Table 4 Matrix based on relevant review literature^a relating to mechanisms^b that are likely to contribute to or counter decision-making for non-beneficial (NBT) and / or inappropriate end-of-life (EoL) treatment according to stakeholder perspectives^c 

Motivation to Address Conflict & Seek Agreement

Patients & family/ guardians

Healthcare practitioners

Conflict and disputes (n = 14)

Agreement seeking (n = 12)

Conflict between practitioners and family on agreeing goals of care

• Conflict between medical staff and family/guardians ^{5, 19, 20, 21, 32} (n = 5)

• Conflict within the family ^{21, 64} (n = 2)

Getting patients and families to engage and seek consensus

• Mandatory family meetings ¹⁸ (n = 1)

• Patient’s wishes, explicitly sought ^{13, 18, 19} (n = 3)

Conflict and lack of consensus seeking demonstrated across practitioner groups

• Discord and hierarchical ‘pulling rank’, between doctors and nurses or between senior doctors and junior doctors on what constitutes NBT ^{7, 18, 33, 43, 47, 53, 61, 65} (n = 8)

Practitioners seeking consensus and collaboration

• Environments or interactions promoting collaboration within medical team ^{2, 12, 24, 40, 41, 43, 58, 61} (n = 8)

• Reaching consensus across practitioner groups with multi-disciplinary meetings ^{36, 58} (n = 2)

Valuing Clear Communication and Sharing of Information

Patients & family/ guardians

Misunderstandings and stonewalling (n = 13)

Sharing information well (n = 8)

Misunderstanding of treatment and prognosis

• Problem of not clearly communicating treatment and prognosis to lay people/patients ^{5, 10, 19, 22, 25, 29, 37, 42} (n = 8)

Presence of medical paternalism

• Lack of sufficient communication between clinicians and patient or family/guardian, such that agreement on goals of care is curtailed ^{5, 20, 27, 29, 43, 46, 50} (n = 7)

Public awareness and education

• Awareness and education of what constitutes NBT and appropriate decision-making at EoL ^{5, 36, 37} (n = 3)

Healthcare practitioners

Poor communication within medical team

• Lack of collaborative decision-making within medical team across groups (i.e. nurses, junior doctors, senior doctors) ^{12, 14, 33, 43, 48, 60} (n = 6)

Promoting ongoing dialogues among practitioners

• Engaging practitioners in formal and informal communication on NBT ^{1, 3, 5, 18, 51, 52} (n = 6)

Choices around Timing & Documenting of EoL Decisions

Patients & family/ guardians

Healthcare practitioners

Suboptimal timings and communication (n = 8)

Planning ahead well (n = 4)

Engaging too late to agree goals of care, with inadequate communication tools

• Discussions regarding EoL decision-making are delayed or stalled ^{10, 13, 50, 66} (n = 4)

Documenting patient decisions

• Improved advanced care planning, do not resuscitate and goals of care documentation ^{1, 13, 50, 64, 66} (n = 5)

Fixed directives that don’t account for changing circumstances

• Can oblige the practitioner to carry on with NBT that may be causing suffering in incapacitated patients ^{3, 23, 48, 64} (n = 4)

Consolidation and streamlining of care

• Having a team leader or primary clinical point-of-contact (i.e. specialist nurse) to oversee decision-making process relating to NBT across entire hospitalization ^{10, 50} (n = 2)