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How individual ethical frameworks shape physician trainees’ experiences providing end-of-life care: a qualitative study
  1. Sarah Rosenwohl-Mack1,
  2. Daniel Dohan2,
  3. Thea Matthews2,
  4. Jason Neil Batten3,4,
  5. Elizabeth Dzeng5,6
  1. 1 Family and Community Medicine, University of California San Francisco, San Francisco, California, USA
  2. 2 Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
  3. 3 Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
  4. 4 Department of Anesthesia, Stanford University, Stanford, CA, USA
  5. 5 Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
  6. 6 Cicely Saunders institute, King's College London, London, UK
  1. Correspondence to Dr Elizabeth Dzeng, Division of Hospital Medicine, University of California San Francisco, San Francisco, CA 94115, USA; liz.dzeng{at}


Objectives The end of life is an ethically challenging time requiring complex decision-making. This study describes ethical frameworks among physician trainees, explores how these frameworks manifest and relates these frameworks to experiences delivering end-of-life care.

Design We conducted semistructured in-depth exploratory qualitative interviews with physician trainees about experiences of end-of-life care and moral distress. We analysed the interviews using thematic analysis.

Setting Academic teaching hospitals in the United States and United Kingdom.

Participants We interviewed 30 physician trainees. We purposefully sampled across three domains we expected to be associated with individual ethics (stage of training, gender and national healthcare context) in order to elicit a diversity of ethical and experiential perspectives.

Results Some trainees subscribed to a best interest ethical framework, characterised by offering recommendations consistent with the patient’s goals and values, presenting only medically appropriate choices and supporting shared decision-making between the patient/family and medical team. Others endorsed an autonomy framework, characterised by presenting all technologically feasible choices, refraining from offering recommendations and prioritising the voice of patient/family as the decision-maker.

Conclusions This study describes how physician trainees conceptualise their roles as being rooted in an autonomy or best interest framework. Physician trainees have limited clinical experience and decision-making autonomy and may have ethical frameworks that are dynamic and potentially highly influenced by experiences providing end-of-life care. A better understanding of how individual physicians’ ethical frameworks influences the care they give provides opportunities to improve patient communication and advance the role of shared decision-making to ensure goal-aligned end-of-life care.

  • end of life care
  • palliative care
  • autonomy
  • clinical ethics
  • decision-making

Data availability statement

All data relevant to the study are included in the article.

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Data availability statement

All data relevant to the study are included in the article.

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  • Contributors ED and SR-M contributed to the conception, study design and data collection for the study. TM, ED, DD, JNB and SR-M contributed to the creation of the interview guide. SR-M and ED contributed to the data analysis and interpretation and drafted the manuscript and DD, JNB, and TM revised the manuscript. All authors vouch for the accuracy and completeness of the manuscript and reviewed and approved the final manuscript. ED is the guarantor and corresponding author. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding This study was funded by the UCSF Gibbs Family Medicine Fellowship, the National Institute for Aging Grants for Early Medical/Surgical Subspecialty Transition to Aging Research (GEMSSTAR) (1R03AG060098), and the California Department of Public Health Alzheimer’s Disease Research Award.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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