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Background: Healthcare providers working in hospitals have significant exposure to patients with palliative care needs. For many patients, these needs often reflect non-specialist rather than specialist palliative care needs. Embedding a palliative care approach in acute hospital-based care however is challenging., Aim: To identify core indicators for the integration of a palliative care approach in hospitals., Design: A Delphi technique used three sequential online survey rounds. Preliminary indicators were identified in a concept analysis of a palliative care approach, and a systematic review of hospital-based healthcare providers' views of a palliative care approach., Participants: An international expert panel of three key stakeholder groups (clinicians, researchers, patients/family members) participated in each Delphi round., Results: The Delphi participants were recruited from 12 countries; 97 individuals responded to round 1, 78 to round 2 and 72 to round 3 (74% overall response rate). Consensus was achieved (defined a priori as >70%) on 32 core indicators of a hospital-based palliative care approach, with five structural indicators (relating to infrastructure and governance), 21 organisational indicators (relating to clinical care processes) and six staff indicators (relating to training and support for healthcare providers)., Conclusions: This study offers multi-level guidance for clinical practice, policy and research related to integration of a palliative care approach in hospitals, based on evidence and international consensus from major stakeholder groups. These core indicators provide a means to assess, review and communicate the core elements of a palliative care approach in hospitals., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability., Aim: To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers., Design: Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure., Setting: European., Participants: International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation., Results: A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided., Conclusions: This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals., Competing Interests: Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that there is no conflict of interest. The authors (apart from HB and SMS) participated in the Delphi process. However, the two researchers coordinating the consensus process and the evaluation (HB and SMS) did not participate, thus preventing any bias in the evaluation.

Background: The Covid-19 pandemic has highlighted weaknesses in the National Health Service critical care provision including both capacity and infrastructure. Traditionally, healthcare workspaces have failed to fully incorporate Human-Centred Design principles resulting in environments that negatively affect the efficacy of task completion, patient safety and staff wellbeing. In the summer of 2020, we received funds for the urgent construction of a Covid-19 secure critical care facility. The aim of this project was to design a pandemic resilient facility centred around both staff and patient requirements and safety, within the available footprint., Methods: We developed a simulation exercise, underpinned by Human-Centred Design principles, to evaluate intensive care designs through Build Mapping, Tasks Analysis and Qualitative data. Build Mapping involved taping out sections of the design and mocking up with equipment. Task Analysis and qualitative data were collected following task completion., Results: 56 participants completed the build simulation exercise generating 141 design suggestions (69 task related, 56 patient and relative related, 16 staff related). Suggestions translated to 18 multilevel design improvements; five significant structural changes (Macro level) including wall moves and lift size change. Minor improvements were made at a Meso and Micro design level. Critical care design drivers identified included functional drivers (visibility, Covid-19 secure environment, workflow, and task efficiency) and behavioural drivers (learning and development, light, humanising intensive care and design consistency)., Conclusion: Success of clinical tasks, infection control, patient safety and staff/patient wellbeing are highly dependent on clinical environments. Primarily, we have improved clinical design by focusing on user requirements. Secondly, we developed a replicable approach to exploring healthcare build plans revealing significant design changes, that may have only been identified once built., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Peter Watkinson worked part time for Sensyne Health and has received grant funding from National Institute for Health Research, Wellcome, and Sensyne Health outside the submitted work. All other authors declare no competing interests., (© The Intensive Care Society 2022.)

Background: Palliative care services seek to improve the wellbeing of family carers of people living with serious and life-limiting illness. To help achieve this goal, systematic reviews have recommended priority areas for family carer research and the need to improve the quality of study design. Policy makers have also advocated for enhanced family carer support. However, there are specific methodological considerations and challenges in designing and conducting carer research conducted during the course of the serious illness trajectory and in bereavement., Aim: To develop strategies to improve the design and conduct of research with family carers., Design: Expert elicitation study using an adapted version of the 'Identify, Discuss, Estimate and Aggregate' elicitation protocol, supplemented with strategies from peer-reviewed literature., Setting/participants: Nine members of the management committee of the European Association for Palliative Care's Reference group on family carer research, comprising international senior research academics in family caregiving., Results: A compilation of recommended strategies and checklist was created to: (a) help researchers plan research involving family carers focussing on: preparation, conduct and dissemination and (b) assist ethics committees and funding bodies to evaluate proposals., Conclusions: The strategies and checklist for conducting research with family carers may enhance methodologically rigorous research. Consequently, researchers, practitioners and policy makers will not only gain a more comprehensive understanding of the unmet needs of family carers but also promote the development of empirically sound interventions.

Background: In 2009, the EAPC published recommendations on standards and norms for palliative care in Europe, and a decade later, wished to update them to reflect contemporary practice., Aim: To elicit consensus on standards and norms for palliative care in Europe, taking account of developments since 2009., Design: A Delphi technique used three sequential online survey rounds, and a final expert consultation (EAPC Board). The original 2009 questionnaire with 134 statements was updated with 13 new concepts and practices following a scoping of the literature between 2009 and 2020 (total: 147 statements)., Setting/participants: One contact of Boards of 52 national European organisations affiliated to the EAPC were invited to participate, with subsequent rounds sent to respondees. The EAPC Board ( n  = 13) approved final recommendations., Results: In Round 1: 30 organisations (14 organisations × two people, 16 organisations × one person, total n  = 44) in 27 countries responded (response rate 58% organisations, 82% countries ) , Round 2 ( n  = 40), Round 3 ( n  = 38). 119 statements reached consensus in Round 1, 9 in Round 2, 7 in Round 3. In total 135/145 statements in five domains (terminology, philosophy, levels, delivery, services) reached consensus (defined as >75% agreement), (122) were original EAPC recommendations with 13 new recommendations included emerging specialisms: neonatal, geriatric and dementia care, and better care practices. Seven statements failed to reach consensus and four were removed as irrelevant or repetition., Conclusions: Most recommendations on standards and norms for palliative care in Europe remain unchanged since 2009. Evolving concepts in palliative care can be used to support advocacy.

Background: Social inclusion is an important indicator of recovery in individuals with severe mental illness. The Social Inclusion Questionnaire User Experience (SInQUE) is a new measure of social inclusion for mental health service users which assesses five domains (consumption, production, access to services, social integration and civil engagement). It has good psychometric properties and is acceptable to service users and mental health professionals. It is not clear whether individuals with different diagnostic conditions experience a similar reduction in social inclusion., Aims: (1) Investigate whether current social inclusion differs between diagnostic groups (people with schizophrenia/other psychotic disorders, common mental disorder or personality disorder); (2) Identify factors associated with lower social inclusion; (3) Examine associations between social inclusion and stigma, quality of life and loneliness., Method: Mental health service users with psychotic disorder, personality disorder or common mental disorder, living in the community, completed the SInQUE, alongside other validated outcome measures. Multiple regression investigated associations., Results: About 192 service users (55% with psychotic disorder; 26% with common mental disorder; 19% with personality disorder). Current social inclusion did not vary according to diagnosis, except for the sub-domain of productivity, where individuals with personality disorder were more socially included than the other two groups. Lower social inclusion was associated with older age ( p  = .008), lack of higher education ( p  < .001), more previous admissions ( p  = .005), severity of current symptoms and greater experienced stigma ( p  = .006) and anticipated stigma ( p  = .035). Greater social inclusion was associated with better quality of life ( p  < .001) and less loneliness ( p  < .001)., Conclusions: Barriers to social inclusion in individuals with severe mental health problems include factors related to the illness, such as symptom severity and external factors, such as stigma and discrimination. Social inclusion is a recovery goal and should be routinely assessed. Increasing people's social inclusion benefits service users in terms of improved mental health, better quality of life and reduced loneliness.