Table 3.

Reasons surgeons transfer and accept dying patients

Reason	Description	Representative Quotes
Inability to make the determination that additional treatment will be ineffective	Local surgeons fear they will miss an additional treatment option available at a higher level center	Referring surgeon: It would be hard to not just check and see if they can do anything else.
	Surgeons at higher level centers cannot rely solely on information from phone conversation to make life-ending decisions	Accepting surgeon: “Sometimes they’re probably just not appropriate for surgery either, and perhaps comfort measures need to be taken….It’s very hard to be able to say that over the phone. There’s no way I could make that decision not seeing the patient.”
Need to do “everything”	There is a cultural expectation to exhaust all treatment options which can be assured by transfer to the highest level of care	Referring surgeon: “Some families and some patients just need to die in town; they won’t ever feel that everything was done unless it’s there.”
		Accepting surgeon: “We have gone away from the social fabric that says, ‘Grandpa’s going to die. We’re going to celebrate that with casseroles and good conversation around the dinner table with our friends and family, and we’re going to be okay with that.’ What we’ve gotten to is everything means ventilators, pressors, renal replacement therapy, you name it, sitting in a sterile bed somewhere where two people at a time can come in and hold the hand, and whisper in the ear of some loved one.”
	Surgeons seek rescue of postoperative patients with complications	Referring surgeon: “I want a person that I have messed up on…to not die….I’d really want to make sure that I have come up with everything possible…. If I want to know if there’s anything else I could possibly do for them that [transfer] would be it and certainly on my own complication, I would be wanting to throw the kitchen sink at what I could do to make him live and do okay.”
Tertiary center has unique resources for dying patients	More experience conducting difficult conversations	Accepting surgeon: “When they do finally end up dying or moving towards that there’s somebody else out there that’s going to have that conversation. That’s a conversation that we have as trauma surgeons everyday.…It’s the ability to do that, know how to do it, and do it in a way that may give some solace to this family. I’d rather have that happen than some guy fumble through it and say he’s going to die.”
	Palliative care services are more available at tertiary care centers	Accepting surgeon: “The other thing is that we have very strong palliative care services at this tertiary center which they’re not going to have at other centers…. I’m going to have palliative care involved immediately, preoperatively as well. That’s a service that we have that other places don’t.”