Knowledge and thresholds for palliative care and surgery among healthcare providers caring for adults with serious illness.

Introduction: Timely palliative care and surgical interventions improve symptoms, health-related quality of life (HRQoL), and reduce medical cost for seriously ill adults at end of life (EOL). However, there is still poor delivery and underutilization of these palliative services. We hypothesize that the sub-optimal delivery is due to limited understanding among healthcare providers. Methods: A nationwide cross-sectional online survey was conducted among primary and tertiary healthcare providers. The survey assessed challenges faced, palliative education, confidence in managing palliative patients, and knowledge on palliative surgery. Overall palliative care awareness and knowledge was assessed using a 6-point score. Likelihood of considering various palliative interventions at EOL was also determined using a threshold score (higher score = higher threshold). Results: There were 145 healthcare providers who completed the survey (81.9% response rate); majority reported significant challenges in providing various aspects of palliative care: 57% (n = 82) in the provision of emotional support. Sixty-nine percent (n = 97) in managing social issues, and 71% (n = 103) in managing family expectations. Most expressed inadequate palliative care training in both under-graduate and post-graduate training and lack confidence in managing EOL issues. Up to 57% had misconceptions regarding potential benefits, morbidity and mortality after palliative surgery. In general, most providers had high thresholds for Intensive Care Unit admissions and palliative surgery, and were more likely to recommend endoscopic or interventional radiology procedures at EOL. Conclusion: Healthcare providers in Singapore have poor knowledge and misconceptions about palliative care and surgery. Improving awareness and education among those caring for seriously ill adults is essential.

Public sentiments and the influence of information-seeking preferences on knowledge, attitudes, death conversation, and receptiveness toward palliative care: results from a nationwide survey in Singapore.

Background: Low awareness about palliative care among the global public and healthcare communities has been frequently cited as a persistent barrier to palliative care acceptance. Given that knowledge shapes attitudes and encourages receptiveness, it is critical to examine factors that influence the motivation to increase knowledge. Health information-seeking from individuals and media has been identified as a key factor, as the process of accessing and interpreting information to enhance knowledge has been shown to positively impact health behaviours. Objective: Our study aimed to uncover public sentiments toward palliative care in Singapore. A conceptual framework was additionally developed to investigate the relationship between information-seeking preferences and knowledge, attitudes, receptiveness of palliative care, and comfort in death discussion. Design and Methods: A nationwide survey was conducted in Singapore with 1226 respondents aged 21 years and above. The data were analysed through a series of hierarchical multiple regression to examine the hypothesised role of information-seeking sources as predictors. Results: Our findings revealed that 53% of our participants were aware of palliative care and about 48% were receptive to receiving the care for themselves. It further showed that while information-seeking from individuals and media increases knowledge, attitudes and receptiveness to palliative care, the comfort level in death conversations was found to be positively associated only with individuals, especially healthcare professionals. Conclusion: Our findings highlight the need for public health authorities to recognize people's deep-seated beliefs and superstitions surrounding the concept of mortality. As Asians view death as a taboo topic that is to be avoided at all costs, it is necessary to adopt multipronged communication programs to address those fears. It is only when the larger communicative environment is driven by the media to encourage public discourse, and concurrently supported by timely interventions to trigger crucial conversations on end-of-life issues between individuals, their loved ones, and the healthcare team, can we advance awareness and benefits of palliative care among the public in Singapore.

A nationwide survey to understand public sentiments and the extent that information-seeking preferences can increase knowledge, attitudes, receptiveness of palliative care, and comfort level in death discussion in Singapore Low awareness of palliative care is a barrier that persistently hinders palliative care acceptance among populations in developing and developed countries. As knowledge shapes attitudes and encourages receptiveness, it is vital that researchers uncover factors that influence the motivation to increase knowledge. Health information-seeking is a factor that deserves greater attention in palliative care research because the process of seeking out information on health concerns from other people or the media can greatly increase individuals' knowledge. As such, this nationwide survey involving 1226 participants was carried out in Singapore to understand the public sentiments toward palliative care. It further statistically analyzed if information-seeking (from individuals and the media) will increase knowledge, attitudes, receptiveness toward palliative care, and comfort level in death discussion. Our findings indicated that 53% of our participants were aware of palliative care and about 48% were receptive to receiving the care for themselves. Furthermore, while information-seeking from individuals and media increases knowledge, attitudes, and receptiveness to palliative care, people are only comfortable to engage in death discussion with individuals, especially healthcare professionals. Exposure to media alone is not enough to encourage individuals to want to talk about end-of-life issues including palliative care. As Asians view death as a taboo topic, it is important for public health authorities to recognize people's deep-seated beliefs and superstitions surrounding the concept of mortality. A multipronged communication program is therefore needed to address these fears. It is only when the larger communicative environment driven by the media to encourage public discourse, and concurrently supported by timely interventions to trigger crucial conversations on end-of-life issues between individuals, their loved ones, and the healthcare team, can we advance awareness and benefits of palliative care among the public in Singapore.

Physician-patient boundaries in palliative care.

BACKGROUND: Nurturing effective physician-patient relationships is essential to the provision of patient-centred care. Palliative care physicians may apply boundary-crossings or breaches in professional standards to nurture effective physician-patient relationships. Being highly individualized and shaped by the physician's narratives, clinical experience, and contextual considerations, boundary-crossings are susceptible to ethical and professional violations. To better appreciate this concept, we employ the Ring Theory of Personhood (RToP) to map the effects of boundary-crossings on the physician's belief systems. METHODS: As part of the Tool Design SEBA methodology, a Systematic Evidence-Based Approach (SEBA) guided systematic scoping review was employed to guide the design of a semi-structured interview questionnaire with palliative care physicians. The transcripts were simultaneously content and thematically analysed. The themes and categories identified were combined using the Jigsaw Perspective and the resulting domains formed the basis for the discussion. RESULTS: The domains identified from the 12 semi-structured interviews were catalysts and boundary-crossings. Boundary-crossings attempt to address threats to a physician's belief systems (catalysts) and are highly individualized. Employ of boundary-crossings depend on the physician's sensitivity to these 'catalysts', their judgement and willingness to act, and their ability to balance various considerations and reflect on their actions and their ramifications. These experiences reshape belief systems, understandings of boundary-crossings and may influence decision-making and practice, underscoring the potential for greater professional breaches when unchecked. CONCLUSION: Underlining its longitudinal effects, the Krishna Model underscores the importance of longitudinal support, assessment and oversight of palliative care physicians, and lays the foundation for a RToP-based tool to be employed within portfolios.

Evidence-guided approach to portfolio-guided teaching and assessing communications, ethics and professionalism for medical students and physicians: a systematic scoping review.

OBJECTIVES: Guiding the development of longitudinal competencies in communication, ethics and professionalism underlines the role of portfolios to capture and evaluate the multiple multisource appraisals and direct personalised support to clinicians. However, a common approach to these combined portfolios continues to elude medical practice. A systematic scoping review is proposed to map portfolio use in training and assessments of ethics, communication and professionalism competencies particularly in its inculcation of new values, beliefs and principles changes attitudes, thinking and practice while nurturing professional identity formation. It is posited that effective structuring of portfolios can promote self-directed learning, personalised assessment and appropriate support of professional identity formation. DESIGN: Krishna's Systematic Evidence-Based Approach (SEBA) is employed to guide this systematic scoping review of portfolio use in communication, ethics and professionalism training and assessment. DATA SOURCES: PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases. ELIGIBILITY CRITERIA: Articles published between 1 January 2000 and 31 December 2020 were included. DATA EXTRACTION AND SYNTHESIS: The included articles are concurrently content and thematically analysed using the split approach. Overlapping categories and themes identified are combined using the jigsaw perspective. The themes/categories are compared with the summaries of the included articles in the funnelling process to ensure their accuracy. The domains identified form the framework for the discussion. RESULTS: 12 300 abstracts were reviewed, 946 full-text articles were evaluated and 82 articles were analysed, and the four domains identified were indications, content, design, and strengths and limitations. CONCLUSIONS: This review reveals that when using a consistent framework, accepted endpoints and outcome measures, longitudinal multisource, multimodal assessment data fashions professional and personal development and enhances identity construction. Future studies into effective assessment tools and support mechanisms are required if portfolio use is to be maximised.

Painting and Poetry From a Bereaved Family and the Caring Physician.

This is a case description and personal account shared by a palliative care physician whose team provided specialist palliative care support to a patient who attempted immolation. This case depicts a family at risk of complicated grief due to the violent nature of self-inflicted burns and the lingering social stigmatization of suicide. Here, we explore important psycho-emotional considerations and share our experience using art and poetry to build therapeutic connections with the grieving family.

A systematic scoping review on patients' perceptions of dignity.

BACKGROUND: A socioculturally appropriate appreciation of dignity is pivotal to the effective provision of care for dying patients. Yet concepts of dignity remain poorly defined. To address this gap in understanding and enhance dignity conserving end-of-life care, a review of current concepts of dignity is proposed. METHODS: To address its primary research question "How do patients conceive the concept of dignity at the end of life?", this review appraises regnant concepts and influences of dignity, and evaluates current dignity conserving practices. To enhance accountability, transparency and reproducibility, this review employs the Ring Theory of Personhood (RToP) as its theoretical lens to guide a Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) of patient perspectives of dignity. Three independent teams of reviewers independently analysed included articles from a structured search of PubMed, Embase, PsycINFO, Scopus, CINAHL and Cochrane Databases using thematic and content analyses. The themes and categories identified were compared and combined using the Funnelling Process to create domains that guide the discussion that follows. RESULTS: Seventy-eight thousand five hundred seventy-five abstracts were identified, 645 articles were reviewed, and 127 articles were included. The three domains identified were definitions of dignity, influences upon perceptions of dignity, and dignity conserving care. CONCLUSIONS: This SSR in SEBA affirms the notion that dignity is intimately entwined with self-concepts of personhood and that effective dignity conserving measures at the end of life must be guided by the patient's concept of dignity. This SSR in SEBA posits that such personalised culturally sensitive, and timely support of patients, their family and loved ones may be possible through the early and longitudinal application of a RToP based tool.

A systematic scoping review of communication skills training in medical schools between 2000 and 2020.

BACKGROUND: Communication skills training (CST) remains poorly represented and prioritised in medical schools despite its importance. A systematic scoping review (SSR) of CST is proposed to better appreciate current variability in their structure, content, and assessment. This is to guide their future design in medical school curricula. METHODS: The Systematic Evidence-Based Approach (SEBA) was used to guide concurrent SSRs of teaching and assessment in CST. After independent database searches, concurrent thematic and content analysis of included articles were conducted separately. Resultant themes/categories were combined via the jigsaw perspective to provide a more holistic view of the data. These were then compared to tabulated summaries of the included articles to create funnelled domains. RESULTS: 52,300 papers were identified, 150 full-text articles included, and four funnelled domains were identified: Indications, Design, Assessment, and Barriers and Enablers of CST. CSTs confer numerous benefits to physicians and patients. It saw increased confidence, improved diagnostic capabilities and better clinical management, as well as greater patient satisfaction and treatment compliance. Skills may be divided into core, prerequisite competencies, and advanced skills pertinent to more challenging and nuanced scenarios - such as population or setting-specific situations. CST teaching and assessment modalities were found to align with Miller's Pyramid, with didactic teaching gradually infused with experiential approaches to enhance their understanding and integration. A plethora of CST frameworks, teaching and assessment methods were identified and are presented together. CONCLUSION: While variable in approach, content and assessment, CST in medical schools often employ stage-based curricula to instil competency-based topics of increasing complexity throughout medical school education. This process builds on the application of prior knowledge and skills, influencing practice and, potentially, the students' professional identity formation. In addition, the institution plays a critical role in overseeing training, ensuring longitudinal guidance and holistic assessments of the students' progress.

Operationalization of critical care triage during a pandemic surge using protocolized communication and integrated supportive care.

Triage becomes necessary when demand for intensive care unit (ICU) resources exceeds supply. Without triage, there is a risk that patients will be admitted to the ICU in the sequence that they present, disadvantaging those who either present later or have poorer access to healthcare. Moreover, if the patients with the best prognosis are not allocated life support, there is the possibility that overall mortality will increase. Before formulating criteria, principles such as maximizing lives saved and fairness ought to have been agreed upon to guide decision-making. The triage process is subdivided into three parts, i.e., having explicit inclusion/exclusion criteria for ICU admission, prioritization of patients for allocation to available beds, and periodic reassessment of all patients already admitted to the ICU. Multi-dimensional criteria offer more holistic prognostication than only using age cutoffs. Appointed triage officers should also be enabled to make data-driven decisions. However, the process does not merely end with an allocation decision being made. Any decision has to be sensitively and transparently communicated to the patient and family. With infection control measures, there are challenges in managing communication and the psychosocial distress of dying alone. Therefore, explicit video call protocols and social services expertise will be necessary to mitigate these challenges. Besides symptom management and psychosocial management, supportive care teams play an integral role in coordination of complex cases. This scoping review found support for the three-pronged, triage-communication-supportive care approach to facilitate the smooth operationalization of the triage process in a pandemic.

Enhancing Interprofessional Communications Training in Internal Medicine. Lessons Drawn From a Systematic Scoping Review From 2000 to 2018.

INTRODUCTION: Interprofessional communication (IPC) enhances patient experiences and outcomes and improves well-being and satisfaction among health care professionals. This scoping review seeks to guide design of IPC training in internal medicine. METHODS: The framework of Arksey and O'Malley (2005) guided this systematic scoping review in internal medicine across PubMed, Embase, CINAHL, Scopus, PsycINFO, ERIC, JSTOR, and Google Scholar databases for publications from the years 2000 to 2018. RESULTS: Twenty-two thousand eight hundred seventy-four abstracts were retrieved, 326 full-text articles were reviewed, and 32 articles were included. The themes identified using directed content analysis were indications for an IPC program, training stages, and obstacles. The rationale for IPC programs was to improve interprofessional teamwork and enhance patient care. IPC training occurs in five stages beginning with instilling the role, value, and skills behind IPC and gradually practicing these skills within the clinical setting. The challenges to IPC highlight the need to confront workplace hierarchies and the lack of resources. DISCUSSION: The findings of this systematic scoping review also serve to underscore the importance of understanding, evaluating, and influencing the clinical environment and the work environment and the need for new assessment tools that will guide the individualized, longitudinal, competency-based learning process that underpins IPC training.

Addressing the Needs of Migrant Workers in ICUs in Singapore.

BACKGROUND: With nearly 400 000 migrant workers in Singapore, many from Bangladesh, India and Myanmar, language and cultural barriers posed a great many challenges during the COVID-19 pandemic. This was especially so as majority of the COVID-19 clusters in Singapore emerged from their communal dormitories. With concerns arising as to how this minority group could be best cared for in the intensive care units, the need for medical interpreters became clear. MAIN: In response, the Communication and Supportive Care (CSC) workgroup at the Singapore General Hospital developed the 'Medical Interpreters Training for ICU Conversations' program. Led by a medical social worker-cum-ethicist and 2 palliative care physicians, twenty volunteers underwent training. The program comprised of 4 parts. Firstly, volunteers were provided with an overview of challenges within the COVID-19 isolation ICU environment. Discussed in detail were common issues between patients and families, forms of distress faced by healthcare workers, family communication modality protocols, and the sociocultural demographics of Singapore's migrant worker population. Secondly, key practice principles and 'Do's/Don'ts' in line with the ethical principles of medical interpretation identified by the California Healthcare Interpreters Association were shared. Thirdly, practical steps to consider before, during and at the end of each interpretation session were foregrounded. Lastly, a focus group discussion on the complexities of ICU cases and their attending issues was conducted. Targeted support was further provided in response to participant feedback and specific issues raised. CONCLUSION: As a testament to its efficacy, the program has since been extended to the general wards and the Ministry of Health in Singapore has further commissioned similar programs in various hospitals. In-depth training on the fundamentals of medical terminology, language and cultural competency should be provided to all pertinent healthcare workers and hospitals should consider hiring medical interpreters in permanent positions.