Telepalliative care can reduce geographic separation from specialist palliative services, yet technical availability does not guarantee usable, acceptable, equitable, or sustainable care. Rural residence, digital resources, workforce capacity, care organization, and patient preferences may alter whether remote access translates into meaningful service delivery. To synthesize evidence on telepalliative nursing for rural and underserved populations while separating access and reach, acceptability, clinical and service outcomes, equity, and implementation conditions. A systematic review with implementation synthesis was conducted using reproducible telepalliative, rural-access, nursing, digital-equity, and implementation search streams supplemented by targeted citation verification. Sixty record manifestations were identified; 11 duplicates were removed, 49 unique records were screened, 43 reports underwent detailed assessment, and 33 reports were included, representing 32 underlying studies or programs after linkage of one multiple-report intervention. Evidence was appraised according to study design and implementation determinants were organized using CFIR-informed categories. Telepalliative delivery could extend specialty reach, reduce travel demands, and support nursing assessment, coordination, follow-up, transition, and caregiver communication. Benefits were conditional on modality, population, clinical context, digital capability, connectivity, workforce preparation, organizational integration, and availability of escalation to in-person care. Acceptability was generally favorable but variable, and evidence for clinical outcomes was more heterogeneous than evidence for feasibility or convenience. Telepalliative nursing can reduce important access barriers, but successful implementation requires more than remote contact. Its value depends on whether technological reach is converted into clinically appropriate, acceptable, supported, and equitable care.
