Consensus definition of clinical complexity in palliative care: a two-round Delphi Study with a National...

This study aimed to: (1) develop a consensus definition of clinical complexity in adult patients with palliative care (PC) needs, adapted to the Portuguese health system context; (2) identify core determinants; (3) compare agreement between expert and non-expert professionals in a context where no standardised definition of clinical complexity in palliative care (PC) currently exists.

A two-round Delphi study included 79 professionals in round 1, with 57 completing round 2, comprising experts (R1/R2: 52/43) and non-experts (27/14). Consensus was defined as ≥70% of responses in the top two categories of a 5-point Likert scale. Qualitative data were analysed by independent thematic analysis with two coders (κ=0.97).

All core elements of the revised definition achieved consensus (R2): profound suffering (97%), clinical unpredictability (95%), caregiver network (91%), complexity arising from a single dominant factor (84%) and practical examples (81%). The proposed short definition achieved overall agreement of 75%, with higher consensus for clinical relevance (91%) and comprehensiveness (86%) than for clarity (77%). Four thematic clusters were identified: experiential and subjective dimensions, systemic and access-related determinants, relational and social determinants and operationalisation requirements.

This study proposes the first consensus definition of clinical complexity in PC in the Portuguese context-multidimensional, dynamic and centred on profound suffering, clinical unpredictability and the interactions between clinical, relational and systemic determinants, also providing a framework for instrument development, clinical referral improvement and international harmonisation of complexity assessment in PC.