Table 3.

(A-E) Representative Quotes of Emergent Themes Regarding the 4-Step Shared Decision-Making (SDM) Process Itself

(A) Theme Relating to Not All 4 Steps Being Used During the Encounter for a Decision, Not All Steps Being Visible to Both Parties, and/or the Order of the 4 Steps Varied
Clinician discussion with family regarding decision about whether to perform CPR Clinician response to interviewer question: "Tell me what was behind your approach here?"	“There is one thing that [medical team member] and I were talking about, which is, would CPR be helpful if she was to need that? I’d be pushing on the chest. Um, and I think right now, it would be reasonable to not do that if her heart stopped or wasn’t working enough. That’s something that is unlikely to make her better. And it can certainly be, um, uncomfortable and cause problems, especially when she’s on blood thinners. Um, could have some broken bones. So, my suggestion is that we would not do CPR if her heart was to all of a sudden, stop working. Just wanted you to know. And that’s again something that- especially if this is an infection that we can get her better from, we could re-address any time. It’s not a permanent decision.” “I think the belief that compressions wouldn’t really offer her any survival advantage. Um and can have more morbidity with them. And that making a recommendation for what things are reasonable to offer her was more reasonable and helpful for this quiet family who had shared some of their values with us. So, um, um, that just seemed most appropriate, was just to make a recommendation. And if they had come back and said, no, do everything, which some parents do, then...that also would have been okay.” (MS202)
(B) Theme Relating to Not Treating Step 1 and Step 2 as Distinct
Clinician	“X-ray, from my perspective is such small risk. I’m obviously, so biased, because I’m around it all the time and I do it all the time... We’ll just get these and then we’ll know and be able to rule out all these other things.” (MS702)
(C) Theme Related to Decisions Feeling Very Joint Because of Past Exploration of Preferences, Even Though These Preferences Weren’t Revisited During the Current Encounter or for the Current Decision
Parent	“I honestly, I don’t know if there’s been anything that explicit, where it’s been like, ’What’s your opinion on this?’ I think again because we both are very much on the same page, like we came to the table with the same page that he came to the table, that it has felt very joint.” (MS104)
(D) Theme Related to Parent Not Expressing Preferences Because of Trust in Clinician or Clinicians Not Being Explicit About All SDM Steps Because of Parents Trust in Them
Parent	“So, once you get the feel of trusting the doctors or trust the people that take care of you and or your child, there is very little scope that you feel that you should even think about if it is right or wrong.” (MS206)
Clinician	“I suspect that there are some family encounters where that trust isn’t already there and that might be harder to rely on. Um, and I think, like I do think that I’ve got a framework for what he’s got going on. So I feel confident in this decision um, I just want families to also feel confident in the decision.” (MS102)
(E) Theme Related to Equating Eliciting Parent Preferences With Seeking Their Agreement With a Recommendation
Clinician	“Maybe it’s just me wanting to make sure that everybody feels good about the process, but even if it’s a tacit, give me a nod, does it sound reasonable?” (MS702)
Clinician	“I think because he was doing well on the medicine, I just wanted to make sure she also understood that and that she’s okay with it.” (MS406)

CPR indicates cardiopulmonary resuscitation.