, but also the co-benefit of decreasing GHG emissions. The carbon footprint of a facet joint injection in the UK for example was estimated to be 39.6 kg CO₂e (20), roughly equivalent to the emissions of driving a petrol passenger car 200 kilometers (km) (21). Clinical practice guidelines from the NHS discourage the use of facet joint injections for non-specific low back pain and instead recommend a diagnostic medial branch block injection followed by a radiofrequency denervation in responders. Ojelade et al. identified that adherence to these guidelines resulted in a 31.4% (42,511 to 13,368) decrease in initial injections and 7.9% (4,018 to 424) decrease in repeat injections between the time periods of 2015–2016 and 2019–2022. This translated into an estimated emissions savings of 2.8 kilotonnes of CO₂e over five years (20), roughly equivalent to the annual emissions of 1229 North American households (16). Although not investigated directly in end of life care, diagnostic imaging also represents an area of substantial energy consumption. At one hospital, three computed tomography (CT) scanners and four magnetic resonance (MR) scanners collectively accounted for 4% of the facility’s total energy use (17). Conversely, ensuring appropriate and timely diagnostic imaging earlier in a patient’s care trajectory may help prevent later presentations with advanced disease requiring more resource-intensive hospital care (15).

Intensity of care

Hospitals are inherently resource-intensive environments, characterized by their high consumption of energy, medical supplies, and disposable materials due to more aggressive diagnostic and therapeutic practices compared with lower-intensity care settings (11). In Laval, Quebec, annual GHG emissions normalized by bed capacity revealed that one hospital bed-day generated approximately 23 kg CO₂e. This is over seven times higher than a long-term care bed-day at 3.5 kg CO₂e (11). Similarly, in British Columbia, hospital bed-days were associated with an average of 30.3 kg CO₂e, compared to 8.7 kg CO₂e in long-term care facilities (11). Unfortunately in Canada, many patients in acute care beds are awaiting transfer to a more appropriate care setting, such as hospice or long-term care, and many of these patients are in their final year of life (11,22). Additionally, limitations in access to community based care accounted for 58% of emergency department presentations (22) and among patients hospitalized for palliative care, 46% died while awaiting transfer to another facility (11,22). According to Nix et al. [2025], this reliance on acute care for end of life ‘medicalizes death’ (22). Expanding access to hospice and long-term care is necessary to deliver compassionate, goal-concordant end of life support, and would also have the added benefit of providing low-intensity, and environmentally sustainable models of care (11,22). Early referral to palliative care is a mechanism to minimize aggressive end of life care and increase the likelihood that patients receive care in the appropriate setting. This early referral also has the co-benefit of decreasing the resource utilization and environmental impact of care in the last year of life (11).

Advance care planning (ACP) increases the likelihood of patients dying at home rather than in hospital (11). Reducing unnecessary hospital days and medication use, two of the largest contributors to healthcare-related GHG emissions, through improved ACP and home-based palliative services could substantially mitigate the carbon footprint of palliative medicine (11). In addition to facilitating goal-concordant care, re-examining care intensity may also provide a framework for patients to express environmental values in their care preferences. With increasing public awareness of climate change, sustainability itself may emerge as a meaningful consideration in end of life decision-making. Supporting informed discussions about the environmental implications of various care settings and treatment options may enhance both patient autonomy and the alignment of care with evolving societal values (15).

Intensive care units (ICUs) represent the most resource-intensive setting within hospitals, using large quantities of energy, single-use materials, and pharmaceuticals for each patient encounter (15). Care provided during the terminal year of life frequently involves ICU admissions which carry a substantially greater carbon footprint compared to standard hospital bed-days (11). For example, a UK ICU consumes an average of 15 kilowatt hours (kWh) of electricity per patient-day, comparable to the daily use of a four-person household (15). Education and involvement of palliative specialists in the ICU have the potential to increase documentation of goals of care and ACP discussions subsequently decreasing therapeutic interventions, use of artificial nutrition, hydration and mechanical ventilation without adversely impacting overall survival (15). Timely palliative consultation and evaluating care intensity can promote goal-concordant care while decreasing resource utilization and subsequent environmental impact.

Discussion

This narrative review aimed to examine the literature regarding the ecologic impact of palliative medicine and highlight climate conscious clinical recommendations relevant to palliative care. Across the reviewed publications, three major themes emerged: (I) conservative and goal-concordant prescribing, (II) minimization of low-value investigations and procedures, and (III) early ACP and care setting optimization. Collectively, these findings highlight that the basic principles of high-quality palliative care have the co-benefit of improving sustainable healthcare delivery.

The ethical principles of beneficence, non-maleficence and justice are foundational to palliative medicine. Delivery of resource and carbon intense medical care which contributes to environmental degradation and climate change that harms human health creates an ethical tension, particularly for palliative care providers serving vulnerable populations disproportionately impacted by the climate crisis (3). A review by Harris et al. [2024] provides an overview of how climate related events globally impact palliative care with providers reporting an inability to reach patients due to damaged infrastructure, challenges in obtaining opioids, disrupted access to basic essentials like clean water and electricity, increased hospice referrals in part due to hospitals trying to increase their acute care capacity, and an increased 30-day mortality rate in hospices following an extreme weather event. Sustainable health care thus aligns with these core ethical principles: it promotes well-being for current patients and future populations (beneficence), avoids harm to patients through unnecessary, low-value interventions and to the planet by limiting emissions (non-maleficence) and aims to ensure equitable access to quality care while protecting planetary health for vulnerable groups (justice).

Despite the alignment of principles of palliative care and sustainability, the perspective of palliative care physicians regarding planetary health and sustainability remain underexplored. A survey of 175 interventional medicine specialists, with a majority (76%) practicing in the United States may offer some insight. The study identified both enthusiasm and barriers among clinicians wishing to engage in climate-conscious care (23). Reported obstacles include limited knowledge or training in sustainable practice, time constraints, and inadequate institutional support (23). Addressing these barriers through education, resource allocation, and leadership engagement could empower palliative care professionals to become active contributors to healthcare sustainability initiatives.

Pharmaceutical stewardship represented the most commonly examined sustainability initiative. Conservative prescribing and deprescribing was identified as a high-impact intervention with both clinical and environmental benefits (11,15,18,19). Medication return programs for proper disposal and potential safe reuse require further study at both the community and institutional levels with potential for significant environmental benefits and financial savings (18,19,24). While not identified in our literature search, metered-dose inhalers (MDIs) have a substantial carbon footprint due to the hydrofluorocarbon propellants. 100 doses of a MDI is equivalent to the carbon emissions associated with driving a vehicle 290 km (25). Deprescribing inhalers for patients who do not have asthma or chronic obstructive pulmonary disease or substituting MDIs with propellant-free dry powder inhalers where clinically appropriate decreases carbon emissions (26,27). Studies also suggest that the route of medication administration can have a significant impact on carbon emissions (28). For example, a study conducted in the perioperative setting identified that the administration of 1g of paracetamol orally produces a 68-fold lower carbon footprint compared with the equivalent intravenous formulations (29,30). In hospital settings, transitioning to oral formulations when clinically appropriate is often consistent with transitioning to lower intensities of care; however, this change would not apply at end of life when patients lose the oral route.

Early ACP and palliative care referrals are consistently associated with reduced hospitalizations, decreased use of acute care beds, and higher likelihood of patients dying in preferred non-hospital settings (11,31,32). System-level initiatives that expand access to low-intensity care environments or streamline transitions out of acute care can have the added benefit of meaningfully decarbonizing palliative care provision (33). Even within the ICU, targeted palliative care interventions, including structured communication training and early goals-of-care discussions, can reduce invasive treatments, mechanical ventilation, and ICU length of stay without adversely affecting mortality (34-38).

Although not identified in our literature search, a common sustainability recommendation potentially relevant to palliative medicine is the use of virtual care (39). Transportation of patients and healthcare professionals is a major contributor to healthcare-related emissions (39-42). In the post-COVID-19 era, telemedicine has become a sustainable alternative to in-person consultations, reducing travel-associated emissions while maintaining high-quality patient care (17,39). A systematic review by Purohit et al. [2021] reported reductions in carbon emissions ranging from 0.70 to 372 kg CO₂e per consultation, depending on geographical context and mode of transport (43). Avoiding in person visits when clinically appropriate was recommended by nine medical specialities in the Choosing Wisely Guidelines including Oncology, Geriatrics, Psychiatry, Internal Medicine and Family Medicine. When incorporating these recommendations into palliative practice, clinicians must balance the need for in-person assessments to build rapport with patients and families, the value of in-person visits for accurately assessing performance status and prognosis over time, and individual patient preferences.

Beyond individual patient care, research and clinical trials carry substantial environmental implications. A review of 12 pragmatic randomized clinical trials found an average carbon footprint of 78.4 tCO₂e per trial (17). Extrapolating these findings to all trials registered to clinicaltrials.gov estimates a cumulative carbon footprint comparable to that of the entire NHS (17,42,44,45). Incorporating sustainability considerations into clinical trial design, such as reducing unnecessary travel, digitizing data collection, and streamlining logistics, may represent an additional avenue for aligning research with planetary health objectives.

The major themes identified in this review, in combination with Choosing Wisely Canada’s Climate Conscious Recommendations and validated palliative medicine clinical decision making tools such as the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) (46) and the OncPal deprescribing guideline (47) may help inform the development of environmentally sustainable palliative care policy. It is however important to note that both Choosing Wisely Canada and the articles identified in this review were designed within a high-income healthcare context and may not be directly applicable to low and middle income countries (LMICs). Palliative care models in low-resource settings often prioritize home and community based care delivered through mobile outreach, with engagement of community volunteers, religious leaders, and empowerment of family caregivers (48,49). While these models aim to improve access to care, they are inherently less carbon-intensive by reducing patient travel for care and minimizing high emission hospital based care. Palliative care principles in LMIC may actually warrant study in higher income countries in an effort to improve access to care and decrease resource utilization with the potential co-benefit of decreasing carbon emissions.

In developing guidance for environmentally sustainable palliative medicine, the limitations of the current literature need to be considered. Most studies addressing environmental sustainability in clinical care do not focus specifically on palliative settings, and empirical data quantifying environmental impacts of palliative interventions are scarce. Quantifiable data with longitudinal study regarding the carbon implications of deprescribing, reduced procedures and investigations, and transitions to low intensity community care are needed to substantiate the environmental benefits of these practices. The environmental benefits of telemedicine specifically in palliative care requires exploration as does waste management across all palliative settings. In addition to deprescribing, data regarding the environmental impact of medications when multiple options with similar efficacy are available (e.g., opioids or bowel protocols) could inform prescribing alongside current considerations such as potential side effects, drug interactions and financial toxicity.

Further exploration of how to integrate principles of environmental sustainability into palliative care policy development and continuing education are required in addition to the development of metrics to assess impact. As health systems globally aim to provide low-carbon, climate resilient health care services in response to climate change, it is important that any measures implemented are followed longitudinally with careful evaluation of potential impact on quality of clinical care. This evaluation is of particular importance for vulnerable patient populations like those seen in palliative care. While the primary goal of palliative care remains relieving and preventing suffering for patient and families, many palliative care principles such as early ACP, conservative prescribing and deprescribing, and minimizing aggressive interventions have the co-benefit of decreasing the ecologic impact of care, particularly near the end of life.

Conclusions

This narrative review identified that delivering high quality, goal-concordant palliative care can also yield important environmental co-benefits. Principles that are already considered hallmarks of excellent palliative care, such as deprescribing and judicious prescribing, limiting low value interventions, early ACP, and facilitating care in less resource intensive settings can reduce unnecessary resource utilization, pharmaceutical waste and healthcare related GHG emissions. These findings suggest that environmentally sustainable health care does not require departure from core palliative care principles; rather it can emerge as a natural consequence of patient-centred, value-based care. Integrating sustainability within healthcare professional training and policy development is required to ensure that environmental considerations become embedded in routine clinical practice as global health systems transition to lower carbon models of care. The provision of environmentally sustainable palliative care is not an additional obligation, but rather an extension of high-quality, compassionate, goal-concordant care. By aligning clinical excellence with responsible resource stewardship, palliative care has the potential to improve patient and family experiences at the end of life while supporting broader efforts to reduce the environmental impact of healthcare systems.

Acknowledgments

We used artificial intelligence (specifically OpenAI GPT-4o mini and Grok 3 mini) for improving sentence structure and clarity.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-146/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-146/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-1-146/coif). S.L. has received research funding and honoraria from AstraZeneca. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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