European Respiratory Society clinical practice guideline on symptom management for adults with serious respiratory illness.

Respiratory symptoms are ubiquitous and impair health-related quality of life in people with respiratory disease. This European Respiratory Society (ERS) task force aimed to provide recommendations for symptomatic treatment in people with serious respiratory illness. The ERS task force comprised 16 members, including representatives of people with serious respiratory illness and informal caregivers. Seven questions were formulated, six in the PICO (Population, Intervention, Comparison, Outcome) format, which were addressed with full systematic reviews and evidence assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). One question was addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. To treat symptoms in people with serious respiratory illness, the task force suggests the use of graded exercise therapy (conditional recommendation, low certainty of evidence); and suggests the use of a multicomponent services, handheld fan and breathing techniques (conditional recommendations, very low certainty of evidence). The task force suggests not to use opioids (conditional recommendation, very low certainty of evidence); and suggests either administering or not administering supplemental oxygen therapy (conditional recommendation, low certainty of evidence). The task force suggests that needs assessment tools may be used as part of a comprehensive needs assessment, but do not replace patient-centred care and shared decision making (conditional recommendation, low certainty of evidence). The low certainty of evidence, modest impact of interventions on patient-centred outcomes, and absence of effective strategies to ameliorate cough highlight the need for new approaches to reduce symptoms and enhance wellbeing for individuals who live with serious respiratory illness.

Opportunistic screening for COPD among socially marginalized patients.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common disease associated with premature death. Tobacco exposure is the main risk factor, but lower socioeconomic status, early life insults, and occupational exposures are also important risk factors. Socially marginalized people, facing homelessness, substance use disorder, and mental illness, are likely to have a higher risk of developing COPD, and, furthermore, experience barriers to healthcare access and consequently poorer outcomes. OBJECTIVE: This study aims to assess COPD prevalence and the impact of opportunistic screening among hospitalized patients who are in contact with hospital social nurses. These patients constitute a group of patients with a high prevalence of psychiatric and somatic diseases, substance use, low life expectancy, and are socially marginalized. METHODS: The present prospective longitudinal study includes a clinical examination at baseline. Participants will have spirometry done and be interviewed regarding risk factors, socioeconomic conditions, and respiratory symptoms. The 5-year follow-up assessment incorporates data from baseline and register data over the 5 years, including information on morbidity, use of COPD medication, hospital contacts, mortality, and socioeconomic factors. ANTICIPATED RESULTS: Referral for further diagnostic work-up and management after the screening, including COPD treatment and smoking cessation support, is expected to improve survival rates. The study is still enrolling patients. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov , NCT04754308 with study status: "enrolling".

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease.

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

Considerable gaps and differences in rehabilitation after major lower extremity amputations across regions and municipalities in Denmark - A national survey.

INTRODUCTION: Equal access to healthcare is a fundamental principle in the fully tax-financed Danish healthcare system. This study reveals whether this system lives up to the principle of equal access when it comes to the rehabilitation of patients who have major lower extremity amputations. METHODS: With the aim of exploring possible inequality in rehabilitation for patients having major lower extremity amputation in Denmark, a nationwide electronic survey was conducted in the autumn of 2020, which included all hospitals and municipalities in Denmark. RESULTS: Eighty six percent of hospitals (n = 19) and 97% (n = 95) of municipalities responded. Of the 32% (n = 6) of hospitals and 78% (n = 74) of municipalities that provided prosthesis rehabilitation, the majority (hospitals 50% /municipalities 91%) provided prostheses for <10 patients in 2019, and 36% reported having competencies at only a general level among physiotherapists performing prosthetic training. Psychosocial rehabilitation modalities were lacking overall. CONCLUSIONS: This national study documents pronounced geographic inequality in access to qualified rehabilitation services for the relatively few patients undergoing lower extremity amputations in Denmark. The decentralised organisation of amputation rehabilitation makes it difficult to build and maintain specialist competencies among healthcare professionals. Inconsistent availability of psychosocial rehabilitation modalities of all kinds found in this study points to a need for action particularly among patients not in prosthetic rehabilitation where palliative needs should also be considered.

Is it okay to choose to receive bad news by telephone? An observational study on psychosocial consequences of diagnostic workup for lung cancer suspicion.

BACKGROUND: In-person meeting is considered the gold standard in current communication protocols regarding sensitive information, yet one size may not fit all, and patients increasingly demand or are offered disclosure of bad news by, e.g., telephone. It is unknown how patients' active preference for communication modality affect psychosocial consequences of receiving potentially bad news. AIM: To explore psychosocial consequences in patients, who themselves chose to have results of lung cancer workup delivered either in-person or by telephone compared with patients randomly assigned to either delivery in a recently published randomised controlled trial (RCT). METHODS: An observational study prospectively including patients referred for invasive workup for suspected lung cancer stratified in those declining (Patient's Own Choice, POC group) and those participating in the RCT. On the day of invasive workup and five weeks later, patients completed a validated, nine-dimension, condition-specific questionnaire, Consequences of Screening in Lung Cancer (COS-LC). Primary outcome: difference in change in COS-LC dimensions between POC and RCT groups. RESULTS: In total, 151 patients were included in the POC group versus 255 in the RCT. Most (70%) in the POC group chose to have results by telephone. Baseline characteristics and diagnostic outcomes were comparable between POC and RCT groups, and in telephone and in-person subgroups too. We observed no statistically significant between-groups differences in any COS-LC score between POC and RCT groups, or between telephone and in-person subgroups in the POC group. CONCLUSION: Continually informed patients' choice between in-person or telephone disclosure of results of lung cancer workup is not associated with differences in psychosocial outcomes. The present article supports further use of a simple model for how to prepare the patient for potential bad news.

Breaking potentially bad news of cancer workup to well-informed patients by telephone versus in-person: A randomised controlled trial on psychosocial consequences.

BACKGROUND: The use of telephone in delivering cancer care increases, but not in cancer workup. Current protocols for breaking bad news assume a single in-person meeting. Cancer workup involves multiple opportunities for patient information. We investigated the psychosocial consequences in gradually informed patients of receiving lung cancer workup results by telephone versus in-person. METHODS: A randomised, controlled, open-label, assessor-blinded, single-centre trial including patients referred for invasive workup for suspected malignancy (clinical trials no. NCT04315207). Patients were informed on probable cancer at referral, after imaging, and on the day of invasive workup (Baseline visit). Primary endpoint: change (Δ) from baseline to follow-up (4 weeks after receiving workup results) in scores of a validated, sensitive, condition-specific questionnaire (COS-LC) assessing consequences on anxiety, behaviour, dejection and sleep. RESULTS: Of 492 eligible patients, we randomised 255 patients (mean age: 68 years; female: 38%; malignancy diagnosed: 68%) to the telephone (n = 129) or in-person (n = 126) group. Groups were comparable at baseline and follow-up, and no between-groups difference in ΔCOS-LC was observed in the intention-to-treat population, or in subgroups diagnosed with or without malignancy. CONCLUSION: Breaking final result of cancer workup by telephone is not associated with adverse psychosocial consequences compared to in-person conversation in well-informed patients.

Regional and age differences in specialised palliative care for patients with pancreatic cancer.

BACKGROUND: Despite national recommendations, disparities in specialised palliative care (SPC) admittance have been reported. The aims of this study were to characterize SPC admittance in patients with pancreatic cancer in relation to region of residence and age. METHOD: The data sources were two nationwide databases: Danish Pancreatic Cancer Database and Danish Palliative Care Database. The study population included patients (18+ years old) diagnosed with pancreatic cancer from 2011 to 2018. We investigated admittance to SPC, and time from diagnosis to referral to SPC and first contact with SPC to death by region of residence and age. RESULTS: In the study period (N = 5851) admittance to SPC increased from 44 to 63%. The time from diagnosis to referral to SPC increased in the study period and overall, the median time was 67 days: three times higher in Southern (92 days) than in North Denmark Region. The median number of days from diagnosis to referral to SPC was lower in patients ≥70 years (59 days) vs patients < 70 years (78 days), with regional differences between the age groups. Region of residence and age were associated with admittance to SPC; highest for patients in North Denmark Region vs Capital Region (OR = 2.03 (95%CI 1.67-2.48)) and for younger patients (< 60 years vs 80+ years) (OR = 2.54 (95%CI 2.05-3.15)). The median survival from admittance to SPC was 35 days: lowest in Southern (30 days) and highest in North Denmark Region (41 days). The median number of days from admittance to SPC to death was higher in patients < 70 years (40 days) vs ≥ 70 years (31 days), with a difference between age groups in the regions of 1-14 days. CONCLUSIONS: From 2011 to 2018 more patients with pancreatic cancer than previously were admitted to SPC, with marked differences between regions of residence and age groups. The persistently short period of time the patients are in SPC raises concern that early integrated palliative care is not fully integrated into the Danish healthcare system for patients with pancreatic cancer, with the risk that the referral comes so late that the patients do not receive the full benefit of the SPC.

COVID-19: guidance on palliative care from a European Respiratory Society international task force.

BACKGROUND: Many people are dying from coronavirus disease 2019 (COVID-19), but consensus guidance on palliative care in COVID-19 is lacking. This new life-threatening disease has put healthcare systems under pressure, with the increased need of palliative care provided to many patients by clinicians who have limited prior experience in this field. Therefore, we aimed to make consensus recommendations for palliative care for patients with COVID-19 using the Convergence of Opinion on Recommendations and Evidence (CORE) process. METHODS: We invited 90 international experts to complete an online survey including stating their agreement, or not, with 14 potential recommendations. At least 70% agreement on directionality was needed to provide consensus recommendations. If consensus was not achieved on the first round, a second round was conducted. RESULTS: 68 (75.6%) experts responded in the first round. Most participants were experts in palliative care, respiratory medicine or critical care medicine. In the first round, consensus was achieved on 13 recommendations based upon indirect evidence and clinical experience. In the second round, 58 (85.3%) out of 68 of the first-round experts responded, resulting in consensus for the 14th recommendation. CONCLUSION: This multi-national task force provides consensus recommendations for palliative care for patients with COVID-19 concerning: advance care planning; (pharmacological) palliative treatment of breathlessness; clinician-patient communication; remote clinician-family communication; palliative care involvement in patients with serious COVID-19; spiritual care; psychosocial care; and bereavement care. Future studies are needed to generate empirical evidence for these recommendations.

Soluble urokinase plasminogen activator receptor predicts mortality in exacerbated COPD.

BACKGROUND: The inflammatory biomarker soluble urokinase plasminogen activator receptor (suPAR) is elevated in severe acute and chronic medical conditions and has been associated with short-term mortality. The role of suPAR in predicting risk of death following an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has never been studied. We hypothesized that increased suPAR is an independent predictor of short-term mortality in patients admitted to hospital with COPD or acute respiratory failure. METHODS: This retrospective cohort study from a university hospital in the Capital Region of Denmark included 2838 acutely admitted medical patients with COPD as primary (AECOPD) or secondary diagnosis, who had plasma suPAR measured at the time of admission between November 18th, 2013 to September 30th, 2015 and followed until December 31st, 2015. Primary outcomes were 30- and 90-days all-cause mortality. Association of suPAR and mortality was investigated by Cox regression analyses adjusted for age, sex, CRP values and Charlson comorbidity index. RESULTS: For patients with AECOPD or underlying COPD, median suPAR levels were significantly higher among patients who died within 30 days compared with those who survived (5.7 ng/ml (IQR 3.8-8.1) vs. 3.6 ng/ml (2.7-5.1), P < 0.0001). Increasing suPAR levels independently predicted 30-day mortality in patients with COPD with a hazard ratio of 2.0 (95% CI 1.7-2.4) but not respiratory failure. CONCLUSIONS: In this large group of acutely admitted patients with COPD, elevated suPAR levels were associated with increased risk of mortality. The study supports the value of suPAR as a marker of poor prognosis.

First year experiences with a palliative out-patients structure for patients with COPD: a qualitative study of health professionals' expectations and experiences.

BACKGROUND: To improve the care of patients with advanced COPD and be able to address their palliative needs a new outpatient organization (CAPTAIN) was developed and implemented. CAPTAIN was inspired by best practice and existing guidelines and changed the traditional organization of an outpatient structure including the roles of nurses and doctors. Only sparse knowledge exists of the health professionals' expectations and experiences to organizational changes in an outpatient setting. This insight is necessary as health professionals are key stakeholders in implementing new structures and successfully transforming knowledge into practice. The aim of this study was to explore the health professionals' expectations and experiences of a new palliative out-patients structure for patients with advanced COPD. METHODS: The design was interpretive description as described by Thorne. Focus groups and individual interviews were conducted with pulmonary nurses, pulmonary doctors and municipality nurses from 2014 to 2016. RESULTS: The overall theme was dualism. Both nurses and doctors were pending between aspiration and concern in their expectations to the new structure, meanwhile their actual experiences were pending between perceived gain and improvements versus consequences with the new structure. Nurses' and doctors' existing practice was altered and the new structure required new ways for them to cooperate and ways in which skills from each profession were most efficiently utilized. CONCLUSION: Nurses and doctors considered the new structure as a quality boost and it fulfilled their hope of improving the quality of care offered to patients with advanced COPD, however with increased work-related stress as a derived consequence.

The lived experience with idiopathic pulmonary fibrosis: a qualitative study.

The disease course in idiopathic pulmonary fibrosis (IPF) is variable, but patients experience a progressive decline in lung function and increased symptom burden leading to death. Little is known about the patients' experience and their needs during the disease course or about the burden on family caregivers. Both patients and family caregivers face an altered life as the disease progresses. The aim of our study was to increase knowledge of life with IPF for patients and family caregivers.This study had a qualitative descriptive design using in-depth dyadic interviews with IPF patients (n=25) and family caregivers (n=24). We used the five-step analysis from the framework method and analysed the data on three levels: the patient, the family caregivers and couple level.The following six themes emerged as the main results: information and disclosure, reactional dyssynchrony, perpetual vigilance, emotional ambivalence, gradual and tacit role shift, and adapted coping strategies.Our findings suggest that IPF patients need information at the time of diagnosis, but some issues should be paced as the disease progresses. A palliation plan was demanded by patients and their caregivers. Further efforts are required to provide palliative care to IPF patients starting at the time of diagnosis.

Prevalence and management of pulmonary comorbidity in patients with lung and head and neck cancer.

BACKGROUND: The simultaneous presence of cancer and other medical conditions (comorbidity) is frequent. Cigarette smoking is the major risk factor for as well head and neck cancer (HNC) and lung cancer (LC) as chronic obstructive pulmonary disease (COPD). COPD is the most common comorbidity in LC patients, and presence of COPD worsens the prognosis of HNC and LC. COPD is under-diagnosed and under-treated in the Danish population. The aims of this study were to determine the prevalence of COPD in a HNC and LC population, and to determine the need and feasibility of a randomized controlled phase II trial comparing usual care with optimized medical treatment of COPD in cancer patients. MATERIAL AND METHODS: All patients with HNC or LC referred for oncologic treatment in a university hospital during a 10-month period were invited to attend a pulmonary clinic for evaluation of lung function. Patients who were found to have concomitant COPD were randomized to intervention or usual care. Primary endpoints were prevalence of COPD among the referred patients with either LC or HNC, and further whether the patients that were diagnosed with COPD already received treatment in accordance with Danish COPD guidelines. Secondary outcome was feasibility, i.e. the proportion of eligible patients that accepted follow-up in the pulmonary clinic for 24 weeks in addition to oncological treatment. The design of the randomized trail is described in detail. RESULTS: In total 130 patients of whom 65% had LC and 35% HNC have been screened during the first seven months of this ongoing trial. Sixty-eight percent of LC patients and 22% of HNC patients had COPD. All but one of 68 eligible patients accepted randomization. Nearly one third (31%) of the LC and HNC patients with COPD were diagnosed prior to study entry, and of these, only 33% were receiving correct treatment according to current guidelines. CONCLUSION: For patients with LC, and to a lesser extend HNC, there is a need for improved diagnosis and treatment of concomitant COPD. Furthermore, patients found it acceptable to be scheduled for a 24-week follow-up in a pulmonary clinic along with their oncological treatment.

Midazolam Indications and Dosing in Palliative Medicine: Results from a Multinational Survey.

Despite sparse evidence and limited guidance on indications, use, and dosing, midazolam is widely used in palliative care. We aimed to describe and compare the use of midazolam in three different countries to improve clinical practice in palliative care. We performed an online survey among palliative care physicians in Norway, Denmark, and the United Kingdom (UK). The focus was indications, dosing, administration, and concomitant drugs. A web-based questionnaire was distributed to members of the respective national palliative medicine associations. The total response rate was 9.4%. Practices in the UK, Norway, and Denmark were overall similar regarding the indications of midazolam for anxiety, dyspnoea, and pain treatment in combination with opioids. However, physicians in the UK used a higher starting dose for anxiety, dyspnoea, and pain treatment compared to Norway and Denmark, as well as a higher maximum dose. Danish physicians preferred, to a higher degree, on-demand midazolam administration. Despite practice similarities in the UK, Norway, and Denmark, differences exist for midazolam dosing and administration in palliative medicine. We demonstrated a lack of consensus on how midazolam should be used in palliative care, setting the stage for future studies on the topic.

When and how to stop palliative antineoplastic treatment and to organise palliative care for patients with incurable cancer.

BACKGROUND: Improving the organisational aspects of the delivery of palliative care in order to support patients throughout their disease trajectory has received limited attention. AIM: To investigate the opportunities and barriers related to organising palliation for people with terminal cancer and their families. METHODS: An explorative interview study was conducted among 31 nurses and three physicians concerning an intervention facilitating a fast transition from treatment at a cancer centre at a university hospital to palliation at home. A thematic analysis was conducted. FINDINGS: This article presents three out of seven themes: 1) improvement in the cessation of antineoplastic treatment in palliation; 2) improvement in organisations delivering palliation; and 3) improvement in multidisciplinary and cross-sectoral collaboration. CONCLUSIONS: The results demonstrate the demand for flexible, family-centred and integrated palliation at all levels, from communication and the collaborative relationship between healthcare professionals and families to service sectors.

Combined rehabilitation and palliative care interventions for patients with life-threatening diseases - PREGOAL. A scoping review of intervention programme goals.

PURPOSE: WHO recommends integrating rehabilitation into palliative care when providing services for people with life-threatening conditions. Recently, there has been increasing interest in exploring how rehabilitation and palliative care approaches could be combined. The aim of this study was to map and discuss the goals of intervention programmes that combine rehabilitation and palliative care. METHODS: A scoping review was performed. The electronic databases MEDLINE, EMBASE, and CINAHL were searched for papers published between January 2014 and September 2022. Papers were considered eligible if the participants in question had a life-threatening disease and if interventions included both rehabilitation and palliative care. All study types were included. RESULTS: Ten papers describing five interventions were included. Qualitative goals were narratively described, and quantitative goals were analysed according to the International Classification of Functioning, Disability and Health, and the Total Pain framework. Findings showed an overall focus on functioning and quality of life. Further analysis indicated an emphasis on physical and psychological dimensions. Social participation, and the social and spiritual dimensions were rarely evaluated. CONCLUSION: This review indicates that goals relative to social participation, the social and spiritual dimensions, and the patient's own goals may well be overlooked as points of orientation for interventions.

There is an increasing interest in combining palliative care and rehabilitation approaches in clinical work.When rehabilitation and palliative care are combined, goals may be overlooked, and the patient's own goals can be used as a point of orientation for interventions.Future practice should pay special attention to subjective goals, social participation, and the social and spiritual dimensions when combining rehabilitation and palliative care.

Development of a systematic multidisciplinary clinical and teaching model for the palliative approaches in patients with severe lung failure.

Palliative medicine has traditionally focused on people affected by cancer with rapidly advancing disease progression. However, as more people live longer time with serious illnesses, including lung diseases, the need of palliative care for these patients if also increasing. There is a lack of research and clinical knowledge about what palliative care is for people affected by chronic obstructive pulmonary disease and interstitial lung disease. The aim of this paper is to describe the development process of an easy to use and clinically relevant model for the palliative care approach in people affected by severe illnesses. The developed model consists of four components, which originated the title" 4,2,4,2 model". Each number has a specific meaning: the first 4 = the four disease trajectories that patients may experience; 2 = the two forms of knowledge, objective, and intuitive that must be achieved by the health professionals to gain an understanding of the situation; 4 = the four dimensions of suffering physically, mentally, socially and existentially/spiritually; and 2 = the two roles that health-care professionals must be able to take in when treating patients with serious illnesses. The 4-2-4-2 model proposes an easy-to-use and clinically relevant model for palliative approach and integration of PC and pulmonary medicine. Another important purpose of this model is to provide HPs with different educational backgrounds and from different medical fields with a 'golden standard approach' to enhance the focus of the palliative approach in both the clinic and teaching. The effect and consequences of the use of the 4-2-4-2 model should be explored in future clinical trials. Furthermore, it should be investigated whether teaching the model creates a change in clinical approach to patients with serious illnesses as well as whether these changes are long-lasting.

The significance of the COVID-19 pandemic for family caregivers of non-COVID-19 patients in need of specialized palliative care at home: a qualitative study.

PURPOSE: It is well known that being a family caregiver of a palliative patient in general is rewarding as well as burdensome. The COVID-19 pandemic may have exacerbated this situation. We therefore explored the significance of the COVID-19 pandemic for family caregivers of non-COVID-19 patients in need of specialized palliative care at home. METHODS: Open-ended, semi-structured telephone interviews were conducted with 15 family caregivers of patients treated by a specialized palliative outpatient unit in a Danish hospital. Interviews were analysed using inductive thematic analysis. RESULTS: Four themes concerning the significance of the COVID-19 pandemic were identified: 1) being a family caregiver of a patient whose lifespan is already limited, 2) dealing with the risk of passing on COVID-19 oneself, 3) dealing with the risk of others passing on COVID-19 to the patient at home, and 4) living with modified specialized palliative care. CONCLUSION: The COVID-19 pandemic had a radical impact on some family caregivers causing emotional despair. They feared not only infecting the patient with SARS-CoV-2 to cause an untimely death but also being unable to be there for the patient during hospitalization, especially in the patient's final days.

Burnout in physicians: a survey of the Danish society for palliative medicine.

OBJECTIVES: Burnout, which is a state of prolonged physical and psychological exhaustion, seems to be a prevalent and serious problem among healthcare workers. Our aim was to investigate the prevalence of burnout symptoms among members of Danish Society of Palliative Medicine (DSPaM). METHODS: All 160 physician members of DSPaM were invited to a questionnaire survey. The Copenhagen Burnout Inventory (CBI) was used to evaluate and differentiate between personal, work-related and client-related burnout. RESULTS: 76 members responded (47,5%). 51% regularly received supervision. Scores on personal burnout demonstrated that 25% had no symptoms and 55% had symptoms that required attention; however, no respondents needed immediate intervention. Regarding work-related burnout: 40% had no symptoms, 20% had symptoms that needed attention and 3% needed immediate help. Regarding client-related burnout: 65% had no symptoms, 32% had symptoms that needed attention and none needed immediate intervention. CONCLUSIONS: This survey demonstrated a relatively low rate of burnout symptoms among members of the DSPaM. In particular, the client-related burnout score was low, while higher scores were observed in personal and work-related burnout. Despite the relatively low overall levels of burnout, it is notable that about half of the physicians reported personal burnout, which needs to be addressed.

Pride and Uncertainty: A Qualitative Study of Danish Nursing Staff in Temporary COVID-19 Wards.

There is limited knowledge about the psychosocial stress among the nursing staff working on the COVID-19 wards. This article reports on the experiences of frontline health care workers as it was described to supervisors counseling the nursing staff engaged in the response to the outbreak of COVID-19. Frontline health care workers, nurses, and nurses' aides experienced major work changes. Some were transferred to the newly formed COVID-19 wards in a large Danish hospital, were given new tasks, and had to collaborate with new colleagues, while treating a new deadly and contagious disease. This study aimed to describe the reflections and experiences of the nursing staff attending supervision sessions. The palliative unit offered supervision from April 2020. A total of 9 supervision sessions were held as part of this study, and 57 nursing staff members participated in the sessions. The supervision was available to employees until the first COVID wave subsided in June 2020. During each session, supervisors took field notes and wrote field memos. The topics raised by the nursing staff during the supervision sessions ranged between pride and uncertainty. Nursing staff in COVID-19 wards were at risk of feeling an increasing burden, and there was a need for ongoing managerial attention as well as continuous visible presence and support.