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Table 5 Exploring the 5 main themes

From: Quality of transition to end-of-life care for cancer patients in the intensive care unit

1. Achieving a consensus to initiate end of life transitions
 1.1 ‘I have discussed his management with [oncologist] this morning. He agrees that it would not be appropriate to start [mechanical ventilation] [. . .] It is unlikely he will survive beyond the next few hours and even with full invasive ventilation it is unlikely he will survive beyond the next few days. We have therefore moved to palliation. [Wife] is in agreement that it would not be appropriate to intubate and ventilate him. (patient 79)
 1.2 ‘Prof [oncologist] reiterated our conversation we had with [patient] and [husband] this morning about the change from curative to palliative intent. Then we stressed the importance of symptom control, how we were going to involve the palliative care team, and how we would ensure reducing anxiety, distress and any discomfort…’ (patient 63)
 1.3 ‘[patient] agrees to intubation [. . .] but does not want CPR or any heroic measures to prolong her life.’ (patient 59)
 1.4 I talked with [oncologist] yesterday who is keen that we pursue every therapeutic option for [patient] at present and I discussed my reluctance to consider intubation for this gentleman because none of our intensive care treatments were improving his respiratory function [. . .] [Palliative care consultant] talked with the family and indeed I talked to [patient] yesterday who was adamant that he didn’t want further escalation. (patient 16)
2. Concomitant prognostication and managing uncertainty
 2.1 ‘Explained to [husband] that [patient] is gravely unwell at present, and that she may not survive this episode. We have explained to [husband] that we will do everything we can in CCU, and will have more of an idea within the next 24 to 48 hours of how her condition will progress. If she deteriorates further, then we will do everything we can to keep her comfortable… (patient 81)’
 2.2 ‘Unable to wean off FiO2 [oxygen via oscillator mode on ventilator] and respiratory demands continue to increase. [patients]’ condition continued to deteriorate and discussions were had between the family, oncology and CCU team.’ (patient 83)
 2.3 Even were his GVHD to resolve imminently he would still be in multi-organ failure[. . .] (patient 47)
3. Parent medical and critical care team decision-making
 3.1 ‘in view of limited cancer prognosis and, in event of requiring emergency sedation, intubation and ventilation that recovery to the point of acceptable quality of life would be unlikely’ (patient 40)
 3.2 ‘After discussion with [oncologist] and the family we decided not for further active management but continued high quality supportive care’ (patient 84)
4. Integrative palliative care
 4.1 ‘we stressed the importance of symptom control, how we were going to involve the palliative care team, and how we would ensure reducing anxiety, distress and any discomfort. (patient 17)
 4.2 ‘His continuing deterioration is indicative of end of life events and we discussed his management with the palliative care team (patient 15).
5. Family-centred versus patient-centred care
 5.1 ‘Consider discontinuation of NIV at an interval after son’s arrival on Monday. In the meantime—if [patient] wishes us to discontinue the NIV earlier, this would be appropriate—with sensitive communication to the family’ (patient 27)
 5.2 ‘They [family] understand that it is highly unlikely that Mrs D would be able to be weaned from invasive ventilation and agree as to the previous set ceiling of care of NIV [non-invasive ventilation]. They understand she has developed multi-organ failure and that our priority of care now would be solely her comfort.’ (patient 30)
 5.3 ‘Family did not want active treatment if no hope of recovery’ (patient 85)
 5.4 ‘Wife does not want us to try to communicate this to him now but would rather she did that herself if he became more alert later on.’ (patient 80)
 5.5 ‘We will leave her treatment as it as at present instead of withdrawal as her son is in transit from USA.’ (patient 30)