Abstract

BackgroundAlthough desire to die of varying intensity and permanence is frequent in patients receiving palliative care, uncertainty exists concerning appropriate therapeutic responses to it. To support health professionals in dealing with patients´ potential desire to die, a training program and a semi-structured clinical approach was developed. This study aimed for a revision of and consensus building on the clinical approach to support proactively addressing desire to die and routine exploration of death and dying distress.MethodsWithin a sequential mixed methods design, we invited 16 palliative patients to participate in semi-structured interviews and 377 (inter-)national experts to attend a two-round Delphi process. Interviews were analyzed using qualitative content analysis and an agreement consensus for the Delphi was determined according to predefined criteria.Results11 (69%) patients from different settings participated in face-to-face interviews. As key issues for conversations on desire to die they pointed out the relationship between professionals and patients, the setting and support from external experts, if required. A set of 149 (40%) experts (132/89% from Germany, 17/11% from 9 other countries) evaluated ten domains of the semi-structured clinical approach. There was immediate consensus on nine domains concerning conversation design, suggestions for (self-)reflection, and further recommended action. The one domain in which consensus was not achieved until the second round was “proactively addressing desire to die”.ConclusionsWe have provided the first semi-structured clinical approach to identify and address desire to die and to respond therapeutically – based on evidence, patients’ views and consensus among professional experts.Trial registrationThe study is registered in the German Clinical Trials Register (DRKS00012988; registration date: 27.9.2017) and in the Health Services Research Database (VfD_DEDIPOM_17_003889; registration date: 14.9.2017).

Highlights

  • Desire to die of varying intensity and permanence is frequent in patients receiving palliative care, uncertainty exists concerning appropriate therapeutic responses to it

  • We use the term desire to die in a broad sense including an acceptance of death, a wish for hastened death without requiring any accelerating action [3], a request for assisted dying and suicidal ideation [4]

  • We applied the consolidated criteria for reporting qualitative research (COREQ) [29] and the guidelines for conducting and reporting Delphi Studies (CREDES) in palliative care [30]

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Summary

Introduction

Desire to die of varying intensity and permanence is frequent in patients receiving palliative care, uncertainty exists concerning appropriate therapeutic responses to it. We use the term desire to die in a broad sense including an acceptance of death, a wish for hastened death without requiring any accelerating action [3], a request for assisted dying and suicidal ideation [4]. This understanding of desire to die differs from the international consensus definition of the wish for hastened death [5] and refers to the German palliative care guideline for patients with incurable cancer [6]. Desire to die may be assessed by validated instruments such as the Schedules of Attitudes for Hastened Death (SAHD; primary for research purposes) [8] or the Desire for Death Rating Scale (DDRS; initially developed for clinical interviews) [14]

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