Fourteen semi-structured interviews were conducted with eight physicians and six patient organization representatives (PORs) from Sweden. The sampling of the participants were purposive (27) as we chose physicians and PORs working in healthcare areas with high influx of technology (oncology, hematology, neurology, and rare diseases), and thus likely to have experience of withdrawing or withholding treatments. Topic guides were developed with key themes, such as experiences of reimbursement decisions, which factors and arguments affect decisions, and the relationship between the physician and the patient when prioritizing treatments. The topic guides were pilot tested with one interview for each group, and were then revised. The topic guides were flexible and allowed for follow-up questions to obtain a deeper understanding of the interviewees’ experiences.
The interviews were conducted online via Zoom by the first author (A1) between September 2020 and May 2021.They took approximately one hour and were audio recorded and then transcribed and pseudonymized to ensure confidentiality. The physicians are referred to as PHY and patient organization representatives as POR, followed by a number to distinguish between them. A1 took field notes during the interviews and summarized them directly afterwards to capture the immediate impressions. The data was regarded as saturated by the authors when the field notes from the last interview had not given any new major insights.
The data was analyzed following the thematic framework method (27). The transcripts were first read several times by A1 and then labelled using first-order codes close to the participants’ terms. These codes were thereafter sorted into more general themes, with the process being followed iteratively by discussion between A1 and A4. In the next step, empirical statements from each theme were identified. These statements follow what Ritchie and Lewis (27) refer to as explanatory accounts, as analyzing the codes and themes involve detecting patterns in the generated data and the statements are the assigned meaning of the generated data. The coding, thematization, and empirical statements were discussed iteratively among all co-authors, who have previous experience of qualitative methods, politics and policy analysis, ethics, psychology, and economics, to triangulate the interpretation of the generated data and decrease the risk of one-sidedness and distortions (28). The coding was then revised, and the process was repeated until the authors agreed on the identified themes and statements.
Findings
We identified eight different themes, encompassing individual patients’ benefit from the treatments, the relationship and communication between and among patients and physicians, and more systemic concepts such as healthcare responsibility and ethical values (see Table 1). Within these themes, we also identified 55 different empirical statements which are presented in full in Table 2.
Table 1
The Identified Themes and Descriptions
| Theme | Description |
| Patients’ Need for Treatment | How the patient’s need for a treatment affects decisions to withdraw or withhold treatments. |
| Treatment Effect in Relation to Alternative Treatments | How the treatment’s effects affect withdrawing and withholding treatments. |
| Patient–Professional Communication | How communication between patients and professionals affects withdrawing and withholding treatments. |
| Patient–Professional Relationship | How relational factors between the patient and physician affect withdrawing and withholding treatments. |
| Healthcare Responsibility | The responsibilities of the healthcare system and its physicians when withdrawing and withholding treatments. |
| Ethical Values | Ethical values and their relative importance when withdrawing and withholding treatments. |
| Professional Support | The need for and attributes of supporting tools for physicians when withdrawing and withholding treatments. |
| Reimbursement System | Factors which describe the context in which decisions are made about withdrawing and withholding treatments. |
Patients’ Need for Treatment
This theme describes how a patient’s need for a treatment affects a decision to withdraw or withhold treatments. The patient’s medical condition was described by the physicians as a “guiding star” in everything they do, and that they will withhold a treatment if they assess the patient’s “performance status” to be too poor. Similarly, they said that they would withdraw treatment if the patient no longer copes with it. A distinction was made when a patient was very ill. The physicians explained that they become more experimental and willing to take a greater risk when there is a high risk that the patient could die, or when there is a chance of long-term survival, and are therefore less willing to withhold treatments, but not “at any cost”. Furthermore, both physicians and PORs expressed that it might be easier for both the physician and the patient when withdrawing or withholding a treatment from a patient if alternative treatments exist (statement 3). This was described as making it “emotionally easier”, and that withdrawing without providing an alternative would be like “throwing someone into an abyss”.
It makes it much easier when an alternative treatment exists. And this very agreement, that “We will give you the best possible care, the best possible treatment”. And, say, “We will offer the best possible treatment, but the cost is always an aspect for us because we live in a reality, which means that we really want to switch from this to that now and we believe it will work fine. Sure, there is a risk of side-effects, and we might see some worse effect.” But that is kind of compared to “You will receive the best possible treatment, but you do not get this, you get nothing instead”. That’s kind of throwing someone into an abyss. (POR1)
The physicians highlighted that the patient’s quality of life is important when deciding to withdraw or withhold treatments, as is considering the patient’s wishes. An example was given of not withholding a treatment so that a mother in her thirties would get a few months extra with her children. Likewise, it was emphasized by PORs that quality of life “is incredibly important”, and one representative exemplified that it can be different for a 45-year-old compared to an 85-year-old with the same disease, but also that treatments should be assessed due to the actual value they provide for patients.
Treatment Effect in Relation to Alternative Treatments
This theme describes how a treatment’s effect can affect decisions to withdraw or withhold treatments. The healthcare service was described by both physicians and PORs as currently providing patients with ineffective treatments, and that treatments are being withdrawn too late. Participants from both groups also had some experience of treatments being both withheld and withdrawn from patients due to a lack of cost-effectiveness. However, the physicians emphasized that treatments are commonly withdrawn because they are ineffective, rather than for reasons of cost-effectiveness. The two groups also expressed that a treatment that has been proven to be ineffective for a specific patient should be withdrawn (statement 10), and this is described by the physicians as an “uncontroversial” action. One POR highlighted that she does not believe any patient wants a treatment “which is not effective, and which you do not respond to”. It was also noted by a physician that it could be an “obvious choice” to start a treatment so they can test whether it works, but that if it is not effective they must be prepared to withdraw the treatment. This view was generally supported by the PORs. Moreover, the participants expressed that it would be difficult to withdraw a treatment that had proven to be effective for a patient due to a lack of cost-effectiveness. They explained that it is preferable to not withdraw the effective treatment since they cannot be certain of how the patient will react to a treatment before it is given. One physician also stated that they “put the patient in a worse condition” if they withdraw a treatment based on economic calculations. The PORs said that the treatment should not be withdrawn, since the patient still needs the treatment and the only acceptable reason for withdrawing it is that “it doesn’t give any benefit”. These views lead to statement 12: A treatment that has proven to be effective for a specific patient should not be withdrawn by the healthcare service, even if it is not reimbursed.
Because it always becomes a hypothetical question, because if you start a treatment where you do not know if it has a benefit for the patient, then you refrain from a treatment where you do not know the benefit, but in this patient, as you indicate, there you’ve seen a benefit for that patient, and to not get to continue for cost-effectiveness reasons, that feels much more difficult. For the other patient, it might have been that you had started a treatment and it hadn’t been effective, so that’s probably the difference, I think. (PHY3)
Furthermore, the physicians stated that patients who have participated in clinical studies and have had access to a treatment that has proven effectiveness but has not been subsequently recommended due to a lack of cost-effectiveness should not have their treatment withdrawn. This was described as punishing a patient who has made sacrifices for the researcher by “pulling away the carpet”, and as “not ethically correct”. The PORs generally shared this view. However, one representative expressed that patients can understand if a treatment is withdrawn after a clinical study (statement 14) as “it was only research”, while another emphasized that participants in a study must be aware that studies come to an end.
The physicians highlighted that if a patient had an expected positive effect from a treatment, then they would ideally neither withdraw nor withhold it, and the opposite if a negative effect was anticipated. Similarly, both the physicians and the PORs said that it can be helpful for a physician to evaluate a treatment’s effects when deciding to withdraw a treatment (statement 16). A concern was voiced by the PORs that it can be difficult to assess a patient’s benefits from a treatment, as the current methods might “not fit so well with the diagnosis group’s perception of the severity” or possibly measure the patient’s compliance rather than the effectiveness of the treatment. The physicians also acknowledged these concerns. Finally, PORs highlighted an issue that the use of one treatment could exclude the use of alternative treatments (statement 18) due to the treatment’s side-effects, which would reduce the number of available alternative treatments if their treatment is withdrawn.
Patient–Professional Communication
This theme described how communication between the patient and the physician can affect decisions to withdraw or withhold treatments. Both physicians and PORs highlighted that involving patients in decision-making can facilitate treatment withdrawals. The physicians said that if they had involved the patient throughout the treatment discussion and explained their reasons for their decision, then it became a “clear logic” for the patient. Likewise, asking the patient “What is important for you?” and reaching a consensus made the process easier. The PORs emphasized the importance of letting patients make their own decisions, as this would help treatment withdrawal.
So, I don’t really understand why it should be so difficult to withdraw treatments and take away treatments. I believe that we overdramatize it, because it’s more about us needing to be able to talk with each other, you must be able to, and the profession must have that, so that they talk with the patients and explain it in such a way that, so the patients can also make their own choices. (POR2)
Moreover, it was acknowledged by both physicians and PORs that agreements between a physician and a patient can facilitate treatment withdrawals (statement 20). They shared examples of agreements such as the circumstances under which the treatment will be withdrawn and how the treatment might be withdrawn in the case of a negative official recommendation. It was noted by one POR that the history of previous agreements between a physician and a patient could be the difference between withdrawing and withholding treatments, as a patient who has their treatment withheld does not have “the same history or agreements”, and it is an “isolated decision” compared to when treatment is withdrawn.
Finally, both physicians and PORs highlighted that it can be easier to withdraw a treatment if the physician informs the patient of the conditions for the treatment before starting it (statement 22). This was described by the physicians as “preparing the patient”, as “not giving any false hopes”, and as important if a treatment does not have an official recommendation and might have to be withdrawn in the future. One POR stated that “you can do a lot” if the patient is informed, and if the patient is not clearly informed and the physician wants to withdraw the treatment creates a situation “which becomes very, very difficult between the patient and the treating physician”. Likewise, both interviewed groups emphasized the importance of ensuring that the patient understands the information given to them, so that the patient does not have false belief in an ineffective treatment and instead has the right expectations.
Patient–Professional Relationship
This theme described how the relationship between the patient and the physician can both facilitate and hinder treatment withdrawal. The physicians and the PORs unanimously held the view that the physician should represent the patient when deciding to withdraw or withhold treatments (statement 24). The physicians noted that the patient’s needs come first in cases where there are no recommendations, and they would not see withdrawing a treatment due to a lack of cost-effectiveness as an obligation, as the patient is – as one physician put it – “their client”. The PORs suggested that the physician should be “the patient’s best friend” and “not discuss money” with the patient.
The two interviewed groups acknowledged that having a relationship between the physician and the patient can facilitate treatment withdrawal (statement 25). The physicians described how this relationship means that they had “been there throughout the journey”, that they can win the patient’s trust, and that it became easier to get “the information needed to make a wise decision”.
However, I should know the patient, know the patient’s needs, know the patient, have a perception of the patient’s view of their own illness and their own treatment and their own quality of life, so it’s, you must have both an outside perspective which is quite medical, risks, opportunities, purely medically. (PHY5)
The PORs noted that it can be easier to accept a treatment withdrawal if the healthcare service offers emotional support after delivering the decision. Some shared examples such as setting aside more than 20 minutes for such a meeting or letting a nurse come in and explain everything again after the physician has left. One physician also highlighted that it can be comforting for relatives if the physician has the final say on withdrawing or withholding a treatment, as they can feel obliged to “fight for the child in every way”.
Physicians expressed a concern that having too close a relationship with a patient could cause them to act unprofessionally as it becomes more “emotionally charged” to withdraw a treatment and more difficult to maintain a “clear logic in the decision-making” if they have a close relationship. One physician also highlighted that having patient gratitude as a personal motivator can make physicians less inclined to withdraw treatments. However, they also expressed that professional experience makes it easier not to be affected by these emotions.
Both the physicians and the PORs highlighted that the physical meeting with patients makes it more difficult for physicians to decide to withdraw or withhold treatments for specific patients than for patient groups (statement 29). This was described by the physicians as psychologically difficult, as they “want to do what’s best for that individual” in front them and that it felt difficult to explain decisions made by “an economist without a medical background”. The PORs acknowledged the differences between making general decisions and decisions for specific patients, and one representative highlighted that in the physical meeting, the patient “has a human value, which should be equal for everyone”.
Healthcare Responsibility
This theme explains the perceived responsibilities of the healthcare system and its physicians when withdrawing and withholding treatments. The participants unanimously held the view that it is a physician’s obligation to withdraw ineffective or harmful treatments (statement 30). This obligation included discussing it with the patient and withdrawing ineffective treatments in time. The participants also identified that a physician has more obligations when prescribing unofficial treatments to patients (statement 31). One physician described that they had to be aware of going off-label, explain why they are doing so, but also know that such treatments exist and provide them to patients if needed. One POR emphasized that physicians need to know if there are any predictable risks that the treatment will not be recommended.
In such cases it could be that if there’s a treatment which isn’t assessed, and where you don’t have any national guidelines, then it’s first and foremost the treating physician’s responsibility to know about it, and then to ensure that the patient gets it. And that can often be associated with quite a long process involving financing and so on. And that’s very different from case to case, and it’s different at different clinics, and it’s different in different regions. (PHY7)
The physicians were also concerned that patients might lose confidence in the healthcare system if effective treatments are withdrawn because of reimbursement status (statement 32). This was described as “letting the patient down”, and taking away the patient’s hope for improvement. One physician highlighted that the patient has paid income and payroll taxes, and expects to be insured against having their effective treatment withdrawn. The PORs were generally supportive of having these expensive treatments publicly funded as it is “unsustainable” to let clinics finance treatments. There were some concerns that public funding would not solve every problem, and that current payment models need to be more like privatized models, but with the acknowledgement that clinics should be able to turn to a higher level of the healthcare system if they cannot continue to finance an expensive treatment. Moreover, the physicians expressed that the pharmaceutical company should finance effective treatments for patients after a study is completed until an official recommendation is given (statement 34).
Ethical Values
This theme describes the ethical values and their relative importance when withdrawing and withholding treatments. The physicians and the PORs expressed that there is a psychological difference between withdrawing and withholding treatments, with withdrawing being described as more difficult. The physicians generally thought there was also an ethical difference, as the physician sends an “unpleasant” message to the patient, but also that withholding can be justified since the decision would be based on “new knowledge”. The PORs emphasized that cost-effectiveness is important, but that it should be weighed against human values and the need for treatments. It would be “more immoral” to withdraw than to withhold, as giving a treatment gives the patient hope; a treatment that then would be “snatched away”.
The physicians and the PORs expressed that it is more important for physicians to make an individual assessment for patients with previous access to treatments that lack cost-effectiveness than to withdraw treatments to uphold patient equality (statement 37). The physicians acknowledged the distributive injustices caused by not withdrawing a cost-ineffective treatment, but assessed this to be a lesser problem than withdrawing a proven effective treatment. It was highlighted by one physician that patients will always get access to different treatments as time passes, and that cost-effectiveness is not a strong argument for specific patients. The PORs also acknowledged that there are difficulties associated with mixing money with decisions at an individual level, and emphasized the need for “humanity” and “being human” in human meetings. Furthermore, the representatives noted that patients might not experience the same human value if their treatments are withdrawn due to a lack of cost-effectiveness (statement 38). They also expressed that the patient would “feel pretty useless”, “sad and less valued”, “offended”, etc. One representative stated that it would be unethical to make a patient “part of a budget”, or to only look at the bigger picture and not see the human.
You should not do it [withdraw the treatment]. I think it’s unethical that I suddenly become part of a budget. I’m never a budget. I’m a patient, and that patient should have adequate care, and it should be evidence-based, and he or she should have the best care, full stop. Because it becomes tricky then. No, we cannot afford it. (POR5)
Furthermore, the physicians and the PORs identified that a patient who had their treatment withdrawn due to a lack of cost-effectiveness would probably seek healthcare from another healthcare provider. They shared examples of contacting another region or looking abroad. Similarly, the two interviewed groups believed that it is unjust when different healthcare providers withdraw and withhold treatments unequally (statement 40). The physicians stated that it would not be “equal care” and one physician described it as a “heavy ethical stress” which could be worse than simply not providing the treatment. The PORs described it as “horribly unequal”, causing “frustration” and a sense of “giving up”, and one criticized it for happening in Sweden, which “should be so equal and good, and democratic”.
Professional Support
This theme describes the need for and attributes of supporting tools for physicians when withdrawing and withholding treatments. The physicians described how they feel alone when having to decide whether to withdraw or withhold a treatment. This was expressed by one physician as a “vulnerable” situation for the individual physician, and that these decisions have “taken their toll” on her. The physician generally felt that it would be easier to consult a colleague when deciding to withdraw or withhold a treatment, as they would feel less vulnerable if “it isn’t the individual physician who’s made the decision”. Likewise, they highlighted that making decisions together with other colleagues would reduce the risk of the medical decision being negatively affected by the physician’s relationship with the patient. A concern was voiced by one physician that physicians can sometimes have different opinions, resulting in quite “lively discussions”.
The physicians and the PORs unanimously held the view that guidelines from a national level on treating new patients and patients with previous access to treatments after new recommendations can facilitate treatment withdrawals for physicians and patients (statement 43). The potential guidelines were described as making things more equal between regions and leaving individual physicians less vulnerable, and as a decision that politicians and the profession must take. One physician also highlighted that these guidelines need to be readily accessible for physicians so they can get a “good digital overview of what’s okay and not okay”. A concern was raised by the PORs that guidelines from a national level might not be applicable in all individual cases, and that a continuous discussion on healthcare service prioritizations is needed.
Yeah, I mean, once again some kind of equality perspective. It becomes very complicated if we offer treatments to some, but say no to others for cost reasons. Then we find ourselves in an ethical swamp, which becomes extremely difficult for us in the healthcare service to handle. So, but it’s enormously important that the healthcare service and authorities achieve clarity in decisions concerning expensive treatments. Yeah, but when TLV carries out trials and so on, there is some sort of stringency in it all. (PHY8)
The physicians noted that it could be helpful to have reflected on ethical problems related to priorities when making priority decisions. They explained that being involved in “provoking philosophical dialogues” and being involved in discussions about priorities could change their point of view, but also that it “felt good” and “safe” to be familiar with these thoughts.
Reimbursement System
This theme describes reimbursement system factors which can be important for understanding the context in which decisions about withdrawing and withholding are made. The physicians and the PORs were generally positive toward healthcare making priority decisions, and explained that it is important to follow official guidelines so the healthcare service can afford future treatments and be able “to treat everyone”. They also identified a potential problem regarding priorities between patient groups as physicians tend to prioritize treatments for their own patient groups (statement 48) and patient organization representatives represent their own patient groups (statement 49). However, one representative noted that patient organizations could potentially work together with the healthcare service to help patients understand the prioritizations that are made.
Another concern from the PORs was that the treatment assessment process is not sufficiently transparent for patients (statement 50). It was suggested that patients might not find out why their treatments were withdrawn, and that authorities do not explain transparently how specific treatments were assessed or how the patients’ perspectives were represented. The PORs also emphasized that patients should be involved in the treatment assessment process to reduce “faulty prioritizations”, and to give each organization the opportunity to express themselves when a new treatment is being assessed, which one representative said could potentially make “more treatments cost-effective”.
And I also believe when we see treatments that have a good value, and where patients really get the opportunity to explain this and show it, then we will also see that these treatments are cost-effective. (POR2)
The PORs also stated that patients want access to new treatments (statement 52), but criticized the authorities for taking a long time to implement new treatments compared to the rest of Europe. The physicians also acknowledged that it can take a long time to implement treatments after they have been recommended. The two interviewed groups noted that patients cannot demand access to the experimental treatment if they get access to a new treatment by participating in a clinical study.
The physicians highlighted that there is a difference between what is medically best and what is practically possible when prioritizing treatments between patients (statement 55). These limitations could be based on “the tools I’m given”, staff availability, the number of hospital beds, and a need to “compromise and do the best you can in the situation”. One POR also acknowledged that there are various “bottle necks” in the current system, as “things happen, and reality is quite complex”.
| Table 2. The Identified Statements | | | |
| Themes | # | Statement | Context |
| Patients’ Need for Treatment | 1 | An ill medical condition can make a physician’s decision to withdraw or withhold a treatment easier | PHY/POR |
| | 2 | An ill medical condition can make the physician more willing to take higher risks and not withhold treatments | PHY |
| | 3 | It might be easier for both the physician and the patient when withdrawing or withholding a treatment from a patient if alternative treatments exist | PHY/POR |
| | 4 | The patient’s quality of life is important when deciding to withdraw or withhold treatment | PHY/POR |
| Treatment Effect in Relation to Alternative Treatments | 5 | The healthcare sector provides inefficient treatments to patients | PHY/POR |
| | 6 | Treatments are commonly withdrawn too late from patients in practice | PHY/POR |
| | 7 | Physicians sometimes withhold treatment from patients due to cost-effectiveness | PHY/POR |
| | 8 | Physicians sometimes withdraw treatments from patients due to cost-effectiveness | PHY/POR |
| | 9 | Physicians commonly withdraw treatments from patients because they are ineffective or cause harm, rather than for cost-effectiveness reasons | PHY/POR |
| | 10 | A treatment that has been proven to be ineffective for a specific patient should be withdrawn | PHY/POR |
| | 11 | It must be acceptable for physicians to withdraw ineffective treatments | PHY/POR |
| | 12 | A treatment that has proven to be effective for a specific patient should not be withdrawn by the healthcare service, even if it is not reimbursed | PHY/POR |
| | 13 | A treatment that has proven to be effective for a patient participating in a clinical study should not be withdrawn | PHY/POR |
| | 14 | Patients can understand if a treatment is withdrawn after a clinical study | POR |
| | 15 | The expected net patient benefit of a treatment can affect the physician’s decision to withdraw or withhold a treatment | PHY |
| | 16 | It can be helpful for a physician to evaluate a treatment’s effects when deciding to withdraw a treatment | PHY/POR |
| | 17 | It can be difficult for a physician to evaluate all effects a treatment has or will have for a patient | PHY/POR |
| | 18 | The use of one treatment can exclude the use of alternative treatments | POR |
| Note: PHY = physician, POR = patient organization representative |
| Table 2 (continued) | | | |
| Themes | # | Statement | Context |
| Patient–Professional Communication | 19 | Involving patients in decision-making can facilitate withdrawals | PHY/POR |
| | 20 | Agreements between a physician and a patient can facilitate treatment withdrawals | PHY/POR |
| | 21 | Agreements between a physician and a patient can be the difference between withdrawing and withholding treatments | POR |
| | 22 | It can be easier to withdraw a treatment if the physician informs the patient of the conditions for the treatment before starting it | PHY/POR |
| | 23 | It is easier for the physician to withdraw treatments if the patient understands the information given to them | PHY/POR |
| Patient–Professional Relationship | 24 | The physician should represent the patient when deciding to withdraw or withhold treatments | PHY/POR |
| | 25 | Having a relationship between the physician and the patient can facilitate treatment withdrawal | PHY/POR |
| | 26 | Spending extra time to support a patient psychologically makes it easier for the patient if their treatment is withdrawn | POR |
| | 27 | It can be comforting for relatives if the physician decides whether a treatment is withdrawn or withheld | PHY |
| | 28 | Having too close a relationship between the physician and the patient can make the physician act unprofessionally when withdrawing a treatment | PHY |
| | 29 | The physical meeting with patients makes it more difficult for physicians to decide to withdraw or withhold treatments for specific patients than for patient groups | PHY/POR |
| Healthcare Responsibility | 30 | It is a physician’s obligation to withdraw ineffective or harmful treatments | PHY/POR |
| | 31 | A physician has more obligations when prescribing unofficial treatments to patients | PHY/POR |
| | 32 | Patients might lose confidence in the healthcare system if effective treatments are withdrawn because of reimbursement status | PHY |
| | 33 | Expensive treatments should be publicly funded | POR |
| | 34 | The pharmaceutical company should finance effective treatments for patients after a study is completed until an official recommendation is given | PHY/POR |
| Table 2 (continued) | | | |
| Themes | # | Statement | Context |
| Ethical Values | 35 | It is psychologically easier to withhold a treatment due to cost-effectiveness than to withdraw it | PHY/POR |
| | 36 | There is an ethical difference between withdrawing and withholding treatments due to a lack of cost-effectiveness | PHY/POR |
| | 37 | It is more important for physicians to make an individual assessment for patients with previous access to treatments that lack cost-effectiveness than to withdraw treatments to uphold patient equality | PHY/POR |
| | 38 | Patients might not experience the same human value if their treatments are withdrawn due to a lack of cost-effectiveness | POR |
| | 39 | Withdrawing and withholding treatments differently might lead to patients seeking healthcare from other healthcare providers | PHY/POR |
| | 40 | It is unjust when different healthcare providers withdraw and withhold treatments unequally | PHY/POR |
| Professional Support | 41 | Physicians feel alone when deciding to withdraw or withhold treatments | PHY |
| | 42 | It can be helpful for a physician to consult other physicians when deciding to withdraw or withhold treatments | PHY |
| | 43 | Guidelines from a national level on treating new patients and patients with previous access to treatments after new recommendations can facilitate treatment withdrawals for physicians and patients | PHY/POR |
| | 44 | Guidelines from a national level should be accessible for physicians | PHY |
| | 45 | Guidelines from a national level may not be applicable in all healthcare scenarios | POR |
| | 46 | It could be helpful for a physician to have reflected on ethical problems related to priorities when making priority decisions | PHY/POR |
| Table 2 (continued) | | | |
| Themes | # | Statement | Context |
| Reimbursement System | 47 | Physicians and patient organization representatives are supportive of healthcare making priority decisions | PHY/POR |
| | 48 | Physicians tend to prioritize their own patient groups | PHY |
| | 49 | Patient organizations represent their own patient groups | POR |
| | 50 | The treatment assessment process is not sufficiently transparent for patients | POR |
| | 51 | Patients are not sufficiently involved in the treatment assessment process | POR |
| | 52 | Patients want access to new treatments | POR |
| | 53 | It takes a long time for authorities to implement new treatments | PHY/POR |
| | 54 | A patient cannot demand access to the experimental treatment in a clinical study | PHY/POR |
| | 55 | There is a difference between what is medically best and what is practically possible when prioritizing treatments between patients | PHY/POR |