Table 2 Perceived complexities by SCEN physicians during the most difficult consultation, 2015

Patient characteristics

79.7

 No short-term life-threatening disease (e.g. accumulation of age-related health problems, chronic diseases, invalidity)

 Communication was difficult (e.g. coma, confused, not clear, aphasic)

 Psychiatric problems

 Ambivalence towards death wish

 Patient was demanding, angry

 Dementia, cognitive decline

 Patient was young

 Psychosocial problems (e.g. tired of living, loneliness)

 Time pressure due to medical state

Assessment of the due care criteria

 Suffering hard to assess due to the situation of the patient

 An early consultation

 Mental competence hard to assess

 Unbearable suffering hard to imagine

 Treatment options hard to define

 Suffering hard to asses due to lack of information (from patient/file/physician)

 Hard to assess whether the request was voluntary

Patient’s relatives

 Relatives aren’t ready for/have problems with the EAS

 Relatives exert pressure on the physician

 Problems within the family (not related to the EAS e.g. grief, no contact with children, family lives far away)

 Patient wants EAS together with partner

 Family cannot handle the care for the patient

 Patient provides care for children/partner

 Pressure from relatives on patient

Health professionals

 Pressure/not understanding doubts or judgement of the SCEN physician

 Doubting/unclear/unprepared attending physician

 Attending physician does not want to perform the EAS

 Attending physician was influenced by the patient and relatives

 Suboptimal care (e.g. too little care, not in place wished for, futile treatment)

 Attending physician already promised to perform the EAS

 Bad contact between attending physician and patient

 (Part of) health professionals are against EAS/agitation among health professionals

 Attending physician expected more counseling from the SCEN physician

 Attending physician seemed to want consultation/EAS earlier than patient

Other aspects

 An earlier SCEN physician judged differently

 Little experience of SCEN physician with disease

 Resistance of SCEN physician concerning a specific case

 Situation was moving

 Attending physician was also a SCEN physician

 SCEN physician acted awkward him/herself

 Questionable whether the second physician was independent

 Consultation with other SCEN physician necessary

 Other