Table 5 Themes, sub-themes and representative quotations from qualitative analysis of 6 physicians interviews

 Communicating the end of active therapy

“… Trying guide the patients through small steps toward their real situation [the end of curative treatments] is a sort of ‘art of the relationship’, to build through small steps” (Ph 2)

“When you comes to this point [the end of curative treatments] there is a difficulty in transferring this information to the patient.. This conversation should be anticipated much earlier and not just when you stop the treatment” (ph 3)

 Talking about prognosis

“Telling to a patient the prognosis ... There is always something to do but, from that precise moment, you start to lie ... Obviously, I can’t say that there are four weeks of survival left!” (Ph 1)

“Sometimes there is a sort of omission in communicating a poor prognosis to the hematological patient. This step can really missing …” (Ph 3)

“Communicating the prognosis to a patient you have known for a long time. We always tend to show the glass half full …” (Ph 4)

 Handling interference from relatives

“There are family members who ‘overturn’ the suffering of their loved one not to the disease but the work of health professionals” (ph 1)

“Situations in which there is an oppositive behavior or even an aggression by family members, and these become the cases that are most difficult to manage” (Ph 2)

“Families who do not give up, who cannot cut this sort of umbilical cord that unites them with their loved one …” (Ph 3)

“The relative who continues to search and ask for treatments even when things are over” (Ph 5)

 Experience

“I have to say that age and experience help me, so it is easy for me knowing both advanced cancer patient’s previous history and how that history will continue in the future. Therefore, I can also ‘touch’ the sensitive points of what that patient would like to be told, to know …” (Ph 1)

“It seems to me that I have absorbed some communication techniques ... I would not seem presumptuous” (Ph 2)

“Our thirty years of experience, in my opinion, is enough!” (Ph 6)

 Collaboration with colleagues

“In some situations, your resources are not enough. Then you ask for help to other specialists who will be the psychologist, or the palliative care physician, or your collaborators and colleagues” (Ph 1)

“I learned communication from briefings, structured meetings, meetings with colleagues on more complex cases” (Ph 3)

“The confrontation with our team ... with the psychologist” (Ph 4)

“We improved in keeping a common line when we communicate with patients, and this helps” (Ph 5)

 Personal attitude

“Patients and relatives confirm that I can establish a fairly empathic relationship with them. This probably derives from my previous training, from my personality, from my capacity of getting understandably and easily certain speeches” (Ph 2)

“Surely there is an attitude allowing me to easily establish relationship with patients ... an ability to listen to them ... an attitude in understanding them... adaptability ... sensitivity ...” (Ph 1)

 Becoming more empathetic

“Knowing how to leave a little hope even in the face of bad news” (Ph 6)

“Knowing how to give more consolation when the epilogue cannot be favorable” (Ph 1)

 Improving communication with colleagues

“Knowing how to listen more my colleagues, other operators. The clinical eye of the nurse for example” (Ph 3)

“Improving communication between operators” (Ph 5)

 Experiencing less stress

“Approaching myself in a less stressful way in the face of these bad communications that we have to deliver every day” (Ph 4)