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Table 2 Data extraction and quality assessment of included articles divided into quantitative method articles

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

First author, publication years, country Aim of the study Participants Methodology/data gathering Main outcome Barriers Facilitators Quality assessment
Latour, J
[28]
2009/Netherlands
To investigate experiences and attitudes of European intensive care nurses regarding end-of-life care (EOL) Nurse (n = 419) A self-administered questionnaire Approximately three-quarters of respondents (73.4%) said they took an active part in decision-making, while a slightly larger percentage (78.6%) stated their commitment to EOL decisions being made with family involvement. Just under half of the respondents stated that patients should be kept deeply sedated, almost equal numbers were for and against the maintenance of nutritional support (41.6 and 42.3%, respectively). The general consensus was against patients being moved to single rooms (78%).   *Presence of family members during dying process Low-Moderate
Jox, R
[29]
2010/Germany
To investigate the practices and perspectives of German intensive care nurses and physicians on limiting LST. Nurses (n = 268) and physicians (n = 95) Survey/questionnaire written in German It was apparent that half of the junior physicians and an equal number of nurses were unclear as to the correct decision-making process. The physicians were the least certain about the procedures, citing a lack of training, and were worried about the possibility of litigation if there had been a failure in carrying out the correct procedure *Decision-making process
*Lack of standardized documentation practice
*Ignoring involved nurses and family in decision-making
  Moderate
Voigt
[30]
2015/USA
To evaluate the frequency, characteristics, and outcomes of ethics consultations in critically ill patients with cancer. Nurse ethicists (n = 30)
Nurses with 10 years of experience (n = 46)
Team
(n = 50)
Patients (n = 35)
Retrospective analysis of all adult patients with cancer Ethics consultations between the ICU team and the patients or their surrogates arose from a lack of agreement between the parties on EOL care. This was evident from a study of 53 patients, most of whom had surrogates, and two-thirds of whom lacked decision-making ability. *Conflict between the patient’s caregiver and the ICU team
*Conflict between physicians about palliative care
*Ethics consultations Moderate- High
Crump SK
[31]
2010/USA
To explore the obstacles (barriers) to, and supports for, EOL care in their critical care units Nurses (n = 56) Survey/questionnaire The outcome was as follows: (1) families and patients needed clear data to make EOL choices; (2) physician-related problems influence the capacity of nurses to provide quality EOL care; (3) critical care nurses need more expertise, skills and a sense of cultural competence to deliver quality care; and (4) clear advance directive guidelines can decrease confusion about care objectives. *Different family and friends issues
*Continuation of aggressive care
*Lack of patient and family knowledge about prognosis
*Designate one contact person per patient
*Teach family members about how to deal with the process of dying
*Meeting of doctor and family after death
Low -Moderate
Kirchhoff, K
[32]
2010/USA
To describe the training, guidance, and support related to withdrawal of life support received by nurses in intensive care unit Nurses
(n = 475)
Survey/questionnaire From respondents’ responses (48.4%), almost half of the nurses in the survey, it was evident that only a small part of their basic education related to the withdrawal of life-support systems (15.5%). In addition, two-thirds of those questioned received no further on-site training (63.1%). The evidence indicated that nurses’ actions during withdrawal were directed primarily by the overseeing physician’s instructions (63.8%), thereafter, by their following a standardized care plan (20%) and finally by complying with standing orders (11.8%). *Lack of training from work site
*Procedural difficulties *Individual physician’s orders *Lack of a palliative care education programme
*Shortage of staff (workload)
* Insufficient emotional support for nurses
*Nurses involvement in family meeting High
Schimmer
[33]
2011/Germany
To assesses the medical and ethical criteria and the method of WH and/or WD of life support treatment in cardiac intensive care units Clinical director, senior ICU physician and head nurse
(n = 237)
Survey/questionnaires The three principal reasons for withholding/withdrawing (WH/WD) life-sustaining treatment were given as cranial computed tomography (CCT) with poor prognosis (91.9%), multi-organ failure (70.9%) and failure to assist device therapy (69.8%). A third (32.6%) of respondents admitted that their decision-making was ethically influenced. The perceptions of the three professional groups in the survey differed considerably over the decision-making issues: multi-organ failure (P = 0.018), failure of assist device therapy (P = 0.009) and cardiac index (P = 0.009). The ethical issues were the poor expected quality of life (P = 0.001), the patient wanting to limit medical care (P = 0.002), interoperative course (P = 0.054), and the family choice (P = 0.032). *Ethical aspects influence the decision-making process   Low
Kamel, G
[34]
2015/USA
To identify residents’ knowledge and their perceived barriers of PC-end-of-life (EOL) care utilization in the ICU Residents (n = 30) Cross-sectional study Residents stated that the greatest failure was in the goals of care provided by the medical teams and those expected by the patients and their families, cited by 18.7% of respondents. The patient was required to be terminally ill before a successful palliative care consultation could be obtained (22.9%). ¨*Discrepancies in care goals between the medical team and patients/families
*Lack of advanced directives at the time of admission
*Lack of a specific protocol for palliative care
*Specialized palliative care team Low
Friedenberg
[35]
2012/USA
Identifying perceived barriers to optimal EOL care based on level of physician training or by discipline Residents (n = 125)
Fellows (n = 20)
Attendants (n = 13)
Nurses (n = 60)
Survey/questionnaire There were important variations in reported obstacles to EOL care by training and education level, discipline, and organization, especially in the field of education and training.
A lower percentage of residents (20%) revealed insufficient training in EOL care and as a big or enormous obstacle to providing palliative care than attendants (62%), fellows (55%) or nurses (36%). Communication related to language difficulties (p = 0.008) and insufficient training in pain and anxiety recognition (p = 0.001) were identified as barriers to providing EOL reported by nurses.
*Difficulty communicating due to language barriers
*Lack of advance directives
*Inadequate care goals
*Inadequate training in recognition of pain and anxiety
*Patient’s inability to participate in care goals
  Moderate- High
Noome, M.
[36]
2016/Netherlands
To examine the effectiveness of supporting intensive care units in implementing the guidelines Nurses (n = 153)
Intervention group
Nurses (n = 112)
Control group
Family
(n = 18)
intervention group
Family
(n = 15)
control group
RCT intervention group Results showed that the intervention group followed the guidelines in most aspects more closely than the control group. Families reported that the intervention group showed a markedly higher level of patient care and general nursing care in comparison to the control group. *Lack of social worker support
*Time constraints in implementing strategies
*Healthcare provider resistance to change
*Involving family in patient care
*Involving other professionals, *Education and support for professionals and the use of guidelines
* Team meeting
* Providing managerial support for implementing guidelines
Moderate- High