Patient-centered Palliative Care Research Articles

Patient-centered palliative care in pediatric cardiology: a cardiophenomenological approach

Despite the success of pediatric cardiology and cardiac surgery in the treatment of severe heart diseases in children, a significant increase in the average life expectancy and quality of life of patients, cardiovascular diseases remain common reasons leading to the need for palliative care. A number of psychological and ethical aspects in pediatric palliative care in cardiology are not sufficiently developed. Cardiac diseases requiring palliative care affect the physiological, psychological and social aspects of patients' lives, and require special attention. It is proposed to use the second-person methods in clinical communication based on the biopsychosocial approach of cardiophenomenology in order to provide a patient-centered environment in palliative care for children with severe heart diseases. Cardiophenomenology can provide non-paternalistic relationships in palliative care for pediatric patients with cardiovascular disease to improve health-related quality of life (HRQoL).

Enhancing Palliative Care With Mindful Touch: Impact of a Manual and Movement Therapy Training Program in an International Multidisciplinary Integrative Oncology Setting

ContextManual and movement therapies (MMTs) play a central role in the integrative oncology setting, significantly improving patients' quality of life (QOL). Despite research supporting the effectiveness and safety of these modalities, most oncology health care providers (HCPs) lack any MMT training. ObjectivesIn this study, we examine the impact of an MMT-based integrative oncology training program with the participation of an international and multidisciplinary group of oncology HCPs. The feasibility of implementing these skills in palliative cancer care is examined. MethodsA three-day evidence-based hands-on teaching program was designed to train oncology HCPs working in supportive cancer care MMT modalities from traditional Chinese and anthroposophic medicine. Prequalitative and postqualitative assessments of the trainees' narratives were analyzed using ATLAS.Ti software (Scientific Software Development GmbH, Berlin, Germany) for systematic coding. ResultsThe training program was attended by 30 participants from Israel (15), Germany (7), Italy (6), Turkey (1), and Cyprus (1). The group included 13 nurses, 10 physicians, 6 complementary/integrative HCPs, and 1 psycho-oncologist. The pretraining expectations that were met at post-training included gaining knowledge and practical QOL-oriented skills, which could be implemented in the palliative and supportive care setting. A significant change in the attitude of trainees to touch therapy was also identified, with respondents seeing MMTs promoting patient-centered palliative care, including nonverbal communication. ConclusionAn MMT training program for oncology HCPs for QOL-related indications is both feasible and likely to be implemented in palliative and supportive cancer care. Nonspecific effects of MMTs were also recognized for their ability to facilitate patient-centered care.

Long-Term Outcome of LVAD in Duchenne Population with End Stage Cardiomyopathy

The aim of this study was to report the effect of long-term use of VAD in patients affected by Duchenne Muscular Distrophy and end stage cardiomyopathy. We collected data of DMD patients with end-stage cardiomyopathy implanted with LVAD in our center (group 1) and the ones in regular follow-up not eligible for LVAD implantation (group 2). Each patient of group 1 underwent extensive pre-operative assessment, in-hospital treatment and was enrolled in a dedicated DMD HF (heart failure) clinic during the post-discharge period. Patients of group 2 were followed in a dedicated DMD HF clinic or as inpatient in case of need of inotropic support. During long-term follow-up all data were recorded including echocardiography, ECG examination, laboratory blood tests, and respiratory function. Survival was represented by Kaplan Meier analysis and compared by log rank. A total of 8 DMD patients (group 1) were implanted with LVAD and treated at our center during the period from 2011 until 2018 (mean age at implantation was 16.9 ± 2.9 years)¸ whilst 4 patients (group 2) were not eligible for LVAD implantation. At the time of the last follow-up, 4 out of 8 patients were alive and 2 out of 8 patients did not have post-operative complications. The principal causes of 3 deaths at the median follow-up of 22 months were sepsis, tracheal bleeding, and cerebral hemorrhage. After 1 year from implantation we noticed a significant decrease in heart rate (p=0.002), in LV volumes and diameters (LVEDD p=0.03, LVESD p=0.02, EDV p=0.01 and ESV p=0.02) and significant increase in ejection fraction (p=0.0036). However, relative wall thickness did not change over time, showing an eccentric remodeling pattern before and after LVADs. Analysis on short and long-term follow-up showed significant improvement of survival in DMD patients treated with LVAD compared to the group that was not implanted (log rank&lt0.001), with a 5-year increase in life expectancy. Our data showed that cardiac atrophy is persistent in Duchenne cardiomyopathy despite the improvement of EF due to a significant ventricular unloading coupled with chronic therapy. LVAD improved outcomes in patients with LVAD when compared to those without. An integration of outpatient DMD HF clinic and patient-centered palliative care will most likely increase the quality of life and delivery of care for this population.

Symptom dimensions in people affected by long-term neurological conditions: a factor analysis of a patient-centred palliative care outcome symptom scale

Long-term neurological conditions (LTNCs) often cause debilitating symptoms. Better understanding of symptom dimensions in LTNCs is needed to support health professionals and improve care. This can be achieved by exploring the factor structure of a standardised measure of symptoms in LTNC patients. The symptom subscale of the Integrated Palliative Outcome Scale for LTNCs (IPOS Neuro-S24) comprises 24 items measuring symptom severity. Descriptive statistics and psychometric properties of the scale were assessed, followed by differential item functioning (DIF), exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Data from N = 238 patients were analysed. The mean IPOS Neuro S-24 score was 27.0 (possible range 0–96) and floor effects were found for 21 items. The scale had good internal consistency (Cronbach’s alpha = 0.77). Weak evidence of DIF was found for nine items. All but one item (falls) loaded onto four factors with loadings > 0.3. The factors represented four clinically meaningful symptom dimensions: fatigue, motor symptoms, oral problems and non-motor symptoms. We identified a reliable four-factor structure of symptom experience in LTNC patients. The results suggest that symptom dimensions are common across LTNCs. The IPOS Neuro S-24 is an appropriate tool to measure symptoms in LTNC patients, which may improve care.

Development and Use of the 'SENS'-Structure to Proactively Identify Care Needs in Early Palliative Care-An Innovative Approach.

Anticipatory planning for end of life requires a common language for discussion among patients, families, and professionals. Studies show that early Palliative Care (PC) interventions based on a problem-oriented approach can improve quality of life, support decision-making, and optimize the timing of medical treatment and transition to hospice services. The aim of this quality-improvement project was to develop a pragmatic structure meeting all clinical settings and populations needs. Based on the Medical Research Council (MRC) framework, a literature review identifying approaches commonly used in PC was performed. In addition, more than 500 hospital-based interprofessional consultations were analyzed. Identified themes were structured and compared to published approaches. We evaluated the clinical usefulness of this structure with an online survey among professionals. The emerged ‘SENS’-structure stands for: Symptoms patients suffer from; End-of-life decisions; Network around the patient delivering care; and Support for the carer. Evaluation among professionals has confirmed that the ‘SENS’-structure covers all relevant areas for anticipatory planning in PC. ‘SENS’ is useful in guiding patient-centered PC conversations and pragmatic anticipatory planning, alongside the regular diagnosis-triggered approach in various settings. Following this approach, ‘SENS’ may facilitate systematic integration of PC in clinical practice. Depending on clearly defined outcomes, this needs to be confirmed by future randomized controlled studies.

A small dose of impertinence in end-of-life care at home

The patient-centred palliative care approach means establishing partnerships between him or her, the caregivers, the family, social sector professionals and care volunteers. Communication, which takes the form of dialogue, listening, establishing a relationship of trust and observing behaviour and body language is essential faced with the uncertainty and existential questioning of the patient and their family. In the patient's home, as this experienced nurse describes, this questioning leads caregivers to reflect on their professionalism and humanity.

Quality of Communication and Trust in Patients With Serious Illness: An Exploratory Study of the Relationships of Race/Ethnicity, Socioeconomic Status, and Religiosity

ContextBetter understanding of clinicians' skill communicating with their patients and of patients' trust in clinicians is necessary to develop culturally sensitive palliative care interventions. Race/ethnicity, socioeconomic status, and religiosity have been documented as factors influencing quality of communication and trust. ObjectivesThe objective of this study was to explore associations of seriously ill patients' race/ethnicity, socioeconomic status, and religiosity with patients' ratings of the quality of clinicians' communication and trust in clinicians. MethodsAn observational analysis was performed using baseline data from a multicenter cluster-randomized trial of a communication intervention. We enrolled consecutive patients with chronic, life-limiting illnesses (n = 537) cared for by primary and specialty care clinicians (n = 128) between 2014 and 2016 in outpatient clinics in Seattle, Washington. We assessed patient demographics (age, gender, race/ethnicity, education, income, and self-rated health status), Duke University Religion Index, Quality of Communication Scale, and Wake Forest Physician Trust Scale. We used probit and linear regression and path analyses to examine associations. ResultsPatients providing higher ratings of clinician communication included those belonging to racial/ethnic minority groups (P = 0.001), those with lower income (P = 0.008), and those with high religiosity/spirituality (P = 0.004). Higher trust in clinicians was associated with minority status (P = 0.018), lower education (P = 0.019), and clinician skill in communication (P < 0.001). ConclusionContrary to prior studies, racial/ethnic minorities and patients with lower income rated communication higher and reported higher trust in their clinicians than white and higher income patients. More research is needed to identify and understand factors associated with quality communication and trust between seriously ill patients and clinicians to guide development of patient-centered palliative care communication interventions.

Palliative Care.

Palliative care prioritizes symptom management and quality of life throughout the course of serious illness. Regardless of whether care is inpatient or outpatient, primary or subspecialty, a solid understanding of the basics of effective communication, symptom management, and end-of-life care is crucial. This article reviews these essentials and provides an overview of current evidence to support patient-centered palliative care.

Promoting patient-centred palliative care: a scoping review of the patient dignity question.

In recent years, there has been a growing interest in promoting dignity in care, and specific interventions have been developed to include it at the end of life. The patient dignity question (PDQ) is a recent, novel and simple intervention that healthcare professionals can implement; however, little information is known about its impact. This scoping review aims to examine and map out the PDQ literature. Studies suggest that patients, families and professionals have a positive view of the PDQ in that it helps to get to know patients and provide them with the best care possible. The PDQ seems to promote an environment of care focused on the person and the prevalence of more human aspects in clinical encounters between professionals and patients. This is especially so in situations in which human aspects of the healthcare relationship at baseline received lower marks. Healthcare professionals thought that performing the PDQ to determine what is important to the patient is a feasible and effective exercise. The published literature suggests that PDQ is a beneficial intervention for approaching and getting to know a patient as a person. More studies are needed that measure pre-post-PDQ changes and that demonstrate their impact on patient care.

African American Elders' Serious Illness Experiences: Narratives of "God Did," "God Will," and "Life Is Better".

The foundation of culturally sensitive patient-centered palliative care is formed from one's social, spiritual, psychological, and physical experiences of serious illness. The purpose of this study was to describe categories and patterns of psychological, social, and spiritual healing from the perspectives of aging seriously ill African American (AA) elders. Using narrative analysis methodology, 13 open-ended interviews were collected. Three main patterns were "prior experiences," "I changed," and "across past, present experiences and future expectations." Themes were categorized within each pattern: been through it . . . made me strong, I thought about . . . others, went down little hills . . . got me down, I grew stronger, changed priorities, do things I never would have done, quit doing, God did and will take care of me, close-knit relationships, and life is better. "Faith" in God helped the aging seriously ill AA elders "overcome things," whether their current illness or other life difficulties.

End-of-life decisions in acute stroke patients: an observational cohort study.

BackgroundCrucial issues of modern stroke care include best practice end-of-life-decision (EOLD)-making procedures and the provision of high-quality palliative care for dying stroke patients.MethodsWe retrospectively analyzed records of those patients who died over a 4-year period (2011–2014) on our Stroke Unit concerning EOLD, focusing on the factors that most probably guided decisions to induce limitation of life-sustaining therapy and subsequently end-of-life-care procedures thereafter.ResultsOf all patients treated at our Stroke Unit, 120 (2.71 %) died. In 101 (86.3 %), a do-not-resuscitate-order (DNRO) was made during early treatment. A decision to withdraw/withhold further life supportive therapy was made in 40 patients (34.2 %) after a mean of 5.0 days (range 0–29). Overall patient death occurred after a mean time of 7.0 days (range 1–30) and 2.6 days after therapy restrictions. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke were possible indicators of decisions to therapeutic withdrawing/withholding. Proceedings of EOL care in these patients were heterogeneous; in most cases monitoring (95 %), medical procedures (90 %), oral medication (88 %), parenteral nutrition (98 %) and antibiotic therapy (86 %) were either not ordered or withdrawn, however IV fluids were continued in all patients.ConclusionsA high percentage of stroke patients were rated as terminally ill and died in the course of caregiving. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke facilitated decisions to change therapeutic goals thus initiating end-of-life-care. However, there is further need to foster research on this field in order to ameliorate outcome prognostication, to understand the dynamics of EOLD-making procedures and to educate staff to provide high-quality patient-centred palliative care in stroke medicine.Electronic supplementary materialThe online version of this article (doi:10.1186/s12904-016-0113-8) contains supplementary material, which is available to authorized users.

Utilizing design theory to create a patient-centered palliative care model in cancer survisorship care.

164 Background: Palliative medicine (PM) is an essential component of survivorship care from point of diagnosis. While PM is philosophically committed to supporting patient and family survivorship goals, very few programs incorporate patient and family input into the formation of a patient-centered model of care for symptom management and quality of life. We utilized design theory to develop novel interventions for primary and specialist PM delivery. Methods: Baseline data collected in Fall 2014 revealed a need for assistance navigating support services as well as barriers to PM integration including branding, lack of primary palliative skills, and poor understanding of outcomes of PM integration. In February 2015, we convened a multidisciplinary group of 25 patients, family members, oncology clinicians and experts in patient experience and health services research, to evaluate current state data and formulate ideas for optimizing PM to support symptom management and quality of life. During a 1-day workshop, the group generated interventions for primary and specialist PM. Small teams were assigned to pilot projects based on these recommendations. Proposed solutions are being tested from July - October 2015. Results: The design team generated five focus areas for meeting patient needs and overcoming barriers: standard processes for access to PM, education on primary PM, rapid reporting of outcomes, relationship-building with referring clinicians, and improved access to primary and specialist palliative resources. Three interventions are being developed to address these: 1. A subspecialist “hub” that allows single referrals and streamlined access to supportive care, 2. a novel two-question probe about goals conducted by the oncologist, and 3. a peer support system between PM social work and nursing staff to proactively manage patients with complex needs. Conclusions: Patient and family-centered PM mandates a novel approach. Design theory allows for clear delineation of problem areas, generation of multiple solution sets, and rapid testing and refinement prior to large-scale adoption. A participatory design approach emphasizes user values and limitations and creates values-based solutions.

Health behaviors and coping among informal caregivers of lung and colorectal cancer survivors: Distribution and interrelationships.

229 Background: Family/informal caregivers play a critical role in the palliative care and support of cancer survivors, yet are at risk of poorer health outcomes than non-caregivers. Self-care, including positive health behaviors and coping, are important for long-term caregiver well-being, and potentially that of care recipients. This study sought to evaluate the distribution of and interrelationships among health behaviors and coping strategies among cancer caregivers. Methods: This study used data from the Cancer Care Outcomes Research &amp; Surveillance Consortium (CanCORS). Caregivers reported by survey their health behaviors, coping, and sociodemographic and caregiving characteristics. Descriptive statistics assessed the distribution of caregivers’ health and coping behaviors, and multivariable linear regressions assessed the associations between health behaviors and coping styles. Results: Many caregivers reported positive health behaviors (i.e., moderate physical activity, adequate sleep, low rates of binge drinking). Caregivers most frequently reported using emotion-focused coping styles (religion, acceptance, positive reframing, emotional support). Caregivers reporting higher levels of physical activity or feeling less well-rested used problem-focused coping styles more frequently (Effect sizes [ES] up to 0.21, p &lt; 0.05) . Those with some physical activity (1-149 minutes/week vs none) scored higher on emotion-focused coping, while drinkers (1+ drink in the past 30 days vs 0) and binge drinkers (5+ drinks in a row vs 0) scored lower on this subscale (ES = 0.16, 0.12, and 0.25; p &lt; 0.05). Caregivers reporting current smoking (ES = 0.21), binge drinking (ES = 0.49), and feeling less well-rested (ES up to 0.48) scored higher on dysfunctional coping (p &lt; 0.05). Conclusions: Caregivers’ health behaviors and coping strategies were interrelated. Interventions targeting both factors concurrently may be particularly efficacious at improving family caregiver self-care, potentially improving caregiving quality and patient-centered palliative care. Future research is needed to design and test such interventions and the potential impact on palliative care.

Correlates of and interrelationships among social stressors, relationship quality, and family functioning among informal cancer caregivers.

230 Background: Informal/family caregivers play a critical role in supporting cancer patients and are often an important part of the palliative care team. To better understand how informal caregivers are influenced by their role and inform future interventions, this study sought to evaluate the distribution and correlates of social and family factors among caregivers of cancer patients. Methods: This cross-sectional study used data from the Cancer Care Outcomes Research &amp; Surveillance Consortium (CanCORS). Lung and colorectal cancer patients nominated an informal caregiver to participate in a caregiving survey. Caregivers reported their sociodemographic and caregiving characteristics, social stress, relationship quality with the patient, and family functioning. Descriptive statistics were used to assess the distribution of caregivers’ social factors. Multivariable linear regressions were used to examine the independent correlates of each social factor. Results: Most caregivers reported low-to-moderate levels of social stress and good relationship quality and family functioning. In multivariable analyses older age was associated with lower social stress and better family functioning, but worse relationship quality, with effect sizes (Cohen’s D) up to 0.40 (p &lt; 0.05). Caring for a female patient was associated with lower social stress and better relationship quality, but worse family functioning (effect sizes up to 0.16, p &lt; 0.05). Few caregiving characteristics were associated with social stress, while several were significant independent correlates of relationship quality. Finally, social factors were important independent correlates of one another. Conclusions: The results highlight the importance of personal and caregiving-related characteristics and the broader family context to social factors. As social factors may play an important role in the health, quality of life, and caregiving efficacy of informal caregivers, future work is needed to better understand these pathways and assess whether interventions targeting social factors can improve caregiver well-being, thereby potentially improving patient-centered palliative care.

Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care.

To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury." We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

Goal setting in palliative care: A structured review

BackgroundPalliative care and rehabilitation both aim to support patients to live as actively as possible. Goal setting has been identified in health policy and clinical guidelines as a mechanism to achieve this. While goal setting is well established in traditional rehabilitation, it is unclear how it should be implemented within palliative care where people are faced with diminishing abilities.AimTo identify and synthesize published literature regarding goal setting in palliative care.MethodElectronic searches were carried out on MEDLINE, PSYCHINFO, EMBASE, CINAHL, ASSIA, and Google Scholar databases between November 2010 and January 2011. Papers were included if they focused on patient-centred goal setting in palliative care. No restrictions were placed on study design or type of paper. Papers were classified according to the type and design and research papers were quality appraised. Papers were read and analysed using framework analysis.FindingsSixteen papers met the inclusion criteria. Three themes were identified:1. Definitions, process, and functions of goal setting;2. The challenges of delivering goal setting;3. Theories underpinning goal setting.ConclusionsGoal setting is recognized as an important component of patient-centred palliative care, but there is no agreement regarding ‘best practice’ and clinicians face particular challenges when trying to set goals with patients in this context. Little attention has been paid to developing a robust, theory-based approach to goal setting in this setting. Hope theory and theories of how people adapt to life-threatening illness could inform the process of goal setting in palliative care.

A qualitative analysis of patient and family perspectives of palliative care.

To provide truly patient-centered palliative care services, there is a need to better understand the perspectives and experiences of patients and families. Increased understanding will provide insight into the development of health care team competencies and organizational changes necessary to improve patient care. Our aim was to explore patient and family perceptions of palliative care services at the end of life or during serious illness and to identify facilitators and barriers to receipt of palliative care services. In-depth, semi-structured patient and family interviews were conducted, transcribed, and independently reviewed using grounded theory methodology and preliminary interpretations. A combined deductive and inductive iterative qualitative approach was used to identify recurring themes. The study was conducted in a physician-led, not-for-profit, multispecialty integrated health system serving three large, western, rural states. A purposive sample of 14 individuals who received palliative care services were interviewed alone or with their families for a total of 12 interviews. Presence, Reassurance, and Honoring Choices emerged as central themes linked to satisfaction with palliative care services. Themes were defined as including health care professional attributes of respect, approachability, genuineness, empathy, connectedness, compassion, sensitivity, an ability to listen, good communication, provision of information, empowerment, and timeliness. Honoring Choices included those pertaining to treatment, spirituality, and family needs. At end of life or during times of serious illness, patients and families identified behaviors of Presence, Reassurance, and Honoring Choices as important. According to patients/families, health care providers must be compassionate and empathetic and possess skills in listening, connecting, and interacting with patients and families.

A palliative approach to dialysis care: a patient-centered transition to the end of life.

As the importance of providing patient-centered palliative care for patients with advanced illnesses gains attention, standard dialysis delivery may be inconsistent with the goals of care for many patients with ESRD. Many dialysis patients with life expectancy of <1 year may desire a palliative approach to dialysis care, which focuses on aligning patient treatment with patients' informed preferences. This commentary elucidates what comprises a palliative approach to dialysis care and describes its potential and appropriate use. It also reviews the barriers to integrating such an approach into the current clinical paradigm of care and existing infrastructure and outlines system-level changes needed to accommodate such an approach.

Advance Care Planning in Belgium and The Netherlands: A Nationwide Retrospective Study Via Sentinel Networks of General Practitioners

Context Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe. Objectives To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors. Methods A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present. Results Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient’s family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4–6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6–4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7–4.1), died of cancer (OR 1.46; 95% CI 1.1–2.0), or died at home (OR 2.16; 95% CI 1.5–3.0). Conclusion In these countries, ACP is done with approximately one-third of the studied terminally ill patient population. Most agreements are made only verbally, and care also is often planned with family only. ACP relates strongly both to patient factors and to health care measures performed at the very end of life.

Teaching Small Groups in Palliative Care

Small group learning (i.e., tutorial, seminar, or small problem-solving class) is uniquely suited to transformative change as the ultimate goal of education, and especially appropriate for use in teaching about palliative care. The small group can be a fertile environment for both individual and communal development on both personal and professional levels by recognizing the unique needs of small group facilitation, and developing necessary faculty skills, and by modeling thoughtful preparation, reflective execution, and perceptive feedback. The small group learning approach focuses on learning facilitation and enhancing students' communications skills, which are vital to providing effective, patient-centered palliative care.