Challenges in Implementing Guideline on Integrative Oncology and Pain: The Israeli Perspective.

CONTEXT AND OBJECTIVES: To explore the feasibility of implementing the joint guideline on integrative medicine for pain management in oncology, published by the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO), for integrative oncology (IO) services in supportive and palliative care. METHODS: A qualitative research methodology was co-designed by the SIO-ASCO guideline committee, with the Society for Complementary Medicine, Israel Medical Association (IMA). A questionnaire with five open-ended questions exploring barriers and enablers to implementing the guideline was distributed to chairs and board members of nine IMA-affiliated medical societies; four deans of Israeli medical schools; and nurses from the Israeli Society for Oncology Nursing. Respondent narratives were qualitatively analyzed using ATLAS.Ti software for systematic coding. RESULTS: Questionnaires were completed by 52 physicians and nurses from medical oncology, hematology, gynecological oncology, pediatric oncology, palliative medicine, pain, family medicine, internal medicine, and integrative medicine. The SIO-ASCO guidelines were endorsed by nine IMA-affiliated societies. The domains identified included the importance of guideline implementation in clinical practice; barriers and facilitators to implementation; practical aspects required for this implementation (e.g., IO training); clinical indications for referral; budget-related issues; and clinical and administrative models enabling practical implementation of the guideline. CONCLUSION: We found across-the-board consensus among the nine IMA-affiliated societies supporting the current guideline. This, while identifying potential facilitators and barriers in order to address the implementation of the SIO-ASCO guideline recommendations.

Opioid consumption by cancer patients in an Israeli Health Maintenance Organization from 2007-2018.

PURPOSE: Opioids are the cornerstone of therapy for cancer patients with moderate to severe pain. The objective was to characterize opioid purchases by cancer patients in Clalit Health Services (CHS), the largest Health Maintenance Organization in Israel, over the years 2007-2018. METHODS: Data for all CHS cancer patients aged 18 years old and above who purchased an opioid at least once during the 12-year study period were obtained from computerized databases. The amount of opioids was converted into oral morphine equivalents (OME). RESULTS: 108,543 cancer patients who purchased opioids at least once were enrolled. They comprised 30.5% of the CHS purchasers of opioids in the study period. The total number of cancer patients who purchased an opioid at least once increased gradually from 13,057 in 2007 to 20,675 (58% increase) in 2018, while the annual number of CHS cancer patients increased by only 39%. The annual OME per capita increased from 753 mg in 2007 to 1,432 mg in 2018 (91% increase). In 2007 8.1% of the cancer patients purchased opioids and 9.2% in 2018. Two thirds of all cancer patients purchased opioids for three months or less, 11.9% continued for more than one year, and 5.8% for more than two years. CONCLUSIONS: There is a clinically non-significant increase in the rate of cancer patients purchasing opioids. About two thirds of the cancer patients purchased opioids for only three months, and 94% for up to two years. Under-treatment of cancer pain should still be of concern. While patients are prescribed higher doses, under-prescription may still be a problem..

Place of Death for Israeli Cancer Patients Over a 20-Year Period: Reducing Hospital Deaths, but Barriers Remain.

BACKGROUND: Cancer remains a leading cause of mortality worldwide. While the main focus of palliative care (PC) is quality of life, the elements that comprise the quality of death are often overlooked. Dying at home, with home-hospice-care (HHC) support, rather than in-hospital, may increase patient satisfaction and decrease the use of invasive measures. We examined clinical and demographic characteristics associated with out-of-hospital death among patients with cancer, which serves as a proxy measure for HHC deaths. METHODS: Using death certification data from the Israel Central Bureau of Statistics, we analyzed 209,158 cancer deaths between 1998 and 2018 in Israel including demographic information, cause of death, and place of death (POD). A multiple logistic regression model was constructed to identify factors associated with out-of-hospital cancer deaths. RESULTS: Between 1998 and 2018, 69.1% of cancer deaths occurred in-hospital, and 30.8% out-of-hospital. Out-of-hospital deaths increased by 1% annually during the study period. Older patients and those dying of solid malignancies were more likely to die out-of-hospital (OR = 2.65, OR = 1.93, respectively). Likelihood of dying out-of-hospital varied with area of residency; patients living in the Southern district were more likely than those in the Jerusalem district to die out-of-hospital (OR = 2.37). CONCLUSION: The proportion of cancer deaths occurring out-of-hospital increased during the study period. We identified clinical and demographic factors associated with POD. Differences between geographical areas probably stem from disparity in the distribution of PC services and highlight the need for increasing access to primary EOL care. However, differences in age and tumor type probably reflect cultural changes and suggest focusing on educating patients, families, and physicians on the benefits of PC.

[PALLIATIVE SOCIAL WORK IN ISRAEL - CHALLENGES AND OPPORTUNITIES].

INTRODUCTION: Israel, a young country that constantly absorbs immigrants from different cultures, has a unique social structure. The mosaic of culture and values that exist in it, the delicate balance that exists between religion and state, advanced legislative processes, the central place of the family in individual life, combined with the principles of autonomy in which the health system operates, require deliberate action to formulate solutions and meet current challenges. In this unique space the contribution of the palliative social workers is reflected through the application of models for individual and family assessment, clinical interventions implemented with cultural sensitivity and out of consideration for the family unit as an essential system for treatment planning. This coping occurs in the absence of recognition in the palliative care field as a unique area of expertise that requires specific training for palliative social workers, as exists for the nursing and medical professions. The field of palliative care provides social workers with space for meaningful interventions and channeling the challenges into the opportunity for professional growth, in coming to formulate professional responses to the needs emerging in the rich mosaic of patients and families in Israel.

[PALLIATIVE CARE IN ISRAEL -WHERE ARE WE GOING TO AND FROM WHERE ARE WE COMING?]

INTRODUCTION: The epidemiological transition to non-communicable diseases in the 20th century necessitated the development of new public health approaches to address the problems of the new age. As understanding of the determinants of health became more sophisticated, so did public health practice. Thus, palliative care became an integral component of the health definition. It is an approach which improves quality of life of patients and their families facing chronic serious illness and life-threatening diseases. This is performed through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual. Palliative care is provided without giving up cure or slowing disease progression.

[CHEMOTHERAPY FOR CANCER PATIENTS - ARE WE CHOOSING WISELY?]

INTRODUCTION: The American Society of Clinical Oncology has identified non-evidence-based chemotherapy as one of the 10 most prevalent examples of futile care and has identified chemotherapy at the last month of life as a quality indicator of oncology practice. OBJECTIVES: To characterize chemotherapy treatment and the use of palliative and other healthcare services during the last year of life among cancer patients in an Israeli Health Maintenance Organization (HMO). METHODS: A cross-sectional study was conducted of members of Leumit Health Services (LHS) who died of cancer between 2009 and 2013. Data captured from LHS databases included: diagnosis, target drugs prescribed, health services utilization, and demographic data. Patients were stratified by time that elapsed between their last chemotherapy treatment and the date of death. The groups were compared in terms of demographics, morbidity, health services utilization and palliative care referrals over the six months prior to death. RESULTS: The study included 2,617 patients who received chemotherapy during their last year of life. Of these patients, 18.8% received chemotherapy 0-14 days prior to death. Palliative care referrals were less frequent among patients who received their last chemotherapy treatment during the 14 days prior to death (15.8%) and highest among patients who received their last chemotherapy treatment ≥180 days prior to death (31.9%: P<0.0001(. CONCLUSIONS: Survival and the probability of administering palliative care at the end of life are inversely associated with the probability of administering chemotherapy. DISCUSSION: Efforts should be made to increase awareness amongst oncologists that aggressive treatment during the last weeks of life may be futile.

[AN INSTRUMENT TO ASSESS HOSPITAL NURSES' PERCEIVED SELF-EFFICACY IN PROVIDING PALLIATIVE END-OF-LIFE CARE: A VALIDATION STUDY]

BACKGROUND: The trend of increasing numbers of terminally ill patients hospitalized in general wards requires nursing staff to be able to provide palliative care (PC). The self-efficacy (SE) to provide PC was found to be a leading factor predicting future professional behavior. There is no tool in the Hebrew language to evaluate SE for symptoms management and provision of psychosocial care within the PC. OBJECTIVES: To validate a Hebrew version of the "Palliative Care Self-Efficacy Scale )PCSES)" among nursing staff employed in various hospital wards. METHODS: A cross-sectional study was performed among nursing staff employed at four Israeli hospitals in oncology, internal medicine, surgical and emergency care wards. RESULTS: The PCSES questionnaire was translated into Hebrew and was completed by 588 nurses. Cronbach's alpha coefficients for the translated tool were high: 0.89 for the tool as a whole, 0.82 for the scale regarding ability to deal with questions regarding end-of-life care, and 0.85 for the symptoms management scale. As in the original tool, two factors that in combination explain 58.6% of the variance were found: ability to deal with questions regarding end-of-life care (46.43%) and symptoms management (12.2%). CONCLUSIONS: The psychometric characteristics of this tool demonstrate that it can be used to estimate SE in providing PC among nurses employed in various hospital wards. DISCUSSION: This tool should be used and evaluated among additional professionals involved in providing PC. It should also be tested as a method to identify changes in SE over time.

[ONCOLOGISTS' APPROACHES AND BARRIERS FOR DISCUSSING ADVANCED CARE PLANNING WITH SEVERELY ILL CANCER PATIENTS].

BACKGROUND: Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life (EOL) care and with better quality of life near death. Despite that, these discussions do not always occur between oncologists and their patients. OBJECTIVES: To evaluate oncologists' agendas concerning EOL discussions and advanced directive (AD), and to identify barriers to these discussions. METHODS: The study included oncologists from Israeli hospitals who were asked to complete a questionnaire in order to assess barriers to EOL conversations. The questionnaire was adapted from Canadian research among clinicians in medical wards. Participants were asked to rank the importance of the various barriers. RESULTS: The questionnaires were completed by 84 physicians. Most physicians in this group (97%) thought it was important to have discussions on GOC with the patient, and 67% thought it was important that the patient would sign an AD form. Respondents perceived patient and family-related factors as the most important barriers. Of these, the most important were the patients' and patients' families difficulty accepting their poor prognosis, rated as important by 90% and 78% respectively, and the patients' difficulty understanding the limitations and complications of life-sustaining treatments, rated as an important by 81% of respondents. While physicians and system factors were ranked lower than patient-related factors, time limitations and desire to maintain hope were also considered important, 80% and 74% respectively. CONCLUSIONS: Oncologists ranked patient and family-related factors as the most important barriers to GOC discussions. Time limitations and the desire to maintain hope were also considered important. DISCUSSION: Further work is required to assess patient preferences and perceptions and to develop targeted interventions.

[PALLIATIVE / SUPPORTIVE CARE FOR CHRONIC KIDNEY DISEASE (CKD) PATIENTS].

INTRODUCTION: Patients with advanced/chronic kidney disease (CKD) stage 5 face a high burden of comorbidity, physical and mental symptoms, and impaired quality of life (QOL). Dialysis, which has become a treatment of choice, cannot supply an optimal replacement of the kidney function. Old and fragile dialysis patients with multiple comorbidities often need expensive medical treatments, repeated hospitalizations, and their life expectancy is not longer than those who have chosen not to use dialysis. The WHO emphasizes the need of palliation for serious and incurable diseases, such as CKD stage 5. Among patients who suffer from under-diagnosis and under-treatment of symptoms, some regret having started dialysis. Conservative treatment is offered only in a few cases and only a small proportion of patients have signed an Advanced Care Directive. Patients wish to receive information about their prognosis and treatment choices, thus feeling in control of their treatment. More countries are adopting the ideas of palliative care for CKD patients in order to ensure their QOL and to encourage the patients and their families to be active partners in the decision-making process. Using a palliative care approach can prevent patients from suffering and will reduce treatment costs. This review presents the data published on the subject in world literature.

Normobaric oxygen treatment for mild-to-moderate depression: a randomized, double-blind, proof-of-concept trial.

Oxygen enriched air may increase oxygen pressure in brain tissue and have biochemical effects even in subjects without lung disease. Consistently, several studies demonstrated that normobaric oxygen treatment has clinical benefits in some neurological conditions. This study examined the efficacy of normobaric oxygen treatment in subjects with depression. In a randomized, double-blind trial, 55 participants aged 18-65 years with mild to moderate depression (had a Hamilton Rating Scale for Depression [HRSD] score of ≥ 8) were recruited to the study from the Southern district in Israel. Participants underwent a psychiatric inclusion assessment at baseline and then were randomly assigned to either normobaric oxygen treatment of 35% fraction of inspired oxygen or 21% fraction of inspired oxygen (room air) through a nasal tube, for 4 weeks, during the night. Evaluations were performed at baseline, 2 and 4 weeks after commencement of study interventions, using the following tools: HRSD; Clinical Global Impression (CGI) questionnaire; World Health Organization-5 questionnaire for the estimation of Quality of Life (WHO-5-QOL); Sense of Coherence (SOC) 13-item questionnaire; and, Sheehan Disability Scale (SDS). A multivariate regression analysis showed that the mean ± standard deviation [SD] changes in the HRSD scores from baseline to week four were - 4.2 ± 0.3 points in the oxygen-treated group and - 0.7 ± 0.6 in the control group, for a between-group difference of 3.5 points (95% confidence interval [CI] - 5.95 to - 1.0; P = 0.007). Similarly, at week four there was a between-group difference of 0.71 points in the CGI score (95% CI - 1.00 to - 0.29; P = 0.001). On the other hand, the analysis revealed that there were no significant differences in WHO-5-QOL, SOC-13 or SDS scores between the groups. This study showed a significant beneficial effect of oxygen treatment on some symptoms of depression.Trial registration: NCT02149563 (29/05/2014).

Pain Management Evaluation in Maintenance Hemodialysis Patients.

CONTEXT: Pain is a common complaint in maintenance hemodialysis (MHD) patients, and it is often inadequately assessed and inappropriately treated. OBJECTIVES: The study goal was to preliminarily evaluate pain management in MHD patients. METHODS: The study was a cross-sectional study conducted in 2013-2015. A sample of 277 MHD patients who reported pain within the last 24 hours from five hospital hemodialysis units in Israel were interviewed and evaluated. Study tools included the Brief Pain Inventory, the Pain Management Index (PMI), demographic and clinical characteristics. Pharmacy computerized data were reviewed to identify the type of analgesics used. RESULTS: Mean pain level was 7.2 ± 2.2 (median: 8). Pain level was mild in 17 (6.1%), moderate in 120 (43.3%) and severe in 140 (50.5%) of patients. Only 185 participants (66.8%) were treated with analgesics during the year prior to the interview. Of these, 99 (53.5%) received opioids. Using the PMI to preliminarily assess the appropriateness of the treatment, 214 (77.3%) of patients with pain in the last 24 hours were undertreated, and 52 patients (18.8%) were appropriately treated. In a multivariable analysis, factors associated with inappropriate treatment were severe pain intensity and a higher Functional Independent Measure (FIM). A lower FIM was associated with opioid use in a multivariable analysis. CONCLUSIONS: According to the PMI, most dialysis patients were found to be inappropriately treated. About one third received opioids, but even among them, inappropriate treatment was common. Pain management in MHD patients needs to be improved.

"I Had to Rediscover Our Healthy Food": An Indigenous Perspective on Coping with Type 2 Diabetes Mellitus.

Type 2 Diabetes Mellitus (T2DM) is disproportionally prevalent among the Bedouin minority in Israel, with especially poor treatment outcomes compared to other indigenous groups. This study uses the perspective of the Bedouins themselves to explore the distinct challenges they face, as well as their coping strategies. The study is based on an interpretive interactionist analysis of 49 semi-structured interviews with Bedouin men and women. The findings of the analysis include three themes. First, physical inequality: the Bedouin community's way of coping is mediated by the transition to a semi-urban lifestyle under stressful conditions that include the experience of land dispossession and the rupture of caring relationships. Second, social inequality: they experience an inaccessibility to healthcare due to economic problems and a lack of suitable informational resources. Third, unique resources for coping with T2DM: interviewees use elements of local culture, such as religious practices or small enclaves of traditional lifestyles, to actively cope with T2DM. This study suggests that there is a need to expand the concept of active coping to include indigenous culture-based ways of coping (successfully) with chronic illness.

When they stop drinking-examining end-of-life hydration practices and death rattle occurrence.

PURPOSE: To characterize the practice of subcutaneous hydration provision in the Beer-Sheva home care hospice unit. We also explore the potential connection between the provision of subcutaneous hydration and the incidence of death rattle. METHODS: This was a prospective observational study involving 120 hospice patients. During the 6 days before death, hospice staff recorded whether or not fluids were administered orally and/or subcutaneously; the duration, timing, and quantity of fluid administration; the incidence, timing, and duration of death rattle; and whether medications that can affect death rattle were given. RESULT: Fifty-three percent of the patients received subcutaneous hydration. The mean daily volume administered in the hydration group was 434 ml. There was a significant association between the duration of treatment in the hospice unit and provision of subcutaneous hydration (mean of 51 days in hydration group vs. 31 days in non-hydration group, p = 0.03). Although not statistically significant, males were more likely to receive subcutaneous hydration than females (62% of males vs. 46% of females, p = 0.09). There was a higher incidence of death rattle in men compared to women (54.7% in men vs. 32.8% in women, p = 0.025). A statistically significant association between death rattle and the provision of subcutaneous hydration wasn't demonstrated. CONCLUSION: The decision of whether to provide subcutaneous hydration is individualized taking into consideration the values of the patients and their families. The provision of 500 ml per day of subcutaneous saline during the last 6 days of life does not significantly increase the incidence of death rattle.

Israel Ad Hoc COVID-19 Committee: Guidelines for Care of Older Persons During a Pandemic.

Early on, geriatricians in Israel viewed with increasing alarm the spread of coronavirus disease 2019 (COVID-19). It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country's Ministry of Health, the Israel Medical Association, and the country's largest health fund; this was done to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, a palliative care specialist, and a lawyer/ethicist. The members made every effort to ensure that their recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee's main task was to think through a workable approach because intensive care unit/ventilator resources may be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and in long-term care institutions, a triage instrument, and palliative care. Patient autonomy was emphasized, with a strong recommendation for people of all ages to update their advance directives or, if they did not have any, to quickly draw them up. Considering the value of distributive justice, with respect to triage, a "soft utilitarian" approach was advocated with the main criteria being function and comorbidity. Although chronological age was rejected as a sole criterion, in the case of an overwhelming crisis, "biological age" would enter into the triage considerations, but only in the case of distinguishing between people with equal non-age-related deficits. The guideline emphasized that no matter what, in the spirit of beneficence, anyone who fell ill must receive active palliative care throughout the course of a COVD-19 infection but especially at the end of life. Furthermore, in the spirit of nonmaleficence, the frail, very old, and severely demented would be actively protected from dying on ventilation. J Am Geriatr Soc 68:1370-1375, 2020.

Patient-reported outcomes in maintenance hemodialysis: a cross-sectional, multicenter study.

PURPOSE: The aim of this study is to assess patient-reported outcome measures (PROMs) related to symptoms among maintenance hemodialysis patients (MHDp). METHODS: This cross-sectional study was conducted between 2013 and 2015, with 336 MHDp from five hospital hemodialysis units. It included a comprehensive assessment of the prevalence and intensity of 30 common dialysis-related symptoms quality of life and daily function of MHDp, by using the Dialysis Symptom Index (DSI), Quality of Life Short Form (KDQOL-SF), and demographic and clinical characteristics. RESULTS: The five most commonly reported symptoms were identified as tiredness (80%), difficulty becoming sexually aroused (72%), decreased interest in sex (72%), worrying (67%), trouble staying asleep (65%), and trouble falling asleep (64%). Based on the DSI, the mean Overall Burden of Symptoms (OBS), on a scale of 0-30, was 15.4 ± 6.7, while the mean Overall Symptom Severity Score (OSSS), on a scale of 0-150, was 54.8 ± 29.8. Multivariate quantile regression models indicated that major depression is consistently associated with both the OBS and OSSS across different quantiles, whereas time on dialysis > 24 months was associated with the OBS only. Both the OBS and OSSS were inversely associated with KDQOL-SF: the kidney-related (KDCS), physical (PCS) and mental aspects (MCS), across multiple quantiles in multivariate quantile regression models. CONCLUSIONS: MHDp bear a heavy burden of symptom which are associated with time spent on dialysis as well as depression. Clinical and research resources should be directed at controlling symptoms, improving daily function, detecting depression, and bettering quality of life.

"Death is inevitable - a bad death is not" report from an international workshop.

Palliative care is an approach meant to improve the quality of life of patients facing life-threatening illness and to support their families. An international workshop on palliative care took place in Caesarea, Israel under the auspices of the National Institute for Health Policy Research on July 4-5th, 2018, with the goal of discussing challenges to the development and integration of palliative care services in Israel. At the workshop, both national and international figures in the field of palliative care and health policy addressed several issues, including truth telling, religious approaches to end of life care, palliative care in the community, pediatric palliative care, Israel's Dying Patient Act, the Ministry of Health's National Plan for palliative care, and challenges in using advance directives. We summarize the topics addressed, challenges highlighted, and directions for further advancement of palliative care in the future, emphasizing the critical role of the Ministry of Health in providing a framework for development of palliative care.

Cardiovascular Disease and hospital admissions in African immigrants and former Soviet Union immigrants: A retrospective cohort study.

BACKGROUND: Previous studies reported low prevalence of cardiovascular disease (CVD) despite an increasing prevalence of metabolic abnormalities in immigrants who moved from low CVD-risk regions to Western countries. Nevertheless, little is known about hospital admissions due to CVD in immigrants. METHODS: A retrospective cohort study of East Africa immigrants (EAI), Former Soviet Union immigrants (FSUI) and native-born Israelis (NBI) over 11-year period. Associations between ethnicity, age, sex, CVD, and hospital admission were assessed using logistic and Poisson regression models. Incidence density rates per person-years were calculated. RESULTS: The age-adjusted prevalence rates of ischemic heart disease in EAI, FSUI and NBI, respectively, were 1.8%, 8.2%, and 5.8%, respectively (p < 0.001). The corresponding rates for stroke were 2.6%, 3.5%, and 2.5%, respectively. Multivariate odds ratios for all CVD were found to be significantly lower in EAI for both sexes. Hospitalizations rate due to CVD were 9, 17, and 6 per 1000 person-years in EAI, FSUI and NBI, respectively (p < 0.001). EAI were more likely to be hospitalized due to hypertensive disease, cerebral vascular diseases and heart disease, in comparison to NBI and FSUI. However, when controlling for CVD risk factors profile, EAI had similar admission rates to NBI. EAI were more likely to be hospitalized in internal medicine, geriatrics, and neurology departments, and less likely to be admitted to intensive care units or surgical department. CONCLUSIONS: EAI had low rates of all types of CVD, and low risk of hospitalization after controlling for CVD risk factors profile.

Restored Self: A Phenomenological Study of Pain Relief by Cannabis.

OBJECTIVE: To explore the subjective experience of pain relief by cannabis. DESIGN: Qualitative data were collected through in-depth semistructured interviews. Interview transcripts were analyzed using interpretative phenomenological analysis (IPA). SUBJECTS: Nineteen patients, aged 28 to 79, who were treated with medical cannabis under the supervision of a pain clinic in Israel. RESULTS: Three key themes that emerged from the analysis were explored: 1) the Sigh of Relief, describing the corporal sensation of using cannabis, including a sense of relaxation and reduction in pain; 2) the Return to Normality, describing the comprehensive effect of using cannabis, including an increased ability to sleep, focus, and function; and 3) the Side Effects of using cannabis. CONCLUSIONS: We propose the term Restored Self to conceptualize the effect of medical cannabis. Restored Self is the experience of regaining one's sense of self, sense of normality, and sense of control over one's life.

Secondary Traumatization and Proneness to Dissociation Among Palliative Care Workers: A Cross-Sectional Study.

CONTEXT: Exposure to dying patients can contribute to secondary traumatic stress (STS) among palliative care workers. Peritraumatic dissociation (PETD), an individual's personal proneness to dissociation during exposure to a stressful event, is the strongest predictor of post-traumatic stress, but existing research on its relationship to STS is limited. OBJECTIVE: To compare the level of STS among palliative workers with clinical levels of PETD compared with those without clinical levels of PETD. METHODS: A cross-sectional self-report survey. SETTING/PARTICIPANTS: These include about 420 physicians and nurses working in hospital-based and/or home-based palliative care units. INCLUSION CRITERIA: two years' experience with at least 10 hours/week of direct care for terminally ill patients. RESULTS: About 144 participants returned completed questionnaires (response rate 35%). Sixty percent reported a nonclinical level of dissociation. Workers with a clinical level of dissociation had significantly higher levels of STS compared with workers who did not. Awareness of an interaction effect between PETD and fear of dying progression can advance our understanding of how the development of PETD during exposure to dying can have an impact that is beyond the main effect on STS. CONCLUSIONS: The clinical level of PETD correlates significantly with STS. Further research is needed to understand whether STS is related to the individual's own vulnerability, as reflected by their personal proneness to dissociation, during exposure to death and dying.