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Background Compassion has been identified as important for therapeutic relationships in clinical medicine however there have been few empirical studies looking at how compassion is expressed different contexts. The purpose of this study was to explore how context impacts perceptions and expressions of compassion in the intensive care unit and in palliative care. Methods This was an inductive qualitative study that employed sensitizing concepts from activity theory, realist inquiry, phenomenology and autoethnography. Clinicians working in intensive care units and palliative care services wrote guided field notes on their observations and experiences of how suffering and compassion were expressed in these settings. Data were analyzed using constructivist grounded theory. Results Fifty-eight field notes were generated, along with transcripts from three focus groups. Clinicians conceptualized, observed, and expressed compassion in different ways within different contexts. Patterns of compassion identified were relational, dispositional, activity-focused, and situational. A pattern language of compassion in healthcare was developed based on these findings. Conclusions Recognizing compassion as shifting patterns of diverse attitudes, behaviours, and relationships raises numerous questions as to how compassion can be developed, supported and recognized in different clinical settings. Electronic supplementary material The online version of this article (10.1186/s12904-019-0402-0) contains supplementary material, which is available to authorized users.