Table 4 Barriers with respect to physicians' practice

General

• Competing demands for clinicians' time^b [42]

1

• Unavailability of attending physicians due to rotation systems^c [22]

2

• Hierarchy under physicians is a barrier to their solving problems within the team before talking to the patient^c [22]

• Individual physicians' lack of holistic views^c [26]

7

• Physicians do not routinely check that family members understand the information they are given and do not discuss the family’s role in decision-making^c [29]

10

• Low confidence in taking responsibility; physicians do not refer patients to hospice care, because the patient or the patient’s family does not accept that the patient is dying^b [44]

15

• Not actively recommending the creation of an advance directive^b [38]

21

• Low confidence in taking responsibility; the physician does not take responsibility for collaborative decision-making with the dying patient and thus leaves the patient to die as if the patient has decided when to die^c [15]

• Low confidence in taking responsibility; the physician considers family requests for continued futile treatment as a mandate and not as part of a normal communication and decision-making process^c [17],[31]

• Low confidence in taking responsibility; the physician externalizes control of decision-making to patients, their families and specialists, who they believe expect aggressive treatment^c [17]

• Postponing decision-making until all treatment options are exhausted, until the last moment (surgeons)^c [28]

• No use of professional or local guidelines related to the provision of futile care^b [31]

23

• Lack of time and information are reasons to initiate life support, resulting in futile treatment^c [26]

• Continuation of aggressive treatment is justified, because of lot of money is already invested in the patient, and availability of resources^c [17]

• Aggressive care deemed to be appropriate because of no awareness among providers of existence of advance directive or living will^b [16]

• Low confidence in taking responsibility; the rate of withholding and withdrawing therapy was reduced based upon family’s wishes^b [35]

• Considering withholding and withdrawing decisions inappropriately delayed^b [37]

• No support of an internal multidisciplinary committee or professional policies in cases involving patients who do not have decision-making capacity or a surrogate^b [43]

• Low confidence in taking responsibility; when the patient’s family insists that everything should be done for a patient with a poor prognosis, physicians are less inclined to withdraw treatment than when the family insists on limitation of therapy^b [48]

• Low confidence in taking responsibility; high hopes of the family and their consistent requests to the surgeons contribute to the continuation of therapy which was considered futile by at least two consultants^b [49]