We have found that the interviewees presume they can use teleconsultation to keep a finger on the pulse of patients residing at home, provided that at least one initial face-to-face contact precedes the teleconsultations. Furthermore, if responsibility for a patient is handed over to palliative care professionals, teleconsultations are supposed to fulfill the professional’s need to see this patient immediately. Teleconsultations are even presumed to have a healing effect of their own, as time and digital attention are offered to patients. The members expect that teleconsultation will facilitate more patient-centered care. These advantages may go hand in hand with limitations: the respondents working in the expert center conjecture that teleconsultation will complicate the connectedness with their patients: the physical proximity, and thereby the quality of diagnostics is supposed to become more difficult due to teleconsultations. “Real contact” with the person behind the patient could never be realized by means of teleconsultations alone. Besides, the increased, virtual availability is believed to facilitate patients’ sometimes unrestrained and uncontrolled queries, which may cause increasing dependency and heavy workloads. Teleconsultation is expected to open up an additional ‘gray’ network outside the hierarchical structures of the established chain of transmural palliative care. This network could make it possible to bypass caregivers in charge, causing uncertainty about responsibilities. Medical specialists, family physicians, and nurse practitioners could then easily depart from the treatment policy for a patient either at the hospital or in the home, possibly creating confusion and miscommunication.
As mentioned in the introduction, teleconsultation technology is considered multistable [9, 10]. Teleconsultation involves a technical computer device as well as a designed care process due to the introduction of this device. The fit of this computer device in palliative caregiving is defined by its embeddedness in the particular physical and cultural-social context of the caregiving practice. In this sense, teleconsultation is “a hybrid affair”  as it only appears as a compilation of human action and teleconsultation technologies: the latter encompasses a script that frames social action, roles and identities, but end-users will co-design the telecare services as well [16, 17]. This article’s teleconsultation protocol is a first attempt of hospital-based professionals to condition the offered teleconsultation technology to their daily practice. It is the end-point of this paper, an accumulation of professionals’ assumptions on extended teleconsultation into a palliative telecare service. In future studies, we will investigate more closely whether and how the hospital-based professionals are able to manage both the technology and the service according protocol, as well as whether and how other end-users, like patients, families and family physicians, co-design this palliative telecare product.
In the following, we elaborate on a few theoretical notions on the possible teleconsultation technology-user relationships that could sensitize us to meaningful events for future studies.
Perceiving a patient via teleconsultation: the embodiment relationship
Teleconsultation technology facilitates experiencing through technology for both patients and caregivers. This kind of mediation will extend certain bodily capacities and neutralize others, thereby magnifying certain aspects of the observed world and reducing others. The respondents referred to this embodiment-relationship: they expect extended teleconsultation technology to extend hospital-based professionals’ perceptions of patients, who can now be seen in their homes. Furthermore, continuous, interpersonal, digital contact between patients and caregivers might magnify a patient’s healing capacity .
Further research should address the following questions: how do caregivers actually improve their care when audio-visually communicating with the patient at home? What will be the nature of the mutual digital contacts between specialists and patients? What do teleconsultations exactly mediate that contributes to healing effects?
With regard to the magnification/reduction structure , Ihde claims that, normally, “what is revealed [by technology] excites, and what is concealed may be forgotten”. It is not so much the magnification as the reduction that stands out for the interviewed palliative care professionals: for them, teleconsultation technology compromises connectedness with the patient in that it does not create physical proximity and diminishes professionals’ capacity to get in touch with the person behind the patient and develop a “gut feeling”. This fear seems, at least partly, pertinent as heart-failure nurses working with telemonitoring actually experience losing intimate knowledge of the patient and his/her psycho-social well-being by losing physical proximity . However, interpersonal bonds in modern workplaces, where “telecommuting” is part of daily practice, depend the least on physical proximity .
This foreseen reduction raises questions: how does the loss of physical proximity frustrate adequate diagnosing and what does this mean for palliative care at a distance [21, 22]? How can sympathizing and empathizing with patients be maintained in teleconsultation, and how do patients experience this new proximity? Moreover, researchers should investigate the added value of telecare consultation after initial face-to-face contact [5, 6, 18].
Looking at a screen: the hermeneutic relationship
Besides being something through which caregivers get in touch with their patients, the teleconsultation technology is also an instrument palliative care professionals look at to interpret the patient’s status. The professionals have to learn how to interpret their patients’ images and stories to apply them in a responsible way in medical practice . Interpreting an image of the home is part of the palliative care physician’s diagnosis and has to be learned, similarly to a gynecologist needing to learn how to interpret a sonogram and a radiologist how to interpret magnetic resonance images . An extended follow-up study must include questions about the different interpretative frameworks the communicators use. What do patients and professionals look for in the images? How do professionals and patients know if the teleconsultation images and sounds, in a “semi-opaque cooperation with referent objects” , truthfully refer to the appearance of the conversation partner and his/her social context ? Methods of truth-finding in a virtual context should be part of a follow-up study. We caught a glimpse of such a method when one respondent argued for scepticism towards the teleconsultation images: they can only be diagnostically valuable if verified by clinical reasoning combined with a variety of other information, such as patients’ or colleagues’ stories or lab results; to see a patient with yellow skin simply does not suffice for building a diagnosis.
Transforming transmural care and transporting culture
Teleconsultation in palliative care never fulfills a neutral role [9, 10], but co-shapes the experiences and perceptions of the surrounding world. Teleconsultation is thought to give patients a feeling of control over their care. However, the respondents think this patient-centeredness comes at a cost: teleconsultations might upset the balance of involvement and professional distance, leading to loss of control over “boundaries between absence and presence” . A shared freedom to initiate teleconversations is likely to transform expectations and obligations between professionals and patients [22, 26]: when patients expect continuous access, professionals feel more obliged to be present and to respond quickly and accurately. It is a feeling that goes beyond their earlier advisory role.
Another result of the same shift to quick, easy, and more reciprocal audio-visual communication between patients and professionals is the blending of different domains (home and hospital) into one still developing transmural area. Profound relationships can develop between patients and caregivers who were formerly restricted to a particular domain. These more intense relationships might contribute to a mutual trust and to a patient’s or informal caregiver’s peace of mind , or to mutual dependency at a distance. The feelings of trust and/or dependency could tempt patients and professionals alike to bypass less involved caregivers. This would subvert the hierarchical structure of the established chain of care and create a void when it comes to taking responsibilities.
The teleconsultation equipment itself also functions as a medium for transporting cultures. It is presumed to create a more pluricultural environment  in home and hospital. The hospital culture may intrude in the home through the technology. Patients and family physicians might also bring their formerly home-bound cultures into the hospital, although the hospital-based respondents did not mention this. These interactions of cultures might have consequences for the use of life-prolonging treatment, terminal hospital admissions, and multidimensional decision-making at life’s end. This requires future research.
Although valid, our results originate from a study with a limited number of respondents. Despite the small sample, this case study provides valuable insights into the cultural-social context of palliative care. The respondents are typical representatives of a palliative care practice, who prefer to work within integrated care processes. Most respondents were experienced and older – not uncommon in a field where caregivers are constantly confronted with death and dying. Being experienced and older may have influenced them regarding new technologies. Moreover, they might fear technology more because, at first sight, it endangers certain types of connectedness that are essential parts of their holistic, humanistic care. Nonetheless, age has the advantage of being more independent of hierarchical structures. This creates freedom to participate in innovative projects.
Overall, this paper on the cultural-social context of the practice of palliative care in relation to teleconsultation is a solid base for further research into:
Technology-mediated interactions between palliative care professionals and patients. The potential “disagreement [on], negotiation [on], and potential breakdown [of]”  this innovation will actually enhance access to this field of research as friction exposes itself more easily.
The experiences of designers, palliative care professionals, patients, families, informal caregivers, and family physicians, all involved in working with teleconsultation within transmural palliative care. It is notable that our respondents only referred to teleconsultation technology fitting the professional cultural-social context. It is worth investigating whether and how the technology fits into the actual workplace and home.
The mediation of professional, patient, and family relationships by teleconsultation.
The moral assessment of teleconsultation in palliative care with regard to a dignified last phase of life.
With the results of such a follow-up study, teleconsultation structure can be designed for caregiving that benefits both patients and caregivers and fits the managerial, regulatory, and financial frameworks of the practice of transmural palliative care.