Nonphysical Symptoms Research Articles

Abstract WP157: Withdrawing and Withholding of Life Sustaining Treatment After Stroke: Understanding the Content of Discussion With Families & Review of Symptoms at End of Life

Background: Stroke kills 160,000 patients every year in the US. Most patients who die with stroke do so in hospital. Little is known about the acute dying process or experience of patients with stroke and their families. Objectives: The goal of this quality improvement project is to better understand the end-of-life process in patients dying with stroke at our institution, focusing on patients who were awake at end of life. Methods: Of patients admitted to our academic medical center in 2022 with stroke who died, we collected basic characteristics and information about reasoning behind WLST and the patient’s condition immediately after WLST. Among those who showed signs of wakefulness (tracking examiner or better), we searched the chart for any documentation of broadly defined goals of care conversations and patient or family symptoms assessed at end of life. Results: Of 525 patients, 118 patients (22.5%) died in hospital. Basic characteristics are listed in Table 1. WLST occurred in 99 patients (84% of decedents), of whom 33 (27.8%) showed signs of wakefulness at time of WLST. None of the patients participated in conversations, and a documented advance directive was followed in 5 (15%). After WLST, patient symptoms most frequently documented by clinicians included dyspnea (n=29), pain (n=18), and restlessness (n=12), but no non-physical symptoms (see Table 2). Family symptoms were not documented. Discussion: At least one quarter of hospital decedents after stroke showed signs of wakefulness, with patient-centered symptoms rarely documented. A standardized, systematic symptom assessment is needed to truly understand signs and symptoms during end-of life for patients with stroke.

Medical assistance in dying in Canada: A scoping review on the concept of suffering.

Medical Assistance in Dying (MAiD) has been legal in Canada since June 2016. A person can receive MAiD if their suffering cannot be relieved under conditions that they consider acceptable. Informed consent requires that the person requesting MAiD has received all the information needed to make their decision; that is, medical diagnosis and prognosis, available treatments including palliative care. The evaluation of unbearable suffering is known to be challenging as suffering is often psychological, existential, and social in nature. While interventions to relieve suffering exist, it is unclear how suffering is assessed and addressed in the literature on MAiD practice. No scoping review exists on the topic in Canada. The aim of this study was to understand how the concept of suffering was approached within the Canadian MAiD grey (GL) and scientific (peer-reviewed) literature (SL), specifically: 1- How suffering is defined and assessed in the context of MAiD in Canada and 2- Which interventions in response to suffering are recommended within the process of obtaining informed consent for MAiD and throughout the process of MAiD itself. A scoping review was conducted based on PRISMA-SR guidelines. SL articles (N=1027) were identified from a review of 6 databases and GL documents (N=537) were obtained from the provinces of Quebec, Ontario and British Columbia. Documents were analyzed using NVivo with coding by two-raters and continuous team discussions. A multidimensional definition of suffering, akin to the concept of total pain, is used. The assessment of suffering is based upon patients' reports. Tools to aid in the assessment are not comprehensively covered. Specific interventions to address suffering were often focused on active listening and the management of physical symptoms. No specific interventions were mentioned and there was no reference to clinical practice guidelines in the grey literature to address other components of suffering. The use of a multidisciplinary approach is suggested without specifying the nature of involvement. Our review indicates that published guidelines of MAID assessments could include clearer structure around the assessment and management of suffering, with suggestions of tools that may help clarify types of suffering and reference to clinical practice guidelines and interventions to holistically attend to patient suffering with an attention on non-physical symptoms. Guidelines would benefit from clearer explanations of how members of an interdisciplinary teams could be coherently coordinated.

Explanatory models of stillbirth among bereaved parents in Afghanistan: Implications for stillbirth prevention.

Local perceptions and understanding of the causes of ill health and death can influence health-seeking behaviour and practices in pregnancy. We aimed to understand individual explanatory models for stillbirth in Afghanistan to inform future stillbirth prevention. This was an exploratory qualitative study of 42 semi-structured interviews with women and men whose child was stillborn, community elders, and healthcare providers in Kabul province, Afghanistan between October-November 2017. We used thematic data analysis framing the findings around Kleinman's explanatory framework. Perceived causes of stillbirth were broadly classified into four categories-biomedical, spiritual and supernatural, extrinsic factors, and mental wellbeing. Most respondents attributed stillbirths to multiple categories, and many believed that stillbirths could be prevented. Prevention practices in pregnancy aligned with perceived causes and included engaging self-care, religious rituals, superstitious practices and imposing social restrictions. Symptoms preceding the stillbirth included both physical and non-physical symptoms or no symptoms at all. The impacts of stillbirth concerned psychological effects and grief, the physical effect on women's health, and social implications for women and how their communities perceive them. Our findings show that local explanations for stillbirth vary and need to be taken into consideration when developing health education messages for stillbirth prevention. The overarching belief that stillbirth was preventable is encouraging and offers opportunities for health education. Such messages should emphasise the importance of care-seeking for problems and should be delivered at all levels in the community. Community engagement will be important to dispel misinformation around pregnancy loss and reduce social stigma.

Hubungan Tingkat Stres dengan Sindrom Pramenstruasi pada Mahasiswi Fakultas Kedokteran Angkatan 2021 Universitas Tarumanagara

Premenstrual syndrome (PMS) is physical and non-physical symptoms experienced by women of the reproductive age two to fourteen days before menstruation. One of the factors can cause PMS is stress. Objective: To determined the correlation between stress and premenstrual syndrome among year 2021 Faculty of Medicine students at University of Tarumanagara. Methods: This research was an observational analytic study with a cross-sectional research design. The stress variable was measured using the Depression Anxiety Stress Scales-21 (DASS-21) questionnaire and the premenstrual syndrome variable was measured based on prospective questionnaire by the American College of Obstetricians and Gynecologists (ACOG). The number of respondents obtained was 138 and the chi-square test was analyzed as a hypothesis test. Results: There were 56 (62,2%) respondents classified as having stress and experienced PMS, while 15 (31,3%) respondents not having stress experienced PMS. The 34 (37,8%) respondents were classified as being stressed but not experiencing PMS, and 33 (68,8%) respondents were not stressed and not experiencing PMS. The affective and somatic symptoms most often experienced irritability (77,54%) and joint or muscle pain (49,28%). There was a significant relationship between stress and premenstrual syndrome with p-value = 0,001 (p-value <0,05). Conclusion: There is a statistically significant relationship between stress and PMS (p<0,05). Affective symptoms were felt more than the somatic ones.Keywords: DASS-21, diagnostic criteria of PMS, premenstrual syndrome, stress

Self-Reported Injury History and Health-Related Quality of Life in Competitive, Collegiate Baton Twirlers.

Injury epidemiology and health-related quality of life (HRQOL) have not been researched in baton twirlers. This cross-sectional study described time-loss injuries sustained by competitive collegiate baton twirlers, identified the relationship between training volume and injuries, and established injury impact on HRQOL. An online survey was used to collect activity volume, number and characteristics of time-loss injuries experienced within a 12-month window, and HRQOL via the Short Form-36. Current injury status was addressed to place participants into categories: no injury history (No Injury), history of injury but no symptoms (Injury Hx, No Sx), and currently injured (Current Injury). One hundred forty-two participants met the inclusion criteria. One hundred twenty-eight (90%) participants experienced a time-loss injury with 295 total reported injuries (2.1±1.4; range 1-9 injuries). Sixty-two percent of all reported injuries were still producing symptoms. There was a high average reported injury severity score (6.3±2.3). The most commonly affected area was the hip/thigh (30%), followed by the knee (15%) and ankle (14%). The Current Injury group had worse SF-36 bodily pain (p=0.003), vitality domains (p=0.001), and physical composite score (p=0.015) compared to the No Injury group. Both the No Injury and Injury Hx, No Sx groups performed better than the Current Injury group on physical function (p=0.007 and 0.02, respectively). Competitive collegiate baton twirlers experience the majority of injuries in the lower extremity which cause prolonged physical and non-physical symptoms.

On the receiving end: have patient perceptions of the side-effects of cancer chemotherapy changed since the twentieth century?

BackgroundStudies in 1983 and 1993 identified and ranked symptoms experienced by cancer patients receiving chemotherapy. We repeated the studies to obtain updated information on patient perceptions of chemotherapy-associated symptoms.Patients and methodsA cross-sectional interview and patient-reported outcome questionnaires were administered to out-patients receiving chemotherapy. Patients selected from 124 cards to identify and rank the severity of physical and non-physical symptoms they had experienced and attributed to chemotherapy (primary endpoint). The patient’s medical oncologist and primary chemotherapy nurse were invited to rank the five symptoms they believed the patient would rank as their most severe. We analysed the association of symptoms and their severity with patient demographics, chemotherapy regimen, and patient-reported outcomes. Results were compared to the earlier studies.ResultsOverall, 302 patients completed the interview: median age 58 years (range 17–85); 56% female; main tumour types colorectal 81 (27%), breast 67 (22%), lung 49 (16%); 45% treated with curative intent. Most common symptoms (reported by >50%) were: alopecia, general weakness, effects on family/partner, loss of taste, nausea, fatigue, difficulty sleeping, effects on work/home duties, and having to put life on hold. The most severe symptoms (ranked by >15% in top five) were: concern about effects on family/partner, nausea, fear of the future, fatigue, not knowing what will happen, putting my life on hold, and general weakness. Perceptions of doctors and nurses of patients’ symptom severity closely matched patients’ rankings.ConclusionsCompared to earlier studies, there was an increase in non-physical concerns such as effects on family and future, and a decrease in physical symptoms, particularly vomiting, but nausea, fatigue and general weakness remained bothersome.Highlights• Symptoms related to chemotherapy have changed over time, likely due to less toxic regimens and improvements in supportive care.• Effects on family/partner, fear of the future, not knowing what will happen, and “life on hold” were major issues for patients.• Vomiting has decreased but nausea, fatigue and general weakness remain common symptoms for chemotherapy patients.

Patients and neurologists have different perceptions of multiple sclerosis symptoms, care and challenges

Background: Basic steps in the management of patients with Multiple Sclerosis (MS), such as good patient understanding of the disease and active participation in its management are extremely important, as they directly influence treatment adherence and success. Therefore, this study aimed to evaluate the perception of MS patients and neurologists pertaining to the most common disease symptoms, disabilities that impact on quality of life, and patient concerns and difficulties during medical visits, as information that can be used to improve the doctor-patient relationship. Methods: A cross-sectional study involving two groups: the first composed of neurologists and the second of patients. Participants of the first group were selected by a Steering Committee (15 predetermined neurologists representing each region of Brazil and specialized in MS and neuroimmunological disorders, who also assumed the role of creating the survey and questionnaire). Participants of the second group were selected following dissemination of a questionnaire on the AME's social networks (Amigos Múltiplos pela Esclerose, a non-governmental organization to support patients with MS). Questions about sociodemographic data, disease impact on quality of life, symptoms perception, and concerns and issues regarding disease care were put to both groups. Results: A total of 317 patients and 182 neurologists answered the questionnaires. Significant divergences were found between the perceptions of patients and neurologists in relation to orientation and information given during medical appointments, and also regarding patient participation in treatment and therapy choice. Considering the topic assessing impact on quality of life, more than 70% of neurologists perceived that autonomy to work and travel, and future planning were aspects that most affected patient lives, however, almost 50% of patients reported that disease monitoring did not affect their life in any way. Analysis of data regarding MS symptoms revealed neurologists to consider physical symptoms, such as ambulation issues, imbalance, falls and urinary incontinence, to be those most interfering with patient quality of life, whereas patients considered non-physical symptoms, such as fatigue, pain, cognitive and memory problems to be more significant. Patients with primary progressive MS complained more about ambulation issues, imbalance and falls (p<0.05), when compared to patients with other disease phenotypes. Conclusion: Significant differences in disease perception were found in this study. While neurologists tended to overestimate the consequences and symptoms of the disease, for most patients, the disease impact on activities did not appear to be as significant, with more complaints regarding non-physical symptoms. Although neurologists described involving patients in treatment decisions and providing them with appropriate orientation during medical appointments, the opposite was reported by patients. These results may help to improve treatment adherence and disease outcomes by redefining the doctor-patient relationship.

Acute and long-term impairments regarding emotional symptoms and quality of life in patients suffering from transient ischemic attack and stroke

ABSTRACT Objectives: Ischemic stroke (IS) is often associated with long-lasting physical deficits, linked to emotional symptoms (ES) and lowered quality of life (QoL). However, recent observations raised doubts regarding the traditional perspective of solely impairment-driven ES. In fact, anxiety and depression were also reported after transient ischemic attack (TIA) with a per definition absence of infarction and thus lacking physical deficits. This study follows the hypothesis that TIA patients might exhibit non-physical symptoms affecting individual QoL. Methods: In a prospective single-center observational study, IS patients (n = 73) were compared with TIA patients (n = 24) regarding their neurological deficit, ES and QoL, whereas the latter were evaluated by the Hospital Anxiety and Depression Scale (HADS) and the Short Form 36 Heath Survey (SF-36). Assessments were conducted six times within a one-year follow-up period. Results: Overall, anxiety and depression decreased over time, while anxiety decreased more substantially. TIA patients showed similar levels of anxiety and depression when compared to IS patients. ES were detectable very early after the event and remained throughout the follow-up period in both groups. ES were associated with an impaired QoL including non-functional dimensions, while the strongest interrelations were observed for TIA patients, emphasizing interrelations between QoL and anxiety. Discussion: This study indicates that ES after TIA are comparable to the emotional burden after IS. ES after TIA were associated with QoL, pointing out their crucial role for individual well-being. Although confirmation in larger studies is necessary, these data underpin the need for early clinical awareness regarding non-physical symptoms in TIA patients.

Perioperative Symptoms: A New Frontier for Surgical Palliative Care.

Perioperative Symptoms: A New Frontier for Surgical Palliative Care.

Perception of side effects associated with anticancer treatment in women with breast or ovarian cancer (KEM-GO-1): a prospective trial.

Due to advances in anticancer treatment and supportive care, patients increasingly complained about nonphysical side effects of chemotherapy and targeted therapy in recent years. Therefore, continuous assessment of side effects and patients' perceptions is important. The aim of this study was to evaluate the identification and severity of side effects perceived by ovarian cancer (OC) and breast cancer (BC) patients undergoing contemporary anticancer therapy. Between 2015 and 2017, consecutive chemo-naïve OC and BC patients were enrolled in this prospective cohort study. Interviews were performed 12 ± 3weeks after start of anticancer therapy, and patients were asked to select and rank, according to severity, 72 physical or nonphysical symptoms potentially related to their treatment. Data were analyzed with descriptive statistics. Forty-five OC patients and 98BC patients completed the interview. Sleeping difficulties were ranked as the most troublesome symptom, followed by concerns about family or partner, and loss of hair. Alopecia was the most predominant side effect for BC patients, whereas OC patients were highly afflicted by numbness in limbs. Chemotherapy alone or in combination with targeted therapy caused pronounced sleep disturbances. Prolonged taxane treatment led to shortness of breath and numbness in limbs. Vomiting was ranked by one and nausea by eight women among the five most bothersome symptoms. Sleep disturbances have lately emerged as the most severe problem in women with OC or BC receiving anticancer therapy. Concerns about family and partner were ranked second in the current study and first in previous investigations.

A collaborative approach in dementia care to improve clinical effectiveness and priorities for research through audit.

To provide appropriate cost-effective care for an ageing population, realignment of care provision to conditions common in advanced age, notably, dementia and multi-morbidities is required. The use of outcome measures in practice may enable this. A collaborative baseline audit was undertaken to understand how best to implement outcome measures into services for people with dementia across clinical settings. An academic institution set up a 6-month collaborative baseline audit in 11 English sites. Measures comprised: symptoms/concerns (Integrated Palliative care Outcome Scale for Dementia); Phase of Illness; functional status (Australia-modified Karnofsky Performance Scale); and dementia severity (Functional Assessment Staging). Measures were completed at first assessment for 225 people with dementia across nine sites. Their completion promoted comprehensive assessments, but challenges also existed, including recording the prevalence/severity of non-physical symptoms by proxy. The joining together of clinical academic expertise enabled mobilisation of expert knowledge into and from clinical practice.

Brain onFire:MyMonth ofMadness by Susannah Cahalan

In the spring of 2009, Susannah Cahalan was the 217th person to be diagnosed with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, and this book chronicles both her ‘lost month’ before the diagnosis...

How Should Organized Medicine Respond to Physician-Assisted Death?

Both proponents and opponents agree that wider access to high-quality palliative care and physician-patient communication about end-of-life options is the right response to the growing patient dema...

An overview of the TwinsUK cohort’s anxiety and depression assessment, using the self-reported Hospital Anxiety and Depression Scale

Anxiety and depression are common mental health conditions that frequently coexist. The Hospital Anxiety and Depression (HADS) questionnaire, is a widely used questionnaire, both in the clinic and in research. HADS provides an assessment of anxiety and depression based on non-physical symptoms, hence it can be used in patients with other physical pain and symptoms. This resource provides an overview of all the HADS questionnaires completed by the twins in the TwinsUK registry. This includes both monozygotic and dizygotic twins, over a wide range of age and socioeconomic backgrounds. TwinsUK holds a wide range of phenotype and genotyping data that can be used as confounding factors in the study of mental health.

Development of Composite Scores for the TBI-QOL

ObjectiveTo develop a set of composite scores that can be used for interpreting quality of life (QOL) after traumatic brain injury (TBI) using 9 of the patient-reported outcomes measures from the Traumatic Brain Injury Quality of Life (TBI-QOL) measurement system. DesignParticipants completed 20 item banks from the TBI-QOL as part of a larger assessment. Composite index scores were created with normalized transformation with nonlinear area conversion using scores from 9 of the banks, and are expressed in index score units, with higher composite scores indicating better functioning. For descriptive purposes, associations among composites and individual banks were evaluated using regression, along with patterns of composite scores by injury severity groups using analysis of variance. SettingThree medical centers in the United States. ParticipantsCommunity-dwelling adults (n=504) with a history of TBI. InterventionsNot applicable. Main Outcomes MeasureTBI-QOL. ResultsFive composite indices were generated: global QOL, physical health, emotional health, cognitive health, and social health. Lookup tables are provided herein. Composite scores were highly intercorrelated (all r>.60, P<.0001), and individual TBI-QOL banks all correlate strongly with the global QOL composite in the expected direction (all r>.50, P<.0001). ConclusionResearchers and clinicians can use the TBI-QOL global QOL, physical health, emotional health, cognitive health, and social health composite scores to aggregate results from multiple TBI-QOL banks, which is anticipated to ease interpretation and reliability. This work additionally highlights the importance of considering nonphysical symptoms as outcomes variables for TBI research, as cognitive, social, and emotional domains were some of the most strongly correlated banks with the global QOL composite.

‘The Thing that Really Gets Me Is the Future’: Symptomatology in Older Homeless Adults in the HOPE HOME Study

ContextThe homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults. ObjectivesTo characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults. MethodsWe conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis. ResultsWe found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use. ConclusionHomelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.

A Survey of Hospice and Palliative Care Clinicians' Experiences and Attitudes Regarding the Use of Palliative Sedation.

A variety of terms and attitudes surround palliative sedation (PS) with little research devoted to hospice and palliative care (HPC) clinicians' perceptions and experiences with PS. These factors may contribute to the wide variability in the reported prevalence of PS. This study was designed to better identify hospice and palliative care (HPC) clinician attitudes toward, and clinical experiences with palliative sedation (PS). A 32-question survey was distributed to members of the American Academy of Hospice and Palliative Medicine (n = 4678). The questions explored the language clinicians use for PS, and their experiences with PS. Nine hundred thirty-six (20% response rate) responded to the survey. About 83.21% preferred the terminology of PS compared with other terms. A majority felt that PS is a bioethically appropriate treatment for refractory physical and nonphysical symptoms in dying patients. Most felt PS was not an appropriate term in clinical scenarios when sedation occurred as an unintended side effect from standard treatments. Hospice clinicians use PS more consistently and with less distress than nonhospice clinician respondents. Benzodiazepines (63.1%) and barbiturates (18.9%) are most commonly prescribed for PS. PS is the preferred term among HPC clinicians for the proportionate use of pharmacotherapies to intentionally lower awareness for refractory symptoms in dying patients. PS is a bioethically appropriate treatment for refractory symptoms in dying patients. However, there is a lack of clear agreement about what is included in PS and how the practice of PS should be best delivered in different clinical scenarios. Future efforts to investigate PS should focus on describing the clinical scenarios in which PS is utilized and on the level of intended sedation necessary, in an effort to better unify the practice of PS.

Menopausal syndrome limited to hot flushes and sweating a representative survey study

Objective: The menopausal syndrome is described as a series of various physical and nonphysical symptoms attributed to perimenopausal changes in hormone levels. However, evidence is biased by focusing research on the target group of middle aged women only. To overcome this bias, we examined the occurrence of menopausal symptoms during the entire life span in both women and men.Methods: Therefore, we studied the occurrence of menopausal symptoms with the widely used Menopause Rating Scale (MRS) across the entire life span in both women and men. To this end, we performed a nationwide cross-sectional survey study in Germany in which we examined a representative sample of 2527 persons aged from 14 to 95 years. Additionally, sociodemographic factors and self-efficacy were surveyed.Results: Although the overall MRS score was generally higher for women compared to men, there was no specific peak for the time of menopause. Instead the score increased linearly with age for both sexes. Furthermore, it was stronger associated with sociodemographic variables and self-efficacy than with the sex of the participants. Among all assessed symptoms, only hot flushes and sweating, but none of the others, emerged as specific for the menopausal episode.Conclusions: Our data indicate that among symptoms commonly classified as menopausal only hot flushes and sweating appear to be specific for the perimenopausal episode. Other symptoms may be caused by a multifactorial etiopathogenesis including physical, sociodemographic, cultural and psychological factors that, in turn, might benefit from multimodal treatment regimes.

Equity in patient-provider communication regarding treatment-related symptoms and health-related quality of life (HRQOL) among breast cancer survivors.

127 Background: Compared with white breast cancer patients, black patients more often report inadequate symptom control and decrements in health-related quality of life (HRQOL). Racial differences in patient-provider communication (PPC) are well-documented and linked to worse health outcomes for minorities; however, less is known about inequities in symptom and HRQOL discussions among cancer patients and providers. As part of an NCI-funded systems change intervention to improve racial equity in treatment completion among Black and White cancer patients, we assessed racial differences in PPC regarding treatment-related symptoms, HRQOL issues (e.g., physical, psychosocial, financial, and spiritual well-being), and symptom management among breast cancer survivors (BCS). Methods: We conducted 6 focus groups (FGs) and semi-structured interviews with 22 stage 1-3 BCS (3 black FGs; 3 white FGs) from 2 cancer centers. Guided by a community-based participatory research approach, our diverse community-academic-medical team facilitated FGs and conducted qualitative analyses. Results: Although both black and white BCS reported multiple treatment-related symptoms and changes in HRQOL, perspectives on PPC differed. Some black and white BCS described positive aspects of PPC, including providers’ thorough explanations of treatment side effects and responsiveness to symptom concerns. However, white BCS expressed greater satisfaction with PPC, while black BCS more often described concerns regarding providers’ verbal (e.g., nondisclosure, dismissiveness) and non-verbal communication (e.g., unapproachability, poor eye contact) skills in the context of symptom management. Most BCS, regardless of race, indicated that providers typically discussed physical symptoms/HRQOL issues, but often failed to mention non-physical side effects of treatment (e.g., social isolation, financial toxicity). Conclusions: Racial differences in PPC exist among BCS and may contribute to inequities in symptom management and HRQOL. Inadequate communication regarding non-physical symptoms likely represents a critical missed opportunity for improving the quality and equity of palliative care.

Palliative care and palliative radiotherapy education in radiation oncology: A survey of US radiation oncology program directors.

178 Background: To assess the state of palliative care education curricula in radiation oncology residency programs in the United States. Methods: We surveyed 90 program directors of radiation oncology residency programs in the United States from September 2015 to November 2015. An electronic survey on palliative care education during residency was sent to all program directors. The survey consisted of questions on perceived relevance of palliative care in radiation oncology residency, formal didactics on domains of palliative care, effective teaching formats for palliative care education, and perceived barriers for integrating palliative care into the residency curriculum. Results: Sixty-three percent (57/90) residency program directors completed the survey. Most (93%) program directors agree or strongly agree that palliative care is an important competency for radiation oncologists. A vast majority (90%) of programs have dedicated palliative care services; however, only 57% of programs offer residents an opportunity to spend elective time on a palliative care service. Of these programs, only 30% reported residents rotating on a palliative care service in the past two years. Furthermore, 67% of residency programs have formal educational activities in principles and practice of palliative care. The palliative care curriculum included faculty-led lectures (73%), resident-led lectures (42%), and seminars (22%). Most programs have one or more hours of formal didactics on management of pain (66%), management of neuropathic pain (64%), and management of nausea and vomiting (64%). 35%, 46%, and 48% programs had one or more hours of management of non-physical symptoms including fatigue, anorexia, and anxiety, respectively. Conclusions: Residency program directors believe that palliative care is an important competency for their trainees. The survey revealed that many programs have structured curricula on PSC and palliative radiation education, but that there are still areas for improvement.