Early on there is a cutscene where you injure and at least knock out(possibly kill?) a dog in self defense. Several side missions require you to kill a dog but you do NOT have to finish them to get the good ending. I confirmed this myself. You also come across a number of dead dogs throughout the game.
Nothing is shown on screen but if it needs to be mentioned, a bandit does joke about cutting off male genitals, but to my knowledge that never gets acted on.
Not as a dramatic/plot point. The player gains control of a car in one chapter and can crash into things, depending on their driving. The car suffers no damage from this.
The player searches for documents in a broken down facility. This location is claustrophobic, very dark, and infested with large scorpions that must be repelled with the light of the players lighter. The scorpions can easily jumpscare the player and make it hard for the player to progress.
Not sure if this counts, but there are sex slaves the bad guys own. Nothing actually happens, but it is implied since it's obviously against their will.
You can both fall into the water in this game and you can also go into areas where if you run out of filters for your gas mask, you will start breathing heavy and coughing because the air is poison and you start dying
In the last chapter, you'll see shadows of people who died long ago and far away, in the corner of your eye you'll notice tall shadow people that watch you from a distance before dissapearing. Neither interact directly with you.
The player heals themselves with syrettes during play. Late game cutscenes use autoinjectors. Cutscenes have IV lines, but no depiction of them being inserted.
Its the Metro series, they tend to do a lot of claustrophobic scenes, now this one is opened world but there are tight spaces and another metro in this game
At one point in the game, the player wakes up with their spouse and his spouse is topless. No nudity is shown but her nudity is very obvious and the player can sit and talk to her for a lengthy segment.
It is possible to fall into water and die if the player doesn't have a boat or shore nearby. The player also falls into a river during a cutscene and almost drowns before being rescued and revived by another character.