Background <p>At the end of life, patients frequently experience distressing symptoms. When they become refractory, sedating medications and palliative sedation (PS) may be used to alleviate suffering. PS is mainly practised in specialist settings, as it requires defined procedures and guidelines. Little is known, however, about how registered nurses (RNs) and healthcare assistants (HCAs) manage refractory symptoms and unbearable suffering in nursing homes and how sedating medications are used in this non-specialist setting. This study explored how RNs and HCAs in Swiss nursing homes recognise, assess, and alleviate unbearable suffering, the challenges they face, and the strategies they employ to alleviate residents’ suffering by using sedating medications and PS.</p> Methods <p>This qualitative study involved 22 RNs and six HCAs from nursing homes in German-speaking Switzerland. Seven semi-structured focus group interviews were conducted between October 2023 and January 2024, transcribed verbatim, and analysed using a grounded theory approach.</p> Results <p>The core category, ‘Navigating palliative sedation in nursing homes – tension between alleviating suffering and over-sedating’, was identified, with three subcategories: (1) recognising suffering, (2) assessing suffering, and (3) alleviating suffering. Challenges included distinguishing residents’ suffering from that perceived by relatives or healthcare professionals, negotiating assessments with relatives and general practitioners (GPs), and uncertainties in the use of sedating medications – particularly morphine and midazolam. Strategies to address these challenges included ‘double-checking’ to validate symptom recognition, shared decision-making to ‘get everyone on the same page’ and align treatment goals, and the reliance on internal and external ‘safety nets’ (experienced colleagues and specialised palliative care services). Resource constraints such as personnel and financial resources, as well as beliefs and attitudes were reported to influence the management of unbearable suffering and the use of sedating medication.</p> Conclusions <p>RNs and HCAs in nursing homes face complex challenges when recognising, assessing and alleviating suffering with sedating medications. Ensuring safe and ethical practice requires sufficient staffing, adequate training, clear protocols, and access to specialised palliative care support. Without sufficient expertise, interprofessional collaboration, and shared decision-making, residents risk either inadequate relief of suffering or inappropriate sedation.</p>