Introduction: Medical educators are central to guiding students through the emotional challenges of moral dilemmas in end-of-life (EoL) decisions. However, the literature often overlooks how medical educators support students during these moments. This study explored strategies medical educators employed and challenges they encountered in supporting students facing moral dilemmas in EoL care.

Method: This qualitative study analyzed interviews with fifteen medical educators from diverse clinical settings, focusing on how they support students during EoL decisions to withhold or withdraw life-sustaining therapy.

Results: Medical educators initially offered equal support to all students but progressively adapted their strategies based on perceived student engagement. These strategies were not pre-planned or fully conscious, but emerged in real time as educators navigated the emotional and cognitive demands of EoL decisions. Medical educators increased personalized support to students perceived as “highly engaged”, while gradually reducing support for those perceived as “less engaged”. They struggled to balance their role as comprehensive supporters with time constraints, administrative duties, and a hidden curriculum prioritizing clinical skills over emotional connections and patient-centered care.

Discussion: Building on our previous investigation into medical students’ experiences of moral dilemmas in EoL care, this study shifts the lens to medical educators. It reveals a critical oversight: students feeling emotionally overwhelmed may be misinterpreted as disengagement. This misalignment can hinder educators’ support strategies, potentially reducing support when most needed. The study advocates for an ‘Educational Alliance’ grounded in trust and mutual respect, and calls for structural reforms to sustain educators’ capacity to provide consistent, emotionally attuned support.