Comfort and Conflict in Neonatal End-of-Life Care: A Mixed-Methods Study

Objective To evaluate neonatal providers’ comfort with end-of-life care (EOLC) and perceived palliative care (PC) resources using a two-domain analytic framework. Study Design: Mixed-methods survey of nurses, physicians, advanced practice providers, and trainees in Level III and Level IV NICUs. Items were grouped into two domains: (1) comfort with participation in EOLC and (2) perceived PC resources and support. Multivariable hierarchical linear regression identified independent predictors of each domain, and free-text responses underwent inductive thematic analysis. Results Eighty-three clinicians responded. EOLC experience (p < 0.001) and prior EOLC training (p = 0.037) predicted higher comfort, whereas trainee status predicted lower comfort (p = 0.012) (R²=0.353). For perceived PC resources, provider role and NICU site were associated with higher scores (R²=0.130). Qualitative themes highlighted competency gaps, personal and interpersonal conflicts, variable team culture, and structural constraints. Conclusions Provider comfort in neonatal EOLC reflects experiential, educational, and system-level factors. Interventions must combine training with cultural and structural investment.