Palliative Care Content Research Articles

Palliative care for patients with heart failure: facilitators and barriers - a cross sectional survey of German health care professionals.

BackgroundCompared to patients with cancer, heart failure patients are seldom candidates for palliative care. Numerous studies have investigated reasons why heart failure patients do not receive palliative care; however, none of these studies have ever evaluated the situation in the German health care setting. This study aims to identify German healthcare providers’ (HCP) perception of barriers and facilitators to palliative care of patients with chronic heart failure.MethodsWe conducted an online-survey with 315 nurses and physicians of different medical disciplines.ResultsEven though heart failure patients’ need of palliative care and its advantages has been recognized, HCP see potential for development and improvement. A lack of knowledge about the content and measures of palliative care, poor communication and unclear responsibilities between medical disciplines, difficulties to determine the right time to initiate palliative care, and the feeling not to be prepared to discuss end-of-life issues with the patient has been identified as barriers. Further, HCP believe that patients and relatives do not possess adequate knowledge about the disease and its progression and are therefore unprepared in asking questions regarding palliative care. They rather tend to demand everything possible to be done in order prolong life, and are reluctant to accept that life is limited. Overall, HCP perceive that dying is a taboo subject within our society placing palliative care on the same level as assisted dying. In addition, results indicate that HCP have an inappropriate notion of ideal medicine fearing to lose patient and are worried about the appropriateness of PC remuneration.ConclusionsIn order to overcome the described barriers, HCP, patients, and relatives need to be educated in palliative care. Information and education encompassing the aim, content and measures of palliative care needs to be provided for all parties in order to optimize patient care, to foster communication between healthcare professionals, patients, and relatives, and to overcome perceived barriers.Trial registrationDRKS00007119Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1609-x) contains supplementary material, which is available to authorized users.

To what degree is palliative care integrated in guidelines and pathways for adult cancer patients in Europe: a systematic literature review.

BackgroundPalliative Care (PC) aims to improve the quality of life for patients with cancer and their families and its benefits have been demonstrated by several studies. The objective of this systematic review is to assess the integration of PC in the content of guidelines/pathways of adult cancer patients in Europe.MethodsWe included studies of adult patients with cancer published from 01/01/1995 and 31/12/2013 in Europe in six languages. We searched nine electronic databases, hand-searched six journals and also performed citation tracking. Studies were ranked using Emanuel’s Integrated Palliative Care (IPC) criteria, a tool containing 11 domains to assess PC content in guidelines. Two reviewers screened the results and narrative synthesis has been employed.ResultsWe identified a total of 28,277 potentially relevant articles from which 637 were eligible for full-text screening. The final review included 60 guidelines and 14 pathways. Eighty percent (80 %) of the guidelines/pathways emphasize a holistic approach and 66 % focus on PC interventions aimed at reducing suffering. Fifty seven percent (57 %) did not discuss referral criteria for PC. Of all studies, five fulfilled at least 10/11 IPC criteria. Differences existed with regard to the referral criteria for bereavement care and the continuous adjustment of goals of care.ConclusionOverall, most of the identified guidelines/pathways highlighted the importance of the holistic approach of IPC. The studies that were found to fulfil at least 10/11 Emanuel’s IPC criteria could serve as benchmarks of IPC.

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative CareNovember 13–15, 2014Orlando, Florida

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

A modified systematic review of research evidence about education for pre-registration nurses in palliative care.

BackgroundWe undertook a modified systematic review of research regarding educational approaches to and effectiveness of pre-registration palliative care nursing, to inform the development of a short course in palliative care for pre-registration nursing students in Cameroon. The aim of this review was to examine educational approaches applied to pre-registration palliative care nursing education and their effectiveness, and to discuss implications for the development of palliative care curricula in resource-poor countries.MethodA modified systematic review of research on palliative care educational interventions, conducted with pre-registration student nurses was undertaken. Relevant literature was gathered from CINAHL, EMBASE, MEDLINE and PsychINFO databases for the period 2000–2013. Inclusion was limited to studies of educational interventions evaluating the effectiveness and outcomes of palliative and end of life care education with pre-registration student nurses.Results17 studies were found, all of which were conducted in resource-rich countries: United States of America, Canada, Australia, and United Kingdom. Palliative care nursing education at pre-registration level is either delivered as a discrete course within the curriculum or palliative care content is embedded into other nursing specialty courses throughout the wider curriculum. Palliative care education is delivered to students at a variety of stages in their nursing program, using a mix of both didactic and experiential educational strategies. Course facilitators span palliative care specialists, educators who have attended ‘train-the-trainer’ courses in palliative care, and nurses with hospice experience. Education is underpinned by transformative and experiential learning theories and reported as effective in improving students’ attitudes towards care of the dying.ConclusionThe educational strategies identified in this review may be applicable to resource-poor countries. However, there are challenges in transferability because of the lack of availability of specialist palliative care practitioners who can serve as educators, specialist palliative care units/institutions for experiential learning, funds to design and use high fidelity simulations, and palliative care textbooks and other educational materials. There is thus a need for innovative educational strategies that can bridge these barriers in resource-poor countries. There is also a need for further research into how palliative care education impacts on pre-registration student nurses’ knowledge and practice.

The practice of early palliative care: A qualitative study of patient-clinician encounters.

2 Background: Studies have shown that palliative care (PC) integrated early in the course of metastatic cancer, shortly after diagnosis, leads to improved patient outcomes. Unlike PC in the inpatient setting, PC initiated early, in the ambulatory setting, had not been well studied. Our aim was to elucidate the practice of early PC through analysis of PC clinic visit transcripts. Methods: As part of an ongoing study of early PC in patients with advanced lung and gastrointestinal cancers at the Massachusetts General Hospital, we are audio-recording patients’ outpatient PC clinic visits. To capture the range of PC content, we randomly selected five patients and analyzed three clinic transcripts per patient: early, midway, and late in each patient’s clinical course. We performed thematic analysis on these clinic transcripts using NVivo 10. Results: Our analysis suggests that the elements of early PC that occur most frequently across the disease course are managing symptoms, facilitating coping, and developing the relationship with patients and their family caregivers. Elements that tend to occur during clinical transitions include advising treatment decision-making, facilitating medical understanding, and advance care planning. Our analysis also identifies four broad approaches to PC that are applied longitudinally, over the course of the patient-clinician relationship: 1) eliciting versus commenting on patients’ perspectives, 2) alluding to and preparing for the future, 3) transitioning between managing symptoms and facilitating coping, and 4) transitioning between developing the relationship and facilitating coping. Lastly, we observe three specific techniques applied by PC clinicians: 1) coordinating with oncologists, 2) providing referrals, and 3) addressing family dynamics. Conclusions: Our study identifies the predominant elements, four longitudinal approaches, and three specific techniques of early PC. These novel insights can be applied to care delivered by both PC and non-PC clinicians, well before patients approach the end of life. The longitudinal approaches in particular may help explain the significance of early integration of PC into cancer care.

TEAM-BASED LEARNING: TEACHING THE HEART AND MIND OF PALLIATIVE CARE

As a domain of knowledge for healthcare professionals, palliative care is complex and demanding; not least for educators. Effective teaching in palliative care relies on educators both being able to...

Follow-up of patients needing palliative care in general practice

IntroductionPrimary healthcare, provided by general practitioners (GPs), is the cornerstone of healthcare reforms in Bulgaria. It is difficult to study palliative care in the primary care setting because of limited numbers of patients and the tendency of severely ill patients not to participate in investigations. The aim of this study was to follow-up consultations in order to gather information about the scope and content of palliative care provided in the general practice setting.MethodsSpecial observation card was developed, which consisted of questions related to the patient's socio-demographic data, duration of illness, Karnofsky assessment, symptoms and medication, referral process, home visits; and asked for the patient's self-reported assessment of symptoms. The statistical analyses used descriptive statistics, Pearson's chi-square test, and the Kolmogorov–Smirnov test, and correlation analysis. The level of significance was set at P < 0.05. The data were statistically processed with SPSS software (version 17).ResultsGPs identified 211 patients and recorded 625 consultations. Functional performance was 50 or less in 45% of patients. Differences in symptom assessments between GPs and patients were found regarding pain, sleep, appetite, and depression. The average number of medications administered per patient was 3.56 ± 0.06. A considerable proportion of visits ended with referrals. GPs conducted an average of 4.87 ± 0.84 home visits per patient.DiscussionGPs provide palliative care in the surgery and during home visits, perform a variety of activities. The creation of specialized palliative care services would clarify their role and contribute to improving symptom control and quality of life for patients.

Few U.S. public health schools offer courses on palliative and end-of-life care policy.

Palliative care has been identified by the World Health Organization (WHO) as a critical policy element for the relief of suffering, yet palliative care policy receives minimal attention in mainstream U.S. public health journals, conferences, or textbooks. In the '90s, documentation of the lack of attention to end-of-life and palliative care in medical and nursing curricula led to concerted efforts to improve medical and nursing education in palliative care. No such educational effort has yet been directed toward public health professionals. This study's objective was to quantify current course offerings covering palliative and end-of-life care from a public health and health policy perspective at accredited schools of public health. Using a list of keywords about palliative and end-of-life care, the research team searched publicly accessible websites of all CEPH accredited and affiliated U.S. schools of public health to identify courses that included relevant content about palliative care. For academic years 2011/12 and 2012/13, 3 (6%) of the 49 accredited U.S. schools of public health offered a full course covering public health issues in palliative care. Six schools (12%) included some palliative care content in related courses such as gerontology policy. Schools of public health are not preparing future policy experts with a basic knowledge of the components and systems of palliative care and hospice. Development and dissemination of appropriate curricular material to address the public health and policy aspects of palliative care is needed to address this gap.

Palliative Medicine and Psychiatry: A Reply

Palliative Medicine and Psychiatry: A Reply

Early Palliative Care in Advanced Lung Cancer

BACKGROUND Early ambulatory palliative care (PC) is an emerging practice, and its key elements have not been defined. We conducted a qualitative analysis of data from a randomized controlled trial that demonstrated improved quality of life, mood, and survival in patients with newly diagnosed metastatic non-small cell lung cancer who received early PC integrated with standard oncologic care vs standard oncologic care alone. Our objectives were to (1) identify key elements of early PC clinic visits, (2) explore the timing of key elements, and (3) compare the content of PC and oncologic visit notes at the critical time points of clinical deterioration and radiographic disease progression. METHODS We randomly selected 20 patients who received early PC and survived within 4 periods: less than 3 months (n = 5), 3 to 6 months (n = 5), 6 to 12 months (n = 5), and 12 to 24 months (n = 5). We performed content analysis on PC and oncologic visit notes from the electronic health records of these patients. RESULTS Addressing symptoms and coping were the most prevalent components of the PC clinic visits. Initial visits focused on building relationships and rapport with patients and their families and on illness understanding, including prognostic awareness. Discussions about resuscitation preferences and hospice predominantly occurred during later visits. Comparing PC and oncologic care visits around critical time points, both included discussions about symptoms and illness status; however, PC visits emphasized psychosocial elements, such as coping, whereas oncologic care visits focused on cancer treatment and management of medical complications. CONCLUSIONS Early PC clinic visits emphasize managing symptoms, strengthening coping, and cultivating illness understanding and prognostic awareness in a responsive and time-sensitive model. During critical clinical time points, PC and oncologic care visits have distinct features that suggest a key role for PC involvement and enable oncologists to focus on cancer treatment and managing medical complications.

Situational analysis of palliative care education in thai medical schools.

ObjectiveThe Thai Medical School Palliative Care Network conducted this study to establish the current state of palliative care education in Thai medical schools.MethodsA questionnaire survey was given to 2 groups that included final year medical students and instructors in 16 Thai medical schools. The questionnaire covered 4 areas related to palliative care education.ResultsAn insufficient proportion of students (defined as fewer than 60%) learned nonpain symptoms control (50.0%), goal setting and care planning (39.0%), teamwork (38.7%), and pain management (32.7%). Both medical students and instructors reflected that palliative care education was important as it helps to improve quality of care and professional competence. The percentage of students confident to provide palliative care services under supervision of their senior, those able to provide services on their own, and those not confident to provide palliative care services were 57.3%, 33.3%, and 9.4%, respectively.ConclusionsThe lack of knowledge in palliative care in students may lower their level of confidence to practice palliative care. In order to prepare students to achieve a basic level of competency in palliative care, each medical school has to carefully put palliative care content into the undergraduate curriculum.

Early outpatient palliative care in patients with metastatic NSCLC: A qualitative study.

9101 Background: Early outpatient palliative care (PC) is an emerging practice and its key components have not been defined. We conducted a qualitative analysis of data from a randomized controlled trial which demonstrated improved quality of life, mood and survival in outpatients who received early PC integrated with standard oncologic care versus standard oncologic care alone. Our objectives were to 1) identify the content and key components of early PC clinic visits, 2) explore timing of key components, and 3) compare the content of PC and oncology visit notes at the critical time points of clinical deterioration and radiographic disease progression. Methods: We chose a random selection of 20 patients with newly diagnosed metastatic NSCLC who received early PC who survived within 4 time frames: less than 3 months (n=5), 3 to 6 months (n=5), 6 to 12 months (n=5) and 12 to 24 months (n=5). We performed content analysis on PC and oncology electronic health record notes of these patients using NVivo 9 software. Results: Addressing symptoms and coping ability were the most prevalent components of the PC clinic visits. The content of initial visits focused on building relationships and rapport with patients and their families and illness understanding. Discussions about prognostic awareness occurred during earlier visits while goals of care and hospice discussions occurred in later visits. The frequency of addressing these components was similar regardless of patients’ length of life. Comparing PC and oncology visits around critical time points, both included discussions about current illness status and goals of care; however PC visits emphasized symptoms, coping, and implications of anti-cancer treatments, while oncology visits focused on medical discussions about treatment plans. Conclusions: Early PC clinic visits emphasize managing symptoms, strengthening coping, and cultivating illness understanding and prognostic awareness in a structured, responsive and time-sensitive model. Around critical clinical time points PC and oncology visits have distinct features that suggest a key role for PC involvement while enabling oncologists to focus on anti-cancer management.

Refining a Checklist for Reporting Patient Populations and Service Characteristics in Hospice and Palliative Care Research

ContextIn specialist hospice and palliative care services, variations occur in diagnoses and prognoses of subpopulations referred, service configuration, and the health systems delivering care. These three levels of variation limit the ability to generalize study findings. ObjectivesThis article reports on coding one year of palliative care research using a previously developed checklist. The aims were to 1) quantify current reporting of factors related to generalizability in specialist palliative care research; 2) review and potentially refine the checklist in light of the first aim; 3) demonstrate the feasibility of collecting these data; and 4) set out simple processes to aid researchers in reporting, and clinicians in applying, new research evidence in hospice and palliative care. MethodsA previously published checklist (five domains, 14 core subdomains, and 24 noncore subdomains) was used to code all research articles (n=189) published in 2007 in the three leading palliative care research journals. ResultsThe most frequently reported subdomains were patient age, gender, and diagnosis; model of service delivery; and patient performance status. Data in subdomains, including time from referral to death, socioeconomic indices, and ethnicity, were rarely reported; none reported whole-of-service or whole-of-population data. In total, 2646 (189×14) core subdomains could have been reported. Data were provided in 28% (746/2646). ConclusionChecklists such as the Consolidated Standards of Reporting Trials evaluate study design, focusing mainly on internal validity. The proposed checklist deals with specific content of hospice and palliative care, focusing on external validity.

The experiences of providing children’s palliative care education in undergraduate nursing programmes – A discussion of some practical issues

Despite recent proliferation of palliative care services for children, and the fact that the needs of these children and their families are enshrined in current policy directives, the challenges of providing education for nurses within this area of practice is largely underexplored. This paper examines some of the key issues facing nurse educators who are involved in the delivery of palliative care content in undergraduate children’s nursing programmes. Drawing on the extensive experiences of two nurse educators in children’s palliative care education, research and practice, key issues which should be considered by those involved in curriculum development and delivery will be outlined. Such issues include ambiguity in terminology and resultant lack of conceptual clarity, the limited evidence base to underpin practice and education, the complexities of teaching sensitive topics to large groups and limited teaching expertise to deliver the content. Suggestions for addressing such issues will be outlined.

The Munich Declaration - Key points for the establishment teaching in the new cross-disciplinary area 13: palliative medicine at German faculties.

The development of the teaching of palliative medicine at the medical faculties in Germany and the discussion about the inclusion of palliative care as a subject into the Medical Licensure Act follows a lengthy process [1]. Various publications repeatedly drew attention to existing skills gaps among young physicians and medical students in dealing with terminally ill and dying patients due to inadequate teaching in the field of palliative medicine in Germany [2], [3], [4], [5]. However, the Medical Licensure Act (Appendix 15 to § 29 Para 3 Sentence 2) previously only listed the subject as optional but not mandatory examination material for the second part of the medical examinations towards the end of medical studies. Thus the implementation and delivery of palliative care training remained was left to the commitment of individual universities. Against this backdrop, the development of appropriate structures in Germany was slow. In 2009 only five of 36 medical faculties in Germany had occupied chairs for palliative care, at only 6 universities were compulsory courses in palliative medicine offered, of which only half concluded the course with an exam counting towards the degree [1]. As of 5 August 2009, palliative medicine was integrated into the Medical Licensure Act as the 13th cross-disciplinary area (QB 13) [6]. This means that from 2013 onwards, all medical faculties in Germany will require students to pass relevant examinations in specialist palliative care in order to be admitted to the Practical Year. The fact that by now 34 faculties teach palliative care content - albeit with significant qualitative and quantitative differences - illustrates that in principle both access to qualified lecturers in palliative care and a broad willingness to establish teaching structures exist. So far, only those few faculties with chairs in palliative care can offer high-quality structured training, as described by Alt-Epping et al. for teaching palliative care at the University of Gottingen [7]. To ideally and appropriately facilitate the introduction of palliative care courses which are now legally required into general university curricula at less well-equipped faculties, the chairs of the universities of Aachen, Cologne and LMU Munich in cooperation with the German Society for Palliative Medicine (DGP) and the National Association of Medical Students in Germany (bvmd) organised a workshop on this topic. Lecturers and students from 25 medical schools met on the 2nd and 3rd of July 2010 at the Interdisciplinary Centre for Palliative Medicine in Munich to discuss the possibilities of implementing the new QB 13 “Palliative Care”. The central point of discussion at the event was the question of how high-quality and comparable teaching in palliative care can be established across Germany within the short timeframe and in spite of differences in resources and settings at the various faculties. Common goals and guidelines were recorded in the form of the Munich Declaration and will be presented in the following.

Integrating palliative care content into a new undergraduate nursing curriculum: The University of Notre Dame, Australia – Sydney experience

The majority of society's deaths occur in a health care environment. Regardless of whether a death occurs in acute care, hospice, residential aged care or community settings, nurses are the health professionals that will spend the largest proportion of time with the patient who has a terminal condition and their families. As few nurses have specialist palliative care qualifications it is essential that nursing education prepares graduates to achieve the core capabilities required for the delivery of best evidenced based palliative care. This reality makes the integration of palliative care content into the undergraduate nursing curricula an important priority. This paper aims to describe how palliative care content has been embedded throughout the three-year University of Notre Dame Australia, Sydney (UNDA) undergraduate nursing degree. The School of Nursing at the University of Notre Dame Australia, Sydney campus is committed to ensuring that students graduate with the capabilities to deliver appropriate care to people with requiring end-of-life care. The establishment of this new School of Nursing coincided with the release of the 'The Palliative Care Curricula for Undergraduates Program' (PCC4U) learning resources. These resources have been integrated into relevant units across the three-year nursing curricula. The nursing curriculum has been design to supports the integration of palliative care knowledge into clinical practice. The Palliative Care Curricula for Undergraduates Program Learning resources offer engaging palliative care case studies and scenarios for academics to utilise. Adopting an iterative approach where palliative care content is spiralled across multiple units provides opportunities for undergraduate nursing students to sequentially build and consolidate their palliative care capabilities. Developing a new curricular provided an ideal opportunity to integrate and embed palliative care content into the undergraduate nursing degree. The next stage of the curriculum development is to explore inter-professional palliative care education opportunities. Evaluating the palliative care capabilities of our nursing graduates is also an important consideration. This paper provides practical suggestions for integrating palliative care education into an undergraduate nursing curriculum.

Not Published, Not Indexed: Issues in Generating and Finding Hospice and Palliative Care Literature

Accessing new knowledge as the evidence base for hospice and palliative care grows has specific challenges for the discipline. This study aimed to describe conversion rates of palliative and hospice care conference abstracts to journal articles and to highlight that some palliative care literature may not be retrievable because it is not indexed on bibliographic databases. Substudy A tracked the journal publication of conference abstracts selected for inclusion in a gray literature database on www.caresearch.com.au . Abstracts were included in the gray literature database following handsearching of proceedings of over 100 Australian conferences likely to have some hospice or palliative care content that were held between 1980 and 1999. Substudy B looked at indexing from first publication until 2001 of three international hospice and palliative care journals in four widely available bibliographic databases through systematic tracing of all original papers in the journals. Substudy A showed that for the 1338 abstracts identified only 15.9% were published (compared to an average in health of 45%). Published abstracts were found in 78 different journals. Multiauthor abstracts and oral presentations had higher rates of conversion. Substudy B demonstrated lag time between first publication and bibliographic indexing. Even after listing, idiosyncratic noninclusions were identified. There are limitations to retrieval of all possible literature through electronic searching of bibliographic databases. Encouraging publication in indexed journals of studies presented at conferences, promoting selection of palliative care journals for database indexing, and searching more than one bibliographic database will improve the accessibility of existing and new knowledge in hospice and palliative care.

Update in Quality and How to Use New Resources for Quality Measurement in Palliative Care (521)

1.Discuss the current state of quality measurement for palliative care, including relevance to health policy and healthcare reform.2.Discuss the Cancer Quality-ASSIST measure set and how to apply it.3.Discuss the CMS (Center for Medicare Services) PCPI/PQRI (Physicians' Quality Reporting Initiative) measures relevant to palliative care and how to apply them. In order to justify resource allocation, address National Consensus Project standards, and guide quality improvement, palliative care programs must measure the quality of symptom management, communication, and care planning, both in the settings where we work and as provided by our own teams. However, to date, few resources have been available for validated, standardized, benchmarked quality measurement in these domains. Recently, a number of relevant quality indicators have been developed and tested, and national quality measurement programs have endorsed measures applicable to palliative care domains. This workshop, sponsored by the AAHPM Quality Task Force, will provide an overview of the current state of quality measurement for palliative care, focusing on health policy issues and medical record-based and reporting measures; describe the Cancer Quality-ASSIST measurement set and how to apply it; and discuss the Center for Medicare Services (CMS)/AMA PCPI/PQRI program indicators applicable to palliative care and experience with their implementation. The overview will describe current health policy initiatives, including the role of quality measurement in healthcare reform and nationally available programs and measures, such as the relevant ASCO (American Society for Clinical Oncology) QOPI measures and measures endorsed by the National Quality Forum. The section on Cancer Quality-ASSIST will describe the available domains of palliative care; discuss the development and testing of the indicator set across three clinical sites; and describe how to select and implement measures in the inpatient and/or outpatient setting. The section on the CMS/AMA PCPI/PQRI will describe the program, measures currently endorsed and appropriate for palliative care domains, practices' experience with implementing the measures, and inclusion of palliative care content in broader quality measurement areas, such as care transitions. Structure and Processes of Care

Promoting Perinatal, Neonatal, and Pediatric Palliative Care Nursing Education (510)

1.Identify a national project to coordinate nursing efforts in perinatal, neonatal, and pediatric palliative care.2.Identify models of excellence in implementing palliative care in perinatal, neonatal, and pediatric settings.3.Describe barriers to implementing palliative care across perinatal, neonatal, and pediatric settings. The purpose of this presentation is to describe the End-of-Life Nursing Education Consortium Pediatric Palliative Care (ELNEC-PPC), a comprehensive national effort to improve palliative/end-of-life (EOL) care provided by healthcare professionals in perinatal, neonatal, and pediatric settings. The project is based on the original End-of-Life Nursing Education Consortium (ELNEC) training, which is a partnership between City of Hope and the American Association of Colleges of Nursing (AACN). This project is a synthesis of research and knowledge in palliative care and is intended to assist with implementing evidence based practice. Based on the AACN Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Nursing Care and the 1997 Institute of Medicine report, the ELNEC-PPC curriculum focuses on 11 EOL areas: overview of palliative care; pediatric consideration; pain; symptom management; perinatal and neonatal palliative care; loss, grief, and bereavement; communication; ethical issues; quality improvement; and care during the final hours. The ELNEC-PPC curriculum includes detailed supplemental teaching materials to integrate palliative care content into continuing education/in-services for practicing nurses in a variety of clinical settings, and classroom/clinical teaching for students. Since the first course was held in August 2003, eight national train-the-trainer courses have been held, with 735 nurses attending from diverse pediatric settings across the United States and Canada. For more information about the ELNEC-PPC Project, visit http://aacn.nche.edu/ELNEC. Structure and Processes of Care

Multiple sources: mapping the literature of palliative care

Palliative care is an increasingly important area of clinical practice and health service delivery. The heterogeneity of the patient population and the multidisciplinary nature of care draw on knowledge from many fields of clinical practice and academic enquiry. This has implications for the retrieval of evidence and literature and the spread of new knowledge in palliative care. This study shows that the CINAHL, Embase and PsycINFO bibliographic databases hold sizeable repositories of palliative care articles not indexed on Medline. It also highlights the number and range of journals publishing palliative care content. In 2005 alone, 1985 journals published 6983 items. These findings show the challenges for palliative care professionals in managing the complex evidence base for this diverse field of care and the importance of mechanisms that facilitate the identification of palliative care information. Dissemination strategies that ensure that new knowledge reaches the many audiences implicit in the range of journals publishing palliative care are also critical in supporting improvements in clinical practice and service delivery.