Table 2 Summary of Thematic Analysis and Direct Content Analysis

Theme 1: Self

Category 1: Innate Ring

Emotion

Perception of life and death

1. Internal conflict

1. Confrontation with own mortality

2. Management of own expectations

2. Conception of a good death impacting end-of-life care

3. Confrontation with own mortality

3. One has a right to die

4. Apprehension/Distress

Category 2: Individual Ring

5. Fear due to unintentional transference to own family members

Ability to make sense of things

6. Satisfaction in providing end-of-life care

1. Impact ability to make decisions

Thoughts

Abilities to communicate

1. Doubt

1. Loss of ability to communicate and relate to patients

2. Perception of emotional involvement

2. Improvement in communication skills

3. Professional responsibility

Abilities to express feelings

4. Death of a patient perceived to be a personal failure

1. Emotional detachment

5. Death of a patient not perceived to be a personal failure

2. Emotion connection

6. Intervention as prolonging suffering for patients

Acquired ability

7. Intervention as prolonging suffering for patient’s family

1. Lack of knowledge about end-of-life

8. Withdrawal of treatment as life-shortening

2. Inadequate opportunities for end-of-life care training

9. Decision between active treatment or palliative intention

3. Doubt and lack of confidence in clinical skills

10. Perception that nurses do not grasp the complexity of end-of-life decision making

4. Testing of practical skills such as treatment withdrawal techniques

11. Motivated to improve communication skills

5. Acquisition of new skills with experience

12. Perception of intensive care unit as not conducive for palliative care discussions

Beliefs

Behavior

Personal Beliefs

1. Impaired ability to make decisions

1. Dilemmas about the balancing of opposing values

2. Impaired ability to communicate

2. Personal beliefs reflected in end-of-life practices and communication

3. Emotional detachment

Exposed to Ethical dilemmas such as:

4. Difficulty and discomfort when broaching topic of death to patients

1. Differences in ethical opinion surrounding treatment withholding and withdrawal

5. Attempts to avoid discussion of death in general

2. Futile treatment

6. Fear of litigation leading to defensive practice

3. Lack of advanced directives and families’ aggressive care requests causing moral distress

7. Adherence to decisions despite potential legal kickback

Religious views

8. Personal, patient, institutional and societal factors affecting decision making

1. Influenced end-of-life discussion and decision making

9. Poor translation of spiritual ideas to goals of care

2. Did not influence end-of-life practices

Theme 2: Relationships

Perceived role as a doctor

Physician’s family

1. Perceived duty to prolong life causing moral distress

1. Fear due to unintentional transference to own family members

2. Uncertainty about role in end-of-life discussions resulting in no/late end-of-life discussion

Theme 3: Interactions

3. Paternalistic approach to decisionmaking

Patients

4. Satisfaction upon reconciling dual role of saving lives and managing death well

1. Challenges during end-of-life communication

Category 3: Relational Ring

2. Managing expectations of patients

Family

3. Inspiring interactions with patients

1. Fear due to unintentional transference to own family members

Patient’s Family

Category 4: Societal Ring

1. Experiencing conflict with patient’s family

Physical environment

2. Effects of conflict on the relationship

1. Availability of resources in different countries influencing end-of-life care

3. Family’s concern for patient’s possible pain and distress

Cultural environment

4. Managing expectations of patient’s family

1. Physician’s end-of-life care attitudes, behaviors and decisions privy to cultural norms

5. Family’s distress after end-of-life care discussion

2. Death and dying perceived as a “taboo” topic in certain cultures

6. Empowering interactions with patient’s family

3. Need for end-of-life care to be sensitive to different cultures encountered

7. Factors affecting communication

4. Workplace culture impacting attitudes and practices

8. Creation of soft landing when informing patient’s family about death

Societal expectations

9. Perception of intensive care unit as not conducive for palliative care discussions

1. Societal expectations promoting survival and death prevention leading to negative perception of treatment withdrawal as the taking of a patient’s life, affecting physician’s end-of-life decision making

Nurses & ICU Team

Legal standards

1. Conflict between physician and intensive care unit nurses

1. Fear of litigation leading to defensive practice

2. Perception that nurses do not grasp the complexity of end-of-life decision making

2. Adherence to decisions despite potential legal kickback

3. Receiving support from other intensive care unit physicians in managing end-of-life decisions

3. Unclear laws surrounding end-of-life practices breeding legal uncertainty

Physicians from other specialties

Professional Relationships

1. Challenges with interactions

1. Conflict relating to end-of-life decisions with patient’s family and other healthcare professionals

2. Lack of understanding of one another’s role

2. Positive professional relationships

Theme 4: Conflicts in providing end-of-life care

Professional standards

Societal Culture

1. Professional expectation that doctors should not cause death or harm to patients

1. Societal culture impacting decision making

2. Responsibility of treatment withdrawal decision going against physician’s perceived professional standards

2. Stigma associated with death or talking about death

Workplace Culture

1. Shapes the way doctors view death

ICU Environment

1. Suitability for palliative care teaching

2. Intensive care unit as an inappropriate place to die

Legal environment

1. Uncertainty with regards to legal implication of end-of-life practice

Theme 5: Coping strategies

Personal strategies

1. Effective communication to strengthen decision making position

2. Gaining confidence through experience and with end-of-life discussions

3. Taking breaks from the intensive care unit or practicing on other sites

Strategies with patients

1. Collaboration with patients to reduce moral burden of decision making

Strategies with patient’s family

1. Creation of soft landing when informing patient’s family about death

2. Collaboration with patient’s family to reduce moral burden of decision making

Strategies with colleagues

1. Conflict management interventions

2. Emotional and experiential sharing of caring for dying patients

3. Collaboration with interdisciplinary team members