Between T1 and T2, four patients were accompanied during VSED. Demographic data is summarized in Table 1. At each measurement time, 22 team members took part in the study (response rate 41.5%). At T2, 12 team members already participated in the first measurement (54.5%). There were no statistically significant differences when analysing the results of the 12 participants who took part at both points in time.

At both points in time, nurses were represented most, followed by physicians. Few members of other professions participated.

The participants assessed the symptoms causing the greatest burden on patients (multiple answers possible). In total, the 22 participants gave 49 answers at T1 and 39 at T2.

At T1, 18/22 participants (81.8%) anticipated the observed symptoms to occur before VSED was initiated whereas at T2, 90.9% (20/22) participants anticipated them. Team members perceived the symptom complex of psychological distress, anxiety, and agitation to be the most burdensome symptoms for patients (T1: 28/49, 57.1%; T2: 33/59, 55.9%). Thirst was the second most observed symptom by team members (T1: 17/49, 34.7%, T2: 19/59, 32.2%). Symptoms that were only rarely observed were hunger, dyspnea, and pain (T1: 4/49, 8.2%, T2: 7/59, 11.9%).

During the accompaniment, team members experienced stress while trying to treat symptoms adequately. Throughout all professions, psychological distress, anxiety and agitation were perceived as most difficult to treat at T1 (10/22, 45.4%), followed by thirst (5/22, 22.7%). Seven team members (31.8%) did not experience any symptoms as burdensome on themselves. At T2, the most burdensome symptom that team members had to deal with was thirst (14/22, 63.3%) followed by psychological distress and agitation (8/22, 63.7%).

A subgroup analysis was performed to compare nurses and physicians. At T1, 5/9 (55.5%) nurses felt psychological distress, agitation, and anxiety to be the most challenging symptoms to deal with, whereas physicians (4/7, 57.1%) mostly perceived no observed symptom as burdensome (Exact Fisher’s Test: p = 0.5). At T2, 10/13 nurses (76.9%) felt that thirst was a challenging symptom to deal with, physicians felt both thirst (3/6, 50.0%) and psychological distress (3/6, 50.0%) affecting themselves (Exact Fisher’s test: p = 0.3). Professions and their experience of burdensome symptoms were statistically not significantly related.

Overall, at T2, participants felt that the team was burdened while accompanying patients during VSED (11/6, 50.0%; neutral: 6/22, 27.3%; disagree: 5/22, 22.7%), even though this was not further distinguished. In general, participants felt that the patients were granted a death with dignity (T1: 22/22, 100.0%; T2: 21/22, 95.5%).

In general, participants indicated (at T2) that VSED was very relevant to their work (21/22, 95.5%). Most participants stated that VSED was not contradictory to the institution’s culture (18/22, 81.8%) and that VSED was compatible with their world view or religion (18/22, 81.8%). Figure 1 shows the ethical classification of VSED at T2. Subgroup analysis for physicians and nurses showed no statistically significant relation between profession and classification (p = 0.2).

Ethical classification of voluntarily stopping of eating and drinking (VSED). Most team members perceive VSED to be “something else”/ a category of its own kind

Figure 2 shows the results regarding the moral perception and changes of attitude in team members throughout ethical counselling, case supervisions, team meetings and accompaniments in general. Overall, there were only small differences between T1 to T2. At T2, the accompaniment in general gained the highest mean value in regard to change of attitude (T1: SD 1.10; T2: SD 1.31). Overall, the accompaniment of patients was not perceived as morally burdensome (T1: SD 1.01; T2: SD 1.26). Mann-Whitney U test showed no statistical significance in the perceptions between T1 and T2. The results are shown in Table 2.

Moral perception and change of attitude (mean values). 1: I have moral doubts regarding VSED; 2: I would generally accept to accompany patients during VSED; 3: The ethical counselling changed my attitude towards VSED; 4: The case supervision changed my attitude towards VSED; 5: The multi-professional team meeting changed my attitude towards VSED; 6: The accompaniment changed my attitude towards VSED; 7: During VSED, professionals are morally burdened

Figure 3 shows the results of the study participants’ assessment of coping strategies for both T1 and T2. In general, at T1, agreement was higher than at T2, especially regarding the importance of psychiatric assessment beforehand (86.4% versus 54.5%). In contrast, 17/22 (77.3%) participants stated that it is important to determine the patients’ ability to judge the situation at T2. Furthermore, ethical case discussions were regarded more important at T1 than they were at T2 (85.7% versus 63.6%). Only item 2 showed a statistically significant relation (p=0.045).

Evaluation of coping strategies (%, * = p < 0.05). 1: The internal team discussion offered enough space and safety to discuss uncertainties and worries in regards to a possible accompaniment of VSED patients. 2: The specialist psychiatric assessment of the patients’ ability to consent helped me in accepting the patients’ wish to hasten death. 3: After the ethical case discussions, I felt safer in accompanying the patients during VSED. 4: In general, ethical case discussions should take place before deciding on accompanying patients during VSED. 5: The case supervision helped me in coping with the experiences made during the process of VSED