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