BACKGROUND Although 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. METHODS Within 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. RESULTS 11 (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". CONCLUSIONS We 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 REGISTRATION The 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).

中文翻译：

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在姑息治疗中死亡的愿望：一项循序渐进的混合方法研究，以开发一种半结构化的临床方法。

背景技术尽管在接受姑息治疗的患者中经常渴望死于变化的强度和持久性，但是关于对其的适当治疗反应仍存在不确定性。为了支持卫生专业人员应对患者潜在的死亡愿望，制定了培训计划和半结构化的临床方法。这项研究旨在对临床方法进行修订并达成共识，以支持积极应对死亡的愿望以及对死亡和垂死痛苦的常规探索。方法在顺序混合方法设计中，我们邀请了16名姑息患者参加半结构式访谈，并邀请了377名（国际）专家参加了两轮Delphi程序。使用定性内容分析法对访谈进行了分析，并根据预定义的标准确定了Delphi的协议共识。结果来自不同背景的11名患者（69％）参加了面对面的访谈。作为就死亡的渴望进行对话的关键问题，他们指出了专业人员与患者之间的关系，外部专家的设置和支持（如果需要）。一组149名（40％）专家（德国的132/89％，其他9个国家的17/11％）评估了半结构化临床方法的十个领域。关于对话设计，（自我）反思的建议以及进一步建议采取的行动的九个领域立即达成共识。直到第二轮才达成共识的一个领域是“积极应对死亡的愿望”。结论我们基于证据，患者的观点和专业专家的共识，提供了第一个半结构化临床方法来识别和解决死亡的愿望并做出治疗反应。试验注册该研究已在德国临床试验注册（DRKS00012988；注册日期：27.9.2017）和卫生服务研究数据库（VfD_DEDIPOM_17_003889；注册日期：14.9.2017）中进行了注册。