Table 4.

Categories, subcategories, and examples of quotations.

Subcategory	Quotation
Category: bewilderment in dealing with children and their families
Inability to effectively communicate with children and their families	“We are not familiar with the necessary psychological skills for establishing effective communication with patients with chronic and incurable diseases. We don't know when and how we can communicate with children and families who are experiencing a crisis” (Participant no. 6).
Inability to tell the truth about the disease	“Affliction of a child with an incurable disease is like a severe earthquake which ruins all wishes of a family. We can't make a right decision about how to deal with such a family. We can neither give false hope to these families nor tell them the truth about the disease. We feel pangs of conscience in these situations and don't know which decision is the best and complies with the ethical principles. We don't really have the necessary skills for managing these situations” (Participant no. 11). “I don't know whether I should tell the truth to children who are in the last days of life and are still conscious. I know that if I tell the truth to these patients and then something wrong happens to them, their families would definitely attribute that to my truth-telling practice. Do we have adequate legal support in these situations?” (Participant no. 2).
Category: conflicts in decision making
Physician-parent conflicts	“When we have a child with poor prognosis, it is very difficult to inform the family that there is no effective treatment for the child and to persuade them to take the child home. They usually insist on hospitalization and performance of any possible intervention. In these situations, we really become bewildered and don't know what the best decision is and how important the benefit of a child who can't defend himself/herself is” (Participant no. 4).
Parent-child conflicts	“For using some types of mechanical ventilation such as non-invasive ventilation, we need to involve the afflicted children in decision making in order to improve their collaboration. We have had some patients who did not accept such treatments and noted that they preferred death, while their families insisted on treatments. Who is the ultimate decision maker in these situations? Can we respect the decisions of a legally competent child when we know that taking an action or no action is harmful for him/her?” (Participant no. 13). “Conflicts between children and families are serious, though families make the final decisions without involving their children in decision making in almost all situations. This is a cultural problem. What should we do? Taking ethics into account or respecting cultural beliefs?” (Participant no. 12).
Physician-physician conflicts	“We had a terminally-ill patient in our ward who had severe neutropenia, thrombocytopenia, and anemia and was intubated. I really didn't know what decision I could make; discontinuation of all treatments or their continuation despite the child's severe suffering. There was no consensus among colleagues mainly due to their fear over legal prosecution” (Participant no. 4). “Our major challenge is legal concerns about resuscitation. Medical ethics and medical law should be consistent. We need clear formal protocols and guidelines which legally support us” (Participant no. 5).