Speaking up at conference question and answer sessions-disruptive behaviour typography and assessment scale.

Conferences can be a space to present new research, network, and provide an opportunity for learning. Delegates can meet field leaders, peers, top doctors, and international colleagues in various areas of expertise. Challenging behaviours, in particular in the question and answer session, but also during lectures themselves, may reduce overall enjoyment and learning. The authors of this article have written an observational reflection on some observed behaviours and have come up with a 10-point assessment scale. The article aims to stimulate discussion on what constitutes disruptive conduct, but also serves as a guide for conference session chair-people and delegates to spot patterns of contribution that may be unwelcome.

Patient-reported outcome measurement in palliative care: A hermeneutic narrative review.

OBJECTIVES: Recent years have witnessed the rise of patient-reported outcome measures (PROMs) in palliative care (PC), particularly those focused on the standardized measurement of symptom burden. These measures seek to evaluate the quality of PC through the quantification of various aspects of potential suffering (e.g., sleeplessness, loss of appetite, and pain). Further, drawing on patient experience, they provide a framework for evaluating the effectiveness of, and at times expanding, PC services. The aim of this paper is to provide a theoretically informed normative critique of PROMS-PC through a critical engagement with heterogeneous literatures. METHODS: A hermeneutic narrative review underpinned by a view of "knowing" as an ongoing social accomplishment and inspired by complexity theory. RESULTS: This narrative review highlights some limitations to the development of PROMs, including the use of proxies to complete them, and how the outcomes may not always reflect either the character of PC or the key aspects of practice and experience therein. SIGNIFICANCE OF RESULTS: In their current form, PROMs have the potential to skew understandings of service quality, for example, by privileging one aspect of quality, that is, physical symptoms over other aspects of quality such as communication with care providers.

How effective is virtual reality technology in palliative care? A systematic review and meta-analysis.

BACKGROUND: The efficacy of virtual reality for people living with a terminal illness is unclear. AIM: To determine the feasibility and effectiveness of virtual reality use within a palliative care setting. DESIGN: Systematic review and meta-analysis. PROSPERO (CRD42021240395). DATA SOURCES: Medline, Embase, AMED, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science were searched from inception to March 2021. Search terms included 'virtual reality' and 'palliative care'. Eligibility: (1) adult (>18 years old) with a terminal illness (2) at least one virtual reality session and (3) feasibility data and/or at least one patient outcome reported. The ROB-2 and ROBINS tools assessed risk of bias. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool assessed the quality of the evidence. Standardised mean differences (Hedges's g) were calculated from the pre- and post-data. A DerSimonian-Laird random effects model meta-analysis was conducted. RESULTS: Eight studies were included, of which five were in the meta-analysis. All studies had at least some concern for risk of bias. Virtual reality statistically significantly improved pain (p = 0.0363), tiredness (p = 0.0030), drowsiness (p = 0.0051), shortness of breath (p = 0.0284), depression (p = 0.0091) and psychological well-being (p = 0.0201). The quality of the evidence was graded as very low due to small sample sizes, non-randomisation methods and a lack of a comparator arm. CONCLUSIONS: Virtual reality in palliative care is feasible and acceptable. However, limited sample sizes and very low-quality studies mean that the efficacy of virtual reality needs further research.

Online training improves medical students' ability to recognise when a person is dying: The ORaClES randomised controlled trial.

BACKGROUND: Recognising dying is a key clinical skill for doctors, yet there is little training. AIM: To assess the effectiveness of an online training resource designed to enhance medical students' ability to recognise dying. DESIGN: Online multicentre double-blind randomised controlled trial (NCT03360812). The training resource for the intervention group was developed from a group of expert palliative care doctors' weightings of various signs/symptoms to recognise dying. The control group received no training. SETTING/PARTICIPANTS: Participants were senior UK medical students. They reviewed 92 patient summaries and provided a probability of death within 72 hours (0% certain survival - 100% certain death) pre, post, and 2 weeks after the training. Primary outcome: (1) Mean Absolute Difference (MAD) score between participants' and the experts' scores, immediately post intervention. Secondary outcomes: (2) weight attributed to each factor, (3) learning effect and (4) level of expertise (Cochran-Weiss-Shanteau (CWS)). RESULTS: Out of 168 participants, 135 completed the trial (80%); 66 received the intervention (49%). After using the training resource, the intervention group had better agreement with the experts in their survival estimates (δMAD = -3.43, 95% CI -0.11 to -0.34, p = <0.001) and weighting of clinical factors. There was no learning effect of the MAD scores at the 2-week time point (δMAD = 1.50, 95% CI -0.87 to 3.86, p = 0.21). At the 2-week time point, the intervention group was statistically more expert in their decision-making versus controls (intervention CWS = 146.04 (SD 140.21), control CWS = 110.75 (SD 104.05); p = 0.01). CONCLUSION: The online training resource proved effective in altering the decision-making of medical students to agree more with expert decision-making.

The role of behavioural modification and exercise in the management of cancer-related fatigue to reduce its impact during and after cancer treatment.

BACKGROUND: Fatigue is a symptom that can occur during treatment as an acute side effect but can also result in persistent fatigue as a long-term side effect or late effect. MATERIALS AND METHODS: We undertook a narrative review of the current literature and discuss the current evidence of assessment of fatigue and we specifically focus on the role of promoting behavioural change and focused rehabilitation to minimise these long-term effects and update the literature relating to this area from 2012 to date. RESULTS: We suggest there are behavioural change models that can be scaled up to enable patients to manage long-term fatigue using exercise. However, from this updated review there are limitations to the current infrastructure and evidence base that will impact on the ability to do this. CONCLUSION: We continually need to raise awareness amongst health professionals to continue to suggest modifications to impact on fatigue at all stages of cancer treatment and into survivorship and late effects. These can range from simple brief interventions suggested in the clinic to full scale rehabilitation programmes if the correct infrastructure is available. Whichever approach is adopted we suggest exercise will be the mainstay of the treatment of fatigue in this group.

Pharmacological treatments for fatigue associated with palliative care.

BACKGROUND: This review updates the original review, 'Pharmacological treatments for fatigue associated with palliative care' and also incorporates the review 'Drug therapy for the management of cancer-related fatigue'.In healthy individuals, fatigue is a protective response to physical or mental stress, often relieved by rest. By contrast, in palliative care patients' fatigue can be severely debilitating and is often not counteracted with rest, thereby impacting daily activity and quality of life. Fatigue frequently occurs in patients with advanced disease (e.g. cancer-related fatigue) and modalities used to treat cancer can often contribute. Further complicating issues are the multidimensionality, subjective nature and lack of a consensus definition of fatigue. The pathophysiology is not fully understood and evidence-based treatment approaches are needed. OBJECTIVES: To evaluate the efficacy of pharmacological treatments for fatigue in palliative care, with a focus on patients at an advanced stage of disease, including patients with cancer and other chronic diseases. SEARCH METHODS: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO and EMBASE, and a selection of cancer journals up to 28 April 2014. We searched the references of identified articles and contacted authors to obtain unreported data. To validate the search strategy we selected sentinel references. SELECTION CRITERIA: We considered randomised controlled trials (RCTs) concerning adult palliative care with a focus on pharmacological treatment of fatigue compared to placebo, application of two drugs, usual care or a non-pharmacological intervention. The primary outcome had to be non-specific fatigue (or related terms such as asthenia). We did not include studies on fatigue related to antineoplastic treatment (e.g. chemotherapy, radiotherapy, surgical intervention). We also included secondary outcomes that were assessed in fatigue-related studies (e.g. exhaustion, tiredness). DATA COLLECTION AND ANALYSIS: Two review authors (MM and MC) independently assessed trial quality and extracted data. We screened the search results and included studies if they met the selection criteria. If we identified two or more studies that investigated a specific drug with the same dose in a population with the same disease and using the same assessment instrument or scale, we conducted meta-analysis. In addition, we compared the type of drug investigated in specific populations, as well as the frequent adverse effects of fatigue treatment, by creating overview tables. MAIN RESULTS: For this update, we screened 1645 publications of which 45 met the inclusion criteria (20 additional studies to the previous reviews). In total, we analysed data from 18 drugs and 4696 participants. There was a very high degree of statistical and clinical heterogeneity in the trials and we discuss the reasons for this in the review. There were some sources of potential bias in the included studies, including a lack of description of the methods of blinding and allocation concealment, and the small size of the study populations. We included studies investigating pemoline and modafinil in participants with multiple sclerosis (MS)-associated fatigue and methylphenidate in patients suffering from advanced cancer and fatigue in meta-analysis. Treatment results pointed to weak and inconclusive evidence for the efficacy of amantadine, pemoline and modafinil in multiple sclerosis and for carnitine and donepezil in cancer-related fatigue. Methylphenidate and pemoline seem to be effective in patients with HIV, but this is based only on one study per intervention, with only a moderate number of participants in each study. Meta-analysis shows an estimated superior effect for methylphenidate in cancer-related fatigue (standardised mean difference (SMD) 0.49, 95% confidence interval (CI) 0.15 to 0.83). Therapeutic effects could not be described for dexamphetamine, paroxetine or testosterone. There were a variety of results for the secondary outcomes in some studies. Most studies had low participant numbers and were heterogeneous. In general, adverse reactions were mild and had little or no impact. AUTHORS' CONCLUSIONS: Based on limited evidence, we cannot recommend a specific drug for the treatment of fatigue in palliative care patients. Fatigue research in palliative care seems to focus on modafinil and methylphenidate, which may be beneficial for the treatment of fatigue associated with palliative care although further research about their efficacy is needed. Dexamethasone, methylprednisolone, acetylsalicylic acid, armodafinil, amantadine and L-carnitine should be further examined. Consensus is needed regarding fatigue outcome parameters for clinical trials.

Beyond treatment - Psychosocial and behavioural issues in cancer survivorship research and practice.

The population of cancer survivors has grown steadily over the past several decades. Surviving cancer, however, is not synonymous with a life free of problems related to the disease and its treatment. In this paper we provide a brief overview of selected physical and psychosocial health problems prevalent among cancer survivors, namely pain, fatigue, psychological distress and work participation. We also address issues surrounding self-management and e-Health interventions for cancer survivors, and programmes to encourage survivors to adopt healthier lifestyles. Finally, we discuss approaches to assessing health-related quality of life in cancer survivors, and the use of cancer registries in conducting psychosocial survivorship research. We highlight research and practice priorities in each of these areas. While the priorities vary per topic, common themes that emerged included: (1) Symptoms should not be viewed in isolation, but rather as part of a cluster of interrelated symptoms. This has implications for both understanding the aetiology of symptoms and for their treatment; (2) Psychosocial interventions need to be evidence-based, and where possible should be tailored to the needs of the individual cancer survivor. Relatively low cost interventions with self-management and e-Health elements may be appropriate for the majority of survivors, with resource intensive interventions being reserved for those most in need; (3) More effort should be devoted to disseminating and implementing interventions in practice, and to evaluating their cost-effectiveness; and (4) Greater attention should be paid to the needs of vulnerable and high-risk populations of survivors, including the socioeconomically disadvantaged and the elderly.

What makes for a 'Top Doc'? An analysis of UK press portrayals of so-called top doctors.

OBJECTIVE: To determine the characteristics of medical practitioners designated 'top doctor' or 'Top Doc' in the UK press. DESIGN: Observational study of news stories related to the term top doctor (or Top Doc) with analysis using data from publicly available databases. SETTING: News reports in the UK press accessed via a database from national newspapers from 1 January 2019 to 31 December 2019, prior to the COVID-19 pandemic. Stories relating to disciplinary/criminal matters were analysed separately. MAIN OUTCOME MEASURES: Results were cross-referenced with the General Medical Council register of medical practitioners for gender, year of qualification, whether on the general practitioner (GP) or the specialist register, and if on the specialist register, which specialty. RESULTS: There was a gender divide, with 80% of so-called top doctors being male. National top doctors had been qualified for a median time of 31 years. Top doctors are widely spread among specialties; 21% of top doctors were on the GP register. Officers of the British Medical Association and the various Royal Colleges are also well represented. 'Top doctors' facing disciplinary proceedings are more overwhelmingly male, working in hospital specialties and less obviously eminent in their field. CONCLUSION: There is no clear definition of a 'top doctor', nor are there objective leadership criteria for journalists to use when applying this label. Establishing a definition of 'top doctor', for instance, via the UK Faculty for Medical Leadership and Management, which offers postnominals and accreditation for high-achieving medical professionals, may reduce subjectivity.

Methylphenidate Versus Placebo for Treating Fatigue in Patients With Advanced Cancer: Randomized, Double-Blind, Multicenter, Placebo-Controlled Trial.

PURPOSE: To compare effects and side effects of 6 weeks of individually dose-titrated methylphenidate or placebo on fatigue in palliative care patients with advanced cancer. METHODS: This is a randomized, double-blind, placebo-controlled, multicenter trial. Eligible patients had advanced incurable cancer and fatigue >3/10. Principal exclusions were hypertension; psychiatric, cardiovascular, cerebrovascular, renal, liver, or blood disorders; substance dependency; and epilepsy. Patients were randomly assigned 1:1 methylphenidate or placebo starting at 5 mg twice daily. Dose of methylphenidate/placebo was titrated once per week, over 6 weeks, up to a maximum of 20 mg three times daily. Trial ended at 10 weeks. Primary outcome was the difference in Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) scores between groups at 6 ± 2 weeks. Secondary outcomes included adverse effects, quality of life, and mood. RESULTS: One hundred sixty-two patients (73 men; mean, 65.8; standard deviation [SD], 10.3 years) were randomly assigned, and three were excluded from analysis. Seventy-seven were allocated placebo (baseline FACIT-F = 22 [SD, 10]); 82 were allocated methylphenidate (FACIT-F = 20 [SD, 9]). After 6 ± 2 weeks, FACIT-F scores were 1.97 points (95% CI, -0.95 to 4.90; P = .186) higher (better) on methylphenidate than placebo. Across 10 weeks of the study, FACIT-F was nominally higher in the methylphenidate group versus placebo (Diff, 2.20 [95% CI, 0.39 to 4.01]), but this did not reach the minimally clinically important difference (5-points). At 6 weeks, there were no differences between groups in quality-of-life or symptom domains except for depression scores (nominally reduced in the methylphenidate group: Diff, -1.35 [95% CI, -2.41 to -0.30]). There were no differences in mortality or serious adverse events. CONCLUSION: After 6 ± 2 weeks of treatment, methylphenidate was not superior to placebo for treating fatigue in advanced cancer. Methylphenidate was safe and well-tolerated.

Digitally Recording Comfort Observations in the Last Days of Life.

Background: 37.5% of deaths in our area occur in hospital. There are known high unmet needs of adult patients dying in hospital, this unmet need can be reduced by using an individualised care plan and specialist palliative care review. Intervention: In 2022 UHSussex developed an electronic comfort observation chart and individualised care plan, with a centralised dashboard allowing Palliative Care Teams (SPCT) to view trends, target interventions, and a rolling prospective audit. Results: 3000 patients have had their care supported with electronic comfort observations (e-comfort obs). Over 72% of all deaths in the Trust in the last 3 months have been on e-comfort obs, with 2/3 of all deaths in the first 12 months on e-comfort obs. The average length of time on e-comfort obs is 4 days resulting in 70,000 sets of e-comfort obs recorded since launch. Seven percent of e-comfort obs record moderate or severe symptoms. We have identified benefits to people who are dying, those important to them, ward staff, SPCT and on a systems level. Conclusion: E-comfort obs can be successfully embedded in a large acute Trust. This development should improve quality of end of life care in our hospitals both for individuals and for future patients, through on-going targeted education and intervention. Further work is needed to develop the system further including integrating data from electronic prescribing.

An Analysis of Healthcare Usage & Place of Death in England for All Adults Who Died in 2021/22.

OBJECTIVE: We wanted to examine the healthcare use and non-elective activity in the UK population of expected deaths over an 1-year period to highlight and examine the reasons for variation. We did this to identify areas to focus interventions or resources on to reduce unnecessary emergency care use at the end of life. METHODS AND ANALYSIS: We assembled a data set of approximately 400 000 adults who died in England in the financial year 2021/22 (April 2021-March 2022). Any adults classified as a 'sudden death' were excluded. We used available data to ensure outcome measures were relevant used expert consensus to agree what to examine. We recorded place of death and examined urgent care in terms of admissions in the last year and 90 days of life. We also used recorded hospital care days as elective and non-elective usage. RESULTS: There were over 400 000 decedents included in our regression models. Close to half died in hospital (44%). Three-quarters (77%) had at least one day of unplanned hospital care in the 90 days before they died, and half (56%) had at least one day of planned hospital care. CONCLUSION: Reliance on urgent care for those approaching end-of-life may indicate poor care planning and integration of services. A relatively modest increase in the amount of community care a person receives at end-of-life can substantially reduce the likelihood of dying in hospital. Those with a cancer cause of death are far less likely to die in hospital.

Cancer-related fatigue and its impact on functioning.

This article presents the contrasting European and American perspectives on cancer-related fatigue (CRF) and its impact on functioning in cancer survivors. The content is presented in 3 sections: state of the art, intervention studies, and future areas of research, followed by a discussion. Gaps identified include a lack of understanding of the etiology, definition, and measurement of CRF. Models to guide the study of CRF, selection of biomarkers, and design of interventions are needed. There is overlap between Europe and the United States concerning the future directions for research and collaboration related to CRF. The authors suggest the need for international consensus regarding the defining features of CRF in cancer survivors to identify phenotypes, a harmonized measurement of CRF outcomes using instruments that have demonstrated measurement equivalence across languages and cultures, and interventions (including exercise, rehabilitation, and psychoeducational) that have been manualized to permit intervention fidelity across diverse contexts. Coordinated intercontinental efforts would increase understanding of the biological, psychological, and social mechanisms underlying CRF and assist in the design of future intervention studies as well as revisions to clinical guidelines.

What can you learn as a foundation doctor from analysing deaths in hospital?

Deaths in hospital represent a vital learning opportunity for both individual clinicians and the wider healthcare system. Many deaths are reviewed and discussed in morbidity and mortality meetings, with the Royal College of Physicians promoting Structured Judgement Review (SJR) methodology to support this discussion. An analysis of 1 year of SJRs in one hospital was undertaken, generating a toolkit to support junior doctors in evaluating in-hospital deaths. Here, the opportunities and limitations of this analysis are discussed, with consideration of ways to improve the uptake of SJR across the hospital team. These reviews exemplify one way of maximising learning from in-hospital deaths.

Medical student anxiety in caring for dying patients and their family: a cross-sectional study.

OBJECTIVES: To investigate the level of medical student anxiety in caring for a dying patient and their family and identify influencing factors. METHODS: We conducted a cross-sectional survey in a UK medical school to measure medical student anxiety using a validated Thanatophobia Scale questionnaire. RESULTS: In total, 332 questionnaires were completed. Mean thanatophobia score was 19.5 (SD 7.78, range 7-49). Most respondents were female (67.4%) and did not have a previous undergraduate degree (56%). Median student age was 22 years (IQR 20-24). Year of study influenced anxiety level, with second year students displaying an increase in mean thanatophobia score of 6.088 (95% CI 3.778 to 8.398, p<0.001). No significant differences were observed between final year and first year thanatophobia scores. For each 1-year increase in student age, mean thanatophobia score reduced by -0.282 (95% CI -0.473 to -0.091, p=0.004). Degree status and gender identity did not significantly affect thanatophobia score. CONCLUSION: A degree of thanatophobia exists among medical students, with no significant improvement observed by completion of training. Recognising this anxiety to care for the dying earlier in undergraduate curricula will give educators the opportunity to address students' fears and concerns and better prepare our future doctors for their role in caring for our dying patients and their families.

Evaluation of Palliative Care Related Hospital Admissions in a Regional Centre.

OBJECTIVES: A significant proportion of adults admitted to hospital are in their last year of life. We evaluated admissions for these patients. METHODS: We identified ambulance callouts to patients known to the palliative care team. Data collected included admission outcome (e.g. discharge or death). RESULTS: There were 162 ambulance callouts between 126 patients known to the palliative care team. 8 patients (6%) died within 72 hours of admission. CONCLUSION: Our data suggests many palliative care patients can be appropriately treated in the community.

Seeking Excellence in End of Life Care UK (SEECare UK): a UK multi-centred service evaluation.

OBJECTIVE: To evaluate the care of patients dying in hospital without support from specialists in palliative care (SPC), better understand their needs and factors influencing their care. METHODS: Prospective UK-wide service evaluation including all dying adult inpatients unknown to SPC, excluding those in emergency departments/intensive care units. Holistic needs were assessed through a standardised proforma. RESULTS: 88 hospitals, 284 patients. 93% had unmet holistic needs, including physical symptoms (75%) and psycho-socio-spiritual needs (86%). People were more likely to have unmet needs and require SPC intervention at a district general hospital (DGH) than a teaching hospital/cancer centre (unmet need 98.1% vs 91.2% p0.02; intervention 70.9% vs 50.8% p0.001) and when end-of-life care plans (EOLCP) were not used (unmet need 98.3% vs 90.3% p0.006; intervention 67.2% vs 53.3% p0.02). Multivariable analyses demonstrated the independent influence of teaching/cancer hospitals (adjusted OR (aOR)0.44 CI 0.26 to 0.73) and increased SPC medical staffing (aOR1.69 CI 1.04 to 2.79) on need for intervention, however, integrating the use of EOLCP reduced the impact of SPC medical staffing. CONCLUSION: People dying in hospitals have significant and poorly identified unmet needs. Further evaluation is required to understand the relationships between patient, staff and service factors influencing this. The development, effective implementation and evaluation of structured individualised EOLCP should be a research funding priority.

Identification of factors associated with cancer related fatigue syndrome in disease-free breast cancer patients after completing primary treatment.

This study is an analysis of variables associated with women who meet the criteria for after completion of successful primary treatment for breast cancer. This analysis was conducted to identify factors independently associated with cancer related fatigue syndrome using a combined dataset from two non-overlapping studies conducted on similar populations. Participants who were clinically (and radiologically) disease-free, between 3 months and 2 years after treatment, were recruited from a single centre. A diagnostic interview was conducted to ascertain whether they met the criteria for cancer related fatigue syndrome. We analysed a number of treatment, laboratory and questionnaire variables between groups. Those that were significantly different were entered into a logistic model. A total of 278 subjects (105 cases of cancer related fatigue syndrome and 173 controls who did not meet the criteria) were analysed. A number of questionnaire responses were significantly different including all of the European Organisation for the Research and Treatment of Cancer core 30 item quality of life questionnaire (EORTC QLQ c30) and Breast questionnaire 23 item subgroup scores. 11 variables were entered into the final model and 5 were independently associated with cancer related fatigue syndrome: Hospital anxiety and depression scale score, EORTC pain and insomnia scales, breast systemic side effects and plasma sodium. There was, however, no association with demographic or treatment variables. As a conclusion, cancer related fatigue syndrome after treatment is linked with sub-clinical mood pain and subjective sleep disturbance and with the side effects of systemic treatment. This study is unable to determine whether these associations are causal, but they provide a potential target for interventions to manage the symptoms of cancer related fatigue syndrome.

Palliative care training in undergraduate medical, nursing and allied health: a survey.

OBJECTIVES: Impending death is poorly recognised. Many undergraduate healthcare professionals will not have experience of meeting or caring for someone who is dying. As death can occur in any setting, at any time, it is vital that all healthcare students, regardless of the setting they go on to work in, have end-of-life care (EOLC) training. The aim was to determine current palliative care training at the undergraduate level, in multiple professions, in recognising and communicating dying. METHODS: Current UK undergraduate courses in medicine, adult nursing, occupational therapy, social work and physiotherapy were included. All courses received an email asking what training is currently offered in the recognition and communication of dying, and what time was dedicated to this. RESULTS: A total of 73/198 (37%) courses responded to the request for information. 18/20 medical courses provided training in recognising when patients were dying (median 2 hours), and 17/20 provided training in the communication of dying (median 3 hours). 80% (43/54) of nursing and allied health professional courses provided some training in EOLC. Many of the course organisers expressed frustration at the lack of resources, funding and time to include more training. Those courses with more palliative care provision often had a 'champion' to advocate for it. CONCLUSIONS: Training in EOLC was inconsistent across courses and professions. Further research is needed to understand how to remove the barriers identified and to improve the consistency of current training.

Care of the dying - medical student confidence and preparedness: mixed-methods simulation study.

OBJECTIVES: Of all doctors, Foundation Year 1 trainees spend the most time caring for dying patients yet report poor preparation and low confidence in providing this care. Despite documented effectiveness of simulation in teaching end-of-life care to undergraduate nurses, undergraduate medicine continues to teach this subject using a more theoretical, classroom-based approach. By increasing undergraduate exposure to interactive dying patient scenarios, simulation has the potential to improve confidence and preparedness of medical students to care for dying patients. The main study objective was to explore whether simulated experience of caring for a dying patient and their family can improve the confidence and preparedness of medical students to provide such care. METHODS: A mixed-methods interventional study simulating the care of a dying patient was undertaken with serial measures of confidence using the Self Efficacy in Palliative Care (SEPC) tool. Significance testing of SEPC scores was undertaken using paired t-tests and analysis of variance. Post-simulation focus groups gathered qualitative data on student preparedness. Data were transcribed using NVivo software and interpreted using Thematic Analysis. RESULTS: Thirty-eight 4th-year students participated. A statistically significant post-simulation increase in confidence was seen for all SEPC domains, with sustained confidence observed at 6 months. Focus group data identified six major themes: current preparedness, simulated learning environment, learning complex skills, patient centredness, future preparation and curriculum change. CONCLUSION: Using simulation to teach medical students how to care for a dying patient and their family increases student confidence and preparedness to provide such care.

Seeking Excellence in End of Life Care (SEE Care): A Multi-Centered Acute Hospitals Service Evaluation.

CONTEXT: A proportion of UK hospital inpatients have palliative care needs but do not access specialist services. OBJECTIVES: To contemporaneously evaluate the significance of unmet specialist palliative care needs within the hospital inpatient population. METHODS: Prospective multi-centered service evaluation was conducted through 4 snapshots across 4 acute NHS hospital trusts. All patients identified as dying in each hospital were included. Data extraction included symptom burden, medications and completion of care plans. RESULTS: End-of-life care plans were completed for 73%, symptom-focused prescribing present in 96%. Symptoms were not well managed for 22%, with 4% suffering moderate to severely. Specific intervention was triggered in 56% of patients, consisting of prescribing advice and holistic support. CONCLUSION: There are significant unmet specialist palliative care needs within the hospital inpatient population. Contemporaneous data collection coupled with an outreach approach helps palliative care services better understand the experiences of dying people, alongside where improvement is needed.