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Table 3 Barriers with regard to physicians'attitudes

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'attitudes
1 • Lack of consensus among the treating team in making end-of-life decisions, surgeons in the ICU do not want to give responsibility to other members of the clinical team, looking only at the small percentage of patients who survive, and one physician could push for futile treatment looking only at a small aspect of the patient’s overall conditionb [20],[26]
• Perception by the critical care attending physician that the consulting specialist controls life-sustaining treatment decision-makingc [17]
• Physicians are overly sure of making the right decision themselves; they do not include patients in care decisions and consensus developmentc [21],[37]
2 • Conflicting opinions of different attending physicians about prognosis and treatment and about recognition that death is a potential reality b [15],[20]
Surgeon’s disagreement with other consultants to accept futility treatmentd [49]
5 • Negative attitude towards relatives who want limitation of treatmentd [37]
6 • Family is thought not to understand end-of-life practice, family was considered not available, or physicians found discussion with relatives unnecessaryd [37]
10 • Palliative care input was limited to the very end of life, `death is not usually expected’, and narrow interpretation of when a patient is dying (that is, that a patient whose vital signs cannot be maintained despite maximal life-sustaining treatment is dyingb [15],[17]
• Physicians sometimes use language that seems to imply abandonment of their patients during the end-of-life decision-making process, as if withdrawal is the sole responsibility of the family, without mentioning another mode of cared [32]
11 • Uneasiness in dealing with surrogate decision makerc [22]
• Family is thought not to understand, family was not available, or physician found discussion unnecessaryc [37],[45]
15 • Negative opinion of advance directives, often perceived as not preventing unwanted aggressive treatment (because of lack of communication with relatives) and lacking a level of specificity necessary to facilitate decision-makingd [16]
• Physicians' own ethical values regarding advance directivesd [38]
18 • Physicians consider do-not-resuscitate orders paperwork, slow, and not applicable to situations related to dying at the ICUc [28]
• Physicians are not aware of patients' preferences regarding do-not-resuscitate ordersd [23]
• Physicians believe that do-not-resuscitate orders should not be appliedd [36]
• Most physicians only discuss do-not-resuscitate order when the prognosis is poor or when the patient’s condition deterioratesc [39],[47]
• Family dynamics and legal concerns were the most important concerns affecting physicians' decision to write or obtain a do-not-resuscitate orderd [39]
• The most important factor influencing do-not-resuscitate decisions was the opinion of the head of the department or the doctor in charge of the patient’s care, not the wishes of the patient and/or the patient’s familyd [46]
21 • No acceptance that the patient is dying; opinion that life should be the foremost concern in end-of-life decision making and that patient’s goal of care is to survive (surgeons); physicians cannot let patients die: "They regard life at any cost to be a success" (comment physician)b [21],[28],[31],[35]
• Conflicting opinion about prognosis, medical uncertainty and focus on narrow physiologic objectives without recognition that the condition of the patient becomes terminal, reaching a point of futility with prolongation of dying; these are barriers limiting the amount of time left for appropriate decision-makingb [15]-[17]
• Surgeons in the team want to continue life-sustaining treatment; they do not accept that they cannot go any further; they do not consider end-of-life discussions in the surgical ICU, which take place later in the patient’s illness trajectory, often in a critical atmosphereb [19],[20]
• Physicians are sure of making the right decisions themselves and do not include patients in care decisions and consensus developmentc [21],[37]
• Think that families do not understand end-of-life practices, that families are not available, or that discussions about goals of care are unnecessaryc [37],[45]
• Think that time spent with family wastes time and energy when families want continuation of aggressive treatment or when there is disagreement or extended hesitation over a decisionc [22]
• No appropriate communication strategy, no information-seeking, but instead arguing with patient and/or the patient’s family or avoiding discussions with them as decision-centred strategyc [30]
• Not eliciting of family’s wishes or assessment of family’s understanding of information; the family is often more told than asked about the nature and context of end-of-life decisionsc [29],[45]
• Feeling of loss of control of referred patients and not believing in giving up on patients are reasons not to refer patients to hospiced [44]
• No recognition of patients’ goals of cared [23]
22 • Physicians find it easier to carry on with treatment than to discuss alternative goals of carec [21]
• Surgeons consider informed consent documentation as a contract for potentially burdensome postoperative therapy after a difficult operation (for example, transplant, neurosurgery)d [24]
23 • Concerns about omission of life-sustaining treatment are larger (missing something treatable, fear of doing something wrong or limiting life-sustaining treatment for a patient who might survive) than concerns about harm of administering life-sustaining treatment (such as iatrogenic harms, prolonging dying, and treating patients against their preferences)b [17],[19]
• Having end-of-life care discussions or engaging in shared decision-making with the patient and/or the patient’s family is considered only when the physician believes that life support should be withdrawnb [18],[29]
• Physicians' concerns about potential legal action taken by families due to forgoing life-sustaining treatment; therefore, they follow families' wishes, even after reading patients' advance directives and even when the medical staff uniformly feels that it is not medically appropriate because treatment is futilec [16],[26],[36],[39],[42]
• Physicians prefer their own ideas about the best interests of the patient, are more focused on medical technical parameters concerning withholding or withdrawing therapy, and continue treatment, not respecting the patient’s and/or the patient’s family’s wishes or the patient’s living will to stop treatmentc [27],[33],[34],[40]
• Diagnostic uncertainty or potential for reversibility of illness is justification for continuation of treatment against the instructions in the patient’s medical enduring power of attorney or the patient’s wishes for palliationc [25],[37]
• Unresponsiveness to treatment already offered is the main factor influencing the physician’s decision to withhold or withdraw therapy, not the patient’s and/or the patient’s family’s requestc [37],[40],[41]
• Doubts about the validity of the patient’s wishes expressed earlierc [25],[27]
• Less respect for patients' wishes by surgeons compared to other ICU physiciansc [28]
• Feeling of betrayal, unhappiness, disappointment and even culpability when family member confronts physician with advance directives in the setting of prolonged life-sustaining treatmentd [24]
• The treating physician considers death in the ICU as a personal failured [24]
• Physician’s distrust of the health care proxy’s motivation to request forgoing life-sustaining treatment and the family’s underlying preferencesd [25]
• Physician's distrust concerning the timing of the completion of the advance directived [25]
• Physician’s conception that medical enduring power of attorney and advance directives provide indications or guidelines rather than a decision that has to be respectedd [25]
• Legal concerns or disagreements with other physicians about whether it is appropriate to write a do-not-resuscitate order or withdraw treatment from patients who lack decision-making capacity and do not have a surrogate decision makerd [43]
• Personal values and beliefs of intensivists, more than comorbidities or the type of acute illness, are barriers to forgoing life-sustaining treatmentd [50]
  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 strong evidence was found. cBarriers for which medium-quality evidence was found. dBarriers for which weak evidence was found.