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Table 1 Data extraction and quality assessment of included articles divided into qualitative articles

From: Factors influencing the integration of a palliative approach in intensive care units: a systematic mixed-methods review

First author, publication year, country Aim of the study Participants Methodology/data
Main outcome Barriers Facilitators Quality assessment
The aim of the study was to explore nurses’ definitions of quality EOL care and to describe the activities that promote quality EOL care in the ICU Nurses (n = 9) Interviewed The interview indicated that nurses undertook a number of methods to improve the quality of EOL care available. Expressions such as ‘balancing’, ‘trial and error’, ‘taking a step back’ and ‘coaching the physicians’ were mentioned. These, combined with a number of personal, environmental and interrelationship factors, were found to both enhance and limit the ability of critical care nurses to administer EOL quality. *Moral distress caused by providing end of life care.
*Noise and technology
*Lack of time and education
*Fragmentation of care
*Neglected transformation of care from curative to palliative
*Trial and error in daily practice Moderate-high
Anderson [20]
To determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness Critical care clinicians (n = 45)
Surrogates (n = 47)
Experts in health communication (n = 26)
In-depth semi-structured interviews It was generally agreed by surrogates that there was a need for open, completely truthful prognosis to be made available to the family. In particular, it was stated that emotional support should be attuned to their needs and that it should be ensured that prognosis was fully understood. A further recommendation was that, in addition to making predictions for the patient, clinicians should make available comparable statistics, such as radiographic images, explaining the physical symptoms of the disease. This recommendation was not endorsed by the majority of physicians, who considered that numerical statistics were not constructive in such cases. This contrasted with the opinions of surrogates and physicians from other disciplines who considered their usage beneficial. Physicians were urged to raise the subject of death early on, when patients were committed to the ICU, and to amplify it with greater detail as the clinical situation progressed. The disclosure procedure should be initiated by physicians, after which there is a need for the various members of the team involved to substantiate the physician’s prognosis to prepare the family for the ultimate outcome. *ICU culture *Ineffective communication with families *Inadequate staffing and time
*Lack of availability of space *Lack of clinician training in communication *Lack of explanations regarding medical terminology
*Use different type of material for medical information *Prognostication information model *Engage different disciplines Moderate
To investigate factors influencing critical care nurses’ provision of end-of-life care and their inclusion of families in that care Nurses (n = 27) A focus group interview “Supporting Families’ Dying Process” clarifies how critical care nurses organize information to construct the ‘big picture’ of the patients’ deteriorating status and artfully communicate this to families *Acting on information
*Trust and knowledge
*Time challenges *The culture of the unit
*Support family involvement and communication Moderate
To study limitations of treatment decision making in real time and to evaluate similarities and differences in the cultural contexts of 4 ICUs and the relationship of those contexts to end of life care decision making (EOLDM) Health care providers, patient and families
(n = 130)
Ethnographic/observation and interviews It was agreed that ICUs were not monolithic. There were similarities, but important
disparities in EOLDM were recognized in the formal and informal guidelines, technology significance and utilization, physician roles and interactions, procedures such as unit rounds, and timing of EOLDM initiation.
  *Planned family meetings Moderate
To explore the end-of-life care beliefs and practices of intensive care nurses. Nurses (n = 5) A descriptive exploratory qualitative/a semi-structured interview Three main categories were identified: end-of-life care beliefs, end-of-life care in the context of ICU and end-of-life care facilitation. Factors that contribute to end-of-life care experiences and methods of intensive care nurses were integrated into the first two classifications. Lack of advanced practice skills *Lack of understanding of the complexity of palliative care *Ambiguity of palliative care *Limited support (protocol) *ICU culture *Lack of emotional support *Family involvement in comfort care environmental peaceful setting (single room) *Creating an atmosphere *Changing environment Moderate –high
C [24]
Describes the views of health professionals using a supportive care pathway in intensive care Healthcare provider (n = 10) Semi-structured interviews The effects of the supportive care pathway on patient care were endorsed by most respondents. It was considered particularly effective in allowing agreement on care planning. Doubts were expressed in identifying the right patients for the pathway, which was mentioned as being a euphemism for dying. *Difficulty in identifying care pathway *Lack of symptom control *Autonomy of clinicians in using supportive care
*Pressures and priority of work
*Enabling consensus in care planning *Supportive care pathway framework *Involving nurse in decision making Moderate –high
To learn the perception of health professionals in an intensive care unit towards palliative care Nurses (n = 12), nursing technicians (n = 11), physical therapists (n = 5), doctors (n = 9) Semi-structured interviews. The survey highlighted the need for care to be executed at the final stage of life in order to avoid unnecessary actions, emphasis to be placed on comfort care and the need for a better care system and increased team training. *Lack of standardized care
*Lack of team training *Ineffective communication
To explore doctors’ and nurses’ experiences of the impact of the LCP in two intensive care units Nurses (n = 6) Interview The nurses’ experience of the LCP depended on their responsibilities and was based on frequency of use and educational level received in the LCP. Education and adequate support have been recognized as being fundamental to the effective implementation of palliative care approaches. *Doctors struggle with palliative care decisions*Lack of guidance regarding applying palliative care *Lack of protocols for palliative care in ICU *Lack of familiarity with palliative care *Palliative care guidelines Moderate al.
To explore the experiences of ICU nurses who had provided EOLC to patients and their families Nurses (n = 5) A phenomenon- logical/Semi structured interviews Five themes were identified: use of integrated care systems, communication, the environment, education and training, staff distress. Nurses stated that they were unprepared to provide end-of-life care. Inadequate communication between staff, patients and families while providing care for patients at end of life. *ICU environment affecting palliative care *Lack of education and training in palliative care *Communication and decision conflict *Staff distress *Integrated care system
*Staff ratios