TABLE I.

Clinician-identified barriers to providing early, systematic, and oncology-integrated palliative care for patients with metastatic colorectal cancer

Category	Theme		Exemplar quote
	Name	Description
Palliative care service
	Insufficient resources	Insufficient resources [staff, time, clinic space (rooms, beds), necessary component of palliative care service in the region]	Not enough nursing support for effective symptom control, management, and follow-up. Not enough clinic room or time to see, follow up patients in a timely fashion — Physician 1, Tertiary Centre 1
	Palliative care services perceived as suboptimal	Clinician is aware of the palliative care referral process and the services provided, but perceives the process or services to be too difficult to access (complexity), too slow to access (timeliness), inadequate (for example, no long-term follow-up), or too limited or insufficient to provide benefit to patients.	Currently, when I refer to palliative care, the patient is seen once or twice and then discharged from clinic once their symptoms are stable. There is no ongoing follow-up, and they need to be re-referred if new symptoms develop. In patients with uncomplicated symptom issues, it is simpler to treat them myself. — Physician 2, Tertiary Centre 2
Clinician
	Poor communication	Insufficient or poor-quality communication processes between clinicians or care teams	All teams are excellent. It is the fact that no one cooperates together. The [patient] and family have to retell their story and journey over and over. They need one point of contact! — Nurse 1, Regional Centre 1
	Professional role confusion	Inadequate clinician role definition when care teams integrate, leading to varied interpretations about who does what.	There seems to be no clear role division. — Nurse 2, Tertiary Centre 1
	Confusion concerning palliative care services	Clinicians are not clear who, how, or when to refer patients to palliative care services, or clinicians are not clear about the services that palliative care provides (or both).	I feel staff need to understand that the palliative care program is not only for patients who are going to pass in “a week.” It is for patients who may have months or years to live, but [who] need extra services. For example, pain control, home care, etc. — Nurse 3, Regional Centre 1
	Difficult conversation	Clinicians are uncomfortable having a conversation about palliative care with the patient.	The need for frank and open discussion, starting with the primary doctors involved. Very difficult discussion for many oncology doctors. — Nurse 1, Regional Centre 1
Patient
	Patient does not qualify for palliative care services	Patient deemed not “qualified” for palliative care services when requested.	They are sometimes refused, as we are told they are not yet a “suitable” client. — Nurse 4, Tertiary Centre 1
	Palliative care not needed	Lack of perceived (by clinician) need for palliative care services at this time	I usually refer patients with more complex symptoms and/or poor performance status (metastatic pancreas patients, etc.). Many metastatic colorectal cancer patients early in their disease course seem less likely to have complex symptoms, and many have good performance status. — Physician 3, Tertiary Centre 2
	Patient declines	Patient declines palliative care referral	Sometimes … I think that a patient would benefit, the patient agrees to the referral, and then when … contacted, the patient feels [that] they don’t need palliative care services. — Nurse 5, Tertiary Centre 2