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Table 2 Barriers with regard to physicians' knowledge

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

Quality indicator no. a Barriers with regard to physicians' knowledge
General • Insufficient physician training in communication about end-of-life issuesb [42]
• Clinician reluctance to use opioids or sedatives because of concern about side effectsb [42]
• Lack of education in palliative medicineb [44]
1 • Involvement of surgeons slows down decision-making because they do not understand patient’s situationc [21]
2 • Lack of communication skills of senior medical residents when interacting with colleaguesc [22]
5 • No familiarity with skilled and timely communicationc [26]
10 • Not taught how to recognize that a person is about to die, no awareness of the process of dyingc [21]
• Unrealistic expectations by clinicians about patient prognosis or effectiveness of ICU treatmentb [42]
16 • Physician uncertainty about the legal details of advance directivesb [38]
• Physician lack of physician experience with advance directivesb [38]
21 • Lack of familiarity to make a prognosisc [15]
• Not knowing how to deal with `feeling helpless• with families pressuring ICU teams to withhold treatment or when family members are upset about aggressiveness of care provided to their unwilling loved onec [22]
• Uncertainty concerning the services provided by local hospice programs and whom to refer to hospicesb [44]
• No awareness of professional or local guidelines that related to provision of futile careb [31]
• Insufficient training in communication with patients and their familiesb [31]
• Lack of discussion of ethical issues in medical programmes; lack of knowledge of ethical issues concerning end-of-life decisionsb [48]
22 • No familiarity with defining futility and how to communicate futility to patients and their familiesc [19]
• No knowledge of management of critical illness by referring specialists; confounding factors in decision-makingc [21]
23 • Conditioned that doing nothing or withdrawing treatment is not helping patientc [19]
• No familiarity with legal framework regarding end-of-life decisions, wrong conception that law prohibits withdrawal of mechanical ventilationc [27],[36]
• No awareness of end-of-life care guidelinesc [27]
• Not being at ease in talking to patients and their families about limitations of therapyb [36]
• No familiarity with end-of-life decision-making (`good prognosis' and `give it a go'often said because of no familiarity with end-of-life decision-making)b [25]
• Insufficient clinician training in techniques for forgoing life-sustaining treatment without causing patient sufferingb [42]
  1. aQuality indicators for adequate communication and decision-making in the ICU as developed by Clarke and colleagues [11] and as outlined above in the Introduction. bBarriers for which weak evidence was found. cBarriers for which medium-quality evidence was found.