Table 2 Overview of included quantitative articles

Randolph et al. (1999) [39]

United States

To investigate how physicians in a PICU make decisions to withdraw/withhold life support

376 PICU physicians, RR: 72% (n = 270); intensivists’ RR: 83% (n = 165/198); oncologists’ RR: 59% (n = 105/178)

Survey included demographic data collection, 8 case scenarios of 2 critically patients and attitudinal questions about LST

213 attending physicians, 52 fellows; 186 males, 84 females; ICU experience, mean = 8.4 ± 7.1 years

Institutional review board at Children’s Hospital of Wisconsin approved study

Keenan et al. (2000) [16]

United States

To determine opinions of members of a PICU team on the appropriateness of aggressive care

45 PICU physicians; 34 anesthesiologists, 11 intensivists; RR: not reported

Survey included demographic data collection, attitudinal questions about supportive care

11 attending physicians, 10 critical care and anesthesia fellows, 24 anesthesia and pediatric residents [68 nurses]

Hospital Institutional Review Board and the Ethics Committee at Children's Hospital and Medical Center approved study

Sakakihara (2000) [40]

Japan

To determine ethical attitude of Japanese physicians concerning patients with severe neurological disabilities

202 pediatric neurologists; RR: 72.3%. (n = 147)

Mixed method; Survey included demographic data collection, 13 closed-ended and 1 open-ended questions about ethical attitudes to LST

Mean practice experience = 24.6 years

Not mentioned

Burns et al. (2001) [41]

United States

To describe attitudes and practices of critical care clinicians on limitations to LST

130 PICU physicians; RR: 85% (n = 110)

Survey included 45 demographic questions, attitudinal and experiential questions about LST

110 attending physicians; mean age = 39 ± 8 years, pediatric critical care experience = 8 ± 6.7 years [92/130 nurses]

Children’s Hospital institutional review board approved protocol; Ensured anonymity

Devictor et al. (2008) [42]

Worldwide

To examine intercontinental differences in EOL practices in PICUs

482 PICU physicians; RR: not reported

Survey included 2 case scenarios with 5 attitudinal questions, each about the management of children in PICUs and ways to process the decision-making process

[170 nurses, 15 allied professionals]

Research Ethics Committee of the Paris Sud-11 University approved study Ensured anonymity

Forbes et al. (2008) [43]

Australia

To better understand attitudes and practices on withholding/withdrawing LST among medical staff in pediatric setting

385 pediatricians, RR: 42% (n = 162); 155 general or sub-specialist pediatricians, 7 surgeons

Mixed method; Survey included demographic data collection, attitudinal and experiential questions about LST

81 senior pediatricians, 81 pediatric trainees; 70 males, 92 females; practice experience 69 have > 15 years, 41 have < 5 years

Human Research Ethics Committee at the Royal Children’s Hospital approved study; Ensured anonymity

Kesselheim et al. (2008) [44]

United States

To study pediatricians’ confidence in confronting ethical dilemmas arising in pediatric practice

215 pediatricians, RR: 69.8% (n = 150)

Survey included demographic data collection, 16 questions about ethics education, and physician confidence in confronting ethical challenges

87 in primary practice, 17 in fellowship training, 16 in inpatient general pediatrics, 5 in residency, 5 are chief resident, 1 in specialty practice; 55 males, 94 females; mean age = 31.8 ± 4 years

Children’s Hospital Boston Committee on Clinical Investigation approved study; Ensured informed consent

Hoehn et al. (2009) [45]

United States

To compare pediatricians’ attitudes about DNAR orders

600 pediatricians; 40 were not available or were self-excluded and 560 remained;, RR: 50% (n = 279); emergency physicians’ RR: 52% (n = 75/143), intensivists’ RR: 51% (n = 73/144), pediatricians for disabled children’ RR: 43% (n = 64/148), campus physicians’ RR: 38% (n = 55/143)

Mixed method; Survey included demographic data collection, four hypothetical vignettes about DNAR in various settings, and 3 attitudinal questions for each vignette; contained closed-ended and open-ended questions

190 received fellowship training, 83 did not receive;170 males, 105 females

University of Chicago Institutional Review Board approved study and waived written informed consent

Talati et al. (2010) [46]

United States

To understand factors that influence pediatricians’ responses to refusals of minors’ prognosis; concordance of parent-minor decision, and minor autonomy

1200 pediatricians; 80 were excluded, 1120 left, RR: 37.6% (n = 421); 144 adolescent pediatricians, 139 pediatricians, 138 hematology oncologists

Survey included demographic data collection, 2 case scenarios with attitudinal questions about treatment refusal

224 received fellowship training, 161 did not receive; 211 males, 174 females; mean age 48.8 ± 11.0 years

University of Chicago Institutional Review Board approved the study and waived written informed consent

Bahus and Føerde (2011) [47]

Norway

To investigate whether attitudes of Norwegian physicians on surrogate decision rights in EOL care conform to legal rules, particularly with regard to child protection

1175 physicians, RR: 54.5% (n = 640); 405 finished the whole questionnaire and their data were analyzed; 203 internists, 92 surgeons, 75 pediatricians, 22 neurologists, 2 neurosurgeons

Survey included demographic data collection, a case scenario with 2 attitudinal questions about EOL decision-making

121 born before 1950, 245 born in or after 1950

Not mentioned

Morparia et al. (2012) [48]

United States

To understand perspectives of pediatric critical care physicians on treatment futility

618 pediatric intensivists, RR: 43% (n = 266)

Mixed method; Survey included demographic data collection, 4 hypothetical vignettes highlighting difficulties in PICU with 4 attitudinal questions for each vignette about LST; contained closed-ended and open-ended questions

145 males. 92 females

Institutional review board at the St. Christopher’s Hospital approved the study Ensured anonymity

Needle et al. (2012) [49]

United States

To characterize relationship between pediatric intensivists’ personal preferences for LST and recommendations they make to families of critically ill children

1694 pediatric intensivists, 119 not available 1575 remained, RR: 30% (n = 471)

Used Personal Preference Score questionnaire; included demographic data collection, 1 scenario, and question about physicians’ personal preference for LST

274 males, 192 females; 230 aged 30–39 years, 156 aged 40–49 years, 70 aged 50–59 years, 13 > 70 years; practice experience 285 have < 10 years, 143 have 10–20 years, 41 have > 20 years

Oregon Health and Science University Institutional Review Board approved study

Rapoport et al. (2013) [50]

Canada

To assess attitudes of palliative care physicians toward providing care for pediatric patients and to describe kind of support they desire

74 palliative care physicians, RR: 59.5% (n = 44)

Mixed method; Survey included demographic data collection, questions about attitudes and level of comfort caring for pediatric patients, contained closed-ended and open-ended questions

Mean palliative care experience = 11.63 ± 7.17 years, range 0–32 years

University of Toronto research ethics board approved study

Boss et al. (2015) [17]

United States

To explore pediatric clinicians’ experiences with LST prior to the MOLST mandate and to describe clinician and family concerns and preferences regarding pediatric MOLST

255 clinicians, RR: 40% (n = 102); 96 completed data collection, 69 pediatricians

Mixed method Survey included demographic data collection, attitudinal and experiential questions about MOLST; contained closed-ended questions and focus group discussion

[27 nurses]

The institutional review board approved study; Ensured informed consent

Sanchez Varela et al. (2015) [51]

Worldwide

To describe differences in ethical decision-making at the EOL among an international sample of pediatric oncologists practicing in countries with a variety of income levels and resource settings

1771 pediatric oncologists, RR: 23% (n = 401)

Survey included demographic data collection, 38 attitudinal questions about knowledge of practicing pediatric oncologists around the world about ethical issues in children and adolescents dying of cancer

No

Institutional review boards at St. Jude Children’s Research Hospital in Memphis, and University of North Carolina at Chapel Hill in Chapel Hill approved study; Ensured informed consent

Grosek et al. (2016) [52]

Slovenia

To assess the attitudes of Slovene pediatricians toward EOL care

323 pediatricians, RR: 46.7 (n = 151); pediatric intensivists’ RR: 69% (n = 24/35), pediatric specialists’ RR: 60% (n = 66/110), pediatric residents’ RR: 34.3% (n = 61/178) 127 pediatricians, 24 intensivists

Survey included demographic data collection, questions about physicians’ attitudes and experiences regarding EOL care, with a focus on limiting LST

20 males, 131 females; mean age 40 years

The Slovene National Medical Ethics Committee approved study; Ensured anonymity

Yotani et al. (2017a) [53]

Japan

To clarify differences in practice of and barriers to ACP and AD for adolescent patients with cancer between pediatricians and internists

3,392 pediatric hematologists, 178 not available, 3214 were left, RR: 18.7% (n = 600); 373 internists, 227 pediatricians

Survey included demographic data collection, 82 closed-ended questions on practice and barriers of ACP

467 males, 133 females; mean age 48.5 ± 8.9 years

Institutional Review Board of Osaka City University Medical School approved study

Yotani et al. (2017b) [54]

Japan

To determine practices regarding ACP and AD among pediatric neurologists with regard to adolescent patients with life-threatening conditions

1081 pediatric neurologists, 37 not available, 1044 were left, RR: 54% (n = 564), data of the 186 pediatric neurologists were analyzed

Survey included demographic data collection, 82 closed-ended questions on practice and barriers of ACP, and AD discussions

Mean age 53.4 ± 10.6 years

Institutional Review Board of Osaka City University Medical School approved study

Wosinski and Newman (2019) [55]

Switzerland

To determine attitudes of physicians faced with life-threatening events in a pediatric setting for patients with one of two severe neurological conditions and to explore personal and professional factors that may influence their attitudes

95 pediatricians, RR: 55% (n = 52); 26 intensivists, 15 neurologists, 7 rehabilitation specialist, 2 pediatricians

Survey included demographic data collection, 2 scenarios and attitudinal questions about withholding/withdrawing LST

26 males, 26 females; 4 aged 25–34 years, 28 aged 35–44 years, 10 aged 45–54 years, 10 aged > 55 years

Regional ethics commission waived the normal agreement; Ensured anonymity

Aljethaily et al. (2020) [56]

Saudi Arabia

To explore pediatricians' perceptions about DNR orders

203 pediatricians RR: not reported

Survey included demographic data collection, 22 closed-ended questions on pediatricians’ knowledge, attitude and experience toward DNR

96 senior pediatricians, 107 residents; 99 males, 104 females; 82 aged < 30 years, 52 aged 30–39, 44 aged 40–50, 25 aged > 50; work experience 87 have < 5 years, 28 have 5–10 years, 88 have > 10 years

Al-Imam University IRB Committee approved the study; Ensured informed consent

Song et al. (2020) [57]

South Korea

To assess pediatricians’ perceptions regarding ACP and barriers to the implementation of ACP in pediatric patients

966 pediatricians, RR: 9.9% (n = 96), data of 89 pediatricians were analyzed; 54 neonatologists, 18 hematology oncologists, 10 neurologists, 7 intensivists

Survey included demographic data collection, 2 scenarios and questions about physicians’ preference, attitudes, experience in decision-making for LST, and barriers to ACP implementation

27 males, 62 females; 38 aged 30–39 years, 35 aged 40–49 years, 10 aged 50–59 years, 6 aged ≥ 60 years; work experience as pediatricians56 ≤ 10 years, 33 > 10 years

Seoul National University Hospital Institutional Review Board waived requirement for informed consent

Yoo et al. (2021) [58]

South Korea

To investigate difficulties physicians experience during LST discussions with seriously ill patients and their families after the enactment of the LST decisions act

868 physicians, RR: 15.2% (n = 132); fellows’ RR: 24.8% (N = 35/141); residents’ RR: 24.1% (71/295); attending physicians’ RR:5.8% (n = 25/432); 58 internists, 21 surgeons, 20 pediatricians, 13 emergency physicians, 11 neurologists, 9 obstetricians and gynecologists

Survey included demographic data collection, 2 cases, questions about difficulties, facilitating strategies, time, implementation experience during LST discussions

71 residents, 35 fellows, 25 attendings; 55 males, 77 females; clinical experience median 4 years, ranged 0.4–30 years

Institutional review board of the Seoul National University Hospital approved study; Ensured anonymity and informed consent

Boer et al. (2022) [59]

European countries and UK

To explore experiences of pediatric trainees facing ethical dilemmas and medical ethics education while assessing their perceptions of ethical dilemmas in current and future practice

327 pediatricians responded, 18 were excluded, 253 were analyzed; 88 intensivists, 49 pediatricians, 10 anesthetists, 9 primary care physicians, 8 emergency physicians, 6 cardiologists, 5 infectious physicians; RR: not reported

Mixed method; Survey included demographic data collection, 41 closed-ended questions and 3 open-ended questions about ethical dilemmas faced and ethics training

179 residents, 74 fellows; 45 males, 208 females; median age 29 years

Scientific committees of European Academy of Pediatrics, European Society of Pediatric and Neonatal Intensive Care and the Ethics Review Committee of the Leiden University Medical Center approved study; Ensured anonymity