Implementing spiritual care education into the teaching of palliative medicine: an outcome evaluation.

BACKGROUND: The concept of "total pain" plays an important role in palliative care; it means that pain is not solely experienced on a physical level, but also within a psychological, social and spiritual dimension. Understanding what spirituality entails, however, is a challenge for health care professionals, as is screening for the spiritual needs of patients. OBJECTIVE: This is a novel, interprofessional approach in teaching undergraduate medical students about spiritual care in the format of a seminar. The aim of this study is to assess if an increase in knowledge about spiritual care in the clinical context is achievable with this format. METHODS: In a mandatory seminar within the palliative care curriculum at our university, both a physician and a hospital chaplain teach strategies in symptom control from different perspectives (somatic domain - spiritual domain). For evaluation purposes of the content taught on the spiritual domain, we conducted a questionnaire consisting of two parts: specific outcome evaluation making use of the comparative self-assessment (CSA) gain and overall perception of the seminar using Likert scale. RESULTS: In total, 52 students participated. Regarding specific outcome evaluation, the greatest gain was achieved in the ability to define total pain (84.8%) and in realizing its relevance in clinical settings (77.4%). The lowest, but still fairly high improvement was achieved in the ability to identify patients who might benefit from spiritual counselling (60.9%). The learning benefits were all significant as confirmed by confidence intervals. Overall, students were satisfied with the structure of the seminar. The content was delivered clearly and comprehensibly reaching a mean score of 4.3 on Likert scale (4 = agree). The content was perceived as overall relevant to the later work in medicine (mean 4.3). Most students do not opt for a seminar solely revolving around spiritual care (mean 2.6). CONCLUSIONS: We conclude that implementing spiritual care education following an interprofessional approach into existing medical curricula, e.g. palliative medicine, is feasible and well perceived among medical students. Students do not wish for a seminar which solely revolves around spiritual care but prefer a close link to clinical practice and strategies.

The employment of art therapy to develop empathy and foster wellbeing for junior doctors in a palliative medicine rotation - a qualitative exploratory study on acceptability.

BACKGROUND: The interdisciplinary realm of medical humanities explores narratives and experiences that can enhance medical education for physicians through perspective-taking and reflective practice. However, there is a gap in comprehension regarding its appropriateness at the postgraduate level, especially when utilising art therapists as faculty. This study aims to assess the acceptability of an innovative art therapy-focused educational initiative among junior doctors during a palliative care rotation, with the goal of cultivating empathy and promoting well-being. METHODS: A qualitative research project was conducted at the Division of Supportive and Palliative Care (DSPC) in the National Cancer Centre Singapore (NCCS). The study involved the recruitment of junior doctors who had successfully completed a three-month palliative care rotation program, spanning from January 2020 to April 2021. In a single small-group session lasting 1.5 h, with 3 to 4 participants each time, the individuals participated in activities such as collage making, group reflection, and sharing of artistic creations. These sessions were facilitated by an accredited art therapist and a clinical psychologist, focusing on themes related to empathy and wellbeing. To assess the acceptability of the program, two individual interviews were conducted three months apart with each participant. An independent research assistant utilised a semi-structured question guide that considered affective attitude, burden, perceived effectiveness, coherence, and self-efficacy. Thematic analysis of the transcribed data was then employed to scrutinise the participants' experiences. RESULTS: A total of 20 individual interviews were completed with 11 participants. The three themes identified were lack of pre-existing knowledge of the humanities, promotors, and barriers to program acceptability. CONCLUSIONS: The participants have mixed perceptions of the program's acceptability. While all completed the program in its entirety, the acceptability of the program is impeded by wider systemic factors such as service and manpower needs. It is vital to address these structural limitations as failing to do so risks skewing current ambivalence towards outright rejection of future endeavours to integrate humanities programs into medical education.

Integrated dual training in palliative care and oncology.

Fellowship training in Hospice and Palliative Medicine (HPM) and Hematology/Oncology (Hem/Onc) share common themes and roots in the holistic care of people living with cancer. As of 2021, approximately 630 physicians in the United States were board-certified in both HPM and Hem/Onc. There is increasing demand for an integrated fellowship pathway, and the inaugural integrated fellowship Match took place in 2022. We present the historical context of the overlap in HPM and Hem/Onc fellowship training, limitations of the standard training paradigm, and an overview of the recently developed integrated training pathway accredited by the Accreditation Council for Graduate Medical Education (ACGME). We explore applications of dual training in clinical care, program development, and research at the intersection of HPM and Hem/Onc. Finally, we consider challenges to the success and how best to assess the outcomes of this program. Integrated fellowship training in HPM and Hem/Onc is 1 avenue to develop a cohort of dual-trained physicians poised to effect broad cultural change in this important and evolving space. A subset of physicians with dual training has the potential to fill unmet needs by promoting enhanced patient-centered care, developing infrastructure for heightened collaboration between these distinct but closely related fields, and prioritizing research focused on advanced communication skills and symptom management for patients with cancer.

Perceptions of Australian Palliative Medicine Specialists Toward Acupuncture for Palliative Care.

Background: With increasing multidisciplinary care strategies, palliative medicine practitioner perceptions toward acupuncture integration are significant. Objective: To evaluate acupuncture availability and acceptability in Australian palliative care. Outcomes: (1) Domains of the survey included participant characteristics, (2) workplace availability, (3) personal attitudes, and (4) recommendation likelihood. Design: An online REDCap survey of Australian palliative medicine practitioners was administered. Results: Acupuncture was mostly not available/permitted at workplaces (45.2%) due to cost/funding (57.1%) and limited evidence (57.1%). When available by workplace (24.2%) or affiliated service (4.8%), doctors mostly administered acupuncture (66.7%). Respondents were not up to date with current research (71.4%). Referral likelihood increased with confidence in provider (80.0%), workplace availability (77.1%), and patient prior/current use (77.1%). Patient acupuncture discussions were rare (62.9%) with barriers of effectiveness uncertainty (71.4%) and limited knowledge of availability (57.1%). Conclusion: Despite available integrative services and acceptability by Australian palliative medicine practitioners, utilization is low. Further research into acupuncture effectiveness for palliative symptoms, feasibility, and patient acceptability is required.

Challenges to delivering evidence-based palliative medicine.

Established as a medical specialty in 1987, palliative medicine approaches middle age facing existential questions of identity, purpose and vision. Time has weakened strong foundations laid by Dame Cicely Saunders in research, education and clinical excellence. Clinical knowledge gaps are wide, and widening. Palliative medicine research is underfunded and underrepresented in discourse. Despite huge advances in modern medicine, there is still clinical uncertainty about simple interventions, such as whether artificial hydration at the end of life is helpful or harmful. Where good quality data do exist, the pace of change is slow, if change is happening at all. Trial design often fails to assess the holistic impact of interventions, using primary endpoints that are inconsistent with outcomes most valued to the patient. Recent years have seen a rapid expansion in innovation and investment in digital technologies, embraced by many in palliative medicine. Experience shows that caution must be applied where the evidence base is sparse. While as a specialty we must remain forward looking and progressive in our mindset, it cannot be assumed that these new interventions alone will provide the solutions to the old problems that exist in palliative medicine.This review summarises the key points presented in the Palliative Medicine section of the RCP Clinical Medicine Conference, 2022.

Revelations from a Machine Learning Analysis of the Most Downloaded Articles Published in Journal of Palliative Medicine 1999-2018.

The Journal of Palliative Medicine (JPM) is globally recognized as a leading interdisciplinary peer-reviewed palliative care journal providing balanced information that informs and improves the practice of palliative care. JPM shapes the values, integrity, and standards of the subspecialty of palliative medicine by what it chooses to publish. The global JPM readership chooses to download the articles that are of most relevance and utility to them. Utilizing machine learning methods, the top 100 most downloaded articles in JPM were analyzed to gain a better understanding of any latent trends and patterns in the topics between 1999 and 2018. The top five topic themes identified in the first decade were different from the ones identified in the second decade of publication. There is evidence of differentiation and maturation of the field in the context of comprehensive health care. Although noncancer serious illnesses have still not risen to the same prominence as cancer palliation, there is a directional quality to the emerging evidence as it pertains to cardiac, respiratory, neurological, renal, and other etiologies. Across both decades under study, there was persistent evidence of the importance of understanding and managing the mental health care needs of seriously ill patients and their families. A cause for concern is that the word "spirituality" was prominent in the first decade and was lacking in the second. Future palliative care clinical and research initiatives should focus on its development as an essential interprofessional and medical subspecialty germane to all types of serious illnesses and across all venues.

Unusual palliative medicine intervention: smoking cessation.

Intervention for smoking cessation in a palliative care setting is not considered to be a standard practise. However, palliative care should support life and improve its quality and be able to approach the patient from a psychosocial perspective. This article discusses the smoking cessation intervention provided in a palliative care setting for an oncology patient. Making patients quit tobacco products in palliative care can increase the effectiveness of cancer treatment as well as the motivation level of the patient.

Enabling flourishing: novel approaches in palliative medicine for children with advanced kidney disease.

PURPOSE OF REVIEW: Paediatric kidney disease results in considerable burden on children and their families. Paediatric palliative care is a holistic, family-centred care approach intended to enable flourishing and address the many impediments to life participation which advanced kidney disease can impose. To date, palliative care resources have been underutilized in paediatric nephrology. This review will highlight recent literature targeting the engagement and life participation of children with advanced kidney disease through implementation of novel palliative care approaches and propose directions for future research. RECENT FINDINGS: Children with advanced kidney disease and their families highly value incorporation of their perspectives, particularly on life participation, within care plan development; but what it means to participate in life can be variable, and clinicians need improved tools to ascertain and incorporate these perspectives. Novel palliative care interventions developed for application in comparable disease states offer potential opportunities for paediatric nephrologists to support this goal. SUMMARY: Children with advanced kidney disease and their families will benefit from incorporation of their perspectives and values, facilitated by palliative interventions.

Expressão da espiritualidade nos cuidados paliativos: revisão narrativa / Expressing spirituality in palliative care: a narrative review / Expresión de la espiritualidad en los cuidados paliativos: una revisión narrativa

Resumo A terminalidade da vida requer uma abordagem ampla, com o alívio das dores física, emocional, familiar e social. Ademais, questões espirituais devem ser abordadas como forma de garantir ao paciente todas as fontes de conforto. Em vista disso, esta revisão narrativa da literatura tem o intuito de discutir os efeitos da espiritualidade/religiosidade nos cuidados paliativos. A partir de uma busca manual de trabalhos nas bases PubMed e Biblioteca Virtual em Saúde, foram selecionados 11 trabalhos para a revisão. As discussões foram divididas em três eixos: espiritualidade dos pacientes terminais, espiritualidade dos profissionais da saúde e espiritualidade dos familiares. Conclui-se que as práticas espirituais durante o fim da vida e no enfrentamento das angústias são cruciais tanto para pacientes e familiares quanto para os profissionais.

Abstract End of life requires a comprehensive approach to relief physical, emotional, family and social pain, addressing spiritual issues as a way to ensure patients all sources of comfort. Given this scenario, this narrative literature review discusses the effects of spirituality/religiosity in palliative care. Based on a manual search for papers in the PubMed and Virtual Health Library databases, 11 articles were selected for the review. The discussions were divided into three axes: spirituality of terminally ill patients, spirituality of health professionals and spirituality of family members. In conclusion, spiritual practices during the end of life and in coping with anguish are crucial both for patients and their families and for professionals.

Resumen El final de la vida requiere un enfoque amplio, con alivio del dolor físico, emocional, familiar y social. Además, las cuestiones espirituales deben abordarse como forma de ofrecer confort al paciente. En este contexto, esta revisión narrativa de la literatura tiene como objetivo discutir los efectos de la espiritualidad/religiosidad en los cuidados paliativos. A partir de una búsqueda de artículos en PubMed y en la Biblioteca Virtual de Salud, se seleccionaron 11 artículos para la revisión. Los debates se dividieron en tres ejes: espiritualidad de los pacientes terminales, espiritualidad de los profesionales sanitarios y espiritualidad de los familiares. Se concluye que las prácticas espirituales durante el final de la vida y en el afrontamiento de la angustia son cruciales tanto para los pacientes y sus familias como para los profesionales de la salud.

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.

Refractory angina is a growing challenge for palliative medicine: a systematic review of non-invasive interventions.

BACKGROUND: Refractory angina can have a significant effect on quality of life. Non-invasive interventions have been suggested but there are few guidelines on management. Our aim was to systematically review all studies that reported non-invasive interventions for refractory angina and report on their effectiveness and safety. METHODS: We performed a literature search of six databases and a grey literature search. Treatments considered first line or second line according to the European Society of Cardiology were excluded, as were interventions that had undergone review within the last 3 years. Design, setting and outcomes were extracted and quality was assessed. A narrative synthesis was undertaken, including an analysis of adverse effects. RESULTS: 4476 studies were screened, 14 studies were included in our analysis. Interventions were specialist multidisciplinary programmes, transcutaneous electrical nerve stimulation (TENS), perhexiline, medical optimisation, morphine and intranasal alfentanil. The effects of specialist programmes and perhexiline treatment were mixed. Positive effects were reported with TENS, opioids and medical optimisation, with improvements in symptoms, exercise capacity and quality of life. No major adverse effects were noted in any of the treatments. CONCLUSION: There are non-invasive treatments for refractory angina that are overlooked by current guidelines. While the quality of these studies varies, positive changes have been reported in symptoms, exercise tolerance and quality of life with few adverse effects. There is a need for further research into these treatments which could be useful within the contexts of cardiology and palliative care.

Spirituality and religiosity in a palliative medicine population: mixed-methods study.

BACKGROUND: Spiritual care allows palliative care patients to gain a sense of purpose, meaning and connectedness to the sacred or important while experiencing a serious illness. This study examined how Australian patients conceptualise their spirituality/religiosity, the associations between diagnosis and spiritual/religious activities, and views on the amount of spiritual support received. METHODS: This mixed-methods study used anonymous semistructured questionnaires, which included the Functional Assessment of Chronic Illness Therapy-Spiritual Scale-12 (FACIT-SP-12) and adapted and developed questions examining religion/spirituality's role and support. RESULTS: Participants numbered 261, with a 50.9% response rate. Sixty-two per cent were affiliated with Christianity and 24.2% with no religion. The mean total FACIT-SP-12 score was 31.9 (SD 8.6). Patients with Christian affiliation reported a higher total FACIT-SP-12 score compared with no religious affiliation (p=0.003). Those with Christian and Buddhist affiliations had higher faith subscale scores compared with those with no religious affiliation (p<0.001). Spirituality was very important to 39.9% and religiosity to 31.7% of patients, and unimportant to 30.6% and 39.5%, respectively. Following diagnosis, patients prayed (p<0.001) and meditated (p<0.001) more, seeking more time, strength and acceptance. Attendance at religious services decreased with frailty (p<0.001), while engagement in other religious activities increased (p=0.017). Patients who received some level of spiritual/religious support from external religious/faith communities and moderate to complete spiritual/religious needs met by the hospitals reported greater total FACIT-SP-12 spirituality scores (p<0.001). CONCLUSION: Respectful inquiry into patients spiritual/religious needs in hospitals allows for an attuned approach to addressing such care needs while considerately accommodating those disinterested in such support.

Do you need compassion to work in palliative medicine?

Compassion is deemed a "basic social emotion" (Nussbaum) and decreed a National Health Service core value-yet, what does 'compassion' really mean? Moreover, why is it so important, how can we deliver it best and how do we measure achievement here?This essay will argue that compassion stands apart from other forms of interpersonal engagement as a deeply human recognition of another's suffering which inherently motivates action to do something about this. There are two inextricable elements here: the role of suffering, and the resultant call to action it motivates.The role of compassion pivots on suffering, and thus, our interpretation of suffering and what we consider its upstream cause: the problem to be fixed. Palliative medicine here stands apart, priding itself on the holistic care of what is important to the patient; thus, the symptoms problematic to the patient are the problem, rather than the underlying cause per se.Compassion drives motivation to act; medicine equips us with the tools by which we can respond to this. Thus, compassion has been described as a 'calling' to healthcare for many who join the profession, and perhaps it is when these tools seem to fail that compassion fatigue takes hold. Though this is beyond the scope of this essay, compassion fatigue is considered a form of burnout directly related to the experiences of a caregiver.Thus, compassion is central, and its outcomes stem first from our perspective of the issue at hand and second from our ability to drive change. The ability to recognise suffering in another and be motivated to help has relevance far beyond work in palliative medicine; perhaps this form of interpersonal engagement extends to humanity itself.

Use of cannabis and cannabinoids in palliative care setting.

PURPOSE OF REVIEW: Cannabis products have been used for various ailments since ancient times. But their use diminished in the medical community due to the legal and social concerns of substance abuse. With evolving evidence of their use in alleviating various symptoms, resurgence of interest in their medicinal use is seen in the past decade. RECENT FINDINGS: Clinical evidence for cannabis products in treating various ailments has been far from robust. Their use is based on anecdotal and low-quality evidence. This review attempts to revisit the recent medical literature available on the merits and demerits of cannabinoid use in palliative medicine. SUMMARY: A few symptoms in palliative care setting can be difficult to treat in a few patients with the available treatment measures. Anecdotal reports and early clinical data have proved cannabinoids to be a promising pharmacological option in managing this subset of patients. However, absence of robust clinical data in proving that cannabinoids have definitely favorable risk-benefit ratio, precludes the inclusion of cannabinoids in the routine recommendation for palliative symptom management. Before cannabinoids enter the broader market with patient-driven and industry-driven hype, high-quality clinical evidence is emergently needed.

Acupuncture as a Treatment Within Integrative Health for Palliative Care: A Brief Narrative Review of Evidence and Recommendations.

Background: Acupuncture is one of the fastest developing evidence bases in Complementary Medicine and is one of the leading therapies included within integrative health care. This narrative review includes two separate parts: the first is about evaluation of the current evidence status in reviews on acupuncture and the second examines and gives examples of available recommendations on acupuncture in treatment guidelines from health care experts and public health organizations recommending acupuncture as a viable treatment in patients in palliative care. Methods: Electronic searches were performed in PubMed using the terms "acupuncture" + "palliative" and adding the term "safety" to find review articles documenting safety and evidence of effectiveness of acupuncture for treatment of symptoms in palliative care patients. Treatment guidelines that recommend use of acupuncture for symptom control in palliative care were found by searching through a database currently under construction by the lead author. Results: Acupuncture shows emerging evidence for 17 indications in palliative care. Examples were found and presented of publications recommending acupuncture for treatment of symptoms for patients in palliative care from Government, public health, oncology, and medical expert sources. The most publications are in oncology, but other conditions were found and a number were found in pediatric care. Conclusions: While the evidence for use of acupuncture to treat symptoms in palliative care patients is relatively weak, the evidence base is growing. Experts worldwide are also increasingly recommending acupuncture as a treatment for symptoms in palliative care. Since acupuncture is a safe, nonpharmacological treatment but with small, clinically significant effects, these recommended uses appear as pragmatic efforts to bridge the gap of treatment options available to this patient group.