Perspectives of physicians and nurses on palliative and end-of-life care practices in ICU beyond the COVID-19 era: An European survey study

Perspectives of physicians and nurses on palliative and end-of-life care practices in ICU beyond the COVID-19 era: An European survey study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perspectives of physicians and nurses on palliative and end-of-life care practices in ICU beyond the COVID-19 era: An European survey study Tereza Prokopová, Jan Hudec, Jos M. Latour, Kamil Vrbica, Jan Stašek, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6804967/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background: The practice of end-of-life (EOL) and palliative care was modified during the coronavirus disease 2019 (COVID-19) pandemic due to several factors, often related to isolation and infection prevention measures. This study aims to explore the current state of EOL and palliative care after the COVID-19 pandemic in European Intensive Care Units (ICUs). Methods: The online cross-sectional survey study was endorsed by the European Society of Intensive Care Medicine (ESICM). Data collection was carried out in ten months (May 2023 to February 2024). Healthcare professionals (HCPs) working in European ICUs were eligible to participate. Univariate and multivariate logistic regression model was used for statistical analysis. Results: Totally, 215 HCPs completed the survey. Patients’ dying without dignity was perceived by 17 (9%) HCPs. The statistically significant factor contributing to perception of dying without dignity was unclear goals of treatment in EOL. Inappropriate care after the COVID-19 pandemic was perceived by 38 nurses (78%) and 127 physicians (91%). Organ support was reported as too long by 109 physicians (72%) and 32 nurses (50%), while 88 physicians (58%) and 16 nurses (25%) perceived organ support as too extensive. When organ support was perceived as inappropriate, 27 nurses (75%) and 113 physicians (90%) actively expressed their concerns. However, these expressed opinions were not respected in 40 physicians (35%) and 14 nurses (52%). Moral distress was perceived as an issue even after the COVID-19 pandemic among 129 (72%) respondents. HCPs whose EOL practices changed during the COVID-19 pandemic had nearly 8 times higher odds (OR (95% CI) 7.969 (2.890–21.975)) of experiencing moral distress post-pandemic (p < 0.0001). Among the HCPs who acknowledged the presence of moral distress after the pandemic, 65 (50%) felt that the level of distress was comparable to pre-pandemic levels. Conclusions: Palliative care at ICU after the COVID-19 pandemic has the potential for improvement in dignified dying and appropriate care. The major factor connecting the moral distress of HCPs and improvement in palliative care quality seems to be communication. Further research and interventions to improve communication among the HCPs and between HCP and family might benefit patients and also HCPs. Trial registration ClinicalTrials.gov (NCT05089032) End-of-life (EOL) Palliative Care Moral Distress European/international survey Physicians Nurses Intensive Care Unit (ICU) Figures Figure 1 Figure 2 Background End-of-life (EOL) is a demanding and challenging period for all healthcare professionals (HCPs) involved in caring for patients in the Intensive Care Unit (ICU). Providing appropriate organ support for patients in the EOL is one of the critical and challenging features and a potential source of stress [ 1 , 2 ]. Goals of care aligning with patients' values and preferences should be set for each patient through structured end-of-life family conferences between HCPs and relatives. This shared decision-making model ensures the best quality of care according to the patients' values and preferences and medical indications [ 1 , 2 ]. These themes were frequently discussed in ICUs not only during the coronavirus disease 2019 (COVID-19) pandemic, but the pandemic escalated these discussions [ 3 , 4 ]. Therefore, the need for high-quality end-of-life decisions (EOLDs) and EOL care is of great significance [ 5 ]. This statement is also supported by the recently published ESICM guidelines on end-of-life and palliative care in intensive care units [ 5 ]. EOLDs can potentially put an emotional and moral strain, especially on the HCPs [ 6 ]. If the process of EOLD is not handled sensitively, it could lead to severe consequences for patients, their families and HCPs. The burden, if unrecognised or untreated, could be from emotional responses such as anxiety, depression, anger, moral distress or burnout syndrome to the development of post-traumatic stress disorder (PTSD) in family members and HCPs as well [ 1 , 7 , 8 ]. Consequently, EOL processes could affect patients, their families, and the attending HCPs, who are often burdened with ethical dilemmas, the weight of responsibility, emotional strain, cultural differences and communication challenges [ 9 , 10 ]. These issues could have serious economic, personal, and social consequences, and it is necessary to study them to improve patient care and prevent the risk of HCPs´ developing moral distress. The aim of this study was to describe EOL practices and the possible changes beyond the COVID-19 pandemic across European ICUs and to assess the moral distress of HCPs, including its potential risk factors. We hypothesised that the process of providing EOL care at the ICU differs according to the type of workplace, demographic characteristics of HCPs and their education. Methods Study design The cross-sectional survey (PEOPLe-C19-EU) is based on a pilot survey study (PEOpLE-C19) performed in the Czech Republic during the COVID-19 pandemic (June - September 2021) (3). The Faculty of Medicine of Masaryk University Brno Ethics Committee approved the PEOPLe-C19-EU survey on 16 June 2021 (No.61/2021). The study was also registered on the ClinicalTrials.gov registry (NCT05089032). The CROSS checklist was used to publish this survey [ 11 ]. Aim of study The survey aims to explore the physicians´ and nurses´ perception of the palliative care at ICUs after the COVID-19 pandemic. The study goal is the potential aspects of palliative care, which could lead to moral distress and point it out for further research to improve the quality of palliative care at ICUs. Questionnaire development A team of experts from the Faculty of Medicine, Masaryk University Brno (TP, JH, KV, JM) and the Faculty of Medicine, Charles University Prague (KR), in cooperation with an expert consultant from the University of Plymouth, United Kingdom (JML), developed this questionnaire. The modified Delphi technique plus ACADEMY and CHERRIES guide were used to create the questionnaire [ 12 ]. The domains and questions had been tested in the PEOpLE-C19 study for the first time [ 3 ]. According to respondents' feedback and the goals of the PEOPLe-C19-EU study, some questions were modified. In-depth interviews with opinion leaders in palliative care and intensive care medicine and potential respondents were conducted to determine the relevance of the new questionnaire after the COVID-19 pandemic era. The questionnaire was reviewed to guarantee reliability and comprehensibility after the consensus of focus groups about the medical issues. The survey was endorsed by the European Society of Intensive Care Medicine (ESICM). Questionnaire description The questionnaire was divided into four main domains and consisted of 33 questions. The first part focused on sociodemographic characteristics of participants and hospitals. In the second domain, we have been investigating the experiences of palliative care before and after the COVID-19 pandemic. The third domain was focused on describing palliative care and EOL after the pandemic. In the last part, we explored experiences and possible factors leading to the moral distress of HCPs (physicians, nurses, or other non-physician practitioners). The complete list of questions and the scaling of the responses can be found in Appendix 1. Data collecting process The survey was carried out online, the survey link ( https://redcap.med.muni.cz/surveys/?s=MCNWXXNX3A ) was circulated by email to all ESICM members (about 10.000 members), and it was attached to the official website of ESICM. In addition, the link was disseminated by social media (e.g. Facebook) to all ESICM followers. HCPs were invited to anonymously complete the questionnaire open for ten months (1 May 2023 to 29 February 2024). The inclusion criteria for participation were HCPs older than 18 working in the ICU. Non-ICU staff could not participate in this study. The survey was accessible only once from a unique IP address to prevent multiple participation. Respondents indicated their consent to participate in the survey when entering the online form. Statistical analysis Absolute and relative counts were used to describe categorical data from the survey, while continuous parameters were summarised using the mean with standard deviation (SD) and the median with lower (Q1) and upper quartile (Q3). Summaries were provided separately for physicians and non-physician practitioners (primarily general nurses). Differences in continuous parameters between the groups were tested using a two-sample t-test if the normality assumption was met or the Mann-Whitney test otherwise. Differences in frequencies were assessed using Pearson’s chi-squared test if the expected frequency assumption was met; otherwise, Fisher’s exact test was used. Associations between responses to various survey questions were explored using contingency tables, with statistical significance evaluated using Pearson’s chi-squared test or Fisher’s exact test, as appropriate. Predictive abilities of age on various statements were evaluated using the binomial logistic regression. Binomial logistic regression was also performed to identify potential predictors of moral distress and to estimate odds ratios (ORs) with 95% Wald confidence intervals (CIs). Responses to the question “Were you exposed to moral distress during the COVID-19 pandemic?” were grouped as follows: “Strongly agree” and “Somewhat agree” were combined into “I was exposed to moral distress.” “Somewhat disagree” and “Strongly disagree” were combined into “I was not exposed to moral distress.” Responses “Do not know” occurred infrequently and were excluded from the analysis. A univariate logistic regression model was employed for each potential predictor of moral distress. Predictors significant at an alpha level of 0.1 were further analysed using a multivariate logistic regression model. Parameters significant at an alpha level of 0.05 (p < 0.05) were considered independent predictors of moral distress. Given the exploratory nature of the analysis and the unbalanced groups compared, p-values should be interpreted cautiously. All statistical analyses were conducted using SAS 9.4 (SAS Institute, Cary NC). Results In total, 215 HCPs working in ICUs worldwide opened and completed the survey, accounting for 75.7% of all surveys opened. The characteristics of the respondents, their workplaces, and their COVID-19 experiences are summarised in Table 1 . Table 1 Characteristics of respondents Parameter, statistics Physicians N = 151 Non-physician practitioners N = 64 Overall N = 215 Sex , n / n miss 151 / 0 64 / 0 215 / 0 Male, n (%) 88 (58.3%) 11 (17.2%) 99 (46.0%) Female, n (%) 63 (41.7%) 53 (82.8%) 116 (54.0%) Age , n / n miss 147 / 4 64 / 0 211 / 4 Mean (SD) 43.8 (10.40) 39.9 (10.82) 42.6 (10.66) Median (Q1, Q3) 42.0 (36.0, 51.0) 38.0 (30.0, 48.5) 41.0 (34.0, 50.0) Min, Max 28, 69 22, 66 22, 69 Profession , n / n miss 151 / 0 64 / 0 215 / 0 Nurse, n (%) 58 (90.6%) 58 (27.0%) Physician, n (%) 151 (100.0%) 151 (70.2%) Physiotherapist, n (%) 1 (1.6%) 1 (0.5%) Psychologist, n (%) 1 (1.6%) 1 (0.5%) Other, n (%) 4 (6.3%) 4 (1.9%) Physician vs. non-physician practitioners , n / n miss 151 / 0 64 / 0 215 / 0 Physician, n (%) 151 (100.0%) 151 (70.2%) Non-physician practitioners, n (%) 64 (100.0%) 64 (29.8%) European region* , n / n miss 132 / 19 62 / 2 194 / 21 Central Europe, n (%) 62 (47.0%) 32 (51.6%) 94 (48.5%) Non-European, n (%) 14 (10.6%) 1 (1.6%) 15 (7.7%) Northern Europe, n (%) 23 (17.4%) 27 (43.5%) 50 (25.8%) Southern Europe, n (%) 33 (25.0%) 2 (3.2%) 35 (18.0%) Type of hospital , n / n miss 151 / 0 64 / 0 215 / 0 Primary (regional, remote), n (%) 10 (6.6%) 9 (14.1%) 19 (8.8%) Secondary (community, urban), n (%) 34 (22.5%) 14 (21.9%) 48 (22.3%) Tertiary (university or teaching hospital), n (%) 107 (70.9%) 40 (62.5%) 147 (68.4%) Other, n (%) 1 (1.6%) 1 (0.5%) ICU type , n / n miss 151 / 0 64 / 0 215 / 0 Medical, n (%) 25 (16.6%) 7 (10.9%) 32 (14.9%) Surgical, n (%) 14 (9.3%) 10 (15.6%) 24 (11.2%) Mixed, n (%) 108 (71.5%) 41 (64.1%) 149 (69.3%) Other, n (%) 4 (2.6%) 6 (9.4%) 10 (4.7%) Direct care of COVID-19 subjects in ICU during pandemic , n / n miss 150 / 1 64 / 0 214 / 1 Yes, n (%) 142 (94.7%) 59 (92.2%) 201 (93.9%) No, n (%) 8 (5.3%) 5 (7.8%) 13 (6.1%) Critical care medicine/nursing practice [years], n / n miss 147 / 4 64 / 0 211 / 4 Mean (SD) 43.8 (10.40) 39.9 (10.82) 42.6 (10.66) Median (Q1, Q3) 42.0 (36.0, 51.0) 38.0 (30.0, 48.5) 41.0 (34.0, 50.0) Min, Max 28, 69 22, 66 22, 69 Finished speciality training , n / n miss 151 / 0 64 / 0 215 / 0 Yes, n (%) 134 (88.7%) 53 (82.8%) 187 (87.0%) No, n (%) 17 (11.3%) 11 (17.2%) 28 (13.0%) % = percentage out of subjects with available data; Max = Maximum; Min = Minimum; N = total number of subjects per analysis group; n / n miss = number of available values / number of missing values of the parameter; Q1 = First quartile; Q3 = Third quartile; SD = Standard deviation. COVID-19 = Coronavirus Disease; ICU = Intensive Care Unit. *Central Europe: Austria, Belgium, Czech Republic, France, Germany, Poland, Slovakia, Switzerland; Northern Europe: Denmark, Estonia, Finland, Netherlands, Ireland, Norway, United Kingdom, Sweden; Southern Europe: Greece, Israel, Italy, Portugal, Spain, Croatia, Romania, Serbia; Non-European: Argentina, Brazil, Colombia, Ethiopia, India, Indonesia, Japan. Table 1 Palliative care before, during and after COVID-19 pandemic Table 2 provides an overview of HCPs' experiences delivering palliative care before and during the COVID-19 pandemic. Table 2 Palliative care and EOLD before and during the COVID-19 pandemic Parameter, statistics Physicians N = 151 Non- physician practitioners N = 64 P-value Experience with delivering palliative care before the COVID-19 pandemic , n / n miss 140 / 11 56 / 8 Yes, n (%) 123 (87.9%) 47 (83.9%) 0.4639 P No, n (%) 17 (12.1%) 9 (16.1%) My practice of end-of-life care changed during the COVID-19 pandemic , n / n miss 142 / 9 56 / 8 I strongly agree, n (%) 25 (17.6%) 11 (19.6%) 0.0228 P I somewhat agree, n (%) 58 (40.8%) 24 (42.9%) I do not know, n (%) 10 (7.0%) 11 (19.6%) I somewhat disagree, n (%) 27 (19.0%) 8 (14.3%) I strongly disagree, n (%) 22 (15.5%) 2 (3.6%) Factors that could have led to this difference* , n / n miss 83 / 0 35 / 0 Staff factors, n (%) 46 (55.4%) 20 (57.1%) 0.8634 P Administrative factors, n (%) 40 (48.2%) 8 (22.9%) 0.0105 P Equipment limitation, n (%) 32 (38.6%) 7 (20.0%) 0.0503 P Different characteristics and prognosis of subjects with COVID-19 disease, n (%) 44 (53.0%) 18 (51.4%) 0.8750 P Overwhelmed healthcare, n (%) 44 (53.0%) 14 (40.0%) 0.1966 P Difficult communication, n (%) 25 (30.1%) 9 (25.7%) 0.6293 P Process of End-of-Life-Decision making, n (%) 50 (60.2%) 20 (57.1%) 0.7543 P Different ethical principles, n (%) 24 (28.9%) 7 (20.0%) 0.3148 P Impact of emotions in the decision making, n (%) 19 (22.9%) 11 (31.4%) 0.3307 P Other, n (%) 2 (2.4%) 3 (8.6%) 0.1540 F Have you ever found yourself in a situation known as resource scarcity** during the COVID-19 subjects care in your ICU , n / n miss 141 / 10 56 / 8 Yes, frequently, n (%) 42 (29.8%) 13 (23.2%) 0.4347 P Yes, occasionally, n (%) 76 (53.9%) 30 (53.6%) No, n (%) 23 (16.3%) 13 (23.2%) Have you ever felt that limitations of resources were used as an argument in end-of-life decision making , n / n miss 141 / 10 56 / 8 Yes, n (%) 61 (43.3%) 20 (35.7%) 0.3315 P No, n (%) 80 (56.7%) 36 (64.3%) If so, what was your perspective* , n / n miss 61 / 0 20 / 0 I was not comfortable incorporating resource scarcity into the decision-making process, n (%) 23 (37.7%) 10 (50.0%) 0.3315 P I understand the need to incorporate resource scarcity into the decision-making process, n (%) 39 (63.9%) 9 (45.0%) 0.1348 P Other, n (%) 2 (3.3%) 3 (15.0%) 0.0936 F % = percentage out of subjects with available data; N = total number of subjects per analysis group; n / n miss = number of available values / numbers of missing values of the parameter. COVID-19 = Coronavirus Disease; EOLD = End-of-Life Decision; ICU = Intensive Care Unit. *More than one answer possible. **Resource scarcity is a situation characterised by lack of time, medication or equipment. The difference in frequencies was tested using Pearson’s (P) chi-squared test if the expected frequency assumption was met or Fisher’s (F) exact test if it was not. Table 2 Inappropriate care of patients was reported by 38 nurses (77.6%) and 127 physicians (90.7%) after the COVID-19 pandemic. Organ support was perceived as too long by 109 physicians (72.2%) and 32 nurses (50.0%), while 88 physicians (58.3%) and 16 nurses (25.0%) perceived organ support as too extensive. Both differences were statistically significant (p = 0.0172 and p < 0.0001), respectively. When organ support was perceived as inappropriate, 27 nurses (75%) and 113 physicians (89.7%) actively expressed their concerns (p = 0.0493). However, these expressed opinions were not respected in 40 physicians (35.4%) and 14 nurses (51.9%) (p = 0.1146), as shown in Fig. 1 . The difference between nurses and physicians in expressing their concerns about inappropriate care was statistically significant, and the extent to which these concerns were taken into account was not statistically significant. Details of the current state of palliative care and EOLD-making in the aftermath of the COVID-19 pandemic are illustrated in Table 3 . Table 3 Palliative and EOL care after the COVID-19 pandemic Parameter, statistics Physicians N = 151 Non- physician practitioners N = 64 P-value Local protocol for EOLD , n / n miss 140 / 11 49 / 15 No, n (%) 80 (57.1%) 25 (51.0%) 0.4579 P Yes, n (%) 60 (42.9%) 24 (49.0%) Dedicated palliative care team available in hospital , n / n miss 140 / 11 51 / 13 No, n (%) 41 (29.3%) 15 (29.4%) 0.9865 P Yes, n (%) 99 (70.7%) 36 (70.6%) Who is involved in the EOLD* , n / n miss 151 / 0 64 / 0 Patient, n (%) 86 (57.0%) 32 (50.0%) 0.3488 P Head of department, n (%) 66 (43.7%) 17 (26.6%) 0.0182 P Attending physician, n (%) 127 (84.1%) 39 (60.9%) 0.0002 P Nurse manager, n (%) 37 (24.5%) 16 (25.0%) 0.9384 P Attending nurse, n (%) 90 (59.6%) 33 (51.6%) 0.2759 P Family (relatives) of patient, n (%) 113 (74.8%) 39 (60.9%) 0.0407 P Palliative care physician, n (%) 35 (23.2%) 14 (21.9%) 0.8349 P Consultant physician, n (%) 66 (43.7%) 16 (25.0%) 0.0098 P Primary (family) physician, n (%) 5 (3.3%) 3 (4.7%) 0.6976 F Other, n (%) 4 (2.6%) 3 (4.7%) 0.4273 F Form of EOLD discussions with family , n / n miss 140 / 11 50 / 14 Face-to-face in a separate room, n (%) 112 (80.0%) 43 (86.0%) 0.2686 F Face-to-face at the bedside, n (%) 23 (16.4%) 5 (10.0%) By telephone, n (%) 3 (2.1%) The family has not been contacted, n (%) 1 (0.7%) Other, n (%) 1 (0.7%) 2 (4.0%) Usual involvement of family in decision to transition the patient to a comfort care approach* , n / n miss 151 / 0 64 / 0 Family fully decides on EOLD, n (%) 9 (6.0%) 2 (3.1%) 0.5125 F Family is part of the team and participates in EOLD, n (%) 92 (60.9%) 25 (39.1%) 0.0032 P Family is only informed of the EOLD made solely by the medical team; the EOLD is carried out, unless the patient's relatives disagree with the decision, n (%) 44 (29.1%) 18 (28.1%) 0.8807 P Family is only informed of the EOLD made solely by the medical team; the EOLD is carried out, even if the patient's relatives disagree with the decision, n (%) 14 (9.3%) 8 (12.5%) 0.4751 P Family is not informed at all about the EOLD, n (%) 2 (1.3%) 2 (3.1%) 0.5842 F I cannot comment, I did not participate in these discussions, n (%) 1 (0.7%) 7 (10.9%) 0.0010 F Other, n (%) 3 (2.0%) 1 (1.6%) 1.0000 F Have you experienced a situation where you perceived a patient's care as inappropriate* , n / n miss 151 / 0 64 / 0 Yes, life support was administered for too long, n (%) 109 (72.2%) 32 (50.0%) 0.0017 P Yes, life support was too intensive, n (%) 88 (58.3%) 16 (25.0%) < 0.0001 P Yes, life support was administered for too short, n (%) 25 (16.6%) 6 (9.4%) 0.1705 P Yes, life support was not intensive enough, n (%) 26 (17.2%) 5 (7.8%) 0.0726 P No, I have not experienced this situation, n (%) 13 (8.6%) 11 (17.2%) 0.0678 P Did you express your opinion about inappropriate care? n / n miss 126 / 1 36 / 2 No, n (%) 13 (10.3%) 9 (25.0%) 0.0493 F Yes, n (%) 113 (89.7%) 27 (75.0%) Was your opinion respected? n / n miss 113 / 0 27 / 0 No, n (%) 40 (35.4%) 14 (51.9%) 0.1146 P Yes, n (%) 73 (64.6%) 13 (48.1%) % = percentage out of subjects with available data; N = total number of subjects per analysis group; n / n miss = number of available values / numbers of missing values of the parameter. COVID-19 = Coronavirus Disease; EOL = End-of-Life; EOLD = End-of-Life Decision; ICU = Intensive Care Unit. *More than one answer possible. The difference in frequencies was tested using Pearson’s (P) chi-squared test if the expected frequency assumption was met or Fisher’s (F) exact test if it was not. Table 3 Figure 2 illustrates who is typically involved in EOLD making depending on whether palliative care services are available in the hospital. In hospitals with a dedicated palliative care team, patients are involved in EOLD making in 68.9% of cases, compared with 44.6% in hospitals without such a team (p = 0.0017). A similar difference was observed in the involvement of nurse managers (36.3% vs. 7.1%, p < 0.0001) and attending nurses (69.6% vs. 51.8%, p = 0.0190). Additionally, palliative care physicians are involved in 33.3% of cases in hospitals with a dedicated team, compared to 7.1% in hospitals without a dedicated team. (p = 0.0002). Moral distress Table 4 presents a comprehensive comparison of healthcare professionals' experiences of moral distress after the COVID-19 pandemic. Table 4 Healthcare professionals' experiences of moral distress after COVID-19 pandemic Parameter, statistics Physicians N = 151 Non-physician practitioners N = 64 P-value Moral distress is a feature after the COVID-19 pandemic , n / n miss 133 / 18 47 / 17 I strongly agree, n (%) 53 (39.8%) 13 (27.7%) 0.1656 F I somewhat agree, n (%) 47 (35.3%) 16 (34.0%) I do not know, n (%) 16 (12.0%) 12 (25.5%) I somewhat disagree, n (%) 10 (7.5%) 5 (10.6%) I strongly disagree, n (%) 7 (5.3%) 1 (2.1%) Was the level of moral distress you felt after the COVID-19 pandemic comparable to levels experienced before the pandemic , n / n miss 99 / 1 29 / 0 I strongly agree, n (%) 13 (13.1%) 4 (13.8%) 0.8502 F I somewhat agree, n (%) 37 (37.4%) 11 (37.9%) I do not know, n (%) 13 (13.1%) 4 (13.8%) I somewhat disagree, n (%) 21 (21.2%) 8 (27.6%) I strongly disagree, n (%) 15 (15.2%) 2 (6.9%) What were the possible sources of moral distress experienced after the COVID-19 pandemic* , n / n miss 151 / 0 64 / 0 Organisational/institutional, n (%) 40 (26.5%) 8 (12.5%) 0.0243 P Interpersonal relationships, n (%) 57 (37.7%) 15 (23.4%) 0.0421 P Difficulty of the work, n (%) 57 (37.7%) 25 (39.1%) 0.8561 P The need to make decisions in a situation of resource scarcity - care prioritisation, n (%) 36 (23.8%) 12 (18.8%) 0.4124 P Changes in standards of care, n (%) 41 (27.2%) 12 (18.8%) 0.1912 P Administration of experimental drugs or non-indicated drugs outside studies, n (%) 14 (9.3%) 4 (6.3%) 0.4645 P Other, n (%) 7 (4.6%) 3 (4.7%) 1.0000 F Currently subjects die with dignity in your ICU , n / n miss 135 / 16 46 / 18 I strongly agree, n (%) 75 (55.6%) 23 (50.0%) 0.7904 F I somewhat agree, n (%) 42 (31.1%) 16 (34.8%) I do not know, n (%) 5 (3.7%) 3 (6.5%) I somewhat disagree, n (%) 11 (8.1%) 3 (6.5%) I strongly disagree, n (%) 2 (1.5%) 1 (2.2%) Factors that contribute to the lack of dignity at the end of life* , n / n miss 60 / 0 23 / 0 Inadequate control of the patient's symptoms, n (%) 13 (21.7%) 8 (34.8%) 0.2186 P Inadequate communication within the team, n (%) 25 (41.7%) 12 (52.2%) 0.3887 P Organisational issues, n (%) 28 (46.7%) 10 (43.5%) 0.7941 P Lack of understanding of the principles of comfort care, n (%) 23 (38.3%) 10 (43.5%) 0.6682 P Resource scarcity, n (%) 5 (8.3%) 2 (8.7%) 1.0000 F Inconsistency of physicians' views on palliative care, n (%) 37 (61.7%) 16 (69.6%) 0.5026 P Inconsistency of nurses' views on comfort care 17 (28.3%) 6 (26.1%) 0.8378 P Other, n (%) 5 (8.3%) 1 (4.3%) 1.0000 F The goals of care in EOL are always clearly set and explained to the team , n / n miss 136 / 15 47 / 17 I strongly agree, n (%) 45 (33.1%) 8 (17.0%) 0.0558 F I somewhat agree, n (%) 61 (44.9%) 21 (44.7%) I do not know, n (%) 6 (4.4%) 4 (8.5%) I somewhat disagree, n (%) 18 (13.2%) 13 (27.7%) I strongly disagree, n (%) 6 (4.4%) 1 (2.1%) Do you know where to ask for help if you, or a team member, are experiencing distress or emotional overload , n / n miss 136 / 15 47 / 17 I strongly agree, n (%) 35 (25.7%) 20 (42.6%) 0.0465 F I somewhat agree, n (%) 54 (39.7%) 18 (38.3%) I do not know, n (%) 21 (15.4%) 3 (6.4%) I somewhat disagree, n (%) 10 (7.4%) 5 (10.6%) I strongly disagree, n (%) 16 (11.8%) 1 (2.1%) % = percentage out of subjects with available data; N = total number of subjects per analysis group; n / n miss = number of available values / numbers of missing values of the parameter. COVID-19 = Coronavirus Disease; EOL = End-of-Life; EOLD = End-of-Life Decision; ICU = Intensive Care Unit. The difference in frequencies was tested using Pearson’s (P) chi-squared test if the expected frequency assumption was met or Fisher’s (F) exact test if it was not. *More than one answer possible. Table 4 Currently, 117 physicians (90.0%) agree (strongly agree or somewhat agree) that patients die with dignity in the ICU; similarly, 39 nurses (90.7%) share this perspective. Nevertheless, as shown in Table 4 , HCPs who did not strongly agree or did not know marked any factors contributing to the lack of dignity at the end of life. There was a statistically significant difference in factors that contribute to the lack of dignity at the end of life between HCPs for whom the goals of treatment in EOLD are and are not always clearly set and explained to the team. For example, 7.4% of HCPs for whom the goals of care in EOLD are always set and explained to the team stated inadequate control of the patient's symptoms as a factor compared to 26.3% of HCPs for whom the goals are not always set and explained (p = 0.0030). Overall, all factors listed in Table 5 were more frequently reported in HCPs for whom the goals of care in EOLD were not always clearly set and explained to the team. Univariate analysis showed that the age of HCPs significantly influenced their agreement on whether the inconsistency of physicians' views on palliative care contributed to the lack of dignity in the EOLD. Specifically, with increasing age, the odds of perceiving this inconsistency as contributing to the lack of dignity decrease (OR = 0.942, 95% CI: 0.900–0.987, p = 0.0111). Additionally, age was identified as a statistically significant predictor of agreement that EOLD treatment goals are always clearly defined and communicated to the team. Older HCPs were more likely to agree with this statement (OR = 1.079, 95% CI: 1.033–1.126, p = 0.0006). Table 5 Relationship between disagreement about EOL goals of care and factors contributing to lack of dignity Are the goals of treatment in EOL always clearly set and explained to the team? Factors that contribute to the lack of dignity at the end of life No N = 38 Yes N = 135 P-value Inadequate control of the patient's symptoms (e.g. pain, dyspnoea), n (%) 10 (26.3%) 10 (7.4%) 0.0030 Inadequate communication within the team, n (%) 20 (52.6%) 11 (8.1%) < .0001 Organisational issues (e.g. isolation and therefore entering the patient's room possible only at certain), n (%) 12 (31.6%) 20 (14.8%) 0.0187 Lack of understanding of the principles of comfort care, n (%) 17 (44.7%) 10 (7.4%) < .0001 Resource scarcity (e.g. sedatives, analgesics...), n (%) 3 (7.9%) 2 (1.5%) 0.0712 Inconsistency of physicians' views on palliative care, n (%) 27 (71.1%) 21 (15.6%) < .0001 Inconsistency of nurses' views on comfort care, n (%) 14 (36.8%) 8 (5.9%) < .0001 Other, n (%) 1 (2.6%) 5 (3.7%) 1.0000 % = percentage out of HCPs in the given subgroup; N = total number of HCPs per analysis group. EOL = End-of-Life Subject who answered 'I do not know' were not considered. P-values were obtained through testing with Pearson's chi-squared test or Fisher exact test where applicable. Table 5 Also, a higher age of HCPs has been shown to be a statistically significant predictor of reduced experience of moral distress after the COVID-19 pandemic (OR = 0.945, 95% CI: 0.905–0.986, p = 0.0090). Furthermore, more years of critical care medicine (or nursing practice experience) decrease the probability of moral distress after the COVID-19 pandemic (OR = 0.941, 95% CI: 0.898–0.985, p = 0.0094). The hospital type has also been identified as a statistically significant predictor for moral distress after the COVID-19 pandemic. Specifically, primary hospitals exhibited lower odds for moral distress (OR = 0.067, 95% CI: 0.010–0.430, p = 0.0060). These statistically significant predictors for moral distress in a univariate model were incorporated into a multivariate model. The hospital type (primary vs. secondary) remained a statistically significant predictor while accounting for the effect of other predictors. Working in the primary hospital type reduces the odds of moral distress by approx. 65% compared to the secondary hospital type (OR = 0.035, 95% CI: 0.004–0.284, p = 0.0023). HCPs whose EOLD practices changed during the COVID-19 pandemic had nearly 8 times higher odds (OR = 7.969, 95% CI: 2.890–21.975, p < 0.0001) of experiencing moral distress post-pandemic. Among those who acknowledged the presence of moral distress after the pandemic, 50.4% felt that the level of distress was comparable to pre-pandemic levels, while 49.6% did not. Discussion This cross-sectional online survey is a follow-up to the PEOpLE-C19 study and describes aspects of moral distress and palliative care practice at the ICU beyond the COVID-19 pandemic in Europe. The study’s unique contribution lies in its focus on all HCPs, not only physicians. We identified several factors leading to moral distress and factors changing EOL care during the COVID-19 pandemic. The findings of this survey support essential insights that have the potential to improve the ethical climate in EOL processes and should be intensely discussed. According to our results, in the post-pandemic era, respondents continue to perceive palliative care at ICU as a challenge for all HCPs. The most clinically significant results pertain to the quality of EOL care. In contrast to the findings during the COVID-19 pandemic, when the majority of HCPs reported that patients died without dignity [ 3 ], this study reveals contrasting evidence. In this study, the majority of HCPs acknowledged that the patients dying were dignified. Dying without dignity has been demonstrated to be a risk factor for moral distress for caring HCPs [ 3 , 13 ]. The study's findings indicated that inconsistency in physicians' views on comfort care, organisational issues, and inadequate communication in the team were contributing factors to this phenomenon. The failure to appropriately control of patient's symptoms has been demonstrated to be a risk factor for caregivers' moral distress and the development of PTSD in the patient's family [ 14 , 15 ]. Communication about EOLD with patients, their families or among the HCPs is acknowledged to be challenging but of paramount importance. Consequently, structured training in these aspects should be standard for HCPs involved in EOLD [ 13 , 16 ]. An intriguing finding from our survey is that a significant proportion of nurses and nearly all physicians occasionally perceived inappropriate care of patients. These observations align with the findings of other studies [ 13 , 17 , 18 ]. The study results confirm that excessive care remains a significant concern within ICUs, potentially one of the most significant triggers for moral distress. A statistically significant disparity was observed between physicians and non-physician practitioners in reporting inappropriate care and the degree to which these concerns were considered. The discrepancy underscores the need to acknowledge this problem, as the DISPROPRICUS study emphasised that improving the ethical climate is essential for identifying excessive care [ 19 ]. A notable finding pertains to the role of the palliative team in EOLD. The nurses and patients in the EOLD are more frequently included when a palliative team is present. This discrepancy could be attributed to the varying approaches adopted by palliative care specialists and ICU physicians in addressing EOLD [ 20 ]. While the collaboration between the palliative team and ICU staff during EOLD can be beneficial, especially in a challenging situation, the current rate of participation of the palliative team in EOLD seems to be low [ 21 ]. A significant finding emerged from the questions concerning age and experience. Older respondents asserted that the EOLD goals of care are always clearly defined and communicated to the team more frequently than the younger respondents. This finding aligns with the notion that older physicians possess a wealth of clinical experience, potentially leading to the inner comprehension of complex concepts. Conversely, the ambiguity about less clearly articulated plans has the potential to be confusing, especially for young physicians [ 22 ]. Furthermore, the younger respondents, who perceived the patients dying as undignified, were more likely to attribute the inconsistency in physicians' perception of palliative care as a contributing factor. The findings of this study confirm the existence of elevated moral distress among younger HCPs, which could be associated with low hierarchical levels, as described in other studies [ 23 , 24 ]. Hence, the authors emphasised recommendations from different studies to implement regular and early interprofessional discussions to improve the ethical and safety climate [ 7 , 8 , 25 ]. The present study yielded another noteworthy finding. Specifically, one of the statistically significant factors of moral distress is the level of the hospital. Working in secondary hospitals is a stronger predictor for the development of moral distress than working in primary hospitals. Despite the absence of studies describing the level of moral distress depending on the levels of hospitals, an article was identified that described the higher level of moral distress and a higher propensity to leave a job in a hospital setting compared to working in a community setting [ 26 ]. The study's findings suggest that moral distress remains an issue after the COVID-19 pandemic. There has been a discernible improvement in palliative care at the ICU, leading to a decline in the number of patients dying without dignity. EOLD practice seems to be a space for improvement, such as enhancing nurses' engagement in the discussions, encouraging the team members to voice their concerns about the feeling of inappropriate care, and actively listening to their perceptions. The study's notable strength lies in the international sample of respondents, which enhances the generalizability of the results. However, it is important to note that the PEOpLE-C19-EU is not without some limits. Despite the endorsement and distribution of the survey by the ESICM, the response rate of about 2% was suboptimal, and the number of responses was lower than expected. The potential cause could be exhaustion caused by the COVID-19 pandemic and survey overload. The discrepancies in national guidelines, cultural expectations and recommendations for the practice of palliative care at the ICU are another possible limitation. These guidelines could be specific for each European country. Another limitation is the predominant responses from academic centres, which may limit the generalizability of our findings. A final limitation of this study could be the terminology, which was clarified in guidelines published after the study's conclusion. Notwithstanding these limitations, this study's findings could offer valuable insights and contribute to the direction of future research in EOLD. Conclusions The study's findings indicate that moral distress among HCPs working in ICUs remains an issue even after the COVID-19 pandemic. Dying without dignity was reported even by approximately 10% of respondents, and most of them reported providing inappropriate care with particular attention to care provided over and above patient benefits. The improvement in EOLD practice, exemplified by comprehensive and profound discussion within the whole team, has the potential to improve understanding of the goals of care and prevent the perception of inadequate care or overly different approaches to palliative care practice. The enhancement of communication within the healthcare team has the potential to benefit both patients and healthcare professionals. Abbreviations CI…confidence interval COVID-19…coronavirus disease 2019 SARS-CoV-2 EOLD…end-of-life decision EOL…end-of-life ESICM…European Society of Intensive Medicine HCP…healthcare professional ICU…intensive care unit OR…odds ratio PEOpLE-C19-EU…Perspectives of physicians and nurses on palliative and end-of-life care practices in ICU beyond the COVID-19 era PTSD…post-traumatic stress disorder SD…Standard deviation Q1…lower quartile Q3…upper quartile Declarations Ethics approval and consent to participate The Faculty of Medicine of Masaryk University Brno Ethics Committee approved the PEOPLe-C19-EU survey on 16 June 2021 (No.61/2021). The study was also registered on the ClinicalTrials.gov registry (NCT05089032). The study was conducted in accordance with the ethical standards of the Declaration of Helsinki and its subsequent amendments. Informed consent Respondents consented was obtained from all participants prior to their inclusion in the study ensuring they were fully aware of the study’s purpose, procedures, potential risks and benefits. Filling out this questionnaire was voluntary. Consent for publication Not Applicable Availability of data and materials The complete datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding Supported by the national budget through MEYS, LRI CZECRIN (LM2023049), through MEYS, MH, Czech Republic–conceptual development of research organisation (FNBr, 65269705) and by Specific University Research provided by MŠMT (MUNI/A/1733/2024, MUNI/A/1771/2024). The trial funders had no role in the study design or the collection, analysis, or interpretation of the data Authors' contributions TP, JH, JML, KV, JS, KR, AP, PŠ and JM contributed to the concept and design. TP, JH, KV, and JM were involved in acquiring, analysing, or interpreting data and drafting the manuscript. JS, AP, RG, PŠ, and KR contributed to the critical manuscript revision for important intellectual content. LN and RŠ were involved in statistical analysis. TP, JH, and KV contributed to administrative, technical, or material support. JM was involved in supervision. All authors contributed to the critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors thank all respondents for their responses, the members of the RIPE-ICU initiative for their work, and Lenka Dobrovolná for her administrative support. RIPE-ICU study group: Jan Maláska, Kateřina Rusinová, David Černý, Jozef Klučka, Andrea Pokorná, Miroslav Světlák, František Duška, Milan Kratochvíl, Alena Slezáčková, Petr Štourač, Tomáš Gabrhelík, Josef Kuře, Daniel Suk, Tomáš Doležal, Tereza Prokopová, Jana Čerňanová, Kamil Vrbica, Klára Fabiánková, Eva Straževská, Jan Hudec. Authors' information (optional) Tereza Prokopová and Jan Hudec contributed equally to this work. References Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med. 2024;39(8):715–32. Akdeniz M, Yardımcı B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE Open Med. 2021;9:205031212110009. Prokopová T, Hudec J, Vrbica K, Stašek J, Pokorná A, Štourač P, et al. Palliative care practice and moral distress during COVID-19 pandemic (PEOpLE-C19 study): a national, cross-sectional study in intensive care units in the Czech Republic. Crit Care. 2022;26(1):221. Hermann B, Benghanem S, Jouan Y, Lafarge A, Beurton A, the ICU French FOXES (Federation Of eXtremely Enthusiastic Scientists) Study Group. The positive impact of COVID-19 on critical care: from unprecedented challenges to transformative changes, from the perspective of young intensivists. Ann Intensive Care. 2023;13(1):28. Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses. JAMA Intern Med. 2016;176(8):1095. Michels G, Schallenburger M, Neukirchen M, ICU Palliative Study Group, John S, Janssens U, et al. Recommendations on palliative care aspects in intensive care medicine. Crit Care. 2023;27(1):355. Hinzmann D, Schütte-Nütgen K, Büssing A, Boenisch O, Busch HJ, Dodt C, et al. Critical Care Providers’ Moral Distress: Frequency, Burden, and Potential Resources. Int J Environ Res Public Health. 2022;20(1):333. Fumis RRL, Junqueira Amarante GA, De Fátima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71. Brooks LA, Manias E, Nicholson P. Barriers, enablers and challenges to initiating end-of-life care in an Australian intensive care unit context. Aust Crit Care. 2017;30(3):161–6. Rubbai YS, Chong MC, Tang LY, Abdullah KL, Mohammad WT, Mohajer S, et al. Barriers in providing quality end-of-life care as perceived by nurses working in critical care units: an integrative review. BMC Palliat Care. 2024;23(1):217. Sharma A, Minh Duc NT, Luu Lam Thang T, Nam NH, Ng SJ, Abbas KS, et al. A Consensus-Based Checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med. 2021;36(10):3179–87. Eysenbach G, Correction. Improving the Quality of Web Surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2012;14(1):e8. Kesecioglu J, Rusinova K, Alampi D, Arabi YM, Benbenishty J, Benoit D, et al. European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit. Intensive Care Med. 2024;50(11):1740–66. Lokker ME, Swart SJ, Rietjens JAC, Van Zuylen L, Perez RSGM, Van Der Heide A. Palliative sedation and moral distress: A qualitative study of nurses. Appl Nurs Res. 2018;40:157–61. Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC Anesthesiol. 2018;18(1):106. Azoulay É, Timsit JF, Sprung CL, Soares M, Rusinová K, Lafabrie A, et al. Prevalence and Factors of Intensive Care Unit Conflicts: The Conflicus Study. Am J Respir Crit Care Med. 2009;180(9):853–60. Piers RD, Azoulay E, Ricou B, DeKeyser Ganz F, Max A, Michalsen A, et al. Inappropriate Care Eur ICUs Chest. 2014;146(2):267–75. Anstey MH, Adams JL, McGlynn EA. Perceptions of the appropriateness of care in California adult intensive care units. Crit Care. 2015;19(1):51. the DISPROPRICUS study group of the Ethics Section of the European Society of Intensive Care Medicine, Benoit DD, Jensen HI, Malmgren J, Metaxa V, Reyners AK, et al. Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA. Intensive Care Med. 2018;44(7):1039–49. Chiarchiaro J, White DB, Ernecoff NC, Buddadhumaruk P, Schuster RA, Arnold RM. Conflict Management Strategies in the ICU Differ Between Palliative Care Specialists and Intensivists. Crit Care Med. 2016;44(5):934–42. Seino Y, Kurosawa H, Shiima Y, Niitsu T. End-of‐life care in the pediatric intensive care unit: Survey in Japan. Pediatr Int. 2019;61(9):859–64. Alameddine M, Dainty KN, Deber R, Sibbald WJ, Bill. The intensive care unit work environment: Current challenges and recommendations for the future. J Crit Care. 2009;24(2):243–8. Beck J, Falco CN, O’Hara KL, Bassett HK, Randall CL, Cruz S, et al. The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States. Teach Learn Med. 2023;35(3):335–45. Dalton A. Mitigating burnout and enhancing wellness in anesthesiologists: individual interventions, wellness programs, and peer support. Int Anesthesiol Clin. 2021;59(4):73–80. Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330–42. Giannetta N, Sergi R, Villa G, Pennestrì F, Sala R, Mordacci R, et al. Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study. Healthcare. 2021;9(12):1673. Additional Declarations No competing interests reported. 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20:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6804967/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6804967/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85363904,"identity":"c00264bb-cdd4-4ec9-9a93-d7d64bd93977","added_by":"auto","created_at":"2025-06-25 06:25:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":277162,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eExpression and respect of HCPs opinion regarding perceiving inappropriate care (see also table 3)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 26 subjects did not answer the question “Have you experienced a situation where you perceived a patient's care as inappropriate?” These subjects are, therefore, not included in the corresponding parts of the figure.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6804967/v1/3ca9047106cd950b7011fc09.png"},{"id":85363906,"identity":"05baec2e-d5bd-4e9e-bca5-f6fc741a641a","added_by":"auto","created_at":"2025-06-25 06:25:30","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":537508,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePeople involved in the EOLD according to presence of a dedicated palliative care team\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6804967/v1/2f51de2e3b0e49306c68479a.jpeg"},{"id":85365979,"identity":"75440670-ebea-4dc9-9dce-40f9685acf72","added_by":"auto","created_at":"2025-06-25 06:49:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3149975,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6804967/v1/d2c5d398-94c7-42d6-8136-d57ea545d28b.pdf"},{"id":85363902,"identity":"91b8a64e-0a07-452a-9c27-b47b3c6235a6","added_by":"auto","created_at":"2025-06-25 06:25:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":188106,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6804967/v1/72e28a27a9343abd803a274d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perspectives of physicians and nurses on palliative and end-of-life care practices in ICU beyond the COVID-19 era: An European survey study","fulltext":[{"header":"Background","content":"\u003cp\u003eEnd-of-life (EOL) is a demanding and challenging period for all healthcare professionals (HCPs) involved in caring for patients in the Intensive Care Unit (ICU). Providing appropriate organ support for patients in the EOL is one of the critical and challenging features and a potential source of stress [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Goals of care aligning with patients' values and preferences should be set for each patient through structured end-of-life family conferences between HCPs and relatives. This shared decision-making model ensures the best quality of care according to the patients' values and preferences and medical indications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These themes were frequently discussed in ICUs not only during the coronavirus disease 2019 (COVID-19) pandemic, but the pandemic escalated these discussions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Therefore, the need for high-quality end-of-life decisions (EOLDs) and EOL care is of great significance [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This statement is also supported by the recently published ESICM guidelines on end-of-life and palliative care in intensive care units [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEOLDs can potentially put an emotional and moral strain, especially on the HCPs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. If the process of EOLD is not handled sensitively, it could lead to severe consequences for patients, their families and HCPs. The burden, if unrecognised or untreated, could be from emotional responses such as anxiety, depression, anger, moral distress or burnout syndrome to the development of post-traumatic stress disorder (PTSD) in family members and HCPs as well [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsequently, EOL processes could affect patients, their families, and the attending HCPs, who are often burdened with ethical dilemmas, the weight of responsibility, emotional strain, cultural differences and communication challenges [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These issues could have serious economic, personal, and social consequences, and it is necessary to study them to improve patient care and prevent the risk of HCPs\u0026acute; developing moral distress.\u003c/p\u003e \u003cp\u003eThe aim of this study was to describe EOL practices and the possible changes beyond the COVID-19 pandemic across European ICUs and to assess the moral distress of HCPs, including its potential risk factors. We hypothesised that the process of providing EOL care at the ICU differs according to the type of workplace, demographic characteristics of HCPs and their education.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThe cross-sectional survey (PEOPLe-C19-EU) is based on a pilot survey study (PEOpLE-C19) performed in the Czech Republic during the COVID-19 pandemic (June - September 2021) (3).\u003c/p\u003e \u003cp\u003e The Faculty of Medicine of Masaryk University Brno Ethics Committee approved the PEOPLe-C19-EU survey on 16 June 2021 (No.61/2021). The study was also registered on the ClinicalTrials.gov registry (NCT05089032). The CROSS checklist was used to publish this survey [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim of study\u003c/h2\u003e \u003cp\u003eThe survey aims to explore the physicians\u0026acute; and nurses\u0026acute; perception of the palliative care at ICUs after the COVID-19 pandemic. The study goal is the potential aspects of palliative care, which could lead to moral distress and point it out for further research to improve the quality of palliative care at ICUs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuestionnaire development\u003c/h3\u003e\n\u003cp\u003eA team of experts from the Faculty of Medicine, Masaryk University Brno (TP, JH, KV, JM) and the Faculty of Medicine, Charles University Prague (KR), in cooperation with an expert consultant from the University of Plymouth, United Kingdom (JML), developed this questionnaire. The modified Delphi technique plus ACADEMY and CHERRIES guide were used to create the questionnaire [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The domains and questions had been tested in the PEOpLE-C19 study for the first time [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to respondents' feedback and the goals of the PEOPLe-C19-EU study, some questions were modified. In-depth interviews with opinion leaders in palliative care and intensive care medicine and potential respondents were conducted to determine the relevance of the new questionnaire after the COVID-19 pandemic era. The questionnaire was reviewed to guarantee reliability and comprehensibility after the consensus of focus groups about the medical issues. The survey was endorsed by the European Society of Intensive Care Medicine (ESICM).\u003c/p\u003e\n\u003ch3\u003eQuestionnaire description\u003c/h3\u003e\n\u003cp\u003eThe questionnaire was divided into four main domains and consisted of 33 questions. The first part focused on sociodemographic characteristics of participants and hospitals. In the second domain, we have been investigating the experiences of palliative care before and after the COVID-19 pandemic. The third domain was focused on describing palliative care and EOL after the pandemic. In the last part, we explored experiences and possible factors leading to the moral distress of HCPs (physicians, nurses, or other non-physician practitioners). The complete list of questions and the scaling of the responses can be found in Appendix 1.\u003c/p\u003e\n\u003ch3\u003eData collecting process\u003c/h3\u003e\n\u003cp\u003eThe survey was carried out online, the survey link (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://redcap.med.muni.cz/surveys/?s=MCNWXXNX3A\u003c/span\u003e\u003cspan address=\"https://redcap.med.muni.cz/surveys/?s=MCNWXXNX3A\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) was circulated by email to all ESICM members (about 10.000 members), and it was attached to the official website of ESICM. In addition, the link was disseminated by social media (e.g. Facebook) to all ESICM followers. HCPs were invited to anonymously complete the questionnaire open for ten months (1 May 2023 to 29 February 2024). The inclusion criteria for participation were HCPs older than 18 working in the ICU. Non-ICU staff could not participate in this study. The survey was accessible only once from a unique IP address to prevent multiple participation. Respondents indicated their consent to participate in the survey when entering the online form.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAbsolute and relative counts were used to describe categorical data from the survey, while continuous parameters were summarised using the mean with standard deviation (SD) and the median with lower (Q1) and upper quartile (Q3). Summaries were provided separately for physicians and non-physician practitioners (primarily general nurses). Differences in continuous parameters between the groups were tested using a two-sample t-test if the normality assumption was met or the Mann-Whitney test otherwise. Differences in frequencies were assessed using Pearson\u0026rsquo;s chi-squared test if the expected frequency assumption was met; otherwise, Fisher\u0026rsquo;s exact test was used.\u003c/p\u003e \u003cp\u003eAssociations between responses to various survey questions were explored using contingency tables, with statistical significance evaluated using Pearson\u0026rsquo;s chi-squared test or Fisher\u0026rsquo;s exact test, as appropriate.\u003c/p\u003e \u003cp\u003ePredictive abilities of age on various statements were evaluated using the binomial logistic regression. Binomial logistic regression was also performed to identify potential predictors of moral distress and to estimate odds ratios (ORs) with 95% Wald confidence intervals (CIs). Responses to the question \u0026ldquo;Were you exposed to moral distress during the COVID-19 pandemic?\u0026rdquo; were grouped as follows: \u0026ldquo;Strongly agree\u0026rdquo; and \u0026ldquo;Somewhat agree\u0026rdquo; were combined into \u0026ldquo;I was exposed to moral distress.\u0026rdquo; \u0026ldquo;Somewhat disagree\u0026rdquo; and \u0026ldquo;Strongly disagree\u0026rdquo; were combined into \u0026ldquo;I was not exposed to moral distress.\u0026rdquo; Responses \u0026ldquo;Do not know\u0026rdquo; occurred infrequently and were excluded from the analysis. A univariate logistic regression model was employed for each potential predictor of moral distress. Predictors significant at an alpha level of 0.1 were further analysed using a multivariate logistic regression model. Parameters significant at an alpha level of 0.05 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were considered independent predictors of moral distress. Given the exploratory nature of the analysis and the unbalanced groups compared, p-values should be interpreted cautiously. All statistical analyses were conducted using SAS 9.4 (SAS Institute, Cary NC).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 215 HCPs working in ICUs worldwide opened and completed the survey, accounting for 75.7% of all surveys opened. The characteristics of the respondents, their workplaces, and their COVID-19 experiences are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter, \u003cem\u003estatistics\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysicians\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;151\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-physician practitioners\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;64\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;215\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151 / 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 / 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e215 / 0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99 (46.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (82.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116 (54.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e147 / 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e211 / 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.8 (10.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.9 (10.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.6 (10.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedian (Q1, Q3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.0 (36.0, 51.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.0 (30.0, 48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.0 (34.0, 50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMin, Max\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28, 69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22, 66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22, 69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfession\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e215 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (90.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (27.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysician, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e151 (70.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiotherapist, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychologist, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysician vs. non-physician practitioners\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e215 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysician, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e151 (70.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-physician practitioners, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 (29.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEuropean region*\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e132 / 19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e62 / 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e194 / 21\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCentral Europe, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (47.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (51.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94 (48.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-European, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (10.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern Europe, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (25.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouthern Europe, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (18.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of hospital\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e215 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary (regional, remote), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (14.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary (community, urban), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (22.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (21.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 (22.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary (university or teaching hospital), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (70.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e147 (68.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICU type\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e215 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (16.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (10.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (14.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (11.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108 (71.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (64.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e149 (69.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDirect care of COVID-19 subjects in ICU during pandemic\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e150 / 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e214 / 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142 (94.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (92.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e201 (93.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCritical care medicine/nursing practice\u003c/b\u003e [years], \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e147 / 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e211 / 4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.8 (10.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.9 (10.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.6 (10.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedian (Q1, Q3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.0 (36.0, 51.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.0 (30.0, 48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.0 (34.0, 50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMin, Max\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28, 69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22, 66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22, 69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFinished speciality training\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e215 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134 (88.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (82.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e187 (87.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (11.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (13.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e% = percentage out of subjects with available data; Max\u0026thinsp;=\u0026thinsp;Maximum; Min\u0026thinsp;=\u0026thinsp;Minimum; N\u0026thinsp;=\u0026thinsp;total number of subjects per analysis group; n / n miss\u0026thinsp;=\u0026thinsp;number of available values / number of missing values of the parameter; Q1\u0026thinsp;=\u0026thinsp;First quartile; Q3\u0026thinsp;=\u0026thinsp;Third quartile; SD\u0026thinsp;=\u0026thinsp;Standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCOVID-19\u0026thinsp;=\u0026thinsp;Coronavirus Disease; ICU\u0026thinsp;=\u0026thinsp;Intensive Care Unit.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Central Europe: Austria, Belgium, Czech Republic, France, Germany, Poland, Slovakia, Switzerland;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNorthern Europe: Denmark, Estonia, Finland, Netherlands, Ireland, Norway, United Kingdom, Sweden; Southern Europe: Greece, Israel, Italy, Portugal, Spain, Croatia, Romania, Serbia; Non-European: Argentina, Brazil, Colombia, Ethiopia, India, Indonesia, Japan.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e\n\u003ch3\u003ePalliative care before, during and after COVID-19 pandemic\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides an overview of HCPs' experiences delivering palliative care before and during the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePalliative care and EOLD before and during the COVID-19 pandemic\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter, \u003cem\u003estatistics\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysicians\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;151\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon- physician practitioners\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;64\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExperience with delivering palliative care before the COVID-19 pandemic\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e140 / 11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e56 / 8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123 (87.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (83.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.4639\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (12.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (16.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMy practice of end-of-life care changed during the COVID-19 pandemic\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e142 / 9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e56 / 8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (17.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (19.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.0228\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (40.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (19.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (19.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (15.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactors that could have led to this difference*\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e83 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e35 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff factors, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (55.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8634\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministrative factors, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (48.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (22.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0105\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquipment limitation, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (38.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0503\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifferent characteristics and prognosis of subjects with COVID-19 disease, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (53.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (51.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8750\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverwhelmed healthcare, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (53.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1966\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficult communication, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (30.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (25.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6293\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcess of End-of-Life-Decision making, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (60.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.7543\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifferent ethical principles, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (28.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3148\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpact of emotions in the decision making, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (22.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3307\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1540\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave you ever found yourself in a situation known as resource scarcity** during the COVID-19 subjects care in your ICU\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e141 / 10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e56 / 8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, frequently, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (29.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.4347\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, occasionally, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (53.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (53.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (16.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave you ever felt that limitations of resources were used as an argument in end-of-life decision making\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e141 / 10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e56 / 8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (43.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (35.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.3315\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (56.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (64.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIf so, what was your perspective*\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e61 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e20 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI was not comfortable incorporating resource scarcity into the decision-making process, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (37.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3315\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI understand the need to incorporate resource scarcity into the decision-making process, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (63.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (45.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1348\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0936\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e% = percentage out of subjects with available data; N\u0026thinsp;=\u0026thinsp;total number of subjects per analysis group; n / n miss\u0026thinsp;=\u0026thinsp;number of available values / numbers of missing values of the parameter.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCOVID-19\u0026thinsp;=\u0026thinsp;Coronavirus Disease; EOLD\u0026thinsp;=\u0026thinsp;End-of-Life Decision; ICU\u0026thinsp;=\u0026thinsp;Intensive Care Unit.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*More than one answer possible.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e**Resource scarcity is a situation characterised by lack of time, medication or equipment.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eThe difference in frequencies was tested using Pearson\u0026rsquo;s (P) chi-squared test if the expected frequency assumption was met or Fisher\u0026rsquo;s (F) exact test if it was not.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003cp\u003eInappropriate care of patients was reported by 38 nurses (77.6%) and 127 physicians (90.7%) after the COVID-19 pandemic. Organ support was perceived as too long by 109 physicians (72.2%) and 32 nurses (50.0%), while 88 physicians (58.3%) and 16 nurses (25.0%) perceived organ support as too extensive. Both differences were statistically significant (p\u0026thinsp;=\u0026thinsp;0.0172 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), respectively. When organ support was perceived as inappropriate, 27 nurses (75%) and 113 physicians (89.7%) actively expressed their concerns (p\u0026thinsp;=\u0026thinsp;0.0493). However, these expressed opinions were not respected in 40 physicians (35.4%) and 14 nurses (51.9%) (p\u0026thinsp;=\u0026thinsp;0.1146), as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe difference between nurses and physicians in expressing their concerns about inappropriate care was statistically significant, and the extent to which these concerns were taken into account was not statistically significant. Details of the current state of palliative care and EOLD-making in the aftermath of the COVID-19 pandemic are illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePalliative and EOL care after the COVID-19 pandemic\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter, \u003cem\u003estatistics\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysicians\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;151\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon- physician practitioners\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;64\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocal protocol for EOLD\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e140 / 11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e49 / 15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (51.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.4579\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (49.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDedicated palliative care team available in hospital\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e140 / 11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e51 / 13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (29.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (29.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.9865\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (70.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (70.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWho is involved in the EOLD*\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86 (57.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3488\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead of department, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (43.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (26.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0182\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttending physician, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127 (84.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (60.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0002\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse manager, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9384\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttending nurse, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (59.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (51.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2759\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily (relatives) of patient, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113 (74.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (60.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0407\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePalliative care physician, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (21.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8349\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultant physician, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (43.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0098\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary (family) physician, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6976\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4273\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eForm of EOLD discussions with family\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e140 / 11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e50 / 14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFace-to-face in a separate room, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (86.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.2686\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFace-to-face at the bedside, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (16.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBy telephone, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe family has not been contacted, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUsual involvement of family in decision to transition the patient to a comfort care approach*\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily fully decides on EOLD, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5125\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily is part of the team and participates in EOLD, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (60.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (39.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0032\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily is only informed of the EOLD made solely by the medical team; the EOLD is carried out, unless the patient's relatives disagree with the decision, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (29.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8807\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily is only informed of the EOLD made solely by the medical team; the EOLD is carried out, even if the patient's relatives disagree with the decision, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4751\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily is not informed at all about the EOLD, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5842\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI cannot comment, I did not participate in these discussions, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (10.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0010\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0000\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHave you experienced a situation where you perceived a patient's care as inappropriate*\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, life support was administered for too long, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109 (72.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0017\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, life support was too intensive, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, life support was administered for too short, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (16.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1705\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, life support was not intensive enough, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0726\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, I have not experienced this situation, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0678\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDid you express your opinion about inappropriate care?\u003c/b\u003e \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e126 / 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e36 / 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (10.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0493\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113 (89.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (75.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWas your opinion respected?\u003c/b\u003e \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e113 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e27 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (35.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.1146\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (64.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e% = percentage out of subjects with available data; N\u0026thinsp;=\u0026thinsp;total number of subjects per analysis group; n / n miss\u0026thinsp;=\u0026thinsp;number of available values / numbers of missing values of the parameter.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCOVID-19\u0026thinsp;=\u0026thinsp;Coronavirus Disease; EOL\u0026thinsp;=\u0026thinsp;End-of-Life; EOLD\u0026thinsp;=\u0026thinsp;End-of-Life Decision; ICU\u0026thinsp;=\u0026thinsp;Intensive Care Unit.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*More than one answer possible.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eThe difference in frequencies was tested using Pearson\u0026rsquo;s (P) chi-squared test if the expected frequency assumption was met or Fisher\u0026rsquo;s (F) exact test if it was not.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates who is typically involved in EOLD making depending on whether palliative care services are available in the hospital. In hospitals with a dedicated palliative care team, patients are involved in EOLD making in 68.9% of cases, compared with 44.6% in hospitals without such a team (p\u0026thinsp;=\u0026thinsp;0.0017). A similar difference was observed in the involvement of nurse managers (36.3% vs. 7.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and attending nurses (69.6% vs. 51.8%, p\u0026thinsp;=\u0026thinsp;0.0190). Additionally, palliative care physicians are involved in 33.3% of cases in hospitals with a dedicated team, compared to 7.1% in hospitals without a dedicated team. (p\u0026thinsp;=\u0026thinsp;0.0002).\u003c/p\u003e\n\u003ch3\u003eMoral distress\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents a comprehensive comparison of healthcare professionals' experiences of moral distress after the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealthcare professionals' experiences of moral distress after COVID-19 pandemic\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter, \u003cem\u003estatistics\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysicians\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;151\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-physician practitioners\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;64\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMoral distress is a feature after the COVID-19 pandemic\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e133 / 18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e47 / 17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (39.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.1656\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (34.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (12.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWas the level of moral distress you felt after the COVID-19 pandemic comparable to levels experienced before the pandemic\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e99 / 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e29 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (13.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (13.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.8502\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (37.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (37.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (13.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (13.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (21.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (27.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (15.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat were the possible sources of moral distress experienced after the COVID-19 pandemic*\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e151 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganisational/institutional, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (26.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0243\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpersonal relationships, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (37.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (23.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0421\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty of the work, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (37.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (39.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8561\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe need to make decisions in a situation of resource scarcity - care prioritisation, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (23.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4124\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChanges in standards of care, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (27.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (18.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1912\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministration of experimental drugs or non-indicated drugs outside studies, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4645\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0000\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrently subjects die with dignity in your ICU\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e135 / 16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e46 / 18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (55.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.7904\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (31.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (34.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFactors that contribute to the lack of dignity at the end of life*\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e60 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e23 / 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate control of the patient's symptoms, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (21.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (34.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2186\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate communication within the team, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (52.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3887\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganisational issues, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (46.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.7941\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of understanding of the principles of comfort care, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (38.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6682\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResource scarcity, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0000\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInconsistency of physicians' views on palliative care, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (61.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (69.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5026\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInconsistency of nurses' views on comfort care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (26.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8378\u003csup\u003eP\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0000\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe goals of care in EOL are always clearly set and explained to the team\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e136 / 15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e47 / 17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (33.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.0558\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (44.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (44.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (13.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo you know where to ask for help if you, or a team member, are experiencing distress or emotional overload\u003c/b\u003e, \u003cem\u003en / n miss\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e136 / 15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e47 / 17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (25.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (42.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.0465\u003csup\u003eF\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat agree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (39.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (38.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI somewhat disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI strongly disagree, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e% = percentage out of subjects with available data; N\u0026thinsp;=\u0026thinsp;total number of subjects per analysis group; n / n miss\u0026thinsp;=\u0026thinsp;number of available values / numbers of missing values of the parameter.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCOVID-19\u0026thinsp;=\u0026thinsp;Coronavirus Disease; EOL\u0026thinsp;=\u0026thinsp;End-of-Life; EOLD\u0026thinsp;=\u0026thinsp;End-of-Life Decision; ICU\u0026thinsp;=\u0026thinsp;Intensive Care Unit.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eThe difference in frequencies was tested using Pearson\u0026rsquo;s (P) chi-squared test if the expected frequency assumption was met or Fisher\u0026rsquo;s (F) exact test if it was not.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*More than one answer possible.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003c/p\u003e \u003cp\u003eCurrently, 117 physicians (90.0%) agree (strongly agree or somewhat agree) that patients die with dignity in the ICU; similarly, 39 nurses (90.7%) share this perspective. Nevertheless, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, HCPs who did not strongly agree or did not know marked any factors contributing to the lack of dignity at the end of life. There was a statistically significant difference in factors that contribute to the lack of dignity at the end of life between HCPs for whom the goals of treatment in EOLD are and are not always clearly set and explained to the team. For example, 7.4% of HCPs for whom the goals of care in EOLD are always set and explained to the team stated inadequate control of the patient's symptoms as a factor compared to 26.3% of HCPs for whom the goals are not always set and explained (p\u0026thinsp;=\u0026thinsp;0.0030). Overall, all factors listed in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e were more frequently reported in HCPs for whom the goals of care in EOLD were not always clearly set and explained to the team. Univariate analysis showed that the age of HCPs significantly influenced their agreement on whether the inconsistency of physicians' views on palliative care contributed to the lack of dignity in the EOLD. Specifically, with increasing age, the odds of perceiving this inconsistency as contributing to the lack of dignity decrease (OR\u0026thinsp;=\u0026thinsp;0.942, 95% CI: 0.900\u0026ndash;0.987, p\u0026thinsp;=\u0026thinsp;0.0111). Additionally, age was identified as a statistically significant predictor of agreement that EOLD treatment goals are always clearly defined and communicated to the team. Older HCPs were more likely to agree with this statement (OR\u0026thinsp;=\u0026thinsp;1.079, 95% CI: 1.033\u0026ndash;1.126, p\u0026thinsp;=\u0026thinsp;0.0006).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationship between disagreement about EOL goals of care and factors contributing to lack of dignity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eAre the goals of treatment in EOL always clearly set and explained to the team?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors that contribute to the lack of dignity at the end of life\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;38\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003e N\u0026thinsp;=\u0026thinsp;135\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate control of the patient's symptoms (e.g. pain, dyspnoea), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (26.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate communication within the team, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (52.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrganisational issues (e.g. isolation and therefore entering the patient's room possible only at certain), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (31.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of understanding of the principles of comfort care, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (44.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResource scarcity (e.g. sedatives, analgesics...), \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0712\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInconsistency of physicians' views on palliative care, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (71.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInconsistency of nurses' views on comfort care, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (36.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e% = percentage out of HCPs in the given subgroup; N\u0026thinsp;=\u0026thinsp;total number of HCPs per analysis group.\u003c/p\u003e \u003cp\u003eEOL\u0026thinsp;=\u0026thinsp;End-of-Life\u003c/p\u003e \u003cp\u003eSubject who answered 'I do not know' were not considered. P-values were obtained through testing with Pearson's chi-squared test or Fisher exact test where applicable.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003c/p\u003e \u003cp\u003eAlso, a higher age of HCPs has been shown to be a statistically significant predictor of reduced experience of moral distress after the COVID-19 pandemic (OR\u0026thinsp;=\u0026thinsp;0.945, 95% CI: 0.905\u0026ndash;0.986, p\u0026thinsp;=\u0026thinsp;0.0090). Furthermore, more years of critical care medicine (or nursing practice experience) decrease the probability of moral distress after the COVID-19 pandemic (OR\u0026thinsp;=\u0026thinsp;0.941, 95% CI: 0.898\u0026ndash;0.985, p\u0026thinsp;=\u0026thinsp;0.0094). The hospital type has also been identified as a statistically significant predictor for moral distress after the COVID-19 pandemic. Specifically, primary hospitals exhibited lower odds for moral distress (OR\u0026thinsp;=\u0026thinsp;0.067, 95% CI: 0.010\u0026ndash;0.430, p\u0026thinsp;=\u0026thinsp;0.0060). These statistically significant predictors for moral distress in a univariate model were incorporated into a multivariate model. The hospital type (primary vs. secondary) remained a statistically significant predictor while accounting for the effect of other predictors. Working in the primary hospital type reduces the odds of moral distress by approx. 65% compared to the secondary hospital type (OR\u0026thinsp;=\u0026thinsp;0.035, 95% CI: 0.004\u0026ndash;0.284, p\u0026thinsp;=\u0026thinsp;0.0023).\u003c/p\u003e \u003cp\u003eHCPs whose EOLD practices changed during the COVID-19 pandemic had nearly 8 times higher odds (OR\u0026thinsp;=\u0026thinsp;7.969, 95% CI: 2.890\u0026ndash;21.975, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) of experiencing moral distress post-pandemic. Among those who acknowledged the presence of moral distress after the pandemic, 50.4% felt that the level of distress was comparable to pre-pandemic levels, while 49.6% did not.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e This cross-sectional online survey is a follow-up to the PEOpLE-C19 study and describes aspects of moral distress and palliative care practice at the ICU beyond the COVID-19 pandemic in Europe. The study\u0026rsquo;s unique contribution lies in its focus on all HCPs, not only physicians. We identified several factors leading to moral distress and factors changing EOL care during the COVID-19 pandemic. The findings of this survey support essential insights that have the potential to improve the ethical climate in EOL processes and should be intensely discussed. According to our results, in the post-pandemic era, respondents continue to perceive palliative care at ICU as a challenge for all HCPs.\u003c/p\u003e \u003cp\u003eThe most clinically significant results pertain to the quality of EOL care. In contrast to the findings during the COVID-19 pandemic, when the majority of HCPs reported that patients died without dignity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], this study reveals contrasting evidence. In this study, the majority of HCPs acknowledged that the patients dying were dignified. Dying without dignity has been demonstrated to be a risk factor for moral distress for caring HCPs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The study's findings indicated that inconsistency in physicians' views on comfort care, organisational issues, and inadequate communication in the team were contributing factors to this phenomenon. The failure to appropriately control of patient's symptoms has been demonstrated to be a risk factor for caregivers' moral distress and the development of PTSD in the patient's family [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Communication about EOLD with patients, their families or among the HCPs is acknowledged to be challenging but of paramount importance. Consequently, structured training in these aspects should be standard for HCPs involved in EOLD [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn intriguing finding from our survey is that a significant proportion of nurses and nearly all physicians occasionally perceived inappropriate care of patients. These observations align with the findings of other studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The study results confirm that excessive care remains a significant concern within ICUs, potentially one of the most significant triggers for moral distress. A statistically significant disparity was observed between physicians and non-physician practitioners in reporting inappropriate care and the degree to which these concerns were considered. The discrepancy underscores the need to acknowledge this problem, as the DISPROPRICUS study emphasised that improving the ethical climate is essential for identifying excessive care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA notable finding pertains to the role of the palliative team in EOLD. The nurses and patients in the EOLD are more frequently included when a palliative team is present. This discrepancy could be attributed to the varying approaches adopted by palliative care specialists and ICU physicians in addressing EOLD [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. While the collaboration between the palliative team and ICU staff during EOLD can be beneficial, especially in a challenging situation, the current rate of participation of the palliative team in EOLD seems to be low [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA significant finding emerged from the questions concerning age and experience. Older respondents asserted that the EOLD goals of care are always clearly defined and communicated to the team more frequently than the younger respondents. This finding aligns with the notion that older physicians possess a wealth of clinical experience, potentially leading to the inner comprehension of complex concepts. Conversely, the ambiguity about less clearly articulated plans has the potential to be confusing, especially for young physicians [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Furthermore, the younger respondents, who perceived the patients dying as undignified, were more likely to attribute the inconsistency in physicians' perception of palliative care as a contributing factor. The findings of this study confirm the existence of elevated moral distress among younger HCPs, which could be associated with low hierarchical levels, as described in other studies [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Hence, the authors emphasised recommendations from different studies to implement regular and early interprofessional discussions to improve the ethical and safety climate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study yielded another noteworthy finding. Specifically, one of the statistically significant factors of moral distress is the level of the hospital. Working in secondary hospitals is a stronger predictor for the development of moral distress than working in primary hospitals. Despite the absence of studies describing the level of moral distress depending on the levels of hospitals, an article was identified that described the higher level of moral distress and a higher propensity to leave a job in a hospital setting compared to working in a community setting [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study's findings suggest that moral distress remains an issue after the COVID-19 pandemic. There has been a discernible improvement in palliative care at the ICU, leading to a decline in the number of patients dying without dignity. EOLD practice seems to be a space for improvement, such as enhancing nurses' engagement in the discussions, encouraging the team members to voice their concerns about the feeling of inappropriate care, and actively listening to their perceptions.\u003c/p\u003e \u003cp\u003eThe study's notable strength lies in the international sample of respondents, which enhances the generalizability of the results. However, it is important to note that the PEOpLE-C19-EU is not without some limits. Despite the endorsement and distribution of the survey by the ESICM, the response rate of about 2% was suboptimal, and the number of responses was lower than expected. The potential cause could be exhaustion caused by the COVID-19 pandemic and survey overload. The discrepancies in national guidelines, cultural expectations and recommendations for the practice of palliative care at the ICU are another possible limitation. These guidelines could be specific for each European country. Another limitation is the predominant responses from academic centres, which may limit the generalizability of our findings. A final limitation of this study could be the terminology, which was clarified in guidelines published after the study's conclusion. Notwithstanding these limitations, this study's findings could offer valuable insights and contribute to the direction of future research in EOLD.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe study's findings indicate that moral distress among HCPs working in ICUs remains an issue even after the COVID-19 pandemic. Dying without dignity was reported even by approximately 10% of respondents, and most of them reported providing inappropriate care with particular attention to care provided over and above patient benefits. The improvement in EOLD practice, exemplified by comprehensive and profound discussion within the whole team, has the potential to improve understanding of the goals of care and prevent the perception of inadequate care or overly different approaches to palliative care practice. The enhancement of communication within the healthcare team has the potential to benefit both patients and healthcare professionals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCI\u0026hellip;confidence interval\u003c/p\u003e\n\u003cp\u003eCOVID-19\u0026hellip;coronavirus disease 2019 SARS-CoV-2\u003c/p\u003e\n\u003cp\u003eEOLD\u0026hellip;end-of-life decision\u003c/p\u003e\n\u003cp\u003eEOL\u0026hellip;end-of-life\u003c/p\u003e\n\u003cp\u003eESICM\u0026hellip;European Society of Intensive Medicine\u003c/p\u003e\n\u003cp\u003eHCP\u0026hellip;healthcare professional\u003c/p\u003e\n\u003cp\u003eICU\u0026hellip;intensive care unit\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOR\u0026hellip;odds ratio\u003c/p\u003e\n\u003cp\u003ePEOpLE-C19-EU\u0026hellip;Perspectives of physicians and nurses on palliative and end-of-life care practices in ICU beyond the COVID-19 era\u003c/p\u003e\n\u003cp\u003ePTSD\u0026hellip;post-traumatic stress disorder\u003c/p\u003e\n\u003cp\u003eSD\u0026hellip;Standard deviation\u003c/p\u003e\n\u003cp\u003eQ1\u0026hellip;lower quartile\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQ3\u0026hellip;upper quartile\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Faculty of Medicine of Masaryk University Brno Ethics Committee approved the PEOPLe-C19-EU survey on 16 June 2021 (No.61/2021). The study was also registered on the ClinicalTrials.gov registry (NCT05089032). The study was conducted in accordance with the ethical standards of the Declaration of Helsinki and its subsequent amendments. Informed consent Respondents consented was obtained from all participants prior to their inclusion in the study ensuring they were fully aware of the study\u0026rsquo;s purpose, procedures, potential risks and benefits. Filling out this questionnaire was voluntary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe complete datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupported by the national budget through MEYS, LRI CZECRIN (LM2023049), through MEYS, MH, Czech Republic\u0026ndash;conceptual development of research organisation (FNBr, 65269705) and by Specific University Research provided by M\u0026Scaron;MT (MUNI/A/1733/2024, MUNI/A/1771/2024). The trial funders had no role in the study design or the collection, analysis, or interpretation of the data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTP, JH, JML, KV, JS, KR, AP, P\u0026Scaron; and JM contributed to the concept and design. TP, JH, KV, and JM were involved in acquiring, analysing, or interpreting data and drafting the manuscript. JS, AP, RG, P\u0026Scaron;, and KR contributed to the critical manuscript revision for important intellectual content. LN and R\u0026Scaron; were involved in statistical analysis. TP, JH, and KV contributed to administrative, technical, or material support. JM was involved in supervision. All authors contributed to the critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all respondents for their responses, the members of the RIPE-ICU initiative for their work, and Lenka Dobrovoln\u0026aacute; for her administrative support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRIPE-ICU study group: Jan Mal\u0026aacute;ska, Kateřina Rusinov\u0026aacute;, David Čern\u0026yacute;, Jozef Klučka, Andrea Pokorn\u0026aacute;, Miroslav Světl\u0026aacute;k, Franti\u0026scaron;ek Du\u0026scaron;ka, Milan Kratochv\u0026iacute;l, Alena Slez\u0026aacute;čkov\u0026aacute;, Petr \u0026Scaron;tourač, Tom\u0026aacute;\u0026scaron; Gabrhel\u0026iacute;k, Josef Kuře, Daniel Suk, Tom\u0026aacute;\u0026scaron; Doležal, Tereza Prokopov\u0026aacute;, Jana Čerňanov\u0026aacute;, Kamil Vrbica, Kl\u0026aacute;ra Fabi\u0026aacute;nkov\u0026aacute;, Eva Straževsk\u0026aacute;, Jan Hudec.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTereza Prokopov\u0026aacute; and Jan Hudec contributed equally to this work.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDoherty C, Feder S, Gillespie-Heyman S, Akg\u0026uuml;n KM. 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Int J Environ Res Public Health. 2022;20(1):333.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFumis RRL, Junqueira Amarante GA, De F\u0026aacute;tima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrooks LA, Manias E, Nicholson P. Barriers, enablers and challenges to initiating end-of-life care in an Australian intensive care unit context. Aust Crit Care. 2017;30(3):161\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRubbai YS, Chong MC, Tang LY, Abdullah KL, Mohammad WT, Mohajer S, et al. Barriers in providing quality end-of-life care as perceived by nurses working in critical care units: an integrative review. BMC Palliat Care. 2024;23(1):217.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma A, Minh Duc NT, Luu Lam Thang T, Nam NH, Ng SJ, Abbas KS, et al. A Consensus-Based Checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med. 2021;36(10):3179\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEysenbach G, Correction. Improving the Quality of Web Surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2012;14(1):e8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKesecioglu J, Rusinova K, Alampi D, Arabi YM, Benbenishty J, Benoit D, et al. European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit. Intensive Care Med. 2024;50(11):1740\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLokker ME, Swart SJ, Rietjens JAC, Van Zuylen L, Perez RSGM, Van Der Heide A. Palliative sedation and moral distress: A qualitative study of nurses. Appl Nurs Res. 2018;40:157\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC Anesthesiol. 2018;18(1):106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzoulay \u0026Eacute;, Timsit JF, Sprung CL, Soares M, Rusinov\u0026aacute; K, Lafabrie A, et al. Prevalence and Factors of Intensive Care Unit Conflicts: The Conflicus Study. Am J Respir Crit Care Med. 2009;180(9):853\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiers RD, Azoulay E, Ricou B, DeKeyser Ganz F, Max A, Michalsen A, et al. Inappropriate Care Eur ICUs Chest. 2014;146(2):267\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnstey MH, Adams JL, McGlynn EA. Perceptions of the appropriateness of care in California adult intensive care units. Crit Care. 2015;19(1):51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ethe DISPROPRICUS study group of the Ethics Section of the European Society of Intensive Care Medicine, Benoit DD, Jensen HI, Malmgren J, Metaxa V, Reyners AK, et al. Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA. Intensive Care Med. 2018;44(7):1039\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiarchiaro J, White DB, Ernecoff NC, Buddadhumaruk P, Schuster RA, Arnold RM. Conflict Management Strategies in the ICU Differ Between Palliative Care Specialists and Intensivists. Crit Care Med. 2016;44(5):934\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeino Y, Kurosawa H, Shiima Y, Niitsu T. End-of‐life care in the pediatric intensive care unit: Survey in Japan. Pediatr Int. 2019;61(9):859\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlameddine M, Dainty KN, Deber R, Sibbald WJ, Bill. The intensive care unit work environment: Current challenges and recommendations for the future. J Crit Care. 2009;24(2):243\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeck J, Falco CN, O\u0026rsquo;Hara KL, Bassett HK, Randall CL, Cruz S, et al. The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States. Teach Learn Med. 2023;35(3):335\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDalton A. Mitigating burnout and enhancing wellness in anesthesiologists: individual interventions, wellness programs, and peer support. Int Anesthesiol Clin. 2021;59(4):73\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiannetta N, Sergi R, Villa G, Pennestr\u0026igrave; F, Sala R, Mordacci R, et al. Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study. Healthcare. 2021;9(12):1673.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"End-of-life (EOL), Palliative Care, Moral Distress, European/international survey, Physicians, Nurses, Intensive Care Unit (ICU)","lastPublishedDoi":"10.21203/rs.3.rs-6804967/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6804967/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThe practice of end-of-life (EOL) and palliative care was modified during the coronavirus disease 2019 (COVID-19) pandemic due to several factors, often related to isolation and infection prevention measures. This study aims to explore the current state of EOL and palliative care after the COVID-19 pandemic in European Intensive Care Units (ICUs).\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003e The online cross-sectional survey study was endorsed by the European Society of Intensive Care Medicine (ESICM). Data collection was carried out in ten months (May 2023 to February 2024). Healthcare professionals (HCPs) working in European ICUs were eligible to participate. Univariate and multivariate logistic regression model was used for statistical analysis.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eTotally, 215 HCPs completed the survey. Patients\u0026rsquo; dying without dignity was perceived by 17 (9%) HCPs. The statistically significant factor contributing to perception of dying without dignity was unclear goals of treatment in EOL. Inappropriate care after the COVID-19 pandemic was perceived by 38 nurses (78%) and 127 physicians (91%). Organ support was reported as too long by 109 physicians (72%) and 32 nurses (50%), while 88 physicians (58%) and 16 nurses (25%) perceived organ support as too extensive. When organ support was perceived as inappropriate, 27 nurses (75%) and 113 physicians (90%) actively expressed their concerns. However, these expressed opinions were not respected in 40 physicians (35%) and 14 nurses (52%). Moral distress was perceived as an issue even after the COVID-19 pandemic among 129 (72%) respondents. HCPs whose EOL practices changed during the COVID-19 pandemic had nearly 8 times higher odds (OR (95% CI) 7.969 (2.890\u0026ndash;21.975)) of experiencing moral distress post-pandemic (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Among the HCPs who acknowledged the presence of moral distress after the pandemic, 65 (50%) felt that the level of distress was comparable to pre-pandemic levels.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003ePalliative care at ICU after the COVID-19 pandemic has the potential for improvement in dignified dying and appropriate care. The major factor connecting the moral distress of HCPs and improvement in palliative care quality seems to be communication. Further research and interventions to improve communication among the HCPs and between HCP and family might benefit patients and also HCPs.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov (NCT05089032)\u003c/p\u003e","manuscriptTitle":"Perspectives of physicians and nurses on palliative and end-of-life care practices in ICU beyond the COVID-19 era: An European survey study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 06:25:25","doi":"10.21203/rs.3.rs-6804967/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-08T08:35:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-08T03:02:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T18:51:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315233685449969729604121742346232758736","date":"2025-06-24T03:20:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T15:28:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297746298718133798147812254563756118627","date":"2025-06-23T00:27:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297601868199750549625518254285753934216","date":"2025-06-19T22:35:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268870057230727967273497624688682243713","date":"2025-06-17T08:42:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T07:35:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-10T05:33:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-09T20:03:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2025-06-09T20:00:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4972e84d-7094-4a1c-bce1-7a8e21ce53be","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T14:26:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-25 06:25:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6804967","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6804967","identity":"rs-6804967","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}