Acceptance Of Palliative Care Research Articles

Future scenarios of palliative care in health system of Iran: a multi-method study.

Paying attention to palliative care has accelerated in Iran in the last 10 years. Considering the trend of aging, increasing burden of chronic diseases and increasing health costs, planning and development of palliative care is necessary in the future. This study was conducted with the aim of explaining the alternative scenarios of palliative care in the health system of Iran until the horizon of 2030. This study was a multi-method scenario planning with a qualitative using multiple methods design, which was conducted in 3 phases in 2018-2020. In the first phase, a list of driving forces was extracted using qualitative interviews and literature review. In the second phase, all factors identified in the previous phase were examined in terms of degree of uncertainty and cross-impact analysis, and two key uncertainties were extracted. In the third phase, based on two key uncertainties, four future scenarios of palliative care were formulated, validated and scenario strategies were presented. The results indicate two uncertainties, including "governance of palliative care in the health system" and "acceptance of palliative care by society," based on which, four scenarios with the names "climbing to the top," "excruciating climb," "edge of the abyss" and "The bottom of the valley" were compiled. The development of palliative care in health system of Iran is faced with serious uncertainties that it is necessary to focus the developmental activities of palliative care on the two axes of acceptance by society and need for coherent governance by considering all the dimensions and influential components by ministry of health. The application of the results of this research can provide reasonable options for effective interventions and implementation of this category of services to the beneficiaries of palliative care.

Access to palliative care in patients with advanced cancer of the uterine cervix in the low- and middle-income countries: a systematic review

BackgroundWomen with advanced uterine cervical cancer suffer from a combination of moderate to severe physical, psychological, social, and spiritual distress due to their disease and are in need of palliative care to improve their quality of life. Approximately 85% of the women live in the low- and middle-income countries. Whether these women and their families access palliative care is not known.ObjectivesTo understand the geographic accessibility, availability, financial accessibility, and acceptability of palliative care by patients with advanced cervical cancer and their families.MethodsWe conducted a Systematic review following PRISMA guidelines in CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, PsychINFO, PubMed and Scopus for the core concepts: palliative care, access, advanced uterine cervical cancer. Eligible articles were published in English, contained original data on experiences of patients and/or caregivers including symptoms management, and discussed available resources, communication, satisfaction, and healthcare utilization.ResultsOverall there was limited access to palliative care with the few available facilities located in cities, far from the rural areas where most women lived. Pervasive poverty was common with poor affordability of healthcare, travelling, accommodation, and subsistence expenses. Misconceptions and poor knowledge of the disease, cultural beliefs and attitudes, and other health system insufficiencies also presented challenges for access.ConclusionConcerted effort should be made to improve availability of palliative care facilities. Health education to address misconceptions and other cognitive barriers that limit access among cervical cancer patients and their families should be urgently undertaken in the LMICs.

Too Close for Comfort? Attitudes of Gynecologic Oncologists Toward Caring for Dying Patients.

To assess gynecologic oncologists' attitudes relating to palliative care referrals among advanced cancer patients. Gynecologic oncologists were surveyed using validated measures to assess stigmatizing attitudes toward palliative care, anticipated stigma of palliative care, acceptance of palliative care, and willingness to refer to palliative care. Descriptive statistics were calculated. Analysis was performed using linear regression. 1200 physicians received the survey and 108 (9%) completed it. Most were female (69.4%) and white (82.4%). Most practiced in academics (64.8%) in urban environments (71.3%). Respondents did not have anticipated stigma surrounding palliative care referral (mean score 1.89, range 1-7, higher score indicating more stigma), were accepting of palliative care (mean score 1.45, range 1-7, higher score indicating less acceptance), and were willing to refer patients to palliative care (mean score 5.75, range 1-7, higher score indicating more willingness to refer). Linear regression demonstrated females had less anticipated stigma surrounding palliative care (B = -.213, P = .04) and higher acceptance of palliative care (B = -.244, P = .01). Most surveyed derived satisfaction from work with advanced cancer patients (83%). Nineteen percent were depressed by managing advanced cancer patients. One fourth felt emotionally burned out by dealing with too many deaths. Most gynecologic oncologists did not exhibit stigma surrounding palliative care and derive satisfaction from their work. Some gynecologic oncologists experience depression and burnout related to their profession. This close connection with patients as they transition to the end of life may take a toll on providers.

Can cognitive behavioral therapy (CBT) intervention in patients diagnosed with stage 3/4 gastric cancer increase patients’ acceptance of palliative care earlier in the cancer continuum?

Background and Hypothesis: Palliative care, though designed improve quality of life in patients diagnosed with a grave illness, is widely stigmatized as an “end of life” service. Cancer diagnosis has been known to cause mental stress on patients; the added stigmatization of palliative care with death is a barrier to care, especially in gastric cancer patients whose delay in treatment can result in poor cancer prognosis and outcomes. Cognitive Behavior Therapy (CBT) intervention is promising is an ideal intervention in this case, yet, understudied in palliative oncology. Successful CBT intervention can combat guilt, denial and stigma, leading to more positive outlook on life and palliative care. We hypothesize that CBT intervention will increase stage 3/4 gastric cancer patients’ acceptance to start palliative care early in their cancer treatment by decreasing associated stigma. 
 
 Experimental Design and Results: Study will be an interventional, unblinded, randomized clinical trial with an experimental and control group. A CBT video intervention will be used, preceded and followed by a pre-/post session questionnaire generated from IU’s RedCap. Full intervention will have 4 sessions, with experimental groups divided into those receiving <2, 3 or full 4 sessions. All individuals age 18+ with a recent stage 3/4 gastric cancer diagnosis, who have the ability to provide consent/comprehend the CBT video will be illegible to participate in the study. A spearman’s correlation will be used to test significance of CBT. A negative trend is predicted between CBT intervention and palliative care stigma; as the number of CBT sessions increase, palliative care stigma should decrease accordingly. 
 
 Potential Impact: CBT’s effectiveness in alleviating stigma faced by patients with advanced gastric cancer can suggest more psychosocial training for physicians to move away from disease centered approach to one that implements ways that eradicate social barriers to care.

Barriers and Facilitators of Using Quality Improvement To Foster Locally Initiated Innovation in Palliative Care Services in India.

Quality improvement (QI) methods represent a vehicle for fostering locally initiated innovation cycles. We partnered with palliative care services from seven diverse practice settings in India to foster locally initiated improvement projects. To evaluate the implementation experiences of locally initiated palliative care improvement projects at seven diverse sites and understand the barriers and facilitators of using QI to improve palliative care in India. We use a quota sampling approach to capture the perspectives of 44 local stakeholders in each of the following three categories (organizational leaders, clinic leaders, and clinical team members) through a semi-structured interview guide informed by the consolidated framework for implementation research (CFIR). We use standard qualitative methods to identify facilitators and barriers to using QI methods in seven diverse palliative care contexts. Across all sites, respondents emphasized the following factors important in the success of quality improvement initiative: leveraging clinic level data, QI methods training, provider buy-in, engaged mentors, committed leadership, team support, interdepartmental coordination, collaborations with other providers, local champions, and having a structure for accountability. Barriers to using QI methods to improve palliative care services included lack of designated staff, high patient volume, resources, patient population geographic constraints, general awareness and acceptance of palliative care, and culture. Empowering local leaders and medical personnel to champion, design, and iterate using QI methods represents a promising powerful tool to spread palliative care services in developing countries.

Bridging Behavioral Science with Cancer Prevention and Control: Contributions of an NCI Working Group (2009-2019).

Human behavior plays a central role in cancer-related morbidity and mortality. Much behavior is, in turn, attributable to several core biological, cognitive, emotional, motivational, and interpersonal processes. Understanding the systematic and interactive impact of these processes can inform efforts to address cancer-relevant outcomes such as tobacco use, reliance on cancer misinformation, engagement in genetic testing, adherence to treatment, and acceptance of palliative care. Here, we review efforts of the NCI-supported Cognitive, Affective, and Social Processes in Health Research working group. Since 2009, this group has endeavored to advance the integration of basic behavioral science with cancer prevention and control by addressing topics such as the degree to which behavioral interventions alter cognitions underlying behavior, how technological innovations might facilitate behavioral measurement and intervention in areas such as smoking cessation, whether decision science principles might be applied to genetic testing decisions, how the cognitive effects of chemotherapy impair self-regulation, and the extent to which emotional factors drive palliative care decisions. The group has initiated numerous activities to build capacity for research in these areas including state-of-the-science meetings, written syntheses, conference symposia, and training workshops. We conclude with reflections about future needs as well as how to sustain such integrative efforts.

Utilization of palliative care in patients with genitourinary malignancies.

669 Background: Palliative care provides support and improves the quality of life of patients who has terminal illness such as cancer. Studies have shown that integrating palliative care into cancer care soon after the diagnosis of metastatic cancer can improve the quality of life and also prolong survival. The objective of the study was to analyze the acceptance of palliative care and to determine the factors affecting the utilization of palliative care in patients with genitourinary (GU) cancers. Methods: The National Inpatient Sample Database for the year 2016 was queried for the data. Patients who were admitted with a principal diagnosis of Malignant Neoplasm of Prostate (MNP), Renal Cell Carcinoma (RCC), Malignant Neoplasm of Ureter (MNU) were identified using ICD-10 codes and those who had Encounter for Palliative Care (PC) was also identified. Results: A total of 58765 hospitalizations were identified with MNP (n=39853), RCC (n=17786), MNU (n= 1126) during the study period. The total PC utilization for the above patients were 6.4% (n= 3785). Among those, 6.7% (n=1186), 6.3% (n=2531), 6.03% (n=68) from the groups RCC, MNP, MNU respectively received PC. The mean age for the PC utilization was 73 years (MNP= 72 yrs, RCA= 63 yrs, UCC= 73 yrs). Females received more PC when compared to males (6.7% vs 6.4%). Among those who had PC 27.4% (n=1029) died in the hospital. Interestingly, patients who had Medicare and Medicaid had more PC encounters when compared to those with private insurance (OR= 1.21, P= 0.001). Patients admitted on the weekend received more PC when compared to those who admitted during weekdays (OR= 1.12, P= 0.001). Patients admitted to hospitals in the West received more PC than other regions (OR= 1.42, P=0.03). Impact of race, teaching vs non-teaching hospital admissions were not found to be statistically significant in the utilization of PC in the above GU cancers. Conclusions: Medicare and Medicaid patients, weekend admissions, admissions to hospitals in the West received more palliative care. Further studies are needed to reveal the role of socioeconomic status and insurance in the utilization of palliative care in GU malignancies.

Myths that Inhibit the Spread of Palliative Care in India (S733)

•Identify myths about cancer and terminal prognosis that may inhibit the spread of palliative care in India.•Consider strategies to overcome these palliative care myths in India and other developing contexts. Roughly 2% of people have access to palliative pain and symptom management in India. While there are many factors that limit the access to and use of palliative care, this paper aims to identify myths about palliative cancer care and terminal prognosis that may inhibit the adoption and spread of palliative care in India. We use a quota sampling approach to capture the perspectives of local stakeholders from 7 palliative care practice sites throughout India. We collected a total sample of 44 interviews from the following 3 categories (organizational leaders, clinic leaders, and clinical team members) through a semi-structured interview guide. We identified emergent themes using standard qualitative content analysis methods. Myths influencing decision making for palliative care: Theme 1—Cancer is contagious “…cancer is sometimes they[patient]think it is contagious… that is why it affects our [PC] services…” Theme 2—Palliative care is only for patient with cancer “…we are like most organizations in India we are doing mostly cancer palliative care…our training for management of non-cancer palliative care is still very much lacking…” Theme 3—Palliative care is only for end of life “even if you tell a patient that we are referring you to palliative care, they assume that we are actually giving up on actual cancer care..” Theme 4—Quality of life is not relevant when patient has a terminal illness “…probably doctors as well as patients feel that ok we are in the terminal stage why should we need any care kind of a thing…” Theme 5—Managing pain is “giving up.” Myths about what palliative care means and who it is for persist in India and impact perceptions of the appropriateness and acceptability of palliative care.

Understanding of palliative care among members of the public.

71 Background: The World Health Organization (WHO) defines palliative care (PC) as an approach that improves the quality of life of patients and their families facing life-threatening illness. However, the public may be unaware of this definition. We assessed the Canadian public’s knowledge and attitudes toward PC before and after being provided the WHO definition. Methods: We engaged a health research firm to distribute a cross-sectional survey to members of the Canadian public. Eligible participants were >18 years of age, could comprehend English or French, and were currently residing in Canada. We assessed participants’ knowledge of and attitudes towards PC before and after reading the WHO definition of PC. Results were analyzed using the Wilcoxon Signed-Rank test. Results: Of 1518 participants (52% female), 45% (676/1518) stated they knew what PC was and could explain it, 32% (488/1518) knew about PC but could not explain it, 13% (198/1518) had heard of PC but did not know what it was, and 10% (156/1518) had never heard of PC. Of those who had heard of PC, 58% (784/1362) agreed PC is the last resort when other treatments have failed, 64% (877/1362) agreed PC means being close to death, and 67% (914/1362) believed PC meant being at “the stage that you can no longer take care of yourself”. Before reading the WHO definition, 56% (774/1362) agreed/strongly agreed that referral to PC would make them feel afraid; after reading the definition, this percentage was reduced to 41%, and degree of fearfulness was reduced in 46% (p<0.0001). Fifty-nine percent (898/1518) stated they did not know, prior to reading the WHO definition, that PC could be involved early in the course of illness, and 45% did not know PC could be provided together with other treatments aimed at prolonging life. Eighty-nine percent (1344/1518) felt the PC definition helped them to better understand what PC is, and 91% believed that Canadians should be made aware PC can be included early in the course of a patient’s illness. Conclusions: More than half of respondents had limited knowledge of PC and believed it was synonymous with end-of-life care. Provision of the WHO definition improved understanding and allayed fears of PC. Public educational initiatives may improve understanding and increase acceptance of PC.

YouTube Videos as a Source of Palliative Care Education: A Review.

Background: The lack of consumer knowledge and misconception of services could impede requests for and acceptance of palliative care. YouTube has been widely used for health information dissemination. Objective: To explore the availability and characteristics of palliative care educational videos on YouTube and determine how palliative care is portrayed in these videos. Methods: Keyword search and snowball methods were used to identify palliative care videos on YouTube. A structured data collection protocol was developed to record characteristics of a video. Descriptive analysis was used to describe the video features; logistic regression was conducted to determine the association between video characteristics and number of views per day. Results: A total of 833 videos were screened; 84 met criteria for analysis. The most prominent video styles were providing palliative care information (85%) and personal testimony (50%). One-third were uploaded by hospice/palliative care services or medical organizations, while another one-third by advocacy organizations. More than two-thirds mentioned "end-of-life" and 35% mentioned "hospice." Physicians most frequently appeared and served as protagonists. Protagonists were primarily female (71.0%), aged 18-64 years (81.7%), and white (90.3%). Compared with videos uploaded by health care agencies, those uploaded by advocacy organizations had 6.41 times higher odds of having more than one view per day (p = 0.002). Conclusion: Online videos may not provide accurate and appropriate information on palliative care. There is minimal ethnic diversity in terms of physician and family representation. More research is needed to determine the effectiveness of these videos in improving consumer knowledge of palliative care.

Educational Needs on Palliative Care for Cancer Patients in Iran: A SWOT Analysis.

By acceptance of palliative care as a part of health system of each country and due to increasing prevalence of cancer, special focus on stakeholder's educational needs is of vital importance so that palliative care services are improved and the quality of life of patients is enhanced. This study was conducted to explore the educational needs of stakeholders of palliative care for cancer patients in Iran. This qualitative study with 20 semi-structured interviews was conducted from August 2016 to February 2017 in Shohadaye Tajrish and Emam Khomeini Hospitals of Tehran. Participants were selected through purposive sampling and included cancer patients and their family caregivers as well as healthcare providers, experts and policy-makers. The data were analyzed through Conventional Content Analysis of Landman and Graneheim using MAXQDA10 software. Statements of each main category of the study were summarized in SWOT categorizes. A total of 546 codes were extracted from the analysis of the interviews and four main categories and four subcategories were identified. The four main identified categories included: "academic education planning", "workforce education", "public awareness", and "patient and caregiver empowerment" that contained our subcategories as follows: "strengths", "weaknesses", "opportunities" and "threats" (SWOT). Meeting the educational needs of the stakeholders of palliative care requires policy-makers to identify the factors leading to strategies that are based on the use of opportunities, the removal of weaknesses, and coping with the threats to which the organization is faced.

Fuzzy regression model clustering algorithm based assessment, analysis and acceptance of palliative care and psychological behaviors of elderly patients with cancer pain

To investigate the effect of palliative care on the psychological status of patients with advanced cancer. 106 elderly patients with cancer pain were randomly divided into observation group and control group, before enrollment, the symptoms check list was filled to assess the patient’s mental health level; the control group received conventional cancer nursing intervention, the observation group received palliative care intervention in addition to conventional nursing. 2 weeks after nursing intervention, The symptom check list(SCL-90) and Functional Assessment of Cancer Therapy-General(FACT-G) were released in the same way and the two groups of patients were re-evaluated. Symptom check list of the two groups before enrollment was higher than that of the national norm; after 2 weeks of nursing intervention, the score of symptom check list in the observation group was lower than that in the control group. The total scores total number of positive symptoms and the mean was lower than that before the intervention, with significant difference. Palliative care can effectively improve the advanced cancer patients somatization, coercion, interpersonal sensitivity, anxiety, depression and other adverse psychological conditions.

Acceptance of Advance Directives and Palliative Care Referral for Veterans With Advanced Cancer: A Retrospective Analysis.

To evaluate the documentation of advance directive (ADs) and physician orders for life-sustaining treatment (POLST) with acceptance of palliative care (PC) services referral among patients with cancer. We retrospectively reviewed veterans with advanced cancers at the Veterans Administration Palo Alto Health Care System. Chi-square tests estimated AD and POLST documentation and referral to PC. Logistic regression models estimated the odds of AD and POLST documentation and PC referral. Two hundred and forty-six veterans were diagnosed with cancer. In all, 53% had a documented AD, 5% had a POLST, and 47% accepted referral to PC. The AD documentation was not associated with acceptance of PC. We found no association of AD documentation and PC referral. Future studies should evaluate other factors that influence referral to these services.

Impact of Palliative Care Consultation Service on Terminally Ill Cancer Patients: A 9-Year Observational Cohort Study in Taiwan.

The palliative care consultation service (PCCS) that has been enthusiastically promoted in Taiwan since 2005 was designed to provide comprehensive end-of-life care for terminally ill patients with qualified interdisciplinary specialists in acute care ward setting. This study aims to evaluate the impact of PCCS on terminally ill cancer patients.A total of 10,594 terminal cancer patients who were referred to PCCS from a single medical center in Taiwan between 2006 and 2014 were enrolled. The percentages of patients’ and their families’ disease awareness, do-not-resuscitate (DNR) designation, refusal and acceptance of palliative care among terminally ill cancer patients were analyzed retrospectively.At the beginning of PCCS, the percentages of disease awareness among patients and their family were increased from 25.4% to 37.9% (P = 0.007) and from 61.2% to 84.7% between 2006 and 2014 (P = 0.001), respectively. Patients’ disease awareness after PCCS referral between 2006 and 2014 was increased from 47.1% to 64.5% (P = 0.016). Family's awareness of diagnosis and prognosis after PCCS referral researched to a steady plateau, 94.1% to 97.8% in different year cohort (P = 0.34). The percentage of DNR designation rate at the beginning of PCCS (in 2006) was 15.5%, and the designation rate was increased annually and finally reached to 42.0% in 2014 (P = 0.004). The percentage of DNR consents after PCCS was also improved from 44.0% in 2006 up to 80.0% in 2014 (P = 0.005). PCCS refusal rate decreased gradually and dropped to 1.6% in 2014 (P = 0.005). The percentage of PCCS utilization was increased 5-fold during the 9-year period after the promotion of PCCSIn the program of PCCS promotion, an increasing trend of PCCS utilization, better patients’ and their families’ awareness of diagnosis and prognosis, more consent to DNR, more patients were discharged with stable condition at the end of PCCS and a decrease refusal rate of end-of-life palliative care among terminal cancer patients were observed in Taiwan between 2006 and 2014.

Providing palliative care for cardiovascular disease from a perspective of sociocultural diversity: a global view.

This article discusses the available information on providing palliative care for cardiovascular disease (CVD) for individuals from culturally and linguistically diverse populations, and argues the need for cultural competence and awareness of healthcare providers. The burden of CVD is increasing globally and access to palliative care for individuals and populations is inconsistent and largely driven by policy, funding models, center-based expertise and local resources. Culture is an important social determinant of health and moderates health outcomes across the life trajectory. Along with approachability, availability, accommodation, affordability and appropriateness, culture moderates access to services. Health disparities and inequity of access underscore the importance of ensuring services meet the needs of diverse populations and that care is provided by individuals who are culturally competent. In death and dying, the vulnerability of individuals, families and communities is most pronounced. Using a social-ecological model as an organising framework, we consider the evidence from the literature in regard to the interaction between the individual, interpersonal relationships, community and society in promoting access to individuals with cardiovascular disease. This review highlights the need for considering individual, provider and system factors to tailor and target healthcare services to the needs of culturally diverse populations. Beyond translation of materials, there is a need to understand the cultural dimensions influencing health-seeking behaviors and acceptance of palliative care and ensuring the cultural competence of health professionals in both primary and specialist palliative care.

Access to palliative care: insights into ground realities post-2014 amendment to NDPS Act

Medical practice today is disease-focused, ignoring the universally accepted definition of health as not just the absence of disease, but the promotion of complete physical, social and mental well-being. Generations of doctors in India have not studied modern pain management, and palliative care is practically unknown in most parts of the country, causing patients to be rejected by hospitals and doctors when they need help the most. The draconian Narcotic Drugs and Psychotropic Substances (NDPS) Act of 1985, outdated medical and nursing education, lack of public awareness and lack of clear governmental policy are responsible for this sorry state of affairs. The development of a community-oriented palliative care network eventually led to the formulation of a state palliative care policy in Kerala. The acceptance of palliative care as a medical specialty by the Medical Council of India and introduction of a postgraduate degree course in palliative medicine in 2010, the development of a National Programme for Palliative Care in 2012 by the Ministry of Health of the Government of India, and the amendment of the NDPS Act in 2014 have been major positive developments which have the potential to change the current state of affairs. However, these recent achievements represent but one step in the right direction. An improvement in palliative care education, a realistic palliative care policy and implementation of the NDPS Amendment Act are necessary for doing away with the gross, needless violation of the human right to life with dignity.

Barriers to Optimal Palliative Care of Lung Transplant Candidates

The provision of effective palliative care is of great importance to patients awaiting lung transplantation. Although the prospect of lung transplantation provides hope to patients and their families, these patients are usually very symptomatic from their underlying disease. An e-mail questionnaire was sent to members of the American College of Chest Physicians' Transplant NetWork and the Pulmonary Council of the International Society for Heart and Lung Transplantation (ISHLT). The survey included questions about barriers to providing palliative care, the availability of palliative care services, and recommended strategies to improve palliative care for lung transplant candidates. The 158 respondents represented approximately 65% of transplant programs in the ISHLT registry. Respondents were in practice a mean of 11.3 (± 9) years, 70% were pulmonologists, 17% were surgeons, and 13% were other care providers. Barriers were classified into domains including patient factors, family factors, physician factors, and institutional/transplant program/lung allocation system factors. Significant patient/family barriers included unrealistic patient/family expectations about survival, unwillingness to plan end-of-life care, concerns about abandonment or inappropriate care after enrollment in a palliative care program, and family disagreements about care goals. For institutional/program/allocation system barriers, only the requirement for weight loss or gain to meet program-specific BMI requirements was identified. Significant physician barriers included competing time demands and the seemingly contradictory goals of transplant vs palliative care. Strategies recommended to improve palliative care included routine advance care planning for patients awaiting transplantation, access to palliative care specialists, training of transplant physicians in symptom management, and regular meetings among transplant physicians, nurses, patients, and families. Physicians providing care to lung transplant candidates reported considerable barriers to the delivery and acceptance of palliative care and identified specific strategies to improve palliative care for lung transplant candidates.

62 Barriers to Optimal Palliative Care of Lung Transplant Candidates

<h3>Purpose</h3> Provision of palliative and end-of-life care is of special importance for patients awaiting lung transplantation. However, lung transplant program practices may be at odds with palliative care principles. We examined perceived barriers to delivery of palliative care to lung transplant candidates and sought strategies to improve such care. <h3>Methods and Materials</h3> An anonymized e-mail questionnaire was sent to all members of the American College of Chest Physicians Transplant NetWork and of the Pulmonary Council of the ISHLT. It included demographic and practice-related questions, questions about barriers to palliative care of lung transplant candidates, availability of services and utility of strategies to improve palliative care. Transplant program practitioners were eligible for this study. <h3>Results</h3> There were 158 eligible responses. Respondents were in practice 11.3 (±9) years. 70% were pulmonologists, 17% surgeons and 13% other care providers, including coordinators and nurse practitioners. Barriers that were considered at least moderate by >50% of respondents were classified as significant. These included unrealistic patient/family expectations about survival until and after transplant, patient/family unwillingness to plan end-of-life care, patient concerns about inappropriate care or abandonment after enrollment in a palliative care program and family disagreements about care goals. Among program policy barriers, the requirement for weight loss or gain was identified. Clinician barriers included competing time demands and seemingly contradictory goals of transplantation and palliative care. Helpful strategies included routine advanced care planning assistance for listed patients, access to palliative care consultants, training of transplant physicians in symptom management and regular meetings between transplant physicians, nurses, patients and families. <h3>Conclusions</h3> Clinicians providing care to lung transplant candidates perceive important barriers to the delivery and acceptance of palliative care and believe that there are specific strategies that may improve such care.

Current Status of Palliative Care--Clinical Implementation, Education, and Research

Palliative and end-of-life care is changing in the United States. This dynamic field is improving care for patients with serious and life-threatening cancer through creation of national guidelines for quality care, multidisciplinary educational offerings, research endeavors, and resources made available to clinicians. Barriers to implementing quality palliative care across cancer populations include a rapidly expanding population of older adults who will need cancer care and a decrease in the workforce available to give care. Methods of integrating current palliative care knowledge into care of patients include multidisciplinary national education and research endeavors, and clinician resources. Acceptance of palliative care as a recognized medical specialty provides a valuable resource for improvement of care. Although compilation of evidence for the importance of palliative care specialities is in its initial stages, national research grants have provided support to build the knowledge necessary for appropriate palliative care. Opportunities are available to clinicians for understanding and applying appropriate palliative and end-of-life care to patients with serious and life-threatening cancers.

Increased medicalization within palliative care

The specialty of palliative care has developed rapidly in the last two decades, as evidenced by the growth of specialist services, tertiary education programmes and recognition of palliative care as a specialty within professional colleges. In planning cancer services for the future, palliative care is now recognized as an integral component of these services. This acceptance of palliative care, while perhaps not complete, has been largely due to the efforts of committed health professionals from many disciplines, including nursing. The shared philosophy of what was palliative care practice enabled these individuals to argue with one voice. Recent changes in the practice of palliative care bring into question whether this shared view of palliative care remains.