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Table 1 Characteristics and quality assessment of included studies

From: Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review

Study (yr) [ref] Country Study objective Study design Participants Quality assessment
Qualitative studies      
Pattison et al. (2013) [15] UK To explore the meaning of end-of-life care for critically ill cancer patients, their families, oncologists, palliative care specialists, critical care consultants and nurses Qualitative, phenomenological, in-depth interviews 13 physicians 9
Gutierrez (2012) [16] USA To explore the experiences of critical care nurses and physicians with advance directives in an intensive care unit (ICU) to identify the benefits and limitations of advance directives and recommendations for improvement Descriptive ethnographic study with interviews in a 22-bed medical/surgical ICU in a large community hospital 7 attending physicians, 3 fellow physicians 6.5
Barnato et al. (2012) [17] USA To explore norms of decision-making regarding life-sustaining treatments at 2 academic medical centres that contribute to opposite extremes of end-of-life ICU use Mixed-methods study: family meetings, informal and formal interviews, and artefacts Attending physicians at 2 academic medical centres, patients and family 8
Schenker et al. (2012) [18] USA To describe whether and how comfort care was presented as an option in family conferences about treatment options, and to assess whether the strength of the physicians’ belief that life support should be withdrawn was associated with the presentation of comfort care Mixed-methods study of 72 audio-recorded family conferences about end-of-life treatment decisions Physicians and family 8
Jox et al. (2012) [19] Germany To explore how clinicians themselves define medical futility, whom they think should assess this, how they justify performing futile treatment and how they communicate futility situations to patients and caregivers Qualitative mixed-methods approach at a large tertiary referral centre used to analyse protocols of ethics consultations and semistructured interviews 7 physicians 8.5
Baggs et al. (2012) [20] USA To examine the role of the `attending physician’ in four adult ICUs and the consequences of role complexities for clinicians, as well as for patients and their families, particularly in the context of end-of-life decision-making Ethnographic study in a large academic hospital with surgical, medical, cardiovascular and burn/trauma ICU, including observations of end-of-life discussions and interviews 30 physicians 8.5
Coombs et al. (2012) [21] UK To identify the challenges for health care professionals when moving from a recovery trajectory to an end-of-life trajectory in intensive care Semistructured interviews in 2 ICUs in a large university-affiliated hospital in England 13 doctors 9
Ahern et al. (2012) [22] Canada Interview-based qualitative study conducted to identify what is important to physician trainees in the ICU and infer from this positive educational experiences for physician trainees Qualitative approach of hermeneutic phenomenology, semistructured interviews 19 critical care physician trainees in their postgraduate years (R4 to R6) 8.5
Gehlbach et al. (2011) [23] USA Assess the concordance between patients’ code status preferences and their actual code status orders; compare patients/surrogates and their physicians regarding their respective assessments of most important goals of care Survey, interviews with closed-ended and open-ended questions in a medical ICU of a large academic medical centre 15 physician participants 7.5
Schwarze et al. (2010) [24] USA To examine the culture and practice of surgeons to assess attitudes and concerns regarding advance directives for their patients who undergo high-risk surgical procedures Qualitative study in trauma and surgical critical care 10 physicians 7.5
Corke et al. (2009) [25] Australia To examine attitudes of intensive care doctors to advanced care planning and medical enduring power of attorney Survey followed by open-ended questions 275 trainees and fellows 7
Sibbald et al. (2007) [26] Canada To explore how frontline ICU staff defines medically futile care, to discover why they provide it and to identify strategies that might promote a more effective use of ICU resources Qualitative interviews in 16 ICUs of academic and community hospitals 16 medical directors 8
Beck et al. (2008) [27] Germany To identify difficulties and uncertainties in making decisions about withholding and withdrawing mechanical ventilation among intensive care physicians Problem-centred interviews 28 interviewees, 4 consultants, 11 senior registrars, 13 senior house officers (20 of 28 were specialists) 9
Baggs et al. (2007) [28] USA To clarify unit cultures surrounding end-of-life decision-making in 4 US adult medical and surgical ICUs Prospective ethnographic study of 4 adult ICUs in which a 6-member research team used participant observations, field notes, and semistructured interviews of health care providers as well as patients and their families 13 physicians 8
White et al. (2007) [29] USA To determine the nature and extent of shared decision-making about end-of-life treatment in ICUs, which factors are predictive of higher levels of shared decision-making Mixed-methods study: ICU family conferences in 1 county hospital, 1 university hospital and 2 community hospitals, as well as questionnaires to physicians 35 physicians leading conferences 8.5
Hsieh et al. (2006) [30] USA To identify inherent tensions that arose during family conferences in the ICU and the communication strategies clinicians used in response Qualitative content analysis; communication between family members and physicians was analysed using a dialectic perspective in 51 family–clinician conferences in 4 hospitals 36 physicians who led the conferences 8.5
Palda et al. (2005) [31] Canada To explore the process of the provision of futile care in Canadian ICUs Survey with closed- and open-ended questions 114 physicians 6.5
West et al. (2005) [32] USA To identify categories of expressions of nonabandonment in the setting of ICU family conferences concerning withdrawing life-sustaining therapy or the delivery of bad news, and to develop a conceptual model in which nonabandonment is expressed Qualitative analysis of statements of abandonment during family conferences discussing withholding/withdrawing of treatment 35 physicians leading the conferences 7.5
Quantitative studies      
Bülow et al. (2012) [33] European countries (6 countries) To examine whether religion and religiosity are important to end-of-life decisions and patient autonomy in the ICU Structured questionnaires in 6 European countries, 143 ICUs 304 physicians 6
Schimmer et al. (2012) [34] Germany To determine the decision-making process of withholding and/or withdrawing of life-sustaining treatment in cardiac ICUs in Germany Questionnaire distributed to all heart surgery ICUs (N = 79) in Germany 35 clinical directors, 25 senior ICU physicians 6
Kübler et al. (2011) [35] Poland To analyse the attitudes of ICU physicians regarding decisions to forgo life-sustaining treatment for adult ICU patients Survey 217 intensive care physicians working in ICUs in Poland 6
Weng et al. (2011) [36] China To document current attitudes and practices of ICU doctors in China dealing with issues that have strong ethical and moral dimensions; to make comparisons with these attitudes and practices reported by ICU doctors in Hong Kong and Europe Anonymous, written, structured questionnaire survey 315 participants, representing 54 ICUs in 30 cities in 21 of the 31 regions of China 7
Kranidiotis et al. (2010) [37] Greece To study the frequency, type and rationale for limiting life support in Greek multidisciplinary ICUs, the clinical and demographic parameters associated with limiting life support, and the participation of relatives in the decision-making process Prospective observational study, with an anonymous questionnaire in 8 multidisciplinary, general hospital-affiliated ICUs 304 patients and their physicians 7
Schaden et al. (2010) [38] Austria To explore Austrian intensive care physicians’ experiences with, and their acceptance of, the new advance directives legislation 2 years after enactment Survey of all ICUs in Austria 139 participants 6
Westphal and McKee (2009) [39] USA To examine differences between physicians and nurses regarding knowledge about advance directives and do-not-resuscitate orders, and the personal factors that underlie beliefs and practices related to the use of advance directives and do-not-resuscitate orders Survey 53 physicians 6
Sprung et al. (2008) [40] European countries (17 countries) To evaluate physician documentation and the reasoning, considerations and difficulties in end-of-life decision-making in ICUs Prospective study of end-of-life practices and decisions in consecutive patients who died or were subject to any limitation of life-saving interventions in 37 ICUs in 17 European countries ICU physicians 6
Collins et al. (2006) [41] Ireland To study the frequency, rationale and process for withholding and withdrawing life-sustaining treatment in intensive care patients in Ireland Prospective observational study of all consecutive patients admitted to ICU who died or had life-sustaining treatment limited Data of 122 patients, documented by physicians 7
Nelson et al. (2006) [42] USA To improve the understanding of educational needs among residents caring for the critically ill Survey 184 physicians 7
White et al. (2006) [43] USA To determine how decisions are made to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision makers Prospective longitudinal cohort study 47 physicians of patients without decision-making capacity and without a surrogate 6
Moss et al. (2005) [44] USA To assess the knowledge, skills and attitudes that physicians and nurses who practice in West Virginia’s ICUs have concerning end-of-life care Survey 153 physicians 6
Cohen et al. (2005) [45] European Countries (17 countries) To examine the communication of end-of-life decisions in Europe Prospective observational study of 4,248 patients who had any limitation of life-sustaining treatment or died in 37 ICUs in 17 countries Physicians collected data on 4248 patients 7
Élő et al. (2005) [46] Hungary To study the factors associated with limiting resuscitation in Hungary Survey 72 doctors 7
Sinuff et al. (2004) [47] Canada, USA, Sweden, Australia To study the rate of establishing do-not-resuscitate directives, determinants and outcomes of those directives for mechanically ventilated patients Multicentre observational study 3,099 critically ill patients admitted to 15 ICUs, documentation attending physicians' clinical judgements 7
Yap et al. (2004) [48] Hong Kong To examine ethical attitudes of intensive care physicians in Hong Kong Survey 65 physicians 7
Hariharan et al. (2003) [49] West Indies To analyse the characteristics of moribund patients in a surgical ICU and highlight the dilemmas inherent in treating such patients Prospective collection of data from patient records Data of patients recorded by physicians of surgical ICU 6
Garland and Connors (2007) [50] Canada To quantify the influence that ICU staff physicians have on decisions to limit life support for critically ill patients Data prospectively collected in the 13-bed medical ICU of a 520-bed urban university-affiliated teaching hospital 9 staff physicians 7