BackgroundPatients with advanced cancer do receive increasingly aggressive end-of-life care, despite it does often not prolong survival time but entails decreased quality of life for patients. This qualitative study explores the unfolding of aggressive end-of-life care in clinical practice focusing on the decision-making process and the quality of end-of-life care from family members’ perspective.Materials and methodsWe conducted semi-structured interviews with 16 family members (six of cancer patients with and ten without aggressive end-of-life care) at the National Center for Tumor Diseases Heidelberg, Germany. We conducted a content analysis applying a theoretical framework to differentiate between ‘decision-making’ (process of deciding for one choice among many options) and ‘decision-taking’ (acting upon this choice).ResultsWhile patients of the aggressive care group tended to make and take decisions with their family members and physicians, patients of the other group took the decision against more aggressive treatment alone. Main reason for the decision in favor of aggressive care was the wish to spend more time with loved ones. Patients took decisions against aggressive care given the rapid decline in physical health and to spare relatives difficult decisions and arising feelings of guilt and self-reproach.ConclusionTreatment decisions at end-of-life are always individual. Nevertheless, treatment courses with aggressive end-of-life care and those without differ markedly. To account for a longitudinal perspective on the interplay between patients, family members, and physicians, cohort studies are needed. Meanwhile, clinicians should validate patients and family members considering refraining from aggressive end-of-life care and explore their motives.Clinical trial registrationhttps://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022837, identifier DRKS00022837.

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ObjectiveDespite available effective treatments for mental health disorders, few patients in need receive even the most basic care. Integrated telepsychiatry services may be a viable option to increase access to mental healthcare. The aim of this qualitative process evaluation embedded in a randomised controlled feasibility trial was to explore health providers’ experiences with a mental healthcare model integrating mental health specialist video consultations (MHSVC) and primary care.MethodsA qualitative process evaluation focusing on MHSVC in primary care was conducted. In 13 semistructured interviews, we assessed the experience of all mental health specialists, primary care physicians and medical assistants who participated in the trial. A thematic analysis, focusing on the implementation, mechanisms of impact and context, was applied to investigate the data.ResultsConsidering (1) the implementation, participants evaluated the consultations as feasible, easy to use and time saving. Concerning (2) the mechanisms of impact, the consultations were regarded as effective for patients. Providers attributed the patients’ improvements to two key aspects: the familiarity of the primary care practice and the fast access to specialist mental healthcare. Mental health specialists observed trustful therapeutic alliances emerging and described their experience as comparable to same-room care. However, compared with same-room care, specialists perceived the video consultations as more challenging and sometimes more exhausting due to the additional effort required for establishing therapeutic alliances. Regarding (3) the intervention’s context, shorter travel distances for patients positively affected the implementation, while technical failures, that is, poor Internet connectivity, emerged as the main barrier.ConclusionsMHSVCs in primary care are feasible and successful in improving access to mental healthcare for patients. To optimise engagement and comfort of both patients and health providers, future work should focus on empirical determinants for establishing robust therapeutic alliances with patients receiving MHSVC (eg, leveraging non-verbal cues for therapeutic purposes).Trial registration numberDRKS00015812; Results.

Objective: Despite available effective treatments for mental health disorders, few patients in need receive even the most basic care. Integrated telehealth services may be a viable option to increase access to mental health care. The aim of this qualitative process evaluation embedded in a randomized controlled feasibility trial was to explore health providers’ experiences with a mental health care model integrating mental health specialist video consultations (MHSVC) and primary care.Methods: A qualitative process evaluation focusing on MHSVC in primary care was conducted. In 13 semistructured interviews, we assessed the experience of all mental health specialists, primary care physicians, and medical assistants who participated in the trial. A thematic analysis, focusing on the implementation, mechanisms of impact, and context, was applied to investigate the data.Results: Considering (1) the implementation, participants evaluated the consultations as feasible, easy to use, and time-saving. Concerning (2) the mechanisms of impact, the consultations were regarded as effective for patients. Providers attributed the patients’ improvements to two key aspects: the familiarity of the primary care practice and the fast access to specialist mental healthcare. Mental health specialists observed trustful therapeutic alliances emerging and described their experience as comparable to same-room care. However, compared to same-room care, specialists perceived the video consultations as more challenging and sometimes more exhausting due to the additional effort required for establishing therapeutic alliances. Regarding (3) the intervention’s context, shorter travel distances positively affected the implementation, while technical failures, i.e. poor Internet connectivity, emerged as the main barrier.Conclusions: MHSVCs in primary care are feasible and successful in improving access to mental healthcare for patients. To optimize the engagement and comfort of both patients and health providers, future work should focus on empirical determinants for establishing robust therapeutic alliances with patients receiving video consultations (e.g., leveraging nonverbal cues for therapeutic purposes).