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

ObjectiveTo evaluate neonatal providers' comfort with end-of-life care (EOLC) and perceived palliative care (PC) resources using a two-domain analytic framework.Study DesignTwo-site, mixed-methods survey of nurses, neonatologists, pediatric hospitalists, advanced practice providers, and trainees in a Level III and Level IV NICU. 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.ResultsEighty-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.ConclusionsProvider comfort in neonatal EOLC reflects experiential, educational, and system-level factors. Interventions must combine training with cultural and structural investment.