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Heckel M, Herbst FA. Non-kin caregivers of terminally ill people: Contributions, experiences, and needs: A protocol for a mixed-methods study. PLoS One 2024; 19:e0306282. [PMID: 38935665 PMCID: PMC11210750 DOI: 10.1371/journal.pone.0306282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/12/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND The role of non-kin caregivers, such as friends, neighbours, and acquaintances, in providing end-of-life care is significant but often overlooked in research and policy discussions. These caregivers provide extensive support for individuals in end-of-life care, in addition to or instead of family members. However, there is limited evidence in the literature regarding the experiences, burdens, and benefits of non-kin caregivers. AIMS The aim of this research is to examine the role and contributions of non-kin caregivers in end-of-life care. The study intends to uncover their experiences, associated challenges, benefits, and requirements for support. METHODS In order to achieve this objective, a mixed-methods approach will be employed, gathering data through structured questionnaires from approximately 150 non-kin caregivers and in-depth interviews with up to 25 participants. The questionnaires will measure the impact, burden, and benefits of caregiving. The Burden Scale for Family Caregivers, the Benefits of Being a Caregiver Scale, the Family Inventory of Needs, the Positive Mental Health Scale, a Graphic Closeness Scale, and selected items of the Eurofamcare Common Assessment Tool for socio-demographic and caregiving-related data will be used. Quantitative data will be analysed using IBM SPSS Statistics 28 for descriptive analysis and group comparison. The objective of the qualitative in-depth interviews is to obtain a comprehensive picture of the personal experiences, motivations and support needs of members of the non-kin caregivers cohort, who are as heterogeneous as possible in terms of gender, socio-economic status, and facility with the German language. The qualitative data from the interviews will be examined using MAXQDA software, adopting a grounded theory approach for analysis. DISCUSSION This research will develop a comprehensive framework that captures the nuanced experiences of non-kin caregivers at the end of life. The framework will identify areas where support for non-kin caregivers is lacking and where further research is needed. TRIAL REGISTRATION The study was prospectively registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00033889; date of registration: 05 April 2024). The study is searchable under the International Clinical Trials Registry Platform Search Portal of the World Health Organization, under the German Clinical Trials Register number.
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Affiliation(s)
- Maria Heckel
- Department of Palliative Medicine, CCC Erlangen–EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Franziska A. Herbst
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
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Ullrich A, Goldbach S, Hollburg W, Wagener B, Rommel A, Müller M, Kirsch D, Kopplin-Foertsch K, Schulz H, Bokemeyer C, Oechsle K. Specialist palliative care until the very end of life - reports of family caregivers and the multiprofessional team. BMC Palliat Care 2023; 22:153. [PMID: 37814271 PMCID: PMC10563273 DOI: 10.1186/s12904-023-01266-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/20/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Specialist palliative care (SPC) includes care for incurably ill patients and their family caregivers at home or on a palliative care ward until the very end of life. However, in the last days of life, patients can rarely express their needs and little is known about SPC outcomes as reported by multiprofessional SPC teams and family caregivers. METHODS Using the Palliative Care Outcome Scale (POS; Score 0-40), proxy assessments of SPC outcomes in the patient's last 3 days of life were performed by SPC teams and primary family caregivers of three home care and three inpatient services. Additional questions were asked about problems solved 'particularly well' or 'inadequately' (last 7 days), which were content analyzed and quantified. RESULTS Proxy assessments by SPC teams were available in 142 patients (of whom 51% had died at home). Family caregiver assessments exist for a subgroup of 60 of these patients. SPC teams (POS total score: mean 13.8, SD 6.3) reported SPC outcomes slightly better than family caregivers (mean 16.7, SD 6.8). The POS items consistently rated as least affected (= 0) by both, SPC teams and family caregivers, were 'not wasted time' (team 99%/family caregivers 87%), 'information' (84%/47%) and 'support' (53%/31%). Items rated as most affected (= 4) were 'patient anxiety' (31%/51%), 'life not worthwhile' (26%/35%) and 'no self-worth' (19%/30%). Both groups indicated more problems solved 'particularly well' than 'inadequately'; the latter concerned mainly clinically well-known challenges during end-of-life care and family caregiver care. CONCLUSIONS This study shows the range and type of symptoms and other concerns reported in the patient's last days. Starting points for further improvements in family caregiver care and psychosocial and spiritual issues were identified.
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Affiliation(s)
- Anneke Ullrich
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Eppendorf, Hamburg, Germany.
| | - Sven Goldbach
- Specialist outpatient palliative care team 'PalliativPartner Hamburg GbR', Hamburg, Germany
| | - Wiebke Hollburg
- Specialist outpatient palliative care team 'PalliativPartner Hamburg GbR', Hamburg, Germany
| | - Bettina Wagener
- Specialist outpatient palliative care team 'PalliativPartner Hamburg GbR', Hamburg, Germany
| | - Annette Rommel
- Specialist outpatient palliative care team 'Das Palliativteam', Hamburg, Germany
| | - Marten Müller
- Palliative care ward, Asklepios Hospital Rissen, Hamburg, Germany
| | - Denise Kirsch
- Specialist outpatient palliative care team 'PCT Hamburg-West', Hamburg, Germany
| | | | - Holger Schulz
- Department of Medical Psychology, University Medical Center Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Eppendorf, Hamburg, Germany
| | - Karin Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Eppendorf, Hamburg, Germany
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Benichel CR, Meneguin S, Pollo CF, Oliveira MG, de Oliveira C. Psychometric Properties of the Brazilian Version of the Quality of Dying and Death for Adult Family Members of ICU Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5034. [PMID: 36981943 PMCID: PMC10049585 DOI: 10.3390/ijerph20065034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 06/18/2023]
Abstract
Death is a complex, subjective phenomenon that requires an understanding of experiences to be qualified to provide care during the end-of-life process. This study aimed to analyze the psychometric properties of the Portuguese version (Brazil) of the Quality of Dying and Death (QODD) scale on family members of patients who died in adult intensive care units. A methodological study was conducted with 326 family members of patients that died in three ICUs of public hospitals in the state of São Paulo, Brazil. For this study, the QODD 3.2a (25 items and six domains) was administered during the period from December 2020 to March 2022. The analysis was performed using the classic theory of the tests and the goodness of fit of the model was tested using confirmatory factor analysis. We have used Spearman's correlation coefficients between the scores of the overall scale and domains. Cronbach's alpha coefficient and the intraclass correlation coefficient (ICC) were used for the evaluation of internal consistency and temporal stability, respectively. The Horn's parallel analysis indicated two factors that were not confirmed in the exploratory factor analysis. A single factor retained 18 of the initial 25 items and the analysis of the goodness of fit to the unidimensional model resulted in the following: CFI = 0.7545, TLI = 0.690, chi-squared = 767.33, df = 135, RMSEA = 0.121 with 90%CI, and p = 5.04409. The inter-item correlations indicated a predominance of weak correlations among the items of the instrument. The items with the largest number of moderate correlations were questions 13b, 9b, and 10b and a strong correlation was found between questions 15b and 16b. Cronbach's alpha coefficient was 0.8 and the ICC was 0.9. The Quality of Dying and Death-Version 3.2a (intensive therapy) in Brazilian Portuguese has a unidimensional structure and acceptable reliability. However, it did not obtain a good fit to the proposed factorial model.
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Affiliation(s)
- Cariston Rodrigo Benichel
- Department of Nursing, Botucatu Medical School, Paulista State University, São Paulo 18618687, Brazil
| | - Silmara Meneguin
- Department of Nursing, Botucatu Medical School, Paulista State University, São Paulo 18618687, Brazil
| | - Camila Fernandes Pollo
- Department of Nursing, Botucatu Medical School, Paulista State University, São Paulo 18618687, Brazil
| | - Mariele Gobo Oliveira
- Department of Nursing, Botucatu Medical School, Paulista State University, São Paulo 18618687, Brazil
| | - Cesar de Oliveira
- Department of Epidemiology & Public Health, University College London, London WC1E 6BT, UK;
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What do bereaved relatives of cancer patients dying in hospital want to tell us? Analysis of free-text comments from the International Care of the Dying Evaluation (i-CODE) survey: a mixed methods approach. Support Care Cancer 2023; 31:81. [PMID: 36562882 PMCID: PMC9788999 DOI: 10.1007/s00520-022-07490-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE We conducted an international survey of bereaved relatives of cancer patients dying in hospitals in seven countries, with the aim to assess and improve the quality of care. The survey used the i-CODE (International Care of the Dying Evaluation) questionnaire. Here, we report findings from the free-text comments submitted with the questionnaires. We explored for topic areas which would potentially be important for improving the quality of care. Further, we examined who reported free-texts and in what way, to reduce bias without ignoring the function the free-texts may have for those contributing. METHODS We used a combined qualitative-quantitative approach: logistic regression analysis to study the effect of respondents' socio-demographic characteristics on the probability of free-texts contributions and thematic analysis to understand the free-text meaning. The primary survey outcomes, (1) how frequently the dying person was treated with dignity and respect and (2) support for the relative, were related to free-text content. RESULTS In total, 914 questionnaires were submitted; 457/914 (50%) contained free-text comments. We found no socio-demographic differences between the respondents providing free-texts and those who did not. We discovered different types of free-texts ("feedback," "narrative," "self-revelation") containing themes of which "continuity of care," "the one person who can make a difference," and "the importance of being a companion to the dying" represent care dimensions supplementing the questionnaire items. A free-text type of grateful feedback was associated with well perceived support for the relative. CONCLUSION Bereaved relatives used the free-texts to report details related to i-CODE items and to dimensions otherwise not represented. They highlighted the importance of the perceived support from human interaction between staff and the dying patient and themselves; and that more than professional competence alone, personal, meaningful interactions have profound importance.
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Mayland CR, Keetharuth AD, Mukuria C, Haugen DF. Validation of 'Care Of the Dying Evaluation' (CODE TM) within an international study exploring bereaved relatives' perceptions about quality of care in the last days of life. J Pain Symptom Manage 2022; 64:e23-e33. [PMID: 35257928 DOI: 10.1016/j.jpainsymman.2022.02.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 12/01/2022]
Abstract
CONTEXT Assessing quality of care provided during the dying phase using validated tools aids quality assurance and recognizes unmet need. OBJECTIVE To assess construct validity and internal consistency of 'Care Of the Dying Evaluation' (CODETM) within an international context. METHODS Post-bereavement survey (August 2017 to September 2018) using CODETM. Respondents were next-of-kin to adult patients (≥ 18 years old) with cancer who had an 'expected' death within 22 study site hospitals in 7 countries: Argentina, Brazil, Germany, Norway, Poland, United Kingdom, Uruguay. Exploratory and Confirmatory Factor Analysis (EFA and CFA) were conducted, and internal reliability was assessed using Cronbach alpha (α). Known group validity was assessed by ability to discriminate quality of care based in place (Palliative Care Units (PCUs)) and country (Poland, where most deaths were in PCUs) of care. Differences were quantified using effect sizes (ES). RESULTS A 914 CODETM questionnaires completed (54% response rate). 527 (58%) male deceased patients; 610 (67%) next-of-kin female who were most commonly the 'spouse/partner' (411, 45%). EFA identified 4 factors: 'Overall care,' 'Communication and support,' 'Trust, respect and dignity,' and 'Symptom management' with good reliability scores (α = 0.628 - 0.862). CFA confirmed the 4-factor model; these were highly correlated and a bifactor model showed acceptable fit. The ES for quality of care in PCU's was 0.727; ES for Poland was 0.657, supporting the sensitivity of CODETM to detect differences. CONCLUSION Within an international context, good evidence supports the validity and reliability of CODETM for assessing the quality of care provided in the last days of life.
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Affiliation(s)
- Catriona R Mayland
- Yorkshire Cancer Research Senior Clinical Research Fellow and Honorary Consultant in Palliative Medicine (C.R.M.), University of Sheffield, Honorary Clinical Fellow, University of Liverpool, Liverpool, UK.
| | - Anju D Keetharuth
- School of Health and Related Research (A.D.K., C.M.), University of Sheffield, Sheffield, UK
| | - Clara Mukuria
- School of Health and Related Research (A.D.K., C.M.), University of Sheffield, Sheffield, UK
| | - Dagny Faksvåg Haugen
- Regional Centre of Excellence for Palliative Care, Western Norway (D.F.H.), Haukeland University Hospital, and Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
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Bausewein C, Hodiamont F, Berges N, Ullrich A, Gerlach C, Oechsle K, Pauli B, Weber J, Stiel S, Schneider N, Krumm N, Rolke R, Gebel C, Jansky M, Nauck F, Wedding U, van Oorschot B, Roch C, Werner L, Fischer M, Schallenburger M, Reuters MC, Schwartz J, Neukirchen M, Gülay A, Maus K, Jaspers B, Radbruch L, Heckel M, Klinger I, Ostgathe C, Kriesen U, Junghanß C, Lehmann E, Gesell D, Gauder S, Boehlke C, Becker G, Pralong A, Strupp J, Leisse C, Schloesser K, Voltz R, Jung N, Simon ST. National strategy for palliative care of severely ill and dying people and their relatives in pandemics (PallPan) in Germany - study protocol of a mixed-methods project. BMC Palliat Care 2022; 21:10. [PMID: 35027041 PMCID: PMC8756412 DOI: 10.1186/s12904-021-00898-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 12/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background In the SARS-CoV-2 pandemic, general and specialist Palliative Care (PC) plays an essential role in health care, contributing to symptom control, psycho-social support, and providing support in complex decision making. Numbers of COVID-19 related deaths have recently increased demanding more palliative care input. Also, the pandemic impacts on palliative care for non-COVID-19 patients. Strategies on the care for seriously ill and dying people in pandemic times are lacking. Therefore, the program ‘Palliative care in Pandemics’ (PallPan) aims to develop and consent a national pandemic plan for the care of seriously ill and dying adults and their informal carers in pandemics including (a) guidance for generalist and specialist palliative care of patients with and without SARS-CoV-2 infections on the micro, meso and macro level, (b) collection and development of information material for an online platform, and (c) identification of variables and research questions on palliative care in pandemics for the national pandemic cohort network (NAPKON). Methods Mixed-methods project including ten work packages conducting (online) surveys and qualitative interviews to explore and describe i) experiences and burden of patients (with/without SARS-CoV-2 infection) and their relatives, ii) experiences, challenges and potential solutions of health care professionals, stakeholders and decision makers during the SARS-CoV-2 pandemic. The work package results inform the development of a consensus-based guidance. In addition, best practice examples and relevant literature will be collected and variables for data collection identified. Discussion For a future “pandemic preparedness” national and international recommendations and concepts for the care of severely ill and dying people are necessary considering both generalist and specialist palliative care in the home care and inpatient setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00898-w.
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Haugen DF, Hufthammer KO, Gerlach C, Sigurdardottir K, Hansen MIT, Ting G, Tripodoro VA, Goldraij G, Yanneo EG, Leppert W, Wolszczak K, Zambon L, Passarini JN, Saad IAB, Weber M, Ellershaw J, Mayland CR. Good Quality Care for Cancer Patients Dying in Hospitals, but Information Needs Unmet: Bereaved Relatives' Survey within Seven Countries. Oncologist 2021; 26:e1273-e1284. [PMID: 34060705 PMCID: PMC8265351 DOI: 10.1002/onco.13837] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/13/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Recognized disparities in quality of end-of-life care exist. Our aim was to assess the quality of care for patients dying from cancer, as perceived by bereaved relatives, within hospitals in seven European and South American countries. MATERIALS AND METHODS A postbereavement survey was conducted by post, interview, or via tablet in Argentina, Brazil, Uruguay, U.K., Germany, Norway, and Poland. Next of kin to cancer patients were asked to complete the international version of the Care Of the Dying Evaluation (i-CODE) questionnaire 6-8 weeks postbereavement. Primary outcomes were (a) how frequently the deceased patient was treated with dignity and respect, and (b) how well the family member was supported in the patient's last days of life. RESULTS Of 1,683 potential participants, 914 i-CODE questionnaires were completed (response rate, 54%). Approximately 94% reported the doctors treated their family member with dignity and respect "always" or "most of the time"; similar responses were given about nursing staff (94%). Additionally, 89% of participants reported they were adequately supported; this was more likely if the patient died on a specialist palliative care unit (odds ratio, 6.3; 95% confidence interval, 2.3-17.8). Although 87% of participants were told their relative was likely to die, only 63% were informed about what to expect during the dying phase. CONCLUSION This is the first study assessing quality of care for dying cancer patients from the bereaved relatives' perspective across several countries on two continents. Our findings suggest many elements of good care were practiced but improvement in communication with relatives of imminently dying patients is needed. (ClinicalTrials.gov Identifier: NCT03566732). IMPLICATIONS FOR PRACTICE Previous studies have shown that bereaved relatives' views represent a valid way to assess care for dying patients in the last days of their life. The Care Of the Dying Evaluation questionnaire is a suitable tool for quality improvement work to help determine areas where care is perceived well and areas where care is perceived as lacking. Health care professionals need to sustain high quality communication into the last phase of the cancer trajectory. In particular, discussions about what to expect when someone is dying and the provision of hydration in the last days of life represent key areas for improvement.
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Affiliation(s)
- Dagny Faksvåg Haugen
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway.,Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | | | - Christina Gerlach
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - Katrin Sigurdardottir
- Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | - Marit Irene Tuen Hansen
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway.,Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | - Grace Ting
- Academic Palliative and End-of-Life Care Department, Royal Liverpool University Hospital, Liverpool
| | - Vilma Adriana Tripodoro
- Pallium Latinoamérica, Buenos Aires, Argentina.,Instituto de Investigaciones Médicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
| | - Gabriel Goldraij
- Hospital Privado Universitario de Córdoba, Córdoba, Argentina.,Instituto Universitario de Ciencias Biomédicas de Córdoba, Argentina
| | | | - Wojciech Leppert
- Department of Palliative Medicine, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland.,Department of Palliative Medicine, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Lair Zambon
- Department of Internal Medicine, Campinas State University, Campinas, Brazil
| | | | | | - Martin Weber
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - John Ellershaw
- Academic Palliative and End-of-Life Care Department, Royal Liverpool University Hospital, Liverpool.,Palliative Care Unit, University of Liverpool, Liverpool
| | - Catriona Rachel Mayland
- Academic Palliative and End-of-Life Care Department, Royal Liverpool University Hospital, Liverpool.,Palliative Care Unit, University of Liverpool, Liverpool.,Department of Oncology and Metabolism, University of Sheffield, Sheffield
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Kurkowski S, Radon J, Vogt AR, Weber M, Stiel S, Ostgathe C, Heckel M. Hospital end-of-life care: families' free-text notes. BMJ Support Palliat Care 2020:bmjspcare-2020-00239. [PMID: 33243824 DOI: 10.1136/bmjspcare-2020-00239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/27/2020] [Accepted: 11/14/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Palliative care strives to improve quality of life for patients with incurable diseases. This approach includes adequate support of the patients' loved ones. Consequently, loved ones have personal experiences of providing end-of-life care for their next. This is a resource for information and may help to investigate the loved ones' perspectives on need for improvements. AIM To identify further quality aspects considered important by loved ones to improve the quality of care at the end of life as an addition to quantitative results from the Care of the Dying Evaluation for the German-speaking area (CODE-GER) questionnaire. DESIGN Within the validation study of the questionnaire 'Care of the Dying Evaluation' (CODETM) GER, loved ones were asked to comment (free text) in parallel on each item of the CODE-GER. These free-text notes were analysed with the qualitative content analysis method by Philipp Mayring. SETTING/PARTICIPANTS Loved ones of patients (n=237), who had died an expected death in two university hospitals (palliative and non-palliative care units) during the period from April 2016 to March 2017. RESULTS 993 relevant paragraphs were extracted out of 1261 free-text notes. For loved ones, important aspects of quality of care are information/communication, respect of the patient's and/or loved one's will, involvement in decision-making at the end of life (patient's volition) and having the possibility to say goodbye. CONCLUSIONS It is important for loved ones to be taken seriously in their sorrows, to be informed, that the caregivers respect the patients' will and to be emotionally supported. TRIAL REGISTRATION NUMBER This study was registered at the German Clinical Trials Register (DRKS00013916).
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Affiliation(s)
- Sandra Kurkowski
- Department of Palliative Medicine, Friedrich Alexander University Erlangen Nuremberg Faculty of Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Johannes Radon
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, Johannes Gutenberg University, Mainz, Germany
| | - Annika R Vogt
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, Johannes Gutenberg University, Mainz, Germany
| | - Martin Weber
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, Johannes Gutenberg University, Mainz, Germany
| | - Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Hanover, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Friedrich Alexander University Erlangen Nuremberg Faculty of Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine, Friedrich Alexander University Erlangen Nuremberg Faculty of Medicine, University Hospital Erlangen, Erlangen, Germany
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