Palliative Care Professionals Research Articles

Palliative Care Professionals' Perceptions and Communication About Sexual Expression of Older Adults at End of Life: How Biases Compromise Holistic Care.

The sexuality of older people, which has historically been invisible, is increasingly represented and promoted in the media. However, the sexuality of the oldest older adults showing signs of frailty remains obscure and subject to ageist and ableist biases. Studies on sexual expression at the end of life have shown that sexuality and the need for support related to it remain important for many people. This article examines the perceptions and attitudes of professionals regarding the sexuality of older adults in palliative care, based on an exploratory qualitative study. Participants were recruited from several palliative care teams working either in hospital or in home settings in Canada. Professionals (n = 16) held two main views of sexuality: broad and holistic or narrow and genital-focused. Perceptions of sexuality in later life were either described as a continuation of or distinct from middle adulthood. No matter what views were held, most professionals did not discuss sexuality with their patients at the end of life. The lack of communication about sexuality may be largely due to professional's ageist, ableist, and heterosexist views regarding the sexuality of this population group. Results confirm the relevance of providing palliative care training about diverse sexual experiences and the importance of supporting older adults at the end of life with respect to their intimate and sexual needs. Such an approach is in line with the holistic vocation of palliative care.

Generalist palliative care in hospitals during the first wave of the COVID-19 pandemic

ZusammenfassungEinleitung Im Forschungsverbund deutscher universitärer Palliativzentren (PallPan) im Netzwerk Universitätsmedizin (NUM) wurden Handlungsempfehlungen für die Versorgung von Schwerkranken und Sterbenden in Pandemiezeiten erarbeitet. Dazu wurden auch die Erfahrungen und Bedürfnisse von patientennah tätigen Mitarbeitenden im Krankenhaus außerhalb von spezialisierten Palliativstationen während der 1. Welle der COVID-19-Pandemie untersucht. Methode Bundesweite Online-Befragung von 8882 akutstationär tätigen Ärzt*innen, Pflegenden und Therapeut*innen im Zeitraum von Dezember 2020 bis Januar 2021 mittels eines neu entwickelten und pilotierten Fragebogens zu Veränderungen, Belastungen und zur Zusammenarbeit mit der spezialisierten Palliativmedizin. Gruppenbildung anhand der Veränderungen der Anzahl von Schwerkranken und Sterbenden in der ersten Welle der Pandemie. Aufgrund des explorativen Charakters der Studie wurden die Daten deskriptiv analysiert. Ergebnisse 505/8882 vollständig bearbeitete Fragebögen wurden ausgewertet (5,7 %). 167/505 (33,1 %) der Befragten berichteten über eine verschlechterte Versorgungsqualität von Schwerkranken und Sterbenden. 464/505 (91,8 %) berichteten über Ausnahmeregelungen für Besuche von Sterbenden. Der meistgenannte Belastungsfaktor war die wahrgenommene Vereinsamung der Schwerkranken und Sterbenden 437/505 (86,5 %), gefolgt von den verschärften Hygieneregeln 409/505 (81 %), der erhöhten Arbeitsbelastung 372/505 (73,3 %) und der wahrgenommenen psychischen Belastung von Angehörigen und Hinterbliebenen 395/505 (78,2 %). Tablet-PCs zur Unterstützung der Patienten-Angehörigen-Kommunikation wurden von 141/505 (27,9 %) der Befragten genutzt. 310/505 (61,4 %) des in die Patientenversorgung involvierten palliativmedizinischen Fachpersonals und 356/505 (70,5 %) der Befragten hielten weitere palliativmedizinische Angebote für hilfreich. Folgerung Die Erfahrungen und Vorschläge zur Verbesserung der Palliativversorgung in Pandemiezeiten sind in die PallPan-Handlungsempfehlungen integriert. Angehörigenbesuche sollten ermöglicht und um digitale Angebote erweitert werden. Palliativversorgung sollte in Pandemie- und Krisenpläne integriert werden.

Competencies for quality spiritual care in palliative care in Latin America: from the Spirituality Commission of the Latin American Association for Palliative Care.

Spiritual care is an essential part of quality palliative care. However, the literature regarding spiritual care competencies in Latin America is limited. Herein we propose the basic quality standards for spiritual care in palliative care according to best professional practices and provide a common vocabulary and required competencies for quality clinical spiritual care. Both elements, quality standards and a common vocabulary, are part of an essential step implementing continuous educational initiatives among interdisciplinary palliative care teams in Latin America. Members of the Spirituality Commission of the Latin American Association for Palliative Care and three members of independent professional palliative care organizations identified and reviewed our proposed spiritual care competencies and created a consensus document describing the competencies for general spiritual care. In the context of palliative care in Latin America, general spiritual care is provided by members of interdisciplinary teams. We proposed six competencies for high-quality general spiritual care and their observable behaviors that every member of an interdisciplinary palliative care team should have to provide quality clinical spiritual care in their daily practice: (I) personal, spiritual, and professional development; (II) ethics of spiritual care; (III) assessment of spiritual needs and spiritual care interventions; (IV) empathic and compassionate communication; (V) supportive and collaborative relationships among the interdisciplinary team; and (VI) inclusivity and diversity.

Measuring a Patient's understanding of their prognosis: An exploratory analysis.

In patients with cancer across the illness trajectory, treatment decisions are often influenced by one's perception of their prognosis (i.e., curability of disease, life expectancy, quality of life). However, research on how patients understand their prognosis (i.e., prognostic understanding) has been limited by simplistic measurement tools that fail to capture the complexity of the construct. This study describes the initial development of a measure of prognostic understanding: the Prognostic Understanding Perceptions Scale (PUPS) for use in patients with advanced cancer. An initial pool of 16 candidate items were developed through semi-structured interviews with 15 experts (oncology, psycho-oncology and palliative care professionals) and 30 advanced cancer patients. We investigated the dimensionality, internal item structure, item difficulty and item discrimination of the item pool using exploratory factor analysis (EFA), classical test theory (CTT) and item response theory (IRT) analyses. Convergent and divergent validity were based on correlations between PUPS, terminal illness acknowledgement, and self-report measures of depression, anxiety, hopelessness, and death acceptance. The final measure was comprised of nine items encompassing three factors (perceived curability, illness trajectory, treatment options), yielding strong psychometric properties. These results provide preliminarily support for PUPS as a multifaceted measure of prognostic understanding developed for use in patients with advanced cancer. Preliminary findings also highlight the potential utility of the PUPS for clinical settings, as a means of enhancing communication between patients and physicians.

WhatsApp as a facilitator of expressions of gratitude for palliative care professionals

IntroductionFamily members significantly value the professional and humane support that medical teams provide in the process of caring for patients with advanced diseases. Communication is currently changing, making it of interest to explore technology’s possible influence on communication and on the care relationship. It remains unknown whether this can vary based on increased use of technology in patient care. Using communication technologies can facilitate recognition of professional support through the expression of gratitude aimed at healthcare professionals. The objective here is to describe expressions of gratitude sent via WhatsApp messages by patients who receive treatment from a palliative care team and their relatives. MethodA generic qualitative methodology was used. The palliative care service studied used WhatsApp in the patient/family-professional relationship. A content analysis of 130 WhatsApp messages sent to the professionals and containing expressions of gratitude was carried out. Two researchers inductively performed the analysis. Analysis included aspects for which senders were most grateful and others, such as who the messages came from, whether they were reactive or spontaneous and to whom they were directed. ResultsAlmost all of the patients treated transmitted their gratitude via WhatsApp. It was also observed that family members were most grateful for features of the care received (i.e., affection, availability), the professional's support (i.e., accompaniment, comfort) and the professional’s qualities (i.e., professionalism, kindness). They also appreciated symptom control and attempts to resignify loss; these aspects received the most expressions of gratitude in the messages. In turn, all the messages contain expressions of support for palliative care professionals, evidencing a patient/family-professional relationship. ConclusionThe use of communication technologies like WhatsApp can contribute to the perception of professionals’ availability and closeness and become a facilitator of expressions of gratitude that specify the aspects that family members most appreciate from the palliative care team, such as skills related to humane care and availability.

Opioid Rotation and Conversion Ratios Used by Palliative Care Professionals: An International Survey.

Background: The opioid rotation ratios (ORRs) and conversion ratios (CRs) used worldwide among palliative care (PC) professionals to perform opioid rotations (ORs) and route conversions may have a wide variation. Methods: We surveyed PC professionals on opioid ratios used through email to the Multinational Association of Supportive Care in Cancer's PC study group and Twitter and Facebook posts between September and November 2020. Results: We received 370 responses from respondents from 53 countries: 276 (76%) were physicians, 46 (13%) advanced practice providers, 39 (11%) pharmacists, and 9 respondents did not report their profession. There were statistically significant variations in median CR from intravenous (IV) to oral morphine (2-3), IV to oral hydromorphone (2-4.5), ORR from IV hydromorphone to oral morphine (10-20), and ORR from transdermal fentanyl mcg/hour to oral morphine (2-3.5) across various groups. Conclusion: This survey highlights the wide variation in ORRs and CRs among PC clinicians worldwide and the need for further research to standardize practice.

Meaning of life and its association with perspective towards life and way of living: A qualitative study in palliative care professionals

Meaning of life and its association with perspective towards life and way of living: A qualitative study in palliative care professionals

The most important components of out-of-hours community care for patients at the end of life: A Delphi study of healthcare professionals’ and patient and family carers’ perspectives

Background: Community services for palliative patients outside normal working hours are variable and the best evidence-based models of care have not been determined. Aim: To establish expert consensus on the most important components of out-of-hours community palliative care services. Design: Delphi study. The first round listed 68 components generated from systematic literature reviewing, focus groups with healthcare professionals and input from the project’s patient and public involvement advisory group. The components deemed ‘essential’ by over 70% of participants in the first round were refined and carried forward to a second round, asking participants to rank each on a five-point Likert scale (5 highest to 1 lowest). The consensus threshold was median of 4 to 5 and interquartile range of ⩽1. Participants: Community specialist palliative care health professionals, generalist community health professionals and patients and family carers with experience of receiving care out-of-hours at home. Results: Fifty-four participants completed round 1, and 44 round 2. Forty-five components met the threshold as most important for providing out-of-hours care, with highest consensus for: prescription, delivery and administration of medicines; district and community nurse visits; and shared electronic patient records and advance care plans. Conclusions: The Delphi method identified the most important components to provide community palliative care for patients out-of-hours, which are often provided by non-specialist palliative care professionals. The importance placed on the integration and co-ordination with specialist palliative care through shared electronic records and advance care plans demonstrates the reassurance for patients and families of being known to out-of-hours services.

Evaluating the perceived added value of a threefold intervention to improve palliative care for persons experiencing homelessness: a mixed-method study among social service and palliative care professionals

BackgroundPalliative care for persons experiencing homelessness who reside in social service facilities is often late or lacking. A threefold intervention was implemented to improve palliative care for this population by increasing knowledge and collaboration between social service and palliative care professionals. This consultation service comprised: 1) consultations between social service professionals and palliative care professionals; 2) multidisciplinary meetings involving these professionals; and 3) training of these professionals. This study aims to evaluate the perceived added value of this threefold consultation service in three regions in the Netherlands.MethodsA mixed-methods evaluation study using structured questionnaires for consultants, requesting consultants, and attendees of multidisciplinary meetings, semi-structured group and individual interviews with social service and palliative care professionals involved, weekly diaries filled out by consultants, and an implementation diary. Qualitative data were analyzed following the principles of thematic analysis. Quantitative data were analyzed descriptively.ResultsThirty-four consultations, 22 multidisciplinary meetings and 9 training sessions were studied during the implementation period of 21 months. Social service professionals made up the majority of all professionals reached by the intervention. In all regions the intervention was perceived to have added value for collaboration and networks of social service and palliative care professionals (connecting disciplines reciprocally and strengthening collaborations), the competences of especially social service professionals involved (competency in palliative care provision, feeling emotionally supported in complex situations), and the quality and timing of palliative care (more focus on quality of life and dying, advance care planning and looking ahead, and greater awareness of death and palliative care).ConclusionsThe threefold consultation service particularly helps social service professionals connect with palliative care professionals. It helps them to identify palliative care needs in good time and to provide qualitatively better palliative care to persons experiencing homelessness.

Spiritual conversation model for patients and loved ones in palliative care: a validation study

ObjectivesIn palliative care, validated tools for professionals that facilitate day-to-day spiritual conversations with patients and loved ones are scarce. The objective of this study was to validate the Diamond spiritual...

How much information is ‘reasonable’? A qualitative interview study of the prescribing practices of palliative care professionals

Background: Prescribing clinicians have to negotiate ambiguities around information provision and consent for medications on a daily basis, despite the availability of professional guidance. Aim: This study aims to explore some of the many factors prescribing clinicians in the United Kingdom take into account when deciding what information to give to patients about medication choices, and when. Design: In depth face-to-face interviews, utilising both a hypothetical scenario and semi-structured prompts, were conducted in order to elicit extended reflections on how clinicians individually work through such dilemmas and make decisions. Setting/participants: Ten prescribing clinicians (doctors and nurses) from a large combined team of National Health Service (NHS) secondary and community palliative care providers in England. Results: Palliative care staff regularly face choices about information provision in prescribing discussions, in particular when considering whether information might increase distress. Participants presented three overlapping framings that helped them assess the range of factors that could potentially be taken into account; (1) assessing the individual patient, (2) tailoring the provision of information and (3) jointly forming a plan. Conclusions: Information provision about medication choices and effects is a demanding, ongoing process, requiring nuanced judgements that constitute an unacknowledged yet significant aspect of clinical workload. Although current medical guidelines allow clinical discretion about information provision, this can leave individual clinicians feeling vulnerable. Further evolution of guidelines needs to establish a more sophisticated way to acknowledge professional and legal requirements, whilst also promoting professional autonomy and judgement.

Prognostic impact of systemic anti-cancer therapy on patients with advanced cancer at end of life: Analysis of a multicenter prospective cohort study using propensity score methods.

12029 Background: Prognosis is said to worsen when systemic anti-cancer therapy (SACT) is administered until a patient’s end of life (EOL) and professional palliative care is delayed. However, the prognostic impact of SACT at EOL is unclear. Methods: In this pre-planned secondary analysis of a multicenter, prospective East Asian cross-cultural collaborative cohort study, consecutive patients with advanced cancer admitted to palliative care units between January and December 2017 were divided into four groups: patients who had and had not received SACT (SACT vs. non-SACT) and patients whose last administration of SACT was before or within 1 month of study enrolment (non-1M SACT vs. 1M SACT). The primary endpoint was difference in survival time from a palliative performance scale (PPS) of < 20 to death between the SACT and non-SACT groups, and the 1M SACT and non-1M SACT groups. The analysis was adjusted for age; sex; primary cancer site; metastatic site; comorbidity (Charlson comorbidity index); and history of radiotherapy, smoking, and psychiatric disorders. Weighting for inverse probability of treatment was applied. A secondary endpoint was to identify EOL symptom and care factors prognostic for survival time using a Cox proportional hazards model. Results: The 1396 study patients (712 men, 684 women; median age: 73 years) came from 21 institutions throughout Japan. Primary tumor sites were upper gastrointestinal (471 patients), lower gastrointestinal (193 patients), lung (241 patients), breast (93 patients), urologic (101 patients), gynecologic (82 patients), head and neck (56 patients), central nervous system (25 patients), and hematologic (39 patients). Metastatic sites were liver (554 patients), lung (522 patients), bone (373 patients), and brain (199 patients). The SACT, non-SACT, 1M SACT, and non-1M SACT groups consisted of 853, 539, 126, and 1270 patients, respectively. Survival time was significantly shorter in the SACT group (6.83 days, p = 0.03) than in the non-SACT group (9.01 days). No significant difference between the 1M SACT group (7.57 days) and the non-1M SACT group (7.36 days) was evident. Prognostic factors were use of opioids (HR 1.289), antipsychotics (HR 0.787), and anxiolytics (HR 0.867); infusion of more than 1 L daily (HR 0.727); and apnea (HR 0.874), dyspnea (HR 1.874), nausea (HR 0.612), fatigue (HR 1.284), and ascites (HR 1.236). Conclusions: Prognosis was shorter for patients with a history of SACT than for those without a history of SACT at EOL. However, SACT at EOL was not a prognostic factor. This information is useful in advance care planning for selecting and explaining treatment at EOL to patients and their families.

Evaluating the amount of knowledge about palliative care concepts among health professionals and medical students in the Gaza Strip: a cross-sectional study

BackgroundImprovements in diagnostic facilities and health-care services result in increased numbers of patients with end-stage disease being diagnosed and improvements in medical care for these patients resulting in longer life expectancy. This result generates the need to develop an integrative care system covering patient's physical, psychological, social, and spiritual needs. In the Gaza Strip, the scarcity of palliative care professionals reveals the necessity to develop such care systems. This study evaluated the knowledge of physicians, nurses, and medical students in the Gaza Strip hospitals about palliative care concepts. MethodsA cross-sectional study was conducted in five hospitals in the Gaza Strip, occupied Palestinian territory. Eligible to participate were all physicians, nurses, and medical students who were willing to participate. In total, 352 participants completed the self-administered, validated Palliative Care Knowledge Test. The primary outcome was participant's amount of knowledge on palliative care concepts (including 20 questions on five subscales). The sample size was chosen on the basis of the Epi-Info tool (with a confidence level of 0·95). Results were analysed using SPSS version 23, a one-way ANOVA, and post-hoc tests. Ethical approval was obtained from the Palestinian Health Research Council Helsinki Committee and consent was obtained from the participants. FindingsPatients were recruited from Sept 1 to Dec 31, 2019. The mean age of the 352 participants was 31·9 years (SD 9·5). 210 (59·7%) participants were male, 142 (40·3%) were female, 97 (27·6%) were physicians, 162 (46·0%) were nurses, and 93 (26·4%) were students. The overall average total correct score (of which 100% indicated all questions were answered correctly and reflected the maximum level of knowledge) of the subscales was 47·0%. The average scores across all participants were: 68·9% for philosophy, 41·3% for pain, 37·2% for dyspnoea, 48·5% for psychiatric problems, and 39·2% for gastrointestinal problems. Men scored higher than women, but the difference was not significant (p>0·05). There was a statistically significant difference between physicians, nurses, and students in two subscales (philosophy and dyspnoea) as established by a one-way ANOVA (F=7·17, p=0·001 for philosophy; F=4·67, p=0·010 for dyspnoea). A Bonferroni post-hoc test revealed that physicians’ knowledge in philosophy was significantly higher than that of nurses, with a mean difference in questionnaire scores of 25·2%; but notably, the students’ knowledge was significantly higher than that of nurses, with a mean difference of 32·6%. Additionally, physicians’ knowledge in dyspnoea was significantly higher than nurses’ by a mean difference of 0·386 and higher than students’ by a mean difference of 22·7%. Other subscales did not show any significant differences. Significant differences were found in the subscale scores between different hospitals, except for gastrointestinal problems. InterpretationThe overall low Palliative Care Knowledge Test scores indicate large knowledge gaps. Although philosophy and psychiatric problems were better understood than other concepts, the results were still substantially less than the ideal percentage of 100%. Poor knowledge is likely to reflect poor practice and care for patients with end-stage disease. Students undergo intensive palliative care training at one university, as reflected in their significantly better scores for some subscales, suggesting the effectiveness of educational measures. Palliative care integration is a joint responsibility of professionals and decision makers and should be strengthened by building palliative care teams as well as staff education across all hospitals. FundingNone.

Palliative Professionals' Views on the Importance of Religion, Belief, and Spiritual Identities toward the End of Life.

Abundant literature has argued the significance of religion, belief, and spirituality at the end of life. This study aims to add to this literature by exploring palliative professionals’ views in this area. By means of an in-depth interviewing method, this paper reports data from 15 hospice and palliative care professionals. Participants were recruited from five hospice and palliative care organisations, and the data were managed and analysed with thematic analysis and NVivo (version 11). This study found three main reasons that make religion, belief, and spirituality important for patients and their loved ones when facing imminent death: the sense of comfort and security, meaning making, and closure. These reasons are not independent from one another, but complementary. This paper offers some implications for practice and concludes with a call for further research.

Moral distress amongst palliative care doctors working during the COVID-19 pandemic: A narrative-focussed interview study

Background: Palliative care professionals have had to adapt to rapidly changing COVID-19 restrictions with personal protective equipment and physical distancing measures impacting face-to-face communication with patients and relatives. Aim: To explore the narratives of palliative care doctors working during the pandemic to understand their experiences at a personal and professional level. Design: In-depth narrative interviews were carried out via video call. Interviews were transcribed verbatim and analysed using a joint paradigmatic and narrative approach to elucidate common themes and closely explore individual narratives. Setting/participants: Eight palliative care doctors who had worked on a hospice inpatient unit in the UK before and during the pandemic were recruited from two hospices in Scotland. Results: Three intersecting themes are described, the most significant being moral distress. Participants articulated a struggle to reconcile their moral convictions with the restrictions enforced, for example, wanting to provide support to patients through physical proximity but being unable to. To differing degrees, this resulted in internal conflict and emotional distress. Two further themes arose: the first concerned a loss of humanity in interaction and a striving to re-humanise communication through alternative means; the second being a change in staff morale as the pandemic progressed. Conclusions: Restrictions had a considerable impact on palliative care doctors’ ability to communicate with and comfort patients which led to moral distress and contributed to decreasing morale. Future research could explore moral distress in palliative care settings internationally during the pandemic with a view to compare the factors affecting how moral distress was experienced.

Psychospiritual in palliative care services: a literature review

Background: Palliative care provide holistic services at the physical, mental, and spiritual levels. Spiritual care is an intrinsic and essential component of palliative care that WHO has recognized. However, spiritual care is still not widely known by the community and health workers in the practice of palliative care. Methods: This literature review was written based on various books, journals, and scientific articles that related to spiritual care in palliative care. The quantitative and qualitative data were obtained, then collected and sorted into a report based on the appropriate topic. Result: Spirituality is one of the fundamental dimensions in the quality of life and maintaining culture. Thus, spirituality is an important component of palliative care. Many palliative patients understand their spiritual needs and want health professionals to help them address these needs. Various existing studies show that spiritual care provides benefits, especially in emotional needs and the search for meaning in life at the end of life. Palliative care professionals can provide spiritual care, but spiritual care is complex and requires specialized knowledge, expertise, and experience in assessing and meeting patient needs, requiring further training and education. Conclusion: Various studies have shown that palliative patients need psychospiritual care to support comfort and meaning in their lives towards the end of life. So, psychospiritual care in palliative care needs to be implemented and improved, especially in training for palliative care teams.

How should health care providers inform about palliative sedation? A qualitative study with palliative care professionals.

ObjectiveIn Switzerland, palliative sedation consists of using sedatives to relieve terminally ill patients. It is divided into several steps, with one of them consisting of informing patients and relatives about the procedure. In the current recommendations, there is a lack of orientation about how and when this discussion should take place. Hence, we aim to explore perceptions and experiences of palliative care professionals regarding these questions.MethodsQualitative semi‐structured interviews with five physicians and five nurses working in specialised palliative care were conducted. They were then analysed with thematic analysis.ResultsResults showed a uniformity around definition, goals and indications of palliative sedation. However, there was a lack of consistency regarding the process of delivering this information to patients and relatives. Finally, some participants strongly opposed the idea of systematically informing patients in specialised palliative care, while others were more divided on this question.ConclusionDespite a common understanding of the concept of palliative sedation, there is no standard practice when informing patients on palliative sedation among palliative care professionals. Therefore, this study demonstrates the need for further guidelines on this question and calls for a better understanding and knowledge of palliative sedation among health professionals outside palliative care.

Feeling Rule Management and Relational Authority: Fostering patient compliance in palliative care consultations

Once conferred by jurisdictions, hierarchies, or credentials, professional authority is now considered relational and probabilistic, drawing attention to actions that professionals can take to encourage client compliance. In this paper, we use ethnographic observations of palliative care consultations to show that professionals suggest feeling rules that correct patients’ lay understandings and in doing so facilitate compliance. Palliative care professionals suggested three corrective feeling rules that validate patients’ emotions and reattribute them to circumstances aligned with professionals’ expert recommendations for care: that patients should fear curative treatment, that patients should hope for pain relief, and that patients and family members should feel guilty for prolonging misery. We argue that authority depends, in part, on professionals’ ability to manage broader feeling rules instead of individual emotions. Given that feeling rule management involves altering meanings of what is considered appropriate, we contend that professionals’ symbolic power and emotional capital underpin their authority in the professional–client encounter.

Training in palliative care in nursing and medical schools in Chile

Training in Palliative Care (PC) at the undergraduate level has proven to be an effective strategy to expand access to this type of services. In Chile, the increase in magnitude of serious health-related suffering and the recently approved Law that guarantees universal access to Palliative Care, requires the extension of PC undergraduate training in medical and nursing schools. Therefore, this study assessed and described the characteristics of current PC training in the Schools of Medicine and Nursing of Chile through an online survey of their directors. Nursing schools report higher frequency of mandatory training hours and access to clinical training, while Medicine schools report higher frequency of elective internships. However, gaps persist in the number of teaching hours and the teaching methods used, which may be due to the scarcity of qualified professionals in PC, limited access to clinical fields and disciplinary differences. Strengthening and expanding PC training at the undergraduate level with practical and interdisciplinary methodologies are fundamental steps so that future medical and nursing professionals can provide adequate care and relief of serious health-related suffering to an aging population until the end of their life.

Prescribing and medication use for symptom control in palliative care: stakeholder engagement within an activity theory study

Abstract Introduction People with palliative care needs often use prescription medication to achieve symptom control. Prescribing and medication use are complex, multi-step processes influenced by prescribers, patients, carers, and contexts. They are shaped by historically established divisions of labour and normative rules. However, in the care of palliative patients, approximately 20% of NHS serious incident reports involve prescription medications with causes and contributing factors poorly understood (1). Understanding the mismatches between what is intended to happen and what is experienced in practice is key to improving safety and confidence in palliative care. Phase one of this study focuses on how the processes of prescribing and medication use are intended to happen, and comprises stakeholder engagement (presented here) and a scoping review. Aim To develop a model of intended processes of prescribing and medication use for symptom control in palliative care across the contexts of home, hospital, and hospice. Methods Stakeholder engagement was undertaken with a purposive sample of participants who had an interest in, or direct experience of, palliative medications. Invitations to participate were sent to professional networks and a patient and public involvement group. Informal conversations with a topic guide including known steps in the processes of prescribing and medication use were held either via video-call (recorded with permission) or by email. Conversations were examined for content relating to steps in the processes, and for themes that ran across multiple steps. An iterative cycle of listening, identifying steps, theme attribution and development of an intended processes model was undertaken with each recording. Results Twenty video and one email conversations were conducted with 7 family carers, 4 pharmacists/pharmacy researchers, 4 specialist palliative care professionals, 3 non-clinical researchers and 3 general practitioners. Different steps in the intended processes of prescribing and medication use at home and in hospital were identified. Themes of decision-making, prescribing, monitoring/supply, use/administration, and stopping/disposal were all represented. Further themes of deprescribing, anticipatory medicines, and contexts of practice - including out-of-hours care - were all raised. The processes model that resulted was not linear and incorporated complex feedback loops that facilitated ‘tinkering’, safe-to-fail experiments, and negotiations balancing ‘gut feeling’ with protocols and patients’ wishes. Conclusion Engaging with carer and professional stakeholders as a preliminary step in our study provided opportunity for clarification of key concepts, exploration of the nature and diversity of experiences, and identification of knowledge gaps. Whilst our engagement work may have been limited with the inclusion of only one nursing representative and little discussion of the hospice context, these aspects together with the content and themes identified will inform the design of our scoping review using the Joanna Briggs Institute framework. Data from the stakeholder engagement and the scoping review will be combined to finalise a model of intended processes in prescribing and medication use in symptom control in palliative care. Phase two of this study is a focussed ethnography to develop an experienced processes model. Synthesising the intended (phase one) and experienced (phase two) processes models using activity theory (2) will lead to when, how, and why processes in prescribing and medication use are misaligned and to ways in which systems can be improved to support patients and their families. References (1) Yardley I, Yardley S, Williams H, Carson-Stevens A, Donaldson LJ. Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents. Palliat Med. 2018;32(8):1353–62. (2) Engeström Y, Davydov V, Toulmin S, Lektorsky V, Tolman C, Cole M, et al. Theoretical Issues. In: Engeström Y, Miettinen R, Punämaki R-L, editors. Perspectives on Activity Theory. Cambridge: Cambridge University Press; 1999. p. 1–146.