Table 4.

Themes, categories and codes concerning moral barriers and facilitators physicians encounter in ACP

Themes	Categories	Facilitator codes for ACP	Barrier codes for ACP
1. Beneficence and non-maleficence	Decision making at the EOL based on the intention to provide good care	Aiming at decision making based on the patient’s best interests10 21 Avoiding prolongation of suffering1 8 15 33 34	Experiencing EOL decision making as difficult in case of conflicting interests2 6 8 9 16 22 35
		Diminishing emotional burden to patient6 8 33 37 Aiming to resolve a disagreement in favour of patient’s wishes16 23	Hesitating to discuss death because of fear to induce anxiety or emotional harm1 3 8 9 21 31 33 35
		Aiming to provide emotional support to family2 8–10 12 34
	Maintain hope for the future despite a future with inevitable decline	Providing hope for the future3 21	Fearing to destroy patient’s sense of hope for the future by conducting ACP2 3 8 9 31 33 Experiencing moral dilemmas around discussing future goals of care11 13 16 17 21 36 People with dementia focus on immediate concerns rather than on future concerns3 8 10 13 15 21 23 31 33 37
	Physician’s professional attitude towards talking about death and dying: intention and practice	Witnessing illness or death facilitates ACP23 31	Experiencing discomfort in discussing death or EOL3 8 10 17 21 23 34 35 Experiencing patient’s active avoidance of discussing death or EOL1–3 8 10 11 13 17 22 23 33–35 Experiencing patient’s passive avoidance of discussing death or EOL13 17 21 23 Experiencing reluctance of family caregivers to discuss death or EOL2 10 11 23
	Physician’s personal attitude towards talking about death and dying	Perceiving the physician as a fellow human being, not just a professional6	Avoiding the conversation due to personal perspectives on death9 10 13 35 Experiencing a conflict between professional role and private feelings23 35 Experiencing a personal conflict of interest35
2. Respecting dignity	Good death	Ensuring that patients with dementia have the same opportunities for EOL planning1 Increasing patient’s and family members’ control over dying process13	Disregarding decisions agreed on due to families’ poor understanding of how death happens, causing gaps between expectations and reality10
		Physician’s personal perspective on a good death1 9 10	Opposite views among physicians on a good death8 10 12 15 16 23 37
	Respect cultural, spiritual and religious beliefs	Aiming to respect religious, cultural and life issues1 8 9 11 16 33–35	Family and professional caregivers holding different religious, spiritual and cultural beliefs regarding practicing ACP8 9 16 23 32 34 35
	Physician as a person: cultural, spiritual and religious beliefs	Impact of physician’s personal religious beliefs on decision making8 9 15 23	Experiencing no concordance with physician’s personal religious beliefs8 9 15 23 35
	Respect autonomy, wishes and preferences	Viewing ACP as a way of maintaining person’s individual identity1 11 16 17 33 34 36	Experiencing conflicts between personal and relational integrity, concerning patient’s autonomy6 9 13 35
		ACP in regard to future communication inability and lack of decision making capacity3 13 33	Having moral and ethical concerns related to the effects of declining capacity of person with dementia1 3 8–11 13 31 Undermining of physician’s confidence in adhering to wishes when considering changing wishes as dementia progresses1 3 6 8 15–17 31
		Aiming to respect patient’s healthcare or EOL wishes.1 6 8 10 11 16 17 21 22 34 36	Fearing substitute judgement being not truly reflective of wishes of person with dementia9–11 16 17 23 35 36
3. Taking responsibility and ownership	Obligation	Talking about the subject as a legal, professional and moral obligation6 33 36	Fearing litigation or fear of experiencing moral dilemmas regarding ACP3 6 15 21 23 31 34–36
	Responsibility and ownership	Feeling responsible for initiating the discussion given future lack of capacity/ ability of patients to take part in discussion12 13	Feeling that initiating the discussion is inappropriate when patients don’t initiate themselves.13 16 23 31 35 Concern about timing3 8 17 23 31 33 36
		Feeling a professional responsibility for decision making based on patient’s needs6 8 16 22 35 38	Being reluctant to assume responsibility for ACP and decision making2 8 13 15
		Family caregiver requesting physician to bear responsibility for decision making12 16 23	Being uncertain about who is responsible for discussing and decision making1–3 8 9 11 13 15 17 23 33 35 36
4. Relationship	Long-term relationship	Building conditions to maintain long-term relationships1 3 6 8 11 33 38	Not having a long-standing relation with family3 8 9 31 Fearing to disturb the relationship.21 Fearing attachment to the resident is unacknowledged, not allowed and less professional.9 23 35
	Trust and confidence	Having a good relationship with the person with dementia2 8 10–13 16 17 21 23 35
		Having a good relationship between physician and family generates confidence1 2 8 9 22 35 Relationship of importance for decision making10 12 Physician experiencing a strong family attachment to resident1 21 23 35	Not having a close relationship with staff, causing reluctance of family to discuss or to be involved in decision making1 2 8–11 13 15 16 21 33 34 37 38 Physician experiencing lack of empathy and warmth in family–patient relationship1 8 9
5. Courage	Decision making in conflict and crisis	Aiming to reduce EOL crisis decision making8 Prioritise patient’s needs22 23	Experiencing dealing with conflicts about care as a challenge1 8 11 16 21 35
	Legal aspects		Worrying about being blamed or litigation3 6 15 21 23 31 34–36

ACP, advance care planning; EOL, end of life.