The present study aimed at systematically and empirically generating recommendations for the development and expansion of palliative day care clinics in Germany. Recommendations were formulated to optimize the care of terminally ill patients according to their needs and ensure the adequate integration of palliative day care clinics into the existing care landscape.

The project “Improving health care for patients with terminal, progressive illnesses: Status and demand analysis for palliative day care clinics and day hospices and recommendations for health care planning” (ABPATITE) [24] formulated practical recommendations on the basis of empirical data gathered within the project. An online Delphi survey with palliative care experts was conducted to achieve a national consensus on these recommendations.

ABPATITE was divided into three study phases [24]: Phase 1 involved a systematic survey of operating and developing palliative day care clinics and day hospices in Germany. Phase 2 consisted of three work packages aimed at determining the significance of palliative day care clinics: (a) a qualitative study of day hospices and palliative day care clinic management staff, to explore insider views of these facilities; (b) focus groups with local representatives from hospice work and palliative care, to seek the external perspectives of local care networks on the cooperating palliative care services; and (c) a quantitative survey administered to patients and their relatives on care preferences at the end of life. In phase 3, a consensus workshop (i.e., focus groups) was held to reflect on the synthesized evidence from phases 1 and 2 and to derive recommendations for the development and expansion of palliative day care clinics in Germany. The key results of the consensus workshop served as the basis for the present Delphi survey. Recommendations for day hospices were derived separately and are not addressed in this article.

Heterogeneous experts who were currently working with or had experience with in- and outpatient palliative and/or hospice care, including experts employed in palliative day care clinics in Germany, were invited to participate in the national Delphi survey. The group of invited experts was meant to be as heterogeneous as possible, to promote diverse perspectives on the presented recommendations. Existing contacts of the study team and the Institute for General Practice and Palliative Care at Hannover Medical School were used to recruit potential participants. In addition, relevant stakeholders were researched online and participants from previous project phases were invited (e.g., from the German Association for Palliative Medicine, the German Hospice and Palliative Care Association, home care and nursing societies, the National Association of Statutory Health Insurance Physicians, the German Medical Association, the National Association of Statutory Health Insurance Funds, the Association of Private Health Insurance Companies, and municipal branches involved in social and health policy). The experts participated voluntarily and without compensation; however, they were invited to participate in a random draw for five 50€ and ten 5€ vouchers for online stores.

The Delphi technique was employed because it enables consensus to be achieved among a wide range of knowledgeable experts when face-to-face discussion is not feasible. In total, 28 recommendations were administered anonymously online, using the software SoSci Survey V3.4 (SoSci Survey GmbH, München, Germany). The Delphi survey was developed for this study (see Supplementary 1 for Delphi survey of round 1). Participants were asked to rate each recommendation on a 4-point verbal scale (i.e., strongly agree, somewhat agree, rather disagree, disagree), according to its: (a) relevance and (b) feasibility for the development and expansion of palliative day care clinics in Germany. Experts also had the option to abstain from rating individual items by selecting a “no answer” option. Each recommendation was considered consented when at least 80% of all participants who rated the item attributed it a score of 4 (i.e., strongly agree) or 3 (i.e., somewhat agree), for both relevance and feasibility. Recommendations that did not achieve consensus in a Delphi round were revised for content and/or language, according to participants’ free text comments. These recommendations were presented in the next Delphi round to all those who participated in the previous round and entered full data.

After each Delphi round was distributed, participants were reminded of their participation a maximum of two times prior to the round closure. The first two Delphi rounds were closed after 4 weeks, while the third round was closed after 2 weeks.

In the first Delphi round, 28 recommendations were presented in relation to the following topics: (1) the establishment of palliative day care clinics, (2) care provision (i.e., access to palliative day care clinics, integration of family caregivers, opening hours, appointment allocation, public relations), (3) professions and cooperation (i.e., occupational groups, cooperation, volunteer work), and (4) financing. In addition, sociodemographic data were gathered for participants.

Participants in each Delphi survey round confirmed their consent to participate online prior to starting the survey. The results of all Delphi survey rounds, including the sociodemographic data collected, were exported to the software packages IBM SPSS Statistics 28 (SPSS Inc., Chicago, IL, USA) and Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA; USA), and analyzed descriptively. The Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care checklist [25] was used to ensure comprehensive reporting.