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BMC Health Serv Res. 2019 Mar 12;19(1):157. doi: 10.1186/s12913-019-3961-0.

Understanding complexity - the palliative care situation as a complex adaptive system.

Author information

Department of Palliative Medicine, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
Research Unit Ethics, University Hospital Cologne, Cologne, Germany.
Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health, University of Cologne, Cologne, Germany.
Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Munich, Germany.
Ludwig-Maximilians-Universitaet Munich, Munich School of Management, Institute of Health Economics and Health Care Management & Munich Centre of Health Sciences, Munich, Germany.
St. Josephs-Hospital, Department of Palliative Medicine and Interdisciplinary Oncology, Wiesbaden, Germany.
Department of Palliative Medicine, Munich University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.



The concept of complexity is used in palliative care (PC) to describe the nature of patients' situations and the extent of resulting needs and care demands. However, the term or concept is not clearly defined and operationalised with respect to its particular application in PC. As a complex problem, a care situation in PC is characterized by reciprocal, nonlinear relations and uncertainties. Dealing with complex problems necessitates problem-solving methods tailored to specific situations. The theory of complex adaptive systems (CAS) provides a framework for locating problems and solutions. This study aims to describe criteria contributing to complexity of PC situations from the professionals' view and to develop a conceptual framework to improve understanding of the concept of "complexity" and related elements of a PC situation by locating the complex problem "PC situation" in a CAS.


Qualitative interview study with 42 semi-structured expert (clinical/economical/political) interviews. Data was analysed using the framework method. The thematic framework was developed inductively. Categories were reviewed, subsumed and connected considering CAS theory.


The CAS of a PC situation consists of three subsystems: patient, social system, and team. Agents in the "system patient" are allocated to further subsystems on patient level: physical, psycho-spiritual, and socio-cultural. The "social system" and the "system team" are composed of social agents, who affect the CAS as carriers of characteristics, roles, and relationships. Environmental factors interact with the care situation from outside the system. Agents within subsystems and subsystems themselves interact on all hierarchical system levels and shape the system behaviour of a PC situation.


This paper provides a conceptual framework and comprehensive understanding of complexity in PC. The systemic view can help to understand and shape situations and dynamics of individual care situations; on higher hierarchical level, it can support an understanding and framework for the development of care structures and concepts. The framework provides a foundation for the development of a model to differentiate PC situations by complexity of patients and care needs. To enable an operationalisation and classification of complexity, relevant outcome measures mirroring the identified system elements should be identified and implemented in clinical practice.


Complex adaptive systems; Complexity; Palliative care; System theory, classification, qualitative research

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