Table 1.

Exemplars

Category	Subtheme
Increased Unknowns/Uncertainty	Redefining Attitudes and Hardship Due to Collective Uncertainty
Increased stress	“there's no aspect of life that has been unchanged…and thinking about home life and our children and our parents, and all of these ways in which the world is really different and challenging.”- (ID05) “It was challenging because so much was unknown about the virus and the toll that it was going to take on patients and where we were headed.” –(ID03)
Uncertain prognosis	“We are seeing people who are incredibly sick all of a sudden get better. We've seen people who we thought we going to get better, they go home; they get sick; they come back; they die.… We don't like to appear in the medical field like we don't know what we're doing, but being very honest and saying this is new…..”-(ID38)
Uncertain treatment plans	“We change recommendations…Whatever the best decision is today might turn out to be wrong tomorrow. And that's always been true, but people are more cognizant of that, and so I think they feel much more vulnerable.”-(ID04)
Isolation	“The realization of how many people would be dying alone, the realization of how difficult it was going to be for families to grieve the death of their loved one, ….I grieved that in a pretty anxious way.-(ID08)
Unclear communication	“…communicating with people with face shields and masks on. It's really hard to read the face. And so much of what we do is also nonverbal communication.”- (ID09)

Palliative Care Integration Across Hospital	Breaking with the Past Towards an Integrated Concept of Palliative Care
Appreciation for palliative care	“[COVID] demonstrated the importance of palliative care because there's been so much death and so much fear of death associated with COVID that I think it's really made clear how important palliative care is in the spectrum of care that is provided for patients, all patients, and especially patients with a serious illness.”- (ID14)
Integration of PC into ICU and ED	“ED clinicians … said the reason they did not feel morally distressed is because we [palliative care clinicians] had their back. And that was really powerful…it just made me realize how many places there are in the institution that could benefit from partnership with us. I always knew they were there.” - (ID18)

Future Training/Planning for Pandemics	Building Resiliency Through Primary Palliative Care Training
Importance of advanced care planning	“Dying is a big part of medicine, too, and the fact that we can help people do that with dignity and without any kind of suffering and kind of guide those conversations…being trained to have those conversations in a time when it was extremely necessary was extremely helpful…I never thought I would be in a part of the pandemic, but I was grateful for my training to be able to be useful in such a dire time for the country and especially for our hospital.” – (ID20)
Importance of primary palliative care	“primary palliative care and having conversations especially about advance directive is so important as early as possible…we were having those conversations almost too late.if you had that conversation with your family or with your primary care physician prior, we would know your advance directives but not everyone had, which made it just so very clear how necessary it is for palliative care to [be a] part of primary care and primary palliative care takes us.”- (ID12)
Effectiveness of primary palliative care training	“So I think that that was one thing that helped our hospital a lot is that lot of our residents and our attendings get a lot of primary palliative care teaching…. in any pandemic, the number of cases will be much higher than a palliative care team can handle. …how do we teach our hospitalists and our intensivists to have these conversations in advance of the next pandemic.” - (ID35)
Future training	“Palliative care is the medical specialty, but it's also a set of principles and approaches to serious illness that are not consigned and should not be consigned to those who practice palliative care as a medical specialty. There are things that everybody should be doing… by hospitalists and cardiologists and oncologists and intensivists and surgeons and all of the different specialties.”- (ID05)