Inadequate management of opioid-induced constipation in European cancer pain patients: results of a real-world, multicentre, observational study ("E-StOIC").

PURPOSE: The objectives of the study were to determine the prevalence of (uncontrolled) OIC, relevant medications / interventions employed by healthcare professionals, and the additional strategies utilised by patients, amongst European patients with cancer pain. METHODS: This study was a prospective observational study conducted at 24 research sites in ten European countries. Cancer patients receiving opioid analgesics for at least a week were recruited, and asked to complete a questionnaire including background information, single question (Are you constipated?), Rome IV diagnostic criteria for OIC, Bowel Function Index (BFI), and Patient Assessment of Constipation Quality of Life questionnaire (PAC-QOL). Participants were characterised as having / not having OIC on the basis of the Rome IV diagnostic criteria. RESULTS: 1200 participants completed the study. 59.5% met the Rome IV diagnostic criteria for OIC: only 61.5% that met these criteria self-reported constipation. 72% participants were prescribed a regular conventional laxative / peripherally acting mu-opioid receptor antagonist (PAMORA). However, only 66% took their prescribed laxatives every day. Many participants had utilised other strategies / interventions to manage their OIC. Furthermore, 27% had needed to use suppositories, 26.5% had needed to use an enema, and 8% had had a manual evacuation. The use of PAMORAs, and other novel effective medications, was relatively uncommon. CONCLUSION: The results of this study suggest that management in Europe is often inadequate, and this undoubtedly relates to a combination of inadequate assessment, inappropriate treatment, and inadequate reassessment.

"The patient as teacher" - thematic analysis of undergraduate medical students' experiences with an experiential learning project in palliative care.

BACKGROUND: Experiential learning holds high potential for medical students' education in palliative care. At RWTH Aachen University in Germany, medical students can participate in the course "The Patient as Teacher" offering a one-to-one exchange with a terminally ill patient over a period of several weeks complemented with four supervision sessions and writing of a reflective essay. The course had run from 2005 to 2020 before it was paused due to the Covid-19 pandemic. This study aimed to assess the course's value as a palliative care teaching tool by investigating students' motivation and experiences over the years 2005-2020. METHODS: A stratified sample of 24 essays was taken from all submitted essays (n = 78), eight essays from the years 2005-2009, 2010-2014, and 2015-2020. Subsequently, a thematic analysis of the selected essays was conducted. RESULTS: The students felt motivated by the opportunity to gain more experience in palliative care, to improve their communication skills and to decrease insecurities in interaction with terminally ill patients. They learned about the patient's biography and medical history, and encountered physical, psychological, social, and spiritual dimensions of living with a life-limiting disease. Moreover, they experienced relationship building and communication with a terminally ill patient outside their role as future doctors. Ultimately, they considered their participation as a beneficial experience on both a personal and professional level. CONCLUSIONS: The course "The Patient as Teacher" presents a valuable tool for experiential learning in palliative care, which has elicited an unceasingly positive response among the students who participated over the years. It has facilitated medical students in overcoming insecurities in dealing with terminally ill patients and supported them in further developing their professional identity.

Palliative care education and knowledge transfer into practice - a multicenter survey among medical students and resident physicians in Germany using a mixed-methods design.

Objective: In 2009, Palliative care was incorporated into the medical curriculum as Cross-Sectional Subject 13 (QB13) by means of the revision of the Medical Licensing Regulations for Physicians. The aim of this study was to determine the strengths and deficits of QB13 student education for palliative care in clinical practice in a multi-centre setting and to identify potential for improvement. Methods: Online questionnaires filled out by medical students during their Practical Year (PY) and resident physicians from the university hospitals in Aachen, Düsseldorf, and Cologne were descriptively analyzed using SPSS; free-text responses were categorized and quantified. Semi-structured interviews with the resident physicians (using a mixed-methods design) were analyzed through content analysis. Emerging categories were quantified. Results: Analysis of 130 fully completed questionnaires and 23 interviews revealed that participants particularly benefited from patient- and practice-oriented small-group sessions for their clinical work. Despite some university-specific differences, the PY students identified a need for training in end-of-life-care, while resident physicians saw a need for training primarily in dealing with patients and their relatives. They also reported deficits in transferability. Conclusion: QB13 should be organised in cross-university curricula and provide sufficient resources for practical-oriented small-group teaching. Based on the "unit of care", besides caring for palliative patients, dealing with patients' families should also be an education focus. To improve transferability into clinical practice, students should be actively involved in the care of palliative patients.

Scoping review of end-of-life care for persons with anorexia nervosa.

BACKGROUND: End-of-life (EOL) care is the part of palliative care intended for persons nearing death. In anorexia nervosa (AN), providing EOL care instead of coercing life-sustaining measures is controversial. The existing literature has not been synthesized yet. To clearly delineate differing views and identify open questions as well as areas of possible consensus, we conducted the first-ever synthesis of the existing literature. METHODS: We searched EMBASE, PubMed, PsycInfo, and Web of Science for scientific publications on forgoing coerced life-sustaining measures and/or providing EOL care for persons with AN who refuse life-sustaining measures, typically artificial nutrition. Palliative care outside of the EOL context and medical assistance in dying were not reviewed. As very little quantitative studies were identified, we qualitatively analyzed conceptual questions, ethical reasoning, legal aspects, stakeholder attitudes, practical aspects, stakeholder needs, and outcome. RESULTS: We identified 117 eligible publications from 1984 to 2023, mainly case reports (n=26 different cases) and ethical analyses. Conceptualizations of key terms such as terminality, futility, and decision-making capacity (DMC) in AN varied widely and were often value-laden and circular. Ethical reasoning centered on weighing the preservation of life versus quality of life in the context of uncertainty about DMC and likelihood of clinical remission. Studies on stakeholder attitudes reflected this challenge. In some cases, courts ruled against coerced life-sustaining measures and/or in favor of EOL care for persons with AN. While eligibility criteria were contested, recommendations for deliberating about and providing EOL care were consistent. We identified only one study on stakeholder needs and none on outcome. Case reports described quality of life under EOL care as good and death as the most frequent outcome but engagement in voluntary treatment and (partial) clinical remission in some. CONCLUSIONS: The debate around EOL care in AN needs consented, coherent terminology whose value base is reduced to a minimum and made transparent. While more empirical research into decision-making in AN and predictors of outcome might help reduce uncertainty, fundamental normative questions need to be addressed, for example regarding the ethico-legal significance of treatment refusals, the weighing of quantity versus quality of life and the appropriateness of diagnosis-based ethico-legal exceptionalism such as hard paternalism. More research is needed on outcome of and stakeholder needs in EOL care for persons with AN.

Feasibility of a physical exercise intervention for patients on a palliative care unit: a critical analysis.

BACKGROUND: Recent exercise intervention studies have shown promising results in improving quality of life (QoL) and physical function (PF) in diverse chronic disease and advanced cancer patients. However, the effects of structured exercise in palliative care patients, having different therapeutic needs, lower life expectancies and PFs remain unknown. This study primarily aimed to assess the feasibility of an exercise intervention with follow-up by analysing recruitment numbers, screening procedures, acceptability, preferences, and safety of the exercise intervention as well as retention in follow-up. Our secondary aims related to changes in QoL and PF. METHODS: This study comprised of a one-arm design without a control group. Over 6 months, every in-hospital palliative care unit (PCU) patient was screened for eligibility. Eligible patients were asked to participate in a 2-week exercise intervention consisting of resistance training and/or endurance training with moderate or high intensity based on personal preferences and a 4-week follow-up. Before and after the exercise intervention, QoL and PF were assessed and a qualitative interview after the intervention addressed expectations and experiences of the exercise intervention. For follow-up, patients were provided with information on independent training and after 1 and 4 weeks a QoL assessment and qualitative interview were conducted. RESULTS: Of 124 patients screened, 10 completed the intervention with an adherence rate of (80 ± 25%), of which 6 patients completed follow-up. Endurance training was the most performed training type and only a few minor adverse events occurred in certain or likely connection to the exercise intervention. While physical QoL and PF measured by arm curl strength and time up and go performance improved, mental QoL and the other PF tests remained unchanged. CONCLUSION: Despite the challenges that were faced in our screening and testing process, that are specific to the palliative patient population with their unique therapeutic requirements and varying mental-/ physical capabilities, we discovered the 2-week exercise intervention to be feasible, safe, and well tolerated by palliative care patients. Moreover, it seems that short-term improvements in QoL and PF are possible. Further full scale studies are required to confirm our findings. TRIAL REGISTRATION: The study was retrospectively registered on 25.01.2022 in the German Clinical Trials Register (DRKS00027861).

Palliative care training in medical undergraduate education: a survey among the faculty.

BACKGROUND: A minority of European countries have compulsory training in palliative care within all medical schools. The aim of the study was to examine palliative care education in Estonia. METHODS: We used the adapted version of the Palliative Education Assessment Tool (PEAT) to evaluate palliative care education at the University of Tartu, the only medical school in Estonia. The PEAT comprises of different palliative care domains and allows for assessing the curricula for palliative care education. RESULTS: 26 hours (h) of palliative care is taught within the basic medical curriculum, which is divided between 14 courses. Ethical issues (4 h, lecture and seminar) and basics of palliative care (2.5 h, lecture) are well covered however, pain and symptom management (12.5 h, lecture, seminar, workshop), psychosocial, spiritual aspects (5.5 h, seminar), and communication (1.5 h, lecture) teaching do not reach the recommended number of hours. Teamwork and self-reflection are not taught at all. CONCLUSIONS: Increased time, more diverse teaching strategies and clear learning outcomes are required to enable the development of palliative care education in Estonia. The teaching and learning of palliative care is a process that requires constant development and collaboration.

The state of undergraduate palliative care education at Austrian medical schools - a mixed methods study.

BACKGROUND: There is an increasing demand for universal, high-quality access to palliative care in Austria. To ensure this, the implementation of palliative care in the medical studies curriculum is essential. This is the first study to investigate the state of undergraduate palliative care education at Austrian medical schools. METHODS: For this mixed-methods study with concurrent embedded design, expert interviews and online surveys were conducted between March and August 2022. The interviews were subjected to a thematic analysis according to Braun and Clarke, while the questionnaires were analysed descriptively-statistically. For the final integration, the results of both methods for each topic are presented and discussed complementarily. Both the primary qualitative and supportive quantitative data were collected to combine the advantages of the in-depth nature of the qualitative data and the consistent structure of the quantitative data to provide a more precise representation of the state of teaching. RESULTS: Twenty-two persons participated in the study, of whom twenty-one participated in the interview and eight in the questionnaire. The participants were experts in palliative care teaching at Austrian medical schools. Currently, palliative care is taught at seven out of the eight universities. Large differences were found in the number of hours, organisation, teaching formats, and interprofessional education. At present, three universities have a chair for palliative care and at least five universities have access to a palliative care unit. CONCLUSION: Undergraduate palliative care education in Austria is very heterogeneous and does not meet the minimum standards suggested by the European Association for Palliative Care (EAPC) curriculum recommendations. However, several universities are planning measures to expand palliative care teaching, such as the introduction of mandatory teaching or the establishment of new teaching formats. Better coordination and networking within and between universities would be beneficial for the expansion and quality of teaching.

[Transition from intensive care to palliative care : A retrospective analysis of 102 consultation requests]. / Transition von der Intensivmedizin zur Palliativmedizin : Eine retrospektive Analyse von 102 Konsilanforderungen.

BACKGROUND: The transition of patients from the intensive care unit (ICU) to the palliative care (PC) ward often implies changes including establishing a palliative concept. Adaptation of therapeutic goals can be challenging for medical staff, patients and relatives; however, descriptions of these transition trajectories are rare. OBJECTIVE: The aim of this retrospective study was to characterize the consultation requests of the ICU to the PC consultation team as well as the patients by a description of trajectories and interventions. METHODS: Retrospective analysis of all patients receiving intensive care at RWTH Aachen University Hospital in 2019 for whom a PC consultation was requested. The patient population transferred from the ICU to the PC ward was compared with the non-transferred population. In each case, the primary consultation was evaluated regarding the following factors: question, vigilance, length of time from consultation request to its performance, and primary focus of the question. The question focus was categorized into "symptom control", "counselling" and "transfer" (tick options). In addition, a free text field was available for further notes. Exploration of diagnoses was complemented by accessing the electronic health records. RESULTS: A total of 102 consultation requests from the ICU to the PC ward were evaluated. The morbidity of patients was high, and most patients had at least one of the following diagnoses: pulmonary (62%), cardiovascular (61%), and/or neurological disease (55%). Of the patients 32 (31%) were transferred to the PC ward, among whom weakness (94%), fatigue (77%), anxiety (55%), pain (53%), and dyspnea (48%) were the most frequently noted symptoms. Of the transferred patients 5 (16%) could be discharged to home, nursing home, hospice or other. In total, 35 (34%) of all patients who were seen by palliative care specialists on ICUs in 2019 could be discharged alive. The most frequent reasons for nonadmission were lack of capacity of the PC ward (33%), dying while being on the waiting list (20%), and refusal by the patient (20%). Of the patients, 7 (26%) died within 48 h after they had been transferred to the PC ward. Performed consultation services "symptom control" (χ2 = 10.17; p < 0.05) and "counselling" (χ2 = 12.82; p < 0.001), which were requested by the intensive care physicians, showed a significant linkage with the respective intervention performed by the palliative care team. On the other hand, no statistically significant difference was found for requested and performed "transfer" of patients from ICUs to PC ward. Comparing the transferred versus non-transferred patient population, a significantly more frequent transfer of patients with malignant tumors (p = 0.00) was observed. CONCLUSION: The need for palliative care support in the ICUs exceeded the admission capacity of the PC ward. Future studies should further examine palliative care models in intensive care medicine.

The outcomes of postgraduate palliative care education and training: assessment and comparison of nurses and physicians.

BACKGROUND: Within Germany, there is a heterogeneous range of training and continuing education in palliative care for different professional groups. The German Society for Palliative Medicine (DGP), together with the German Hospice and Palliative Care Association (DHPV), have defined quality requirements for postgraduate training in palliative care. These requirements include the evaluation of course structures and the assessment of outcomes. AIM: To assess the 'learning gains' in palliative care nurses and physicians undertaking continuing education programmes, and evaluate the structures and processes. To identify if/how the continuing education programmes could be improved. MATERIAL AND METHODS: The development of Nurses' and Physicians' learning was determined using a retrospective self-assessment procedure. The evaluation was based on learning objectives developed in the DGP Education Working Group, using a six-point Likert scale for each item, and space for 'free-text' comments. Assessments were conducted after training. RESULTS: Five hundred twenty nine self-assessments were recorded (456 nurses / 73 physicians). An increase in learning is demonstrated in all areas (knowledge, skills, social and self-competence) for each profession. The greatest gain was in symptom control. However, there were significant differences in the extent of learning gains between nurses and physicians. CONCLUSION: Analysis suggests current training results in improvements, but personal competences progress less than knowledge and skills. One way to improve this would be to introduce more interprofessional continuing education elements. Evaluation, as a basis for improving training concepts, is essential for continual development.

European interprofessional postgraduate curriculum in palliative care: A narrative synthesis of field interviews in the region of Middle, Eastern, and Southeastern Europe and Central and West Asia.

OBJECTIVES: In 2018, a study was conducted in the Eastern and South-eastern Europe and Central Asia. National leaders of palliative care were asked to describe developments in postgraduate education in their region. They were asked whether the introduction of a European curriculum would be useful in their country. The aim was to explore the structures of postgraduate education at country level in order to define the barriers and opportunities. METHODS: This is an ethnographic study based on semi-structured field interviews. A thematic analysis was chosen for data extraction and a narrative synthesis for the systematic presentation and critical discussion of the results. RESULTS: Thirty-two interviews were recorded in 23 countries. The analysis revealed 4 main themes: (1) general barriers to access, (2) necessary to improve palliative care education, (3) palliative care core curriculum - the theoretical framework, and (4) challenges in implementation. These main themes were complemented by 19 subthemes. SIGNIFICANCE OF RESULTS: Palliative care is understood as a universal idea, which in practice means accepting social pluralism and learning to respect unique individual needs. This makes teaching palliative care a very special task because there are no golden standards for dealing with each individual as they are. In theory, a European curriculum recommendation is useful to convince governments and other key stakeholders of the importance of postgraduate education. In practice, such a curriculum needs to be adapted to the constraints of health services and human resources. Validated quality assessment criteria for palliative care education are crucial to advance postgraduate education.

Perspectives, perceived self-efficacy, and preparedness of newly qualified physicians' in practising palliative care-a qualitative study.

BACKGROUND: Dealing with life-limiting illnesses, death, dying and grief, is uncharted territory for medical graduates. It is a field that is heavily influenced by cultural, religio-spiritual and social factors. This adds complexity to palliative and end-of-life-care, which challenges newly qualified physicians and requires the formation of appropriate knowledge, skills, and attitudes in junior doctors. This study aimed to obtain insight into the perspectives, perceived self-efficacy, and preparedness of newly qualified Nigerian physicians in practising palliative care and identify potential variables influencing them. METHODS: The study was a cross-sectional, multi-centre survey of newly qualified Nigerian physicians, using semi-structured, in-depth qualitative interviews. The data were analysed by applying content-structuring qualitative content analysis. RESULTS: Forty semi-structured interviews were conducted with medical house officers at two tertiary institutions in Nigeria. The perceived self-efficacy and preparedness of newly qualified Nigerian physicians in practising palliative care were reported to be higher in areas of family involvement, and pain and symptom management than in areas of breaking bad news, prognosis, and diagnosing dying. Major influences on the young physicians' perceived self-efficacy and preparedness in practising palliative care were socio-economic circumstances of a resource-limited setting and cultural-religious considerations. In addition, the perceived impact of palliative care education and experience was documented. CONCLUSIONS: This study offers valuable insights into the perceived self-efficacy and preparedness of newly qualified physicians and reveals the influence of socio-cultural and socio-economic variables in Nigeria. Evidence of the social, cultural, and religio-spiritual dimensions of palliative care is indispensable for culturally sensitive care. These results could aid in the development of appropriate knowledge, skills, and attitudes in newly qualified physicians through culturally and contextually appropriate palliative care training measures. The results may be applicable to other sub-Saharan African settings and may be used to improve future palliative care education, training, and practice.

Palliative Care education in Armenia: perspectives of first-year Armenian physician residents.

BACKGROUND: Due to developing demographic changes, including an aging society and the increasing prevalence of non-communicable diseases, Palliative Care is increasingly highlighted as a universal healthcare need. The need for Palliative Care in Armenia is set against the context of an underdeveloped healthcare system. Further, the absence of palliative medicine within medical education, particularly undergraduate education in Armenia presents a major barrier to improving care. This research aimed to assess the perception of young Armenian physicians' understanding of Palliative Care, its perceived status in Armenia and the experience and influence of any engaged Palliative Care education. METHODS: Twenty Armenian first-year residents with different specializations were interviewed July and September 2016 regarding: understanding/knowledge, experiences, perceived competence, and expectations of Palliative Care and Palliative Care education. The transcripts from these semi-structured interviews were analyzed using Qualitative Content Analysis. RESULTS: Participants perceived that Armenia's health care system lacked sufficient Palliative Care and Palliative Care education. Although elements of Palliative Care were included in different specialty teaching, this provided just a partial understanding of typical Palliative Care patients/symptoms, approaches to holistic care, and crucially key communication skills. Challenges noted by participants in caring for Palliative Care patients included emotional difficulties, communication of diagnosis/prognosis, uninformed patients and concerns for patients, families, and physicians. Self-confidence in caring for patients with incurable illness varied. Participants hoped for increasing availability and accessibility of Palliative Care, and extension of clinical education in Palliative Care at all levels (undergraduate, postgraduate, specialization). CONCLUSIONS: Absence of training has resulted in misconceptions and ignorance of common concepts and practices in Palliative Care. Palliative Care education needs to be systematically developed and integrated into clinical training within Armenia. This research may provide a rallying call for changes within the core curricula in Armenia and may also encourage collaborative development in associated countries of the Caucasus region.

[Perceptions on handling of opioids: focus COVID-19 : A survey among anesthesiologists via the specialist societies DGAI/BDA]. / Wahrnehmungen zum Umgang mit Opioiden: Fokus COVID-19 : Eine Umfrage unter Anästhesist:innen über die Fachgesellschaften DGAI/BDA.

BACKGROUND: Opioids are part of the daily routine in anesthesiology and palliative care; however, treatment of dyspnea with opioids is presented heterogeneously in guidelines. This may result in an uncertainty concerning opioid indications and ethical concerns, especially when caring for COVID-19 patients. OBJECTIVE: We aimed to examine the perception of anesthesiologists concerning the handling of morphine as the reference opioid (subsequently termed M/O) for symptom control within and outside of a palliative care setting, including care for COVID-19 patients. MATERIAL AND METHODS: Members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Professional Association of German Anesthesiologists (BDA) received an anonymized online questionnaire (Survey Monkey®; Momentive Inc., San Mateo, CA, USA) in October 2020, containing questions regarding their perception of symptom management with M/O in general, and in particular concerning COVID-19 patients. Participants were asked to rate their perception within and outside a palliative care setting. RESULTS AND DISCUSSION: A total of 1365 anesthesiologists participated; 46% women. Most anesthesiologists were 41-60 years old (58%), worked in a hospital setting (78%), in the operating theatre (63%) and in intensive care units (49%). The majority (57%) reported > 20 years of professional experience (52%) and partial involvement in palliative care (57%). Perception of M/O handling was mostly "certain and confident" (88%) and "clearly regulated" (85%) within a palliative care setting but rated substantially lower for outside palliative care (77%/63%). When caring for COVID-19 patients, handling of M/O was even less often rated "certain and confident" (40%) or "clearly regulated" (29%) outside palliative care. Dyspnea (95%/75%), relief of the dying process (84%/51%), agitation (59%/27%) and anxiety/panic (61%/33%) were more frequently rated as general indications for morphine within versus outside palliative care. The majority of anesthesiologists disputed that M/O is given with the intention to hasten death within (87%) and outside (93%) palliative care. Highest difference in route of administration was reported for the subcutaneous administration of M/O within (76%) versus outside (33%) palliative care, followed by the intravenous route (57%/79%), while oral (66/62%) and transdermal (48%/39%) administration were reported to be used comparatively frequently. Most participants (85%) wanted more frequent involvement of palliative care consultation teams but also more team conferences (75%), supervision (72%), and training on opioid management (69%). CONCLUSION: Anesthesiologists perceived considerable uncertainty in using M/O for nonpalliative care medical settings. Highest uncertainty was seen for the care of patients with COVID-19. The prevalent use of the subcutaneous route for M/O application in palliative care can serve as inspiration for areas outside palliative care as well. Uniform interdisciplinary guidelines for symptom control including dyspnea, education and involvement of a palliative care consultation team should be more considered in the future.

Nurturing Socioculturally and Medically Appropriate Palliative Care Delivery: Lessons Learned by Israeli Medical Faculty.

Israel is one of the few countries worldwide with a national policy and defined standards of palliative care (PC); its culture is highly diverse and more traditionally oriented in comparison with Western countries. This study describes the current state of PC in Israel through examination of: (1) its current status, self-image and structural factors; (2) its relation to cultural and political characteristics; and (3) the chances, goals and obstacles of advancing PC in Israel. Face-to-face interviews were conducted at all five public medical faculties in Israel from November 2017 to February 2018. The following findings are reported: (1) definition of palliative care, (2) multidisciplinary approach, (3) special role of nurses, (4) personal perceptions of death, (5) understanding the role of medicine, (6) specialty palliative medicine, (7) religious, spiritual and cultural aspects, (8) political and economic aspects, (9) obstacles and weaknesses, and (10) prospects and goals of palliative care. Participants perceive PC as an integrative healthcare service that should be available to all patients, including children and their families, at any stage of illness. They internalize that PC principles apply regardless of ethnic, cultural, and religious background. Utilizing nurses' leadership, enhancing multidisciplinary teamwork, and person-centered approach, supports better PC to more people.

[Perceptions on the use of opioids: focus on COVID-19 : Free-text analysis of a survey in anesthesiology/intensive care, internal medicine, and palliative care]. / Wahrnehmungen zum Umgang mit Opioiden: Fokus COVID-19 : Freitext-Analyse einer Umfrage in Anästhesiologie/Intensivmedizin, Innerer Medizin und Palliativmedizin.

BACKGROUND: Opioids efficiently manage pain and dyspnea. However, guidelines on symptom management with opioids differ, which may lead to uncertainty among medical staff concerning opioid indication and ethical implication, especially when caring for COVID-19 patients. AIMS: We aimed to examine the perception of morphine/opioid (M/O) administration for symptom control within and outside palliative care, including care for COVID-19 patients, among members of the German associations for palliative medicine, internal medicine, anesthesiology and intensive care. METHODS: Participants received an anonymized online questionnaire via Survey Monkey® (Momentive Inc., San Mateo, CA, USA) regarding their general perception of symptom management with M/O. These results have been published elsewhere. For systematic and structural analysis of comments in the free-text field, we chose Phillip Mayring's method of summarizing qualitative content analysis. RESULTS: Of the n = 2202 persons who participated, 339 wrote comments in the free-text field which were categorized as follows: main categories 1) personal perceptions of COVID-19 patients, 2) administration and effect of M/O, 3) observations within the palliative care field, 4) imparting knowledge concerning M/O usage and palliative care, and 5) others. CONCLUSIONS: Some participants reported very personal perceptions and deficits of the healthcare system, especially when caring for COVID-19 patients. Uniform interdisciplinary guidelines for symptom control, more education, and support by trained staff confident in symptom control should be increasingly considered in the future.

[Perceptions on the use of opioids in COVID-19 : A survey of members of the German Association for Palliative Medicine]. / Wahrnehmungen zum Umgang mit Opioiden bei COVID-19 : Eine Umfrage unter Mitgliedern der Deutschen Gesellschaft für Palliativmedizin.

BACKGROUND: Opioids efficiently alleviate pain and dyspnea. However, guidelines on symptom management with opioids differ, which may lead to an uncertainty concerning opioid indication and ethical implication among medical staff, especially when caring for COVID-19 patients. AIMS: We aimed to examine the perception of members of the German Association for Palliative Medicine (DGP) concerning the administration of morphine as the gold standard opioid (subsequently termed M/O) for symptom control within and outside of a palliative care (PC) setting, including care for COVID-19 patients. METHODS: DGP members received an anonymized online questionnaire (Survey Monkey®) containing questions regarding their perception of symptom management with M/O in general and in particular concerning COVID-19 patients. Participants were asked to rate their perception within and outside of a PC setting. RESULTS: Of the 6129 DGP members, N = 506 participated. DGP physicians and nurses perceived handling of M/O as "certain and confident" (98%) and "clearly regulated" within PC (95%) but rated it significantly lower for outside PC (48%/38%). When caring for COVID-19 patients, handling of M/O was even less often rated "certain and confident" (26%) or "clearly regulated" (23%) for outside PC. Dyspnea (99%/52%), relief from the dying process (62%/37%), restlessness (30%/15%) and fear or panic (27%/13%) were more frequently rated as general indications for morphine within versus outside PC. Most participants (89%) wished to involve palliative care consultation teams. CONCLUSIONS: DGP members perceived substantial uncertainty in the handling of M/O for medical fields outside PC. Uniform interdisciplinary guidelines for symptom control, more education, and involvement of a PC consultation team should be increasingly considered in the future.

"The education is a mirror of where palliative care stands in Israel today": An exploration of palliative care undergraduate education at medical schools in Israel.

OBJECTIVE: Israel serves as a case study for understanding the importance of undergraduate palliative care (PC) education in implementing, developing, and enabling access to palliative care services. This article presents the findings collected from the five medical schools. METHOD: This qualitative study supported by a survey explores and describes the state of undergraduate PC education at medical schools in Israel. The survey included questions on voluntary and mandatory courses, allocation of different course models, teaching methods, time frame, content, institutions involved, and examinations. Semi-structured interviews with teaching faculty were conducted at the same locations. RESULTS: Eleven expert interviews and five surveys demonstrate that PC is taught as a mandatory subject at only two out of the five Israeli universities. To enhance PC in Israel, it needs to become a mandatory subject for all undergraduate medical students. To teach communication, cultural safety, and other basic competencies, new interactive teaching forms need to be developed and adapted. In this regard, nationwide cooperation is proposed. An exchange between medical schools and university clinics is seen as beneficial. The new generation of students is open to PC philosophy and multidimensional care provision but resources to support their growth as professionals and people remain limited. SIGNIFICANCE OF RESULTS: This study underlines the importance of teaching in PC at medical schools. Undergraduate education is a central measure of PC status and should be used as such worldwide. The improvement of the teaching situation would automatically lead to a better practical implementation for the benefit of people. Medical schools should cooperate, as the formation of expertise exchange across medical schools would automatically lead to better PC education.

Cultural implications for disclosure of diagnosis and prognosis toward terminally ill cancer patients in China: A literature review.

OBJECTIVE: Health professionals in China tend to avoid open communication with terminally ill cancer patients concerning their diagnosis and prognosis. This review aims to explore Chinese cultural beliefs and attitudes concerning disclosure and death among health professionals and cancer patients in China and to investigate preferences of terminally ill cancer patients for a "good death." METHOD: A narrative literature review was conducted in May 2020 on MEDLINE, EMBASE, and WEB OF SCIENCE to include all studies with clear study design which presented its own study data or referred to data within underlying studies, published between January 2000 and May 2020, having cancer patients and/or healthcare professionals as participants, conducted in Mainland China, Hong Kong, or Taiwan and containing relevant data concerning "medical disclosure" or "good death." Quality assessment of publications was conducted using the NIH and CASP checklists. RESULTS: Primary database search revealed a total of 108 papers of which 9 were ultimately included. The additional hand search led to the inclusion of eight further papers. In total, there were 11 quantitative studies, 4 qualitative studies and 2 literature reviews included in this review. Our findings indicated that most terminally ill cancer patients in China want to know the truth about their diagnosis and prognosis and preferred to be informed by their doctors. Terminally ill cancer patients valued a good relationship with family and medical staff as well as being respected as an individual and wanted to be able to prepare for death. SIGNIFICANCE OF RESULTS: Terminally ill cancer patients in China often have a substantial need for information about their condition while their preferences are widely consistent with those in Western societies. Training for health professionals needs to focus on communication skills in order to overcome barriers in patient interaction.