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Theme 1: Self
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Category 1: Innate Ring
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Emotion
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Perception of life and death
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1. Internal conflict
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1. Confrontation with own mortality
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2. Management of own expectations
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2. Conception of a good death impacting end-of-life care
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3. Confrontation with own mortality
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3. One has a right to die
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4. Apprehension/Distress
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Category 2: Individual Ring
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5. Fear due to unintentional transference to own family members
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Ability to make sense of things
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6. Satisfaction in providing end-of-life care
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1. Impact ability to make decisions
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Thoughts
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Abilities to communicate
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1. Doubt
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1. Loss of ability to communicate and relate to patients
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2. Perception of emotional involvement
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2. Improvement in communication skills
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3. Professional responsibility
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Abilities to express feelings
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4. Death of a patient perceived to be a personal failure
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1. Emotional detachment
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5. Death of a patient not perceived to be a personal failure
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2. Emotion connection
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6. Intervention as prolonging suffering for patients
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Acquired ability
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7. Intervention as prolonging suffering for patient’s family
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1. Lack of knowledge about end-of-life
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8. Withdrawal of treatment as life-shortening
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2. Inadequate opportunities for end-of-life care training
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9. Decision between active treatment or palliative intention
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3. Doubt and lack of confidence in clinical skills
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10. Perception that nurses do not grasp the complexity of end-of-life decision making
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4. Testing of practical skills such as treatment withdrawal techniques
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11. Motivated to improve communication skills
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5. Acquisition of new skills with experience
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12. Perception of intensive care unit as not conducive for palliative care discussions
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Beliefs
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Behavior
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Personal Beliefs
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1. Impaired ability to make decisions
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1. Dilemmas about the balancing of opposing values
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2. Impaired ability to communicate
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2. Personal beliefs reflected in end-of-life practices and communication
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3. Emotional detachment
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Exposed to Ethical dilemmas such as:
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4. Difficulty and discomfort when broaching topic of death to patients
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1. Differences in ethical opinion surrounding treatment withholding and withdrawal
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5. Attempts to avoid discussion of death in general
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2. Futile treatment
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6. Fear of litigation leading to defensive practice
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3. Lack of advanced directives and families’ aggressive care requests causing moral distress
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7. Adherence to decisions despite potential legal kickback
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Religious views
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8. Personal, patient, institutional and societal factors affecting decision making
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1. Influenced end-of-life discussion and decision making
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9. Poor translation of spiritual ideas to goals of care
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2. Did not influence end-of-life practices
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Theme 2: Relationships
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Perceived role as a doctor
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Physician’s family
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1. Perceived duty to prolong life causing moral distress
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1. Fear due to unintentional transference to own family members
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2. Uncertainty about role in end-of-life discussions resulting in no/late end-of-life discussion
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Theme 3: Interactions
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3. Paternalistic approach to decisionmaking
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Patients
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4. Satisfaction upon reconciling dual role of saving lives and managing death well
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1. Challenges during end-of-life communication
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Category 3: Relational Ring
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2. Managing expectations of patients
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Family
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3. Inspiring interactions with patients
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1. Fear due to unintentional transference to own family members
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Patient’s Family
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Category 4: Societal Ring
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1. Experiencing conflict with patient’s family
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Physical environment
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2. Effects of conflict on the relationship
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1. Availability of resources in different countries influencing end-of-life care
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3. Family’s concern for patient’s possible pain and distress
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Cultural environment
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4. Managing expectations of patient’s family
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1. Physician’s end-of-life care attitudes, behaviors and decisions privy to cultural norms
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5. Family’s distress after end-of-life care discussion
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2. Death and dying perceived as a “taboo” topic in certain cultures
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6. Empowering interactions with patient’s family
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3. Need for end-of-life care to be sensitive to different cultures encountered
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7. Factors affecting communication
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4. Workplace culture impacting attitudes and practices
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8. Creation of soft landing when informing patient’s family about death
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Societal expectations
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9. Perception of intensive care unit as not conducive for palliative care discussions
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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
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Nurses & ICU Team
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Legal standards
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1. Conflict between physician and intensive care unit nurses
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1. Fear of litigation leading to defensive practice
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2. Perception that nurses do not grasp the complexity of end-of-life decision making
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2. Adherence to decisions despite potential legal kickback
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3. Receiving support from other intensive care unit physicians in managing end-of-life decisions
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3. Unclear laws surrounding end-of-life practices breeding legal uncertainty
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Physicians from other specialties
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Professional Relationships
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1. Challenges with interactions
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1. Conflict relating to end-of-life decisions with patient’s family and other healthcare professionals
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2. Lack of understanding of one another’s role
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2. Positive professional relationships
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Theme 4: Conflicts in providing end-of-life care
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Professional standards
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Societal Culture
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1. Professional expectation that doctors should not cause death or harm to patients
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1. Societal culture impacting decision making
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2. Responsibility of treatment withdrawal decision going against physician’s perceived professional standards
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2. Stigma associated with death or talking about death
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Workplace Culture
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1. Shapes the way doctors view death
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ICU Environment
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1. Suitability for palliative care teaching
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2. Intensive care unit as an inappropriate place to die
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Legal environment
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1. Uncertainty with regards to legal implication of end-of-life practice
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Theme 5: Coping strategies
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Personal strategies
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1. Effective communication to strengthen decision making position
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2. Gaining confidence through experience and with end-of-life discussions
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3. Taking breaks from the intensive care unit or practicing on other sites
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Strategies with patients
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1. Collaboration with patients to reduce moral burden of decision making
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Strategies with patient’s family
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1. Creation of soft landing when informing patient’s family about death
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2. Collaboration with patient’s family to reduce moral burden of decision making
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Strategies with colleagues
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1. Conflict management interventions
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2. Emotional and experiential sharing of caring for dying patients
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3. Collaboration with interdisciplinary team members
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