Expert Agreement on Palliative Reasoning and Monitoring in Heart Failure: International Delphi Study

Context: Palliative reasoning aims to support the integration of palliative care (PC) into heart failure (HF) management and includes multidimensional monitoring of symptoms, wishes, and needs. Objectives: This study aimed to establish expert agreement on palliative reasoning and the content of a PC monitoring instrument within the European context. Methods: A two-round modified Delphi study complemented by expert panel meetings after each round. Experts in HF and PC from nine European countries rated the relevance and wording of 57 items. Agreement was pre-defined as Individual item Content Validity Index (I-CVI) ≥0.80 on a 5-point Likert scale (score ≥4), with items between I-CVI 0.75-0.80 agreement reformulated by the panel and re-assessed in round two. Items with I-CVI<0.75 on relevance were removed. Results: Round one included 155 participants and round two 121 participants (78.1% retention). Agreement was reached in the first Delphi round on all steps of palliative reasoning (I-CVI range across steps: 0.82-0.95). Across the two Delphi rounds, 25 of the 33 symptoms (76%) achieved agreement on both relevance and formulation (I-CVI range for relevance: 0.81-0.99). Nineteen of the 20 items (95%) addressing wishes and needs reached agreement on both relevance and formulation (I-CVI range for relevance: 0.84-0.97). Conclusion: This Delphi study established expert agreement on the steps of palliative reasoning and the content of a multidimensional monitoring instrument. These findings provide a shared foundation for earlier, more person-centred and coordinated PC, while allowing national adaptations.