Table 2 Examples of free text comments describing situations that may lead to moral distress

Patient constraints

 • “what do we do with children with AKI who have no financial means, because we could save them?” (R4)

 • “start dialysis for patients who are not able to continue chronic dialysis because of poverty”(R15)

 • “…a child had been on PD for 6 weeks with no improvement. The decision as to stop PD and palliate” (R17)

 • “patient’s family or relatives requesting you to do haemodialysis in terminal cases, cancer etc.” (R24)

Institutional constraints

 • “no resources available” (R1)

 • “I had to stop dialysis despite no recovery because we have no place in chronic dialysis”(R13)

 • “there is no public dialysis in my country. Diagnosis is made very late. I struggle to fight for prevention”(R8)

 • “the dialysis budget is badly used, Corruption ++”(R7)

 • “Often politicians will interfere with our guidelines on provision of dialysis” (R29)

Physician constraints/strategies

 • “when a patient is being managed in another health facility comes to me I find it difficult to decide where my loyalty lies. To the patient to divulge all the info or to the doctor and I hide things under the carpet?” (R2)

 • “the patient has dementia, family finds resources for dialysis with difficulty. What do I do?”(R13)

 • “Our own renal unit have established committee to decide which patients would be offered the RRT. We have entry and even exit criteria for our haemodialysis programme”(R27)

 • “We have regular meetings with decision makers and stakeholders”(R29)

 • “It is a huge challenge to work as a nephrologist in Africa but with international support from organisations like AFRAN etc. lobbying for a lot of services to be implemented in possible” (R13)

 • “I think transplantation is the good therapy to take care end stage of CKD in our countries - then promote that therapy. Develop a program of screen and prevent CKD which can be proposed in Africa” (R11)a