Table 6.

Surgeons contend with emotional pressure to offer resection

Theme 5. Even when they believe resection will offer no benefit, surgeons face pressure to offer surgery to preserve hope for patients who view it as a favorable treatment option and/or those that have no therapeutic alternatives.
Interpretation	Examples
Deciding not to offer surgery can cause significant emotional burden for surgeons.	“You don't want him to die, but you can't operate on him […] It's just the worst thing because you can't be on his team […] You can't save him with your scalpel […] You feel like a limp noodle, like the most impotent, helpless feeling in the world.”
	“For the most part, patients view surgery relatively favorably […] It can be quite psychologically devastating to patients when you say, ‘you're not a candidate for surgery because you're just medically unfit’ or ‘I think surgery is not going to help you.’”
	“Sometimes there are things where you say, ‘I don't really feel good about this. I don't think it's a good idea. The evidence is kind of pointing me away from doing it’—but you would not necessarily be […] classified as being engaging in egregious professional practices for doing it. So, you have that: Based on the evidence and experience, it's probably not a good idea. To what extent will a patient's desires—after explaining everything—push you in one direction or another?”
	“When she woke up from her [mediastinoscopy], she knew immediately because she didn't have any chest pain [that] she didn't have the resection. Literally spent the entire rest of the day […] crying with her. She was bawling and kept screaming at me to take it out. But I mean, I honestly debated doing it […] because it was [so] heart-wrenching.”

Interview responses revealed that surgeons are often pressured to offer surgical resection for patients for whom there is no expected therapeutic benefit. This theme is supported by quotes from participant interviews.