Table 3 Combined Categories/ Themes
| Subcategory | Elaborations |
|---|---|
| Category/ Theme 1: Innate Ring | |
| 1. Perception of life and death | a) Confrontation with own mortality |
| b) Conception of a good death impacting end-of-life care | |
| c) Death of patient perceived to be a personal failure | |
| d) Death of patient not perceived to be a personal failure | |
| e) Conflict about prolonging life as it prolonged suffering | |
| f) One has a right to die | |
| Category/ Theme 2: Individual Ring | |
| 1. Ability to make sense of things | Impaired end-of-life decision making: |
| a) Personal factors | |
| b) Patient factors | |
| c) Institutional factors | |
| d) Societal culture | |
| Doubt: | |
| e) Doubt in end-of-life decision making | |
| f) Doubt about assessment of patient’s prognosis | |
| g) Doubt due to uncertainties in patient’s trajectories | |
| h) Internal conflict when balancing care goals | |
| i) Internal conflict when managing own expectations | |
| j) Dilemmas about active treatment versus palliative intention | |
| 2. Ability to communicate and relate | a) Loss of ability to communicate and relate to patients |
| b) Poor communication skills | |
| c) Difficulty and discomfort when broaching topic of death to patients | |
| d) Attempts to avoid discussion of death in general | |
| e) Improvement in communication skills | |
| f) Confidence in ability to navigate difficult conversations | |
| g) Motivated to further improve communication skills | |
| 3. Ability to express feelings | a) Emotional detachment |
| b) Emotions perceived as hinderance to job | |
| Apprehension/Distress: | |
| c) From end-of-life care | |
| d) From communication with family | |
| e) From belief that futile treatment prolonged dying process | |
| f) From possibility of litigation | |
| g) Fear due to unintentional transference to own family | |
| h) Emotional involvement being considered as valuable | |
| i) Satisfaction in involvement in patient’s end-of-life care | |
| 4. Acquired ability | a) Lacking knowledge about end-of-life |
| b) Inadequate opportunities for end-of-life care training | |
| c) Doubt and lack of confidence in clinical skills | |
| d) Testing of practical skills such as treatment withdrawal techniques | |
| e) End-of-life decision making differing with years of experience | |
| f) Acquisition of new skills with experience | |
| g) Adequate end-of-life care training | |
| 5. Beliefs | Personal Beliefs |
| a) Conflicting beliefs resulting in distress | |
| b) Dilemmas about the balancing of opposing values | |
| c) Personal beliefs reflected in end-of-life practices and communication | |
| Ethical dilemmas | |
| d) Differences in ethical opinion surrounding treatment withholding and withdrawal | |
| e) Futile treatment | |
| f) Lack of advanced directives and families’ aggressive care requests causing moral distress | |
| Religious views | |
| g) Influenced end-of-life discussion and decision making | |
| h) Did not influence end-of-life practices | |
| 6. Perceived Role as a doctor | a) To care for dying patients |
| b) Perceived duty to prolong life causing moral distress | |
| c) Death of patient perceived to be a professional failure | |
| d) Death of patient not perceived to be a professional failure | |
| e) Uncertainty about role in end-of-life discussions resulting in no/late end-of-life discussion | |
| f) Paternalistic approach to decision making | |
| g) Perceived professional duty to collaborate and care for needs of patient’s family | |
| h) Professional satisfaction from caring for dying patients | |
| i) Satisfaction upon reconciling dual role of saving lives and managing death well | |
| j) Emotions perceived as hinderance to role as doctor | |
| Category/ Theme 3: Relational Ring | |
| 1. Family | a) Fear due to unintentional transference to physician’s own family members |
| Category/ Theme 4: Societal Ring | |
| 1. Physical environment | a) Availability of resources in different countries influencing end-of-life care |
| b) Intensive care unit environment as not conducive for end-of-life discussions | |
| Intensive care unit as an inappropriate place to die | |
| c) Lack of privacy | |
| d) Focus of care not allowing for palliative care | |
| Suitability for palliative care teaching | |
| e) Not suitable | |
| f) Suitable | |
| 2. Cultural norms | a) Physician’s end-of-life care attitudes, behaviors and decisions privy to cultural norms |
| b) Death and dying perceived as a “taboo” topic in certain cultures | |
| c) Need for end-of-life care to be sensitive to different cultures encountered | |
| 3. Workplace cultural norms | a) Influencing views on death, end-of-life care attitudes, behavior and decision making |
| 4. Societal expectations | a) Societal expectations promoting survival and death prevention |
| b) Perception of treatment withdrawal as taking the life of one’s patient affecting physician’s end-of-life decision making | |
| 5. Legal standard | a) Fear of legal challenge affecting end-of-life care leading to defensive practice |
| b) Unclear laws surrounding end-of-life practices breeding legal uncertainty | |
| c) Adherence to decisions despite perceived potential legal kickback | |
| 6. Professional Relationships | Patients |
| a) Challenges faced during end-of-life communication | |
| b) Managing expectations of patients | |
| c) Inspiring interactions with patients | |
| Patient’s family | |
| d) Conflict between physician and patient’s family | |
| e) Effects of conflict on relationship | |
| f) Family members concerned for patient’s possible pain and distress | |
| g) Managing expectations of patient’s family members | |
| h) Family’s distress after end-of-life care discussion | |
| i) Empowering interactions with patient’s family members | |
| j) Factors affecting communication with family members | |
| k) Creation of soft landing when informing family about death | |
| l) Perception of intensive care unit as not conducive for palliative care discussions | |
| Nurses & intensive care unit team | |
| m) Support from other intensive care unit physicians to help manage end-of-life decisions | |
| Physicians from other specialties | |
| n) Challenges with interaction | |
| o) Lack of understanding of one another’s role | |
| 7. Professional Standards | a) Professional expectation for doctors to not cause death or harm to patients |
| b) Responsibility to decide on withdrawal of treatment went against physician’s perceived professional standards | |
| Category/ Theme 5: Conflicts in providing end-of-life care | |
| 1. Interpretation of duty of the physician |
a) Professional expectation that doctors should not cause death or harm to patients b) Responsibility of treatment withdrawal decision going against physician’s perceived professional standards c) Physician’s end-of-life care attitudes, behaviors and decisions d) Need for end-of-life care to be sensitive to different cultured encountered |
| 2.Behavior of the physician |
a) Doubts in self, conflicts in decision making b) Emotional and psychological overlay c) Internal conflict between beliefs and duties |
| 3.Behavior of others |
e) Conflict with intensive care unit nurses f) Challenges with interactions with other professionals g) Perception that nurses do not grasp the complexity of end-of-life decision making |
| 4.Professional Standards |
h) Conflict between respect for cultural norms and general practice i) Conflict between team members on how to interpret way to proceed in grey situations |
| Category/ Theme 6: Coping strategies | |
| 1. Personal strategies |
a) Effective communication to strengthen decision making position Confidence: b) Gaining confidence through experience c) Gaining confidence with end-of-life discussions d) Taking breaks from the intensive care unit or practicing on other sites |
| 2. Strategies with patients | a) Collaboration with patient to reduce moral burden of decision making |
| 3. Strategies with patient’s family |
a) Creation of soft landing when informing patient’s family about death b) Collaboration with patient’s family to reduce moral burden of decision making |
| 4. Strategies with colleagues |
a) Conflict management interventions b) Emotional and experiential sharing of caring for dying patients c) Collaborations with interdisciplinary team members |