End-of-Life Care in the Austere Military Environment.

Introduction: Throughout the Global War on Terror (GWOT), the U.S. military built a revolutionary capacity to deliver life-saving care-even in austere environments-through rapid evacuation, far-forward providers and resources, and advances in prehospital and trauma-critical care. However, the operational reality of future Large Scale Combat Operations (LSCO), as evidenced by wars in Ukraine, Sudan, and Gaza, will be marked by high casualty rates and limited medical resources. The number of patients with non-survivable injuries because of operational constraints such as inability to evacuate, massive demand on medial supplies and providers, or unsecure medical infrastructure will increase the number of casualties classified as "expectant." The article provides guidance for medical and non-medical leaders on recognizing the imminently dying, triaging appropriately, and maintaining morale and dignity under extreme conditions.

Materials and methods: This is a narrative review informed by current military doctrine, clinical palliative and hospice care literature, and other published works on austere palliative care medicine. It integrates guidance from Tactical Combat Casualty Care (TCCC), Prolonged Casualty Care (PCC), the Joint Trauma System (JTS), and civilian palliative standards. It also explores how medical providers must shift from curative to comfort-focused care, often without formal palliative training, and how end-of-life care protocols must be integrated into doctrine, triage systems, and commander education. We offer pragmatic guidance on clinical decision-making, communication strategies with both medical and non-medical leaders, and the delivery of pain relief, emotional support, and dignity at the end of life-even in forward-deployed, under-resourced settings. No institutional review board approval was required, as this is a non-human-subjects literature-based review.

Results: This review emphasizes that end-of-life care must be recognized as a doctrinally supported component of military medicine. Recognition of imminent death based on clinical signs, rather than lab diagnostics, is critical in resource-limited settings. Effective communication with commanders and patients requires reframing "Leave No One Behind" to include dignity and pain relief at the end of life. Clinical management of the expectant patient goes beyond simple pain management; doctrinal guidance should be updated to better reflect this. Psychological support for providers, unit members, and families plays a key role in reducing moral injury and preserving cohesion.

Conclusions: End-of-life care in austere military environments is a moral obligation and a mission-critical capability. Current gaps in doctrine, training, and command understanding threaten to leave providers unsupported and patients inadequately cared for in future conflicts. This review explores the complexities of end-of-life care in austere military environments, and advocates these complexities be integrated across operational medical planning and training. Future efforts should include simulation-based training, pediatric-specific protocols, and expanded telemedicine capabilities. Preparing providers to deliver dignified, compassionate end-of-life care ensures that the military remains capable of honoring life-even when it cannot be saved.