A Systematic Scoping Review on Dignity Assessment Tools.

CONTEXT: The provision of person-centered dignity-conserving care is central to palliative care. It is important to reevaluate current methods of assessing dignity as the concept of dignity is multifaceted. OBJECTIVES: The aim of this study is to understand the tools which are used to assess a patient's dignity and the elements of dignity evaluated in these tools. METHODS: Two independent and concurrent Systematic Evidence-Based Approach guided systematic scoping reviews (SSR in SEBA) on existing dignity assessment tools and on accounts of assessments of dignity were carried out. The SSR in SEBA on dignity assessment tools involving PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Scopus, and CINAHL databases saw 22 full-text articles included from the 645 articles reviewed. The SSR in SEBA on accounts of assessments of dignity featured in the PubMed database identified 102 full-text articles which saw 46 articles included. RESULTS: The domains identified were factors affecting patients' definition of dignity; elements of dignity-conserving care; and components of effective tools. CONCLUSION: Current accounts to assess dignity and assessment tools fail to capture shifting self-concepts of dignity holistically. A portfolio-like appraisal of dignity is proposed to achieve assessments that are timely, longitudinal, and patient-specific. Portfolio-based assessments by members of the multidisciplinary team will better direct timely evaluations of relevant aspects of changing concepts of dignity, without losing the patient's holistic perception of dignity.

The role of patients' stories in medicine: a systematic scoping review.

BACKGROUND: Patients' stories provide Palliative Care physicians with a glimpse into the former's lives and their psycho-emotional, sociocultural, and contextual considerations. Yet, few physicians are trained to interpret and apply patients' stories in their practice. Inherent variability in how stories are transmitted and interpreted raises questions over their potential effects on care. Amidst a dearth of accounts in Palliative Care, we map current use of patient stories to guide the training, assessment, and oversight of this 'care influencing' practice in medicine. METHODS: This systematic scoping review was guided by the Systematic Evidence-Based Approach (SEBA) to ensure a reproducible and structured approach. The themes and categories identified through the Split Approach's concurrent and independent thematic and directed content analyses provided a comprehensive sketch of the included articles. The Jigsaw Perspective combined the themes and categories identified. The last stage of SEBA compared these results with two recent reviews of storytelling to ensure consistency of the domains created that guided the discussion. RESULTS: Ten thousand two hundred seven articles were reviewed, 963 full text articles were evaluated, and 199 articles were included. The four domains identified were study characteristics, benefits, approaches, and positive effects and concerns. CONCLUSION: Stories support patient-centered, personalized, and holistic clinical care. However, variability in the stories, their interpretations and use in care decisions underscore the need for further study on the structuring, teaching, assessing, and delivery of this 'care influencing' practice.

Professional identity formation amongst peer-mentors in a research-based mentoring programme.

BACKGROUND: Mentoring plays a pivotal yet poorly understood role in shaping a physician's professional identity formation (PIF) or how they see, feel and act as professionals. New theories posit that mentoring nurtures PIF by functioning as a community of practice through its structured approach and its support of a socialisation process made possible by its assessment-directed personalized support. To test this theory and reshape the design, employ and support of mentoring programs, we evaluate peer-mentor experiences within the Palliative Medicine Initiative's structured research mentoring program. METHODS: Semi-structured interviews with peer mentors under the Palliative Medicine Initiative (PMI) at National Cancer Centre Singapore were conducted and triangulated against mentoring diaries to capture longitudinal data of their PMI experiences. The Systematic Evidence-Based Approach (SEBA) was adopted to enhance the trustworthiness of the data. SEBA employed concurrent content and thematic analysis of the data to ensure a comprehensive review. The Jigsaw Perspective merged complementary themes and categories identified to create themes/categories. The themes/categories were compared with prevailing studies on mentoring in the Funnelling Process to reaffirm their accuracy. RESULTS: Twelve peer-mentors participated in the interviews and eight peer-mentors completed the mentoring diaries. The domains identified were community of practice and identity work. CONCLUSIONS: The PMI's structured mentoring program functions as a community of practice supporting the socialisation process which shapes the peer-mentor's belief system. Guided by a structured mentoring approach, stage-based assessments, and longitudinal mentoring and peer support, peer-mentors enhance their detection and evaluation of threats to their regnant belief system and adapt their self-concepts of identity and personhood to suit their context. These insights will help structure and support mentoring programs as they nurture PIF beyond Palliative Medicine.

Physician-patient boundaries in palliative care.

BACKGROUND: Nurturing effective physician-patient relationships is essential to the provision of patient-centred care. Palliative care physicians may apply boundary-crossings or breaches in professional standards to nurture effective physician-patient relationships. Being highly individualized and shaped by the physician's narratives, clinical experience, and contextual considerations, boundary-crossings are susceptible to ethical and professional violations. To better appreciate this concept, we employ the Ring Theory of Personhood (RToP) to map the effects of boundary-crossings on the physician's belief systems. METHODS: As part of the Tool Design SEBA methodology, a Systematic Evidence-Based Approach (SEBA) guided systematic scoping review was employed to guide the design of a semi-structured interview questionnaire with palliative care physicians. The transcripts were simultaneously content and thematically analysed. The themes and categories identified were combined using the Jigsaw Perspective and the resulting domains formed the basis for the discussion. RESULTS: The domains identified from the 12 semi-structured interviews were catalysts and boundary-crossings. Boundary-crossings attempt to address threats to a physician's belief systems (catalysts) and are highly individualized. Employ of boundary-crossings depend on the physician's sensitivity to these 'catalysts', their judgement and willingness to act, and their ability to balance various considerations and reflect on their actions and their ramifications. These experiences reshape belief systems, understandings of boundary-crossings and may influence decision-making and practice, underscoring the potential for greater professional breaches when unchecked. CONCLUSION: Underlining its longitudinal effects, the Krishna Model underscores the importance of longitudinal support, assessment and oversight of palliative care physicians, and lays the foundation for a RToP-based tool to be employed within portfolios.

Assessing professional identity formation (PIF) amongst medical students in Oncology and Palliative Medicine postings: a SEBA guided scoping review.

BACKGROUND: Introduction to a multi-professional team who are working and caring for the dying, and facing complex moral and ethical dilemmas during Oncology and Palliative Medicine postings influence a medical student's professional identity formation (PIF). However, limited appreciation of PIF, inadequate assessments and insufficient support jeopardise this opportunity to shape how medical students think, feel and act as future physicians. To address this gap, a systematic scoping review (SSR) of PIF assessment methods is proposed. METHODS: A Systematic Evidence-based Approach (SEBA) guided SSR of assessments of PIF in medical schools published between 1st January 2000 and 31st December 2021 in PubMed, Embase, ERIC and Scopus databases was carried out. Included articles were concurrently content and thematically analysed using SEBA's Split Approach and the themes and categories identified were combined using SEBA's Jigsaw Perspective. The review hinged on the following questions: "what is known about the assessment of professional identity formation amongst medical students?", "what are the theories and principles guiding the assessment of professional identity formation amongst medical students?", "what factors influence PIF in medical students?", "what are the tools used to assess PIF in medical students?", and "what considerations impact the implementation of PIF assessment tools amongst medical students?". RESULTS: Two thousand four hundred thirty six abstracts were reviewed, 602 full-text articles were evaluated, and 88 articles were included. The 3 domains identified were 1) theories, 2) assessment, and 3) implementation in assessing PIF. Differing attention to the different aspects of the PIF process impairs evaluations, jeopardise timely and appropriate support of medical students and hinder effective implementation of PIF assessments. CONCLUSION: The Krishna-Pisupati model combines current theories and concepts of PIF to provide a more holistic perspective of the PIF process. Under the aegis of this model, Palliative Care and Oncology postings are envisaged as Communities of Practice influencing self-concepts of personhood and identity and shaping how medical students see their roles and responsibilities as future physicians. These insights allow the forwarding of nine recommendations to improve assessments of PIF and shape the design of a PIF-specific tool that can direct timely and personalized support of medical students.

Enhancing Mentoring in Palliative Care: An Evidence Based Mentoring Framework.

BACKGROUND: Growing concerns over ethical issues in mentoring in medicine and surgery have hindered efforts to reinitiate mentoring for Palliative Care (PC) physicians following the easing of COVID-19 restrictions. Ranging from the misappropriation of mentee's work to bullying, ethical issues in mentoring are attributed to poor understanding and structuring of mentoring programs, underlining the need for a consistent approach to mentoring practices. METHODS: Given diverse practices across different settings and the employ of various methodologies, a novel approach to narrative reviews (NR)s is proposed to summarize, interpret, and critique prevailing data on novice mentoring. To overcome prevailing concerns surrounding the reproducibility and transparency of narrative reviews, the Systematic Evidenced Based Approach (SEBA) adopts a structured approach to searching and summarizing the included articles and employed concurrent content and thematic analysis that was overseen by a team of experts. RESULTS: A total of 18 915 abstracts were reviewed, 62 full text articles evaluated and 41 articles included. Ten themes/categories were ascertained identified including Nature; Stakeholders; Relationship; Approach; Environment; Benefits; Barriers; Assessments; Theories and Definitions. CONCLUSION: By compiling and scrutinizing prevailing practice it is possible to appreciate the notion of the mentoring ecosystem which sees each mentee, mentor, and host organization brings with them their own microenvironment that contains their respective goals, abilities, and contextual considerations. Built around competency based mentoring stages, it is possible to advance a flexible yet consistent novice mentoring framework.

Structuring Mentoring in Medicine and Surgery. A Systematic Scoping Review of Mentoring Programs Between 2000 and 2019.

INTRODUCTION: Evidence of novice mentoring's successes in having senior clinicians support junior doctors and/or medical students in their clinical, academic, and research goals has spurred efforts to include mentoring in the core medical curriculum. However, lack of effective structuring threatens the viability of mentoring programs, precipitating ethical concerns about mentoring. This review aims to answer the question "what is known about mentoring structures in novice mentoring among medical students and junior doctors in medicine and surgery postings?," which will guide the design of a consistent structure to novice mentoring. METHODS: Levac (2010)'s framework was used to guide this systematic scoping review of mentoring programs in medicine and surgery published between 1 January 2000 and 31 December 2019 in PubMed, ScienceDirect, ERIC, Embase, Scopus, Mednar, and OpenGrey. A "split approach" involving concurrent independent use of a directed content analysis and thematic approach was used to analyze included articles. RESULTS: Three thousand three hundred ninety-five abstracts were identified. There was concordance between the 3 themes and categories identified in analyzing the 71 included articles. These were the host organization, mentoring stages, and evaluations. CONCLUSION: The data reveal the need for balance between ensuring consistency and flexibility to meet the individual needs of stakeholders throughout the stages of the mentoring process. The Generic Mentoring Framework provides a structured approach to "balancing" flexibility and consistency in mentoring processes. The Generic Mentoring Framework is reliant upon appropriate, holistic, and longitudinal assessments of the mentoring process to guide adaptations to mentoring processes and ensure effective support and oversight of the program.

A Systematic Scoping Review of Ethical Issues in Mentoring in Surgery.

BACKGROUND: Mentoring is crucial to the growth and development of mentors, mentees, and host organisations. Yet, the process of mentoring in surgery is poorly understood and increasingly mired in ethical concerns that compromise the quality of mentorship and prevent mentors, mentees, and host organisations from maximising its full potential. A systematic scoping review was undertaken to map the ethical issues in surgical mentoring to enhance understanding, assessment, and guidance on ethical conduct. METHODS: Arksey and O'Malley's methodological framework was used to guide a systematic scoping review involving articles published between January 1, 2000 and December 31, 2018 in PubMed, Embase, Scopus, ERIC, ScienceDirect, Mednar, and OpenGrey databases. Braun and Clarke's thematic analysis approach was adopted to compare ethical issues in surgical mentoring across different settings, mentee and mentor populations, and host organisations. RESULTS: A total of 3849 abstracts were identified, 464 full-text articles were retrieved, and 50 articles were included. The 3 themes concerned ethical lapses at the levels of mentor or mentee, mentoring relationships, and host organisation. CONCLUSIONS: Mentoring abuse in surgery involves lapses in conduct, understanding of roles and responsibilities, poor alignment of expectations, and a lack of clear standards of practice. It is only with better structuring of mentoring processes and effective support of host organisation tasked with providing timely, longitudinal, and holistic assessment and oversight will surgical mentoring overcome prevailing ethical concerns surrounding it.

Effectiveness of Hospital Palliative Care Teams for Cancer Inpatients: A Systematic Review.

BACKGROUND: Although the benefits of palliative care in the outpatient setting are well established, there has been little to support the employing of hospital palliative care services for inpatients with cancer. OBJECTIVE: We conducted a systematic literature review to evaluate the effectiveness of palliative care for cancer patients in the acute inpatient hospital setting. METHODS: Two electronic databases-PubMed and CINAHL Plus-were searched for articles published between 1 January 2005 and 28 May 2015. The search was augmented by hand-searches of specific journals and by examining the reference lists of short-listed articles. Studies were included if they evaluated a hospital palliative care service for cancer patients. Data extracted included study design, patient population, study setting, composition of the team, nature of the intervention, outcomes measured, and main findings. RESULTS: No randomized controlled trials were found. There were 14 pre-post studies that evaluated patient outcomes, of which only 2 had a control group. We also reviewed a further seven studies that evaluated other aspects of the palliative care intervention. The studies were not robust enough to confirm the efficacy of hospital palliative care services for cancer patient outcomes. Nonetheless, published studies provide a glimpse into the wider benefits of palliative care interventions. CONCLUSIONS: Data to support the benefit of palliative care interventions in the inpatient acute hospital setting are still lacking. Future studies should employ innovative strategies to further this field of research.

Distancing sedation in end-of-life care from physician-assisted suicide and euthanasia.

Lipuma equates continuous sedation until death (CSD) to physician-assisted suicide/euthanasia (PAS/E) based on the premise that iatrogenic unconsciousness negates social function and, thus, personhood, leaving a patient effectively 'dead'. Others have extrapolated upon this position further, to suggest that any use of sedation and/or opioids at the end of life would be analogous to CSD and thus tantamount to PAS/E. These posits sit diametrically opposite to standard end-of-life care practices. This paper will refute Lipuma's position and the posits borne from it. We first show that prevailing end-of-life care guidelines require proportional and monitored use of sedatives and/or opioids to attenuate fears that the use of such treatment could hasten death. These guidelines also classify CSD as a last resort treatment, employed only when symptoms prove intractable, and not amenable to all standard treatment options. Furthermore, CSD is applied only when deemed appropriate by a multidisciplinary palliative medicine team. We also show that empirical data based on local views of personhood will discount concerns that iatrogenic unconsciousness is tantamount to a loss of personhood and death.

Place of Care at End of Life: What Factors Are Associated With Patients' and Their Family Members' Preferences?

BACKGROUND: Few Asian studies have elucidated factors influencing patients and their family members on their preferred place of care at the end of life. This pilot study describes the perceptions of Singaporean patients with cancer and their family members that affect their choices in place of care. METHODOLOGY: Patients with cancer and their family members were surveyed at a tertiary hospital in Singapore. This convenience sample was recruited from April to July 2012. RESULTS: Fourteen pairs of patients and their family members (N = 28) were recruited. A majority of patients (64.3%) and family members (71.4%) were found to have a preferred place of care at the end of life. Of the respondents who expressed a preference (n = 19), 88.9% of patients and 90.0% of family members named "home" as their preferred place of care. Quality of care at home was rated "good" or "excellent" by all patients and 85.7% of family members. CONCLUSION: Home is the most favored choice among patients and family members who have a preferred place of care.

Addressing the Concerns Surrounding Continuous Deep Sedation in Singapore and Southeast Asia: A Palliative Care Approach.

The application of continuous deep sedation (CDS) in the treatment of intractable suffering at the end of life continues to be tied to a number of concerns that have negated its use in palliative care. Part of the resistance towards use of this treatment option of last resort has been the continued association of CDS with physician-associated suicide and/or euthanasia (PAS/E), which is compounded by a lack clinical guidelines and a failure to cite this treatment under the aegis of a palliative care approach. I argue that reinstituting a palliative care-inspired approach that includes a holistic review of the patient's situation and the engagement of a multidisciplinary team (MDT) guided by clearly defined practice requirements that have been lacking amongst many prevailing guidelines will overcome prevailing objections to this practice and allow for the legitimization of this process.

Limits to relational autonomy--the Singaporean experience.

Recognition that the Principle of Respect for Autonomy fails to work in family-centric societies such as Singapore has recently led to the promotion of relational autonomy as a suitable framework within which to place healthcare decision making. However, empirical data, relating to patient and family opinions and the practices of healthcare professionals in Confucian-inspired Singapore, demonstrate clear limitations on the ability of a relational autonomy framework to provide the anticipated compromise between prevailing family decision-making norms and adopted Western led atomistic concepts of autonomy. Evidence suggests that despite a growing infusion of Western influence, there is still little to indicate any major shift to individual decision making, particularly in light of the way society and healthcare are structured. Similarly, the lack of employing a shared decision-making model and data that discredit the notion that the complex psychosocial and cultural factors that affect the decision making may be considered "content neutral" not only prevents the application of relational autonomy but questions the viability of the values behind the Principle of Respect for Autonomy. Taking into account local data and drawing upon a wider concept of personhood that extends beyond prevailing family-centric ideals along with the complex interests that are focused upon the preservation of the unique nature of personhood that arises from the Ring Theory of Personhood, we propose and "operationalize" the employing of an authoritative welfare-based approach, within the confines of best interest decision making, to better meet the current care needs within Singapore.

The changing face of personhood at the end of life: The ring theory of personhood.

OBJECTIVE: The manner in which personhood or "what makes you who you are" is conceived is key to the provision of patient-centered care and maintenance of the dignity and quality of life of terminally ill patients. However, there is little agreement on how this pivotal concept ought to be defined. Some have argued in favor of an innate concept of personhood, while others see an individual as a reflection of their familial identity or their conscious function, and all share a common position that personhood is unchanging, and hinges upon the central theme of their respective concepts. The present paper aims to explore a more clinically influenced perspective of personhood. METHOD: We report the case of a 42-year-old Malay Singaporean who had been a caregiver for her husband throughout his cancer and then became a cancer patient herself after his passing. This case explores her changing and multifaceted conceptions of personhood throughout her life and illness, and discussions about end-of-life care. RESULTS: The patient reports a concept of personhood that encompasses the innate, individual, relational, and societal aspects, which are interlinked and vary in terms of depth and conviction according to the various times in her life and illness. SIGNIFICANCE OF RESULTS: Our findings support the ring theory of personhood, which provides a clinically supported model of the conception of personhood that is context dependent and encompasses the four abovementioned aspects.

Depression and anxiety in cancer patients in a Tertiary General Hospital in Singapore.

BACKGROUND: Past research has indicated that distress, anxiety and depression may occur in cancer patients during the course of their illness and treatment. AIMS: This study aims to establish the prevalence of anxiety and depression in cancer patients in a Singapore hospital. It also describes the clinical characteristics of these patients, and examines if cancer patients with a psychiatric diagnosis differ from those without. METHODS: Cross-sectional anxiety and depression symptom data were collected using the MINI International Neuropsychiatric Interview generating DSM IV diagnoses from inpatients of an oncology ward in the tertiary hospital. RESULTS: In all, 315 patients were interviewed. Fifty three (16.8%) were diagnosed with major depression, while 30 (9.5%) were found to have generalized anxiety disorder, three to ten times higher than their corresponding prevalence rates in the general population. Patients with depression or anxiety tend to be unemployed, in stage 4 cancer, who can develop these symptoms at any time from the onset of cancer diagnosis, even when perceived social support is strong. Oncology patients with depression were more likely to be in terminal stages of cancer and to correctly identify themselves to have mental health issues, than those without (p<0.01). CONCLUSIONS: The psychological impact of cancer is appreciable. The lack of identifiable risk factors makes the task of diagnosing psychiatric conditions in cancer patients an onerous one. The psychiatrist involved may want to look beyond socio-demographic variables and consider biological factors in cancer to better help detect psychiatric morbidity in this group of patients.

The influence of the family in conceptions of personhood in the palliative care setting in Singapore and its influence upon decision making.

Conceptions of personhood are critical to the preservation of dignity and quality of life key to a good death and pivotal to the provision of patient centred care. Increasingly there is speculation that this role may be wider still. It has been posited that it is Confucian inspired conceptions of personhood replete with its `dualistic' view of personhood that sees family members as part of the individual's personhood that predispose to the prevailing practices of collusion and the trumping of patient autonomy. In a nation where family centric decision making still dominates end of life decision making, the need to appropriately conceptualise local conceptions of personhood are clear. To this end a mixed methods study of 30 Singaporean oncology and palliative care patients was undertaken. Data accrued revealed local conceptions of personhood to be evolving ideas that are determined by four equally important closely related dimensions. Here Innate Personhood which represents the belief that all persons irrespective of their clinical condition and level of development are deserving of personhood, Individual Personhood which relates to consciousness related faculties, Relational Personhood which relates to the social and familial connections important to the person and Societal Personhood which relates to the roles played in society; combine to proffer the Ring Theory of Personhood. This concept provides a better means of providing for the specific needs of patients with life threatening illnesses whilst providing a unique insight into the role families play in the manner local patients conceive themselves to be.

Feeding: what it means to patients and caregivers and how these views influence Singaporean Chinese caregivers' decisions to continue feeding at the end of life.

INTRODUCTION: The decision-making process underlying caregivers' choice to continue feeding at the end of life is not well understood. OBJECTIVES: To provide a better understanding of the complex interplay of factors that influence the decision by caregivers to continue feeding. METHODS: Palliative care patients and their main caregiver recruited at National Cancer Centre Singapore between May and July 2011 were included. Data were collected using an interviewer-administered questionnaire. RESULTS: One hundred respondents were included. Three major prevailing themes were identified: filial piety, source of hope, and expression of affection. Nonparametric statistical testing showed that patients and caregivers shared similar views about feeding at the end of life. DISCUSSION: The major themes identified above undergird the caregiver's decision to continue feeding at the end of life.