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Theißen T, Ullrich A, Oechsle K, Wikert J, Bokemeyer C, Schieferdecker A. "Being an informal caregiver - strengthening resources": mixed methods evaluation of a psychoeducational intervention supporting informal caregivers in palliative care. BMC Palliat Care 2024; 23:95. [PMID: 38600500 PMCID: PMC11007958 DOI: 10.1186/s12904-024-01428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/04/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Informal caregivers are key support for patients with progressive incurable diseases. However, their own needs often remain unmet. Therefore, we developed, manualised and implemented the intervention "Being an informal caregiver - strengthening resources" aiming to support and empower informal caregivers by addressing relevant information-related, physical, psychological and social needs. METHODS In this pilot study, we evaluated the acceptance and experiences with this psychoeducational intervention. The study was conducted over two years (2019-2021). Informal caregivers were recruited from the University Medical Centre Hamburg-Eppendorf and the metropolitan region of Hamburg, Germany. The intervention was aimed at adult persons who identified themselves as an informal caregiver to an adult patient with a progressive incurable cancer and non-cancer disease. For the evaluation we used a mixed methods approach, combining a longitudinal questionnaire survey (pre-intervention, after each module, 3-months follow-up) and semi-structured interviews post-intervention. Quantitative data were analysed using descriptive statistics and a paired t-Test, interviews were analysed based on the qualitative content analysis according to Mayring. Results were triangulated using a convergent triangulation design. RESULTS Of 31 informal caregivers who received the intervention, 25 returned the follow-up questionnaire and 20 informal caregivers were interviewed. Triangulated results showed a high satisfaction with the implementation of the intervention. Of a broad range of subjective benefits, gaining knowledge, self-awareness and self-efficacy were most apparent. Informal caregivers reported improved preparedness, awareness of own needs as well as confidence regarding handling own emotions and interacting with the ill person. However, implementing the learned skills into daily life can be challenging due to internal and external factors. Motivations and challenges for participating as well as potential for improvement were identified. CONCLUSIONS This pilot study showed an overall positive evaluation and several subjective benefits of the psychoeducational intervention "Being an informal caregiver - strengthening resources". Further research is needed to measure the efficacy of this intervention on informal caregivers' outcomes. Therefore, a multicentre randomized prospective study is planned.
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Affiliation(s)
- Tabea Theißen
- Palliative Care Unit, Department of Oncology, Haematology and BMT, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Anneke Ullrich
- Palliative Care Unit, Department of Oncology, Haematology and BMT, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karin Oechsle
- Palliative Care Unit, Department of Oncology, Haematology and BMT, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Julia Wikert
- Palliative Care Unit, Department of Oncology, Haematology and BMT, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
| | - Carsten Bokemeyer
- Palliative Care Unit, Department of Oncology, Haematology and BMT, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Aneta Schieferdecker
- Palliative Care Unit, Department of Oncology, Haematology and BMT, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Wikert J, Bausewein C, Hodiamont F. More than the sum of its parts-A constructivist grounded-theory study on specialist palliative care during crises like the COVID pandemic. Palliat Med 2024; 38:331-342. [PMID: 38226480 PMCID: PMC10955785 DOI: 10.1177/02692163231222771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND The COVID pandemic is an example of a crisis challenging healthcare systems worldwide. The impact of the pandemic on providing high-quality palliative care calls for a deeper understanding of specialist services during crises. This is essential in preparation for further crises. AIM To develop a conceptual understanding of the impact of the pandemic on specialist palliative care as an example for arising future crises. DESIGN Qualitative interview study across Germany, following a constructivist grounded theory methodology. SETTING/PARTICIPANTS Eleven semi-structured interviews with experts with overarching knowledge of structures and processes in specialist palliative care between 05-07/2020 and between 02-06/2021, 23 semi-structured interviews with healthcare professionals working in a specialist palliative care setting. RESULTS The complex system of palliative care provision during crises has properties that cannot be understood as separated parts of the care process. The pandemic led to unique structural and processual challenges characterized by interconnectedness, uncertainty, dynamic, underlying dilemmas, and unclear long-term goal. In response to the pandemic, teams experienced different phases, which enhanced adaption, innovation, and progress within complex care situations. Creative strategy approaches and dynamic responsiveness facilitated innovative development and could lead to long-lasting improvement within services. Availability of information, transparent communication, comprehensible instructions, participation in decision-making, and search for solutions contributed to teams' proactive development throughout the pandemic. CONCLUSION Addressing the complex problems in specialist palliative care caused by crises requires system thinking and a learning mindset. This can facilitate teams to overcome the crisis and move forward rather than bounce back to normal.
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Affiliation(s)
- Julia Wikert
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
| | - Farina Hodiamont
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
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Gesell D, Hodiamont F, Wikert J, Lehmann-Emele E, Bausewein C, Nauck F, Jansky M. Symptom and problem clusters in German specialist palliative home care - a factor analysis of non-oncological and oncological patients' symptom burden. BMC Palliat Care 2023; 22:183. [PMID: 37978356 PMCID: PMC10655459 DOI: 10.1186/s12904-023-01296-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Specialist palliative home care (SPHC) aims to maintain and improve patients' quality of life in the community setting. Symptom burden may differ between oncological and non-oncological patients. However, little is known about diagnosis-related differences of SPHC patients. This study aims to describe the prevalence of physical symptom burden and psychosocial problems of adult patients in SPHC, and to evaluate diagnosis-related symptom clusters. METHODS Secondary analysis of data from a prospective, cross-sectional, multi-centre study on complexity of patients, registered at the German Register for Clinical Studies (DRKS trial registration number: DRKS00020517, 12/10/2020). Descriptive statistics on physical symptom burden and psychosocial problems at the beginning of care episodes. Exploratory and confirmatory factor analyses to identify symptom and problem clusters. RESULTS Seven hundred seventy-eight episodes from nine SPHC teams were included, average age was 75 years, mean duration of episode 18.6 days (SD 19.4). 212/778 (27.2%) had a non-oncological diagnosis. Main burden in non-oncological episodes was due to poor mobility (194/211; 91.9%) with significant diagnosis-related differences (χ² = 8.145, df = 1, p = .004; oncological: 472/562; 84.0%), and due to weakness (522/565; 92.4%) in oncological episodes. Two symptom clusters (psychosocial and physical) for non-oncological and three clusters (psychosocial, physical and communicational/practical) for oncological groups were identified. More patients in the non-oncological group compared to the oncological group showed at least one symptom cluster (83/212; 39.2% vs. 172/566; 30.4%). CONCLUSION Patients with non-oncological diseases had shorter episode durations and were more affected by symptom clusters, whereas patients with oncological diseases showed an additional communicational/practical cluster. Our findings indicate the high relevance of care planning as an important part of SPHC to facilitate anticipatory symptom control in both groups.
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Affiliation(s)
- Daniela Gesell
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Farina Hodiamont
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Julia Wikert
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Eva Lehmann-Emele
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Maximiliane Jansky
- Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
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Mäurer M, Staudacher J, Meyer R, Mäurer I, Lazaridis L, Müther M, Huber T, Sommer NP, Fleischmann DF, Käsmann L, Ziegler S, Kropf-Sanchen C, Wikert J, Pietzner K, Holzgreve A, Nestler T, Siech C, Sturm MJ, Sulzer S, Heinrich K, Stahler A. Importance of interdisciplinarity in modern oncology: results of a national intergroup survey of the Young Oncologists United (YOU). J Cancer Res Clin Oncol 2023; 149:10075-10084. [PMID: 37261525 PMCID: PMC10423150 DOI: 10.1007/s00432-023-04937-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Modern, personalized treatment concepts in oncology require an interdisciplinary and multiprofessional collaboration. In addition to its relevance in patient care, interdisciplinary collaboration is also becoming increasingly important in clinical research as well as medical education and resident training in oncology. METHODS Between November 2021 and March 2022, an online survey was conducted among German early career research groups, represented by Young Oncologists United (YOU). The aim was to identify the status and need for interdisciplinarity at clinic, educational, and research levels. RESULTS A total of 294 participants completed the questionnaire in full. 90.7% of the respondents fully or predominantly agreed with the statement that interdisciplinary work plays a major role in their daily clinical work. 78.9% wished for more interdisciplinary collaboration. Of the 49.7% of participants who have never participated in an interdisciplinary research project, 80.1% said they would like to participate in such a study project in the future. Lack of time resources, too much organizational effort, and possible political conflicts between institutions were identified as factors that make practical implementation difficult. 74.1% declared their willingness to become active in an oncology early career research group. CONCLUSION Interdisciplinary collaboration has become increasingly important in oncology. Networks that span different disciplines could help to promote interdisciplinary research projects among young scientists and improve exchange in professional practice and education with the implication of improved patient care.
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Affiliation(s)
- Matthias Mäurer
- Department of Radiotherapy and Radiation Oncology, University Hospital Jena, Jena, Germany.
| | - Jonas Staudacher
- Department of Gastroenterology, Rheumatology and Infectiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Meyer
- Institute of Human Genetics and Genomic Medicine, University Hospital Aachen, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, University Hospital Aachen, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Bonn, Germany
| | - Irina Mäurer
- Department of Neurology, Neurooncology Center, University Hospital Jena, Jena, Germany
| | - Lazaros Lazaridis
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Division of Clinical Neurooncology, University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Michael Müther
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Tobias Huber
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Nils P Sommer
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Daniel F Fleischmann
- Clinic and Polyclinic for Radiotherapy and Radiooncology, LMU Clinic Munich, LMU Munich, Munich, Germany
| | - Lukas Käsmann
- Clinic and Polyclinic for Radiotherapy and Radiooncology, LMU Clinic Munich, LMU Munich, Munich, Germany
| | - Sonia Ziegler
- Clinic and Polyclinic for Radiation Therapy and Radiooncology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Julia Wikert
- Clinic and Polyclinic for Palliative Medicine, LMU Klinikum München, Munich, Germany
| | - Klaus Pietzner
- Department of Gynecology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Adrien Holzgreve
- Clinic and Polyclinic for Nuclear Medicine, University Hospital Munich, LMU Munich, Munich, Germany
| | - Tim Nestler
- Clinic for Urology, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
| | - Carolin Siech
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Max-Johann Sturm
- Department of Radiotherapy and Radiation Oncology, University Hospital Jena, Jena, Germany
| | - Sabrina Sulzer
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
| | - Kathrin Heinrich
- Medical Clinic and Polyclinic III, University Hospital Munich, LMU Munich, Munich, Germany
| | - Arndt Stahler
- Charité University Medicine, Medical Clinic m. S. Hematology, Oncology and Tumor Immunology, Berlin, Germany
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Bronsema A, Theißen T, Oechsle K, Wikert J, Escherich G, Rutkowski S, Bokemeyer C, Ullrich A. Looking back: Identifying supportive care and unmet needs of parents of children receiving specialist paediatric palliative care from the bereavement perspective. Palliat Care 2022; 21:87. [PMID: 35610720 PMCID: PMC9131617 DOI: 10.1186/s12904-022-00971-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study examined care needs and utilisation of psychosocial support services among parents of children who had received specialist paediatric palliative care, as well as the relationship between need fulfilment and grief. Possible differences between parents of children who died of cancer versus a non-cancer disease were explored. METHODS This exploratory study, conducted in two specialist paediatric palliative care facilities, included parents who had lost a child within a period of 0.5 to 8 years before this investigation. From the bereavement perspective, parents reported their needs during paediatric palliative care using the Family Inventory of Needs - Peadiatric II (FIN-PED II). Utilisation of psychosocial support services during paediatric palliative care and after the child's death, as well as potential barriers to accessing services were assessed. Grief symptoms were measured using the Inventory of Complicated Grief - German Version (ICG-D). RESULTS Overall, 56 of 157 approached parents participated in the study. Mean time interval after the child's death was 3.2 years. Of the 17 FIN-PED II needs, 13 needs were reported to be very/extremely important to more than 75% of the parents each. Highest ranked needs related to asking questions at any time (100%), sincere care for the child (100%), and information about changes in the child's condition (98%). The highest ranked unmet needs related to hope (61%), interactions with siblings (41-42%), and trust in the health care system (39%). Comparisons showed no significant differences between parents whose child died of cancer (n = 18) versus a non-cancer disease (n = 38). During paediatric palliative care, 61% of the parents had accessed at least one psychosocial support service and 84% had done so after the child's death. The most prominent barriers for accessing services were sufficient informal support (38%), no subjective need (23%), and lack of time (20%). Overall, 52% of the parents showed noticeable symptoms for complicated grief (ICG-D > 25). A higher level of grief symptoms significantly correlated with a lower fulfilment of the need to say goodbye to the child (p = .042) with a medium correlational effect. CONCLUSIONS Our findings may help to guide health care professionals in their assessment of parental needs and provision of support to parents during paediatric palliative care.
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Affiliation(s)
- Annika Bronsema
- Clinic of Paediatric Haematology and Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Tabea Theißen
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karin Oechsle
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Wikert
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Palliative Medicine, University Hospital LMU, Munich, Germany
| | - Gabriele Escherich
- Clinic of Paediatric Haematology and Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Stefan Rutkowski
- Clinic of Paediatric Haematology and Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Carsten Bokemeyer
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anneke Ullrich
- Palliative Care Unit, Department of Oncology, Hematology and BMT, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Wikert J, Gesell D, Bausewein C, Jansky M, Nauck F, Kranz S, Hodiamont F. Specialist palliative care classification: typology development. BMJ Support Palliat Care 2022:bmjspcare-2021-003435. [PMID: 35135807 DOI: 10.1136/bmjspcare-2021-003435] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The heterogeneity of specialist palliative care services requires a classification to enable a clear description and comparison. In Germany, specialist palliative care is provided by palliative care units, palliative care advisory teams in hospitals and palliative home care teams. The differentiation between the three care settings can serve as a first level of classification. However, due to profound variations in regulatory structures and financing systems, services within each setting are heterogeneous and characteristics remain unclear, which impedes quality management. Further characteristics of specialist palliative care models need to be considered to allow for differentiation. Thus, services should be described on a polyhierarchical basis, such as a typology, representing relevant characteristics. We aimed at the development of a comprehensive classification to facilitate the description and differentiation of specialist palliative care models. METHODS Qualitative study including the development of a literature based, preliminary list of structural and processual characteristics, expert interviews and focus groups. Eleven interviews from May to June 2020 and two focus groups, with seven and nine participants each, in January 2021. RESULTS Several structure and process characteristics were identified as suitable features for the specification of specialist palliative care in Germany. A classification in form of a typology including relevant characteristics has been developed. CONCLUSIONS The advanced typology refines the existing level of differentiation within specialist palliative care services in Germany and paves the way for an improved understanding of services. This deeper insight into structure and process characteristics of specialist palliative care is necessary internationally.
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Affiliation(s)
- Julia Wikert
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
| | - Daniela Gesell
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
| | - Maximiliane Jansky
- Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, University Medical Center Goettingen, Goettingen, Germany
| | - Steven Kranz
- German Association for Palliative Medicine, Berlin, Germany
| | - Farina Hodiamont
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
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Hodiamont F, Schatz C, Gesell D, Leidl R, Boulesteix AL, Nauck F, Wikert J, Jansky M, Kranz S, Bausewein C. COMPANION: development of a patient-centred complexity and casemix classification for adult palliative care patients based on needs and resource use - a protocol for a cross-sectional multi-centre study. BMC Palliat Care 2022; 21:18. [PMID: 35120502 PMCID: PMC8814797 DOI: 10.1186/s12904-021-00897-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 12/17/2021] [Indexed: 12/03/2022] Open
Abstract
Background A casemix classification based on patients’ needs can serve to better describe the patient group in palliative care and thus help to develop adequate future care structures and enable national benchmarking and quality control. However, in Germany, there is no such an evidence-based system to differentiate the complexity of patients’ needs in palliative care. Therefore, the study aims to develop a patient-oriented, nationally applicable complexity and casemix classification for adult palliative care patients in Germany. Methods COMPANION is a mixed-methods study with data derived from three subprojects. Subproject 1: Prospective, cross-sectional multi-centre study collecting data on patients’ needs which reflect the complexity of the respective patient situation, as well as data on resources that are required to meet these needs in specialist palliative care units, palliative care advisory teams, and specialist palliative home care. Subproject 2: Qualitative study including the development of a literature-based preliminary list of characteristics, expert interviews, and a focus group to develop a taxonomy for specialist palliative care models. Subproject 3: Multi-centre costing study based on resource data from subproject 1 and data of study centres. Data and results from the three subprojects will inform each other and form the basis for the development of the casemix classification. Ultimately, the casemix classification will be developed by applying Classification and Regression Tree (CART) analyses using patient and complexity data from subproject 1 and patient-related cost data from subproject 3. Discussion This is the first multi-centre costing study that integrates the structure and process characteristics of different palliative care settings in Germany with individual patient care. The mixed methods design and variety of included data allow for the development of a casemix classification that reflect on the complexity of the research subject. The consecutive inclusion of all patients cared for in participating study centres within the time of data collection allows for a comprehensive description of palliative care patients and their needs. A limiting factor is that data will be collected at least partly during the COVID-19 pandemic and potential impact of the pandemic on health care and the research topic cannot be excluded. Trial registration German Register for Clinical Studies trial registration number: DRKS00020517.
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Affiliation(s)
- Farina Hodiamont
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany.
| | - Caroline Schatz
- Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Munich, Germany.,Ludwig-Maximilians-Universität München, LMU Munich School of Management, Institute of Health Economics and Health Care Management, Munich, Germany
| | - Daniela Gesell
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
| | - Reiner Leidl
- Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Munich, Germany.,Ludwig-Maximilians-Universität München, LMU Munich School of Management, Institute of Health Economics and Health Care Management, Munich, Germany
| | - Anne-Laure Boulesteix
- Ludwig-Maximilians-Universität München, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), Munich, Germany
| | - Friedemann Nauck
- Clinic for Palliative Medicine, University Medical Center, Göttingen, Germany
| | - Julia Wikert
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
| | - Maximiliane Jansky
- Clinic for Palliative Medicine, University Medical Center, Göttingen, Germany
| | - Steven Kranz
- German Association for Palliative Medicine, Berlin, Germany
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, Munich, Germany
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