‘A flexible approach incorporating both in-person and telehealth visits’ emerged as the core category that encompassed all three subcategories of (1) elements of in-person outpatient palliative care: building interpersonal connections and trust (2) elements of telehealth palliative care: efficiency, comfort and independence and (3) patient-preferred circumstances for in-person or telehealth visits. Illustrative quotations for these categories, representing both typical and divergent comments, are presented in box 1 and tables 2–4.

Box 1 Core category: a flexible approach incorporating both modalities

I mean, I do think I would want an actual in-person checkout, check-in every once in a while, but I did actually appreciate the option to be able to like sit in the comfort of my own home and still talk about whatever if we needed to talk about in that session (P-005-IPV).

Sometimes the personal visit has some advantage. If I want to talk more about something, if they need to examine me, if I needed it to ask for some support, they immediately take care of that. So yes, the virtual is good, but sometimes you need personal visit (P-006-IPV).

I do believe the hybrid approach is good because it can save a lot of time (P-013-IPV).

So, I think a combination of both is probably, would be really nice, but I know right now with COVID it’s not the best solution… But I think the phone calls shouldn’t stop just because COVID finishes, if it ever does for that matter (P-V6-VO).

Certainly my interaction with palliative care, you know, probably 90% of this can be done virtually. I just sort of miss the 10% then, that’s all (P-V10-VO).

Table 2

Elements of in-person outpatient palliative care: building interpersonal connections and trust

Table 3

Elements of telehealth palliative care: efficiency, comfort and independence

Table 4

Patient-preferred circumstances for in-person or telehealth

Core category: a flexible approach incorporating both in-person and telehealth visits

This core category encompassed the short-term pandemic-related and longer term considerations associated with telehealth visits to the palliative care clinic (box 1). In the immediate aftermath of the declaration of the pandemic, IPV participants recognised the pragmatic approach taken by the cancer centre to switch most visits to telehealth. This switch was perceived as necessary and in keeping with public health messaging regarding physical distancing.

All participants expressed gratitude that their safety and well-being were being prioritised through offering telehealth visits, while maintaining the ability to connect with their palliative care team and other healthcare providers. The ability to meet with the palliative care team via telehealth visits rather than having to travel to the cancer centre, undergo screening and risk exposure to the virus, was appreciated.

While some participants struggled with the technical aspects of telehealth visits (particularly related to videoconferencing), most expressed feeling comfortable with these modalities from the outset, and this comfort grew over time. As participants felt less fearful about contracting COVID-19 with the rollout of vaccinations, they began to consider more broadly the advantages and disadvantages of in-person and telehealth visits as well as how these could be combined into an ongoing hybrid model of outpatient palliative care delivery. These are described in the subcategories below.

Elements of telehealth palliative care: efficiency, comfort and independence

Participants described several advantages of telehealth palliative care visits (table 3). The convenience of not having to travel to the cancer centre for appointments, with its associated direct and indirect costs and conducting a visit from the comfort of their own home, were cited as prominent advantages to telehealth. These logistical and personal factors contributed to their satisfaction with the virtual care delivery model adopted during the pandemic.

Delays and extended wait times with telehealth appointments were generally perceived as less disruptive to patients than delays at IPVs, as patients could continue with their daily activities at home and wait in a comfortable and familiar setting. However, one participant noted that unexpected delays were often more difficult to communicate in a virtual environment. Additionally, travelling to the cancer centre for in-person appointments required some patients to rely on family and friends for assistance. In these cases, telehealth appointments were particularly valued, as they allowed participants to maintain a sense of independence and autonomy.

Patient-preferred circumstances for in-person versus telehealth visits

Participants were asked about their preferences for visit modalities (in-person, phone or videoconference calls) beyond the pandemic. A hybrid model with a blend of in-person and virtual options was perceived as most desirable, with personalisation of the setting based on the circumstances of the visit and the patient’s state of health (table 4).

Participants described various scenarios for such a hybrid model beyond the pandemic. Overall, the major recommendation was that the first visit should be in-person. IPV participants described that having met the palliative team in-person at least once was an integral part of their care and to the establishment of a therapeutic relationship.

VO participants similarly observed that they felt the opportunity to meet with the palliative care team in-person was a missing element of their care during the pandemic, which impacted the establishment of a trusting rapport with the team. A majority agreed that, beyond the pandemic, initial consultations should be offered in-person.

Participants were asked to describe the different circumstances under which they would prefer to see their healthcare team in-person versus via telehealth. Many participants expressed that their palliative care physician should be the one to decide on the optimal visit modality, and some stated that an IPV once or two times per year should be mandatory. Virtual appointments were considered desirable during periods of health stability, as participants felt IPVs were often unnecessary for routine check-ins. In-person follow-up appointments were overall preferred in two scenarios: appointments requiring a physical examination and those where disease progression or advance care planning would be discussed. The latter appointments were perceived as more serious, where participants identified that they may need more direct support from their team. Participants expressed wanting the flexibility to change an appointment from in-person to virtual (or vice versa) depending on their needs for that visit and their perceived health on the day.

With the consensus that telehealth visits should continue beyond the pandemic, some participants reflected that this modality required specific clinical and communication skillsets and that healthcare providers might benefit from additional training to enhance their skills for this new clinical environment. They also felt that guidance for patients around the optimal use of telehealth may be beneficial.