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| Categories and subcategories | Definitions and examples |
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| Category 1 | Structural conditions of prehospital emergency care |
| 1.1. Limited time | Complex symptoms and situations in prehospital emergencies in patients with advanced incurable disease require more time than available in an emergency system, which is focused on fast acting rescue teams
“[…] I do not have the time to take palliative care of a patient at home or even develop a palliative concept […] I have to decide whether the patient can stay at home or needs to be taken to a hospital” (3, 14) |
| 1.2. Lacking medicine and medical equipment | Medical supplies are limited and do not necessarily include the needed items in a palliative situation
“We have restricted varieties of medication and medical equipment, therefore my options are very limited […]” (4, 51) |
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| Category 2 | Medical documentation and orders |
| 2.1. Documentation of illness, past medical treatment and drug therapy | Often there is no precise material about the past medical history and treatment plans at the patients’ home
“A large problem is the documentation. Standard reply: It’s at my general practitioner’s office
But as an emergency physician I’m not there during the general practitioner’s working hours, instead at night, on weekends” (9, 55) |
| 2.2. Advanced directives | Advances directives’ importance if the patient is no longer capable of expressing an own will
“It’s difficult for me when I only have the assumed will I’m told by relatives […] and nothing written. I’m then leaving an end-of-life patient that’s most likely to die […] but personally, I’ve got nothing but the assumed will from people, mostly even without a healthcare proxy” (19, 52) |
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| Category 3 | Finding optimal and patient-centered therapy |
| | Restricted resources and a large variety of patient wishes regarding therapy and their impact on medical emergency decision-making
“Those situations present a conflict on how much to do, how much I can do and still let the patient remain at home” (6, 2) |
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| Category 4 | Uncertainty about legal consequences |
| | Decision-making regarding treatment/stay at home and the impact of possible legal consequences
“[…] with pain medication there’s always the danger of shortening it [life]. I give him pain medication and he gets respiratory insufficient. What are the legal consequences?” (13, 25) |
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| Category 5 | Challenges at the individual (EP) level |
| 5.1. Personal needs and emotions | Personal needs and emotions expressed by the interviewed EPs when facing patients with advanced incurable diseases
“If I leave patients at home I need to know that all people are informed about things to come, can cope with the situation and that suffering is bearable” (2, 2) |
| 5.2. Experiences with palliative care situations | Personal and work experience with patients with advanced incurable disease and treatment
“But to deal with this hopeless situation, it is hard to accept that this is not a personal failure and it is hard to accept that I cannot longer help this patient […]” (7) |
| 5.3. Lacking palliative care knowledge and expertise | Lacking palliative care knowledge due to lack of education and training
“We or some emergency physicians and paramedics aren’t educated and have no specific knowledge on how to cope with those patients and what to do” (20, 66) |
| 5.4. Empathetic behavior | Challenges for empathetic behavior for EPs in the special case of emergencies in patients with advanced incurable disease in their home environment
“However, I think most important are empathy skills, to get involved with the patient and act correctly and adequately in the situation […] this becomes a problem if such skills are lacking” (16, 51) |
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| Category 6 | Challenges at the emergency team level |
| 6.1. Hierarchies | Impact of the emergency team hierarchy on decision-making and treatment plans
“Disagreements in the team. […] we have a clear hierarchy and the emergency physician is in charge of making the decision what to do and when to stop. When you’re unsure, this spreads over the team and the leading position can change” (2, 80) |
| 6.2. Coping with palliative care situations | Different concepts of coping with a patient with advanced incurable disease within the team
“I might be responsible but the whole team has to cope when I decide not to resuscitate. You need to talk about it beforehand. […] especially in palliative emergency settings the team is vital” (16, 47) |
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| Category 7 | Family caregivers’ emotions, coping, and understanding of patient’s illness |
| 7.1. Caregivers’ understanding of the patient’s clinical status | Perception and expectations towards the clinical situation in patients with advanced incurable disease as seen by family caregivers
“I believe it is important for relatives to know and to be incorporated, but that’s something I experience isn’t all too apparent in communication. […] because they sometimes have completely different expectations, I believe you must have honest conversations on how it’s going to be” (6, 2) |
| 7.2. Family caregivers’ emotions and coping with end-of-life situations | Emotional responses and (dysfunctional) coping strategies of family caregivers in end-of-life situations
“Most times we’re not being called for the patient but because the relatives don’t know how to cope with the situation” (1, 26) |
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| Category 8 | Patient’s wishes, coping, and understanding of patient’s illness |
| 8.1. Patient’s coping and understanding of patient’s illness | Varying knowledge and coping strategies from patients in palliative end-of-life situations influences the treatment in emergency settings
“Sometimes patients aren’t informed about all the options they have. They’re sometimes discharged or at least that’s what they say, without knowing what to do in those (emergency) situations” (6, 2) |
| 8.2. Patients’ wishes | Patients’ wishes and expectations at end-of-life and influence on treatment options
“I experience quite a lot that I’m unsure of what to do with a patient and that’s usually because of a discrepancy between what the patient wants on one hand, which is not to be taken to a hospital, the wish to die at home, nursing home or wherever. Quiet without suffering. And what relatives dictate on the other hand” (10, 36) |
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| Category 9 | Social, cultural, and religious background of patients and families |
| 9.1. Cultural/religious beliefs | Belief systems and cultural settings have an impact on the options and wishes in emergency care in patients with advanced incurable disease
“In some cultures, it is common that more and more people enter the room every minute. It makes it impossible for me to find out what’s the patient’s problem, that’s stressful” (9, 78) |
| 9.2. Health literacy | Different socioeconomic statuses and knowledge about options in the healthcare system affect the medical background
“Patients with higher living standards have usually more specific wishes than patients who belong to lower social classes, hence have more often a specialized prehospital palliative care service involved” (1, 74) |
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