Table 4.

System-level themes contributing to surgeons’ use of palliative care

Theme	Subtheme	Reflective quotes
Culture	Fear of dying	People don’t like being told they’re going to die. I don’t want to die, but you know, it’s all going to happen someday.
	Stigma of palliative care	Sometimes we have to be careful because why, as soon as they get palliative care, patients sometimes take this view as, okay, this is palliation. That means nothing can be done. So we have to educate them about palliative care. I think sometimes family members and doctors and nurses view palliative care as giving up or as withdrawal of care. Palliative care I think is complicated because families oftentimes think that they’re interchangeable with hospice and they can potentially get offended if you suggest that we get a palliative care team involved.
Resources	Time constraints	What is the biggest challenge in providing palliative care? Probably one of, I guess my time, to be honest. I think it takes a lot of time.
	Access	The setting of having them a half an hour away and only coming occasionally means that I don’t really have that much of a rapport with any of the palliative-care or hospice people. I don’t really know them on a first-name basis I would say the biggest issue there is that their resources are sometimes a little bit limited at the times you need them the most, like at midnight in the ICU.
	Fragmented care	And I think a really screwy thing sometimes in these environments is there’s three teams taking care of this patient, and all of our sort of mid-level residents are the ones that are the communicators between services.