|Type of influencing factors||Specific factors||Barriers||Facilities|
|1. Organizational structures||Management resources||
- Lack of time, resources and staff shortages to care for palliative patient in ICU [19, 34].|
- Simultaneous requirement to care for other patients while staff work with patients’ palliative need .
- Lack of time to develop and implement strategies .
- Lack of training and education as a result of time and resource constraints [19, 41].
- Lack of spiritual support (assistance is unavailable at weekends) [37, 42].
- Inadequate support of junior nurses from team leaders .
- Absence of palliative care physicians and senior nursing staff in relation to advance directive (AD), orders in ICU and difficulties within the palliative care process .
- Staff ratios. For example, in ICU nurses work in patient/nurse ratios of either one to one or one to two. This allows time to be devoted to dying patients .|
- Assign a nurse for the patient in late palliative stage, for example, patient and family should be cared for by a nurse who is known to them .
- A bereavement programme to support patients and families (use bereavement material) .
- Facilitating palliative care dialogue (standardized tools) .
|Policies and guidelines||
- Lack of protocol and policies guiding palliative care in ICU [22, 23, 34].|
- Lack of written protocol for palliative care nursing such as pain management, dyspnoea, etc. .
- Doctor resistance to applying policy [37, 38].
- Physicians unfamiliar with the guidelines and resistant to using them, plus difficulties encountered in the removal of all mentors .
- Insufficient standardization of care  and the presence of procedural difficulties .
- Strong leadership and management team support (supportive factors) .|
- Guideline recommendations regarding both direct care for palliative patients and palliative care decisions .
- employing guidelines and care policy designed for a humanistic approach for example, medication guidelines designed to improve symptom control .
- An integrated care system (clear guidance, reduced paperwork, adequate structure) .
- Formulating the physician’s strategy .
- Open visiting times for family and friends .
|Knowledge and skills||
- Inadequate education and knowledge of palliative care among nursing staff responsible for delivering care to patients in ICU [21, 38].|
- Inadequate training for physicians and nurses regarding communication skills .
- Lack of understanding about the complexities involved in providing palliative care in ICU .
- Lack of requisite knowledge, skills and experience among physicians [37, 38].
- Lack of skill in the provision of care for dying patients .
- Inadequate information relating to palliative care issues within both current nursing curriculums or courses and hospital orientation .
- Insufficient preparation for palliative care decision-making (inadequate professional training) [29, 32].
- Unpreparedness of ICU nurses for shifting from curative to palliative care models .
- Involving training teams in specialized palliative care while providing care for patients in ICU .|
- Hospital training and the development of a palliative nursing programme .
- Specialist palliative nursing coaching .
- Training workshop communication programme for bedside nurses .
- Trial and error are useful ways to learn from nurses’ experiences .
- Education and professional support while implementing improvements to guidelines .
|Multidisciplinary team involvement||
- Lack of nursing staff involvement in palliative care decision making [28, 29, 42].|
- Lack of palliative care team integration within the ICU [37, 40].
- Involvement of stakeholders from different levels and specialties .|
- Direct palliative care team involvement in care for patients in ICU .
|2- Working environment||Physical environment||
- Absence of infrastructure in the ICU to facilitate family involvement in palliative care (insufficient space for meetings) [20, 25, 35].|
- Inadequate organizational support in promoting humanistic environment in ICU 
- The challenging, hectic and noisy nature of ICU culture [20, 21, 37, 38].
- Inappropriate environments for dying patients [27, 41].
|- Modified bedside environment and use single room for dying patients [23, 36].|
- Moral distress acts as barrier to providing palliative care in the ICU .|
- Distress experienced by nursing staff due to lack of help from managers .
- Colleagues’ unwillingness to appreciate the complexity of palliative care (staff compliance with changes) [23, 36].
- Insufficient emotional support for nurses during and after their providing palliative care for patients in ICU [27, 32].
|3-Patient and Family involvement||Conflict||
- Disagreements, unwillingness to discuss them and conflict between families and physicians regarding palliative care process [22, 23, 32, 35].|
- Family’s refusal of care on the grounds of religious belief .
|- To tailor and adapt the object of care in collaboration with the patients and families .|
Lack of family involvement in any documented wishes that have been expressed by the patient .|
- Language and culture barriers relating to patients and/or their families .
- Lack of understanding and education among patients and family concerning the prognosis and the continuity of palliative care [22, 31].
- Patient inability to participate in palliative care decision-making .
- Patient’s wishes regarding palliative care were insufficiently documented prior to their admission to ICU .
- Family participation and involvement in patient care and decision-making (family-centred care [23, 28, 36, 38].|
- Patient and family wishes considered prior to actual decision-making .
- The establishment of a patient advocate and medical translation team by nurses involved in family meetings .
- Respect for patients’ wishes .
- Lack of effective communication with family members [20, 34].|
- Family’s requests for updates on patient’s prognosis .
- Insufficient information provided to patients and families about death .
- Using multiple means to communicate medical information regarding patients’ prognoses to their families .|
- The allocation of a single point of contact for all family members .
|4. Palliative Care Decision-Making||Transition of care objectives||
Fragmentation of care objectives by different physicians .|
- Discrepancies between the care objectives of the medical team and the family .
-Disagreement between team members about comfort care decisions and inconsistencies in palliative care [27, 36].
- Continuation of aggressive and life-supporting treatments [31, 41].
- Absence of a care plan for palliative care .
- Inconsistent attitudes, approaches and beliefs among physicians providing palliative care [37, 42].
- ICU patient decision-making potentially negated by incapacity .
- Clear and defined goals for providing comfort and care .|
- Consensus regarding objectives among varices involved in health care teams .
- Clear information and documentation about patient’s history, background, status and prognosis .
-Empowered and skilled staff involved in the care process .
- Locating physician participation as central during the establishment of comfort care for patients .
- Establishing a consensus around decision concerning comfort care .
|Withholding or withdrawal of life-sustenance||
- Ethical factors influencing doctors’ decision-making processes .|
- Lack of patients’ advance directives at the time of admission [22, 34, 35, 42].
- Difficulties with palliative care treatment decisions .
|- Ethics consultations .|
- Lack of understanding concerning the assessment of prognostication efforts and pre-death symptoms [24, 25].|
- Critical delays in palliative care prognostication and decision-making .
|- Use numeric prognostic scale .|
|Multidisciplinary team communication||
- Lack of communication and team interaction act as core barriers to providing adequate palliative care in ICU [19, 22].|
- Inadequate communication about identification of care objectives between ICU team members and other clinicians .
- Multidisciplinary meetings with families to improve communication [22, 34].|
- Multidisciplinary team meetings .