Table 3 Matrix based on relevant review literature^a  relating to contexts^b under which non-beneficial (NBT) and / or inappropriate end of life treatment can occur according to stakeholder perspectives^c

Uncertainty

Patients & family/ guardians

Patient wishes unknown (n = 5)

• Mismatch to patient goals/wishes, e.g. clinicians unsure what patient wants or patients not asked what their wishes are ^{5, 19, 27, 37, 50} (n = 5)

Ambiguity in expectations (n = 9)

• Difficulty with sharing prognosis or discordance in decision-making between relevant actors to support adhering to patient wishes ^{22, 29, 32, 39, 42, 50−52} (n = 8)

• Family/guardians doubt physicians’ ability to predict NBT ¹⁶ (n = 1)

Healthcare practitioners

Uncertainty of criteria for prognosis and related legal consideration (n = 37)

• Lack of shared criteria for NBT guiding practitioners ^{2−6, 8, 12, 13, 15−20, 22, 27, 28, 30−33, 35−37, 39, 44−46, 50, 52−59} (n = 37); not being up to date on legal/policy for when to withdraw treatment ^{3, 15, 28, 32, 46, 57} (n = 6)

Lack of shared understanding of duty of care (n = 12)

• Duty of care means different things to different people e.g. “death as failure”, or adhering to moral duty to help provide a “good death” ^{3, 18, 28, 30, 32, 35, 45, 48, 52, 55, 59, 65} (n = 12)

Organizational Culture & Practices Patients & family/ guardians

Emphasis on following directives (n = 4)

• Removes emphasis from agreeing goals of care with the clinical team ^{3, 23, 37, 49} (n = 4)

Healthcare practitioners

Practitioner inexperience and hospital level effects (n = 18)

• Lack of emphasis on shared decision-making for NBT within clinical team across groups, leading to moral distress or burnout, especially among nurses ^{12, 14, 33, 34, 41, 43, 44, 48, 53, 60} (n = 10)

• Practitioners are uncomfortable and unguided in how to deal with death and dying ⁵² (n = 1)

• After adjusting for the role of patient and family role/directives it is shown that hospital and organizational cultural barriers are likely to contribute to NBT ²¹ (n = 1)

• Organizational atmosphere and structure ^{8, 45, 48} (n = 3); lack of organizational support for dealing with NBT and assisting appropriate decision-making ^{3, 26, 32, 36} (n = 4); lack of promoting structure and function of hospital ethics committees⁴⁸ (n = 1)

Resource considerations (n = 10)

• Resource implications of providing potentially NBT ^{2, 29, 31, 36, 40, 48} (n = 6)

• Lacking access to and integration of palliative care, such as from palliative care centers or hospices ^{10, 48, 50, 59, 62} (n = 5)

Profiles & Characteristics

Patients & family/ guardians

Clinical presentation (n = 5)

• Patient is more severely unwell ^{19, 26} (n = 2); emergency admissions to ICU, and a longer ICU or hospital stay ¹⁹ (n = 1); more elderly ^{6, 21, 54} (n = 3)

Religious beliefs can underpin pushing for likely clinically NBT (n = 3)

• Families and patients who are religious (Protestant, Catholic, Jewish) more frequently want more extensive treatment ⁶³ (n = 1)

Healthcare practitioners

• Healthcare professionals with higher religiousness/spirituality more frequently tended to want to provide more extensive treatment ^{47, 52, 63} (n = 3)

Differences were observed between cadres on views about withdrawing likely clinically NBT (n = 15)

• Nurses differed in perception of NBT, especially on when it would be time to withdraw curative attempts, compared to doctors; often nurses or junior doctors placed higher importance in patient quality of life and functionality versus some doctors, especially senior doctors ^{12, 14, 28, 32−34, 41, 43, 44, 47, 48, 53, 60, 61} (n = 15)