Search

AbstractObjective:The efficacy of intranasal fentanyl spray (INFS) was compared with that of oral transmucosal fentanyl citrate (OTFC) for the relief of cancer-related breakthrough pain (BTP) in an open-label, crossover trial.Methods:Adult cancer patients receiving stable background opioid treatment and experiencing BTP episodes were recruited from 44 study centres in seven European countries (Austria, France, Germany, Italy, Poland, Spain and the United Kingdom); of the 196 patients enrolled, 139 were randomised to receive INFS followed by OTFC, or vice versa. Patients were titrated to an effective dose of one agent (50, 100 or 200 µg INFS; 200, 400, 600, 800, 1200 or 1600 µg OTFC) to treat six BTP episodes, then titration and treatment were repeated with the other agent. The primary outcome was patient-recorded time to onset of ‘meaningful’ pain relief. Secondary outcomes included pain intensity difference (PID) at 10 and 30 minutes (PID10, PID30), sum of PID at 15 and 60 minutes (SPID0–15, SPID0–60), ease of administration, treatment preference and relationship between background opioid dose and effective INFS dose. Additional outcome measures included proportions of episodes with ≥33 and ≥50 pain intensity (PI) reduction, and PID at additional time points.Clinical trial registration number:NCT00496392.Results:Among the intention-to-treat population (n  139), median time to onset of ‘meaningful’ pain relief was 11 minutes with INFS versus 16 minutes with OTFC; 65.7 of patients attained faster time to ‘meaningful’ pain-relief onset with INFS (p < 0.001). PID was statistically significantly greater for INFS than OTFC from 5 minutes post-dosing. Significantly more INFS-treated breakthrough pain episodes achieved clinically important pain relief (≥33 and ≥50 PI reduction) up to 30 minutes post-dosing. The proportions of episodes treated with INFS and OTFC achieving a PI reduction of ≥33 at 5 minutes were 25.3 versus 6.8 (p < 0.001), and at 10 minutes were 51.0 versus 23.6 (p < 0.001), respectively; the proportions of episodes treated with INFS and OTFC achieving a ≥50 PI reduction at 5 minutes were 12.8 versus 2.1 (p < 0.001), and at 10 minutes were 36.9 versus 9.7 (p < 0.001), respectively. Higher SPID0–15and SPID0–60scores were achieved with INFS (p < 0.001). More patients preferred INFS than OTFC (p < 0.001) and more patients found it very easy/easy to use. Both treatments were well tolerated. In the safety population (n  139), 56.8 (n  79) of patients experienced ≥1 AE during the trial. The only AE that occurred in ≥5 of patients in either treatment group was nausea. Among those patients who experienced serious AEs (13.7, n  19), none were considered to be related to either study medication. There was a weak correlation between effective INFS doses and background opioid doses.Conclusion:In this open-label, randomised, crossover trial, significantly more patients attained faster ‘meaningful’ pain relief with INFS than OTFC, and more patients preferred INFS to OTFC. [ABSTRACT FROM AUTHOR]

Die gesellschaftlichen und medizinischen Entwicklungen der letzten Jahrzehnte haben einen tief greifenden Wertewandel in der Medizin nach sich gezogen, der sich zwischen dem Gebot der Patientenautonomie und der zunehmend problematischeren Entscheidungsfindung in Fragen der medizinischen Behandlung entspannt. Dieser Konflikt spitzt sich in Situationen eingeschränkter Lebenserwartung, rein palliativer Therapieansätze oder fehlender Einwilligungsfähigkeit der Patienten zu. Juristisch und standesrechtlich wurden in den letzten Jahren viele Unklarheiten beseitigt. Einerseits wurde die Patientenautonomie weiter gestärkt, andererseits sieht die Rechtsprechung den Arzt auch in der Pflicht zur überlegten Indikationsstellung einer Therapie angesichts fehlender kurativer Möglichkeiten. Für diesen häufig schwierigen Entscheidungsfindungsprozess ist ein verändertes Verständnis der Arzt-Patienten-Beziehung notwendig. Der Arzt sollte sich nicht auf die Rolle des neutralen Beraters bei medizinischen Entscheidungen zurückziehen und damit dem Patienten die komplette Verantwortung für die medizinische Behandlung überlassen. Vielmehr wird der Patient erst dadurch befähigt, eine autonome, seinen Bedürfnissen angepasste Entscheidung zu treffen, indem sich der behandelnde Arzt mit seiner Fachkenntnis, seiner eigenen Erfahrung und auch persönlichen Meinung in die Beratung einbringt, solange er diese als solche kenntlich macht. Dadurch wird der Patient befähigt, komplexe medizinische Entscheidungen zu treffen, die seine persönliche Situation, seine Erfahrungen und seine Wertvorstellungen berücksichtigen. Darüber hinaus kann es sinnvoll und für den einzelnen Arzt entlastend sein, schwierige Entscheidungen durch Reflexion innerhalb des Behandlerteams oder durch eine externe ethische Beratung zu erleichtern. Algorithmen können die Abfolgen im Entscheidungsprozess veranschaulichen und so die Entscheidungsfindung unterstützen. [ABSTRACT FROM AUTHOR]

Context: The WHO Model List of Essential Medicines includes 24 medications under the section Medicines for Pain and Palliative Care (EML). The Lancet Commission on Pain and Palliative Care developed the Lancet Essential Package (LEP), including 35 medications designed to alleviate serious health-related suffering worldwide., Objectives: This study aims to provide recommendations on the appropriate use of essential of medicines in palliative care., Methods: The global palliative care community was invited to submit guidelines, of which 19/22 were selected. Data was extracted on initial dose, frequency, and maximum daily dose for medications in the LEP and in the WHO EML. For medications where guidance was not available or information differed, a 2-round Delphi process was conducted with 70 experts across regions and income levels. Consensus was set to ≥70% agreement., Results: Consensus in the guidelines was identified for 24 medications on three parameters. Open questions (mostly on maximum daily dose) were included in the Delphi. 63 experts from 49 countries responded (RR = 90%). No consensus was achieved for the maximum daily dose for nine medications. Significant disparities in medication availability were noted between high-income and low/middle-income countries., Conclusion: We were able to partly achieve our goal, with limited evidence and a wide range of clinical practice described by the experts. This highlights an important gap in critical information which affects mostly the provision of palliative care at the primary care. Both limited availability and lack of training on the adequate use of essential medications may affect how clinicians manage symptoms, possibly relying on personal experience or trial and error, rather than evidence-based information., Competing Interests: Disclosures and Acknowledgments This research received no specific funding/grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest. We are grateful with the IAHPC members who accepted our invitation and responded the survey: Alejandra Palma, Ali Xhixha, Ancu Feng, Andrew Amata, Arnold Nzale Nzali, Carla Ripamonti, Chitra Venkateswaran, Christine Banda, Claudia Bausewein, Dagny Faksvåg Haugen, David Currow, Diego Ezequiel Candelmi, Dingle Spence, Aleesha Adatia, Duncan Kwaitana, Duong Le, Emilia Pinto, Esther Cege-Munyoro, Eve Namisango, Fadi Abu-Farsakh, Fazle Biswas, Felicia Loh, Folaju Oyebola, GV Chamath Fernando, Jane Bates, Jaishree Sharmini, James Cleary, Juhliad Lebenu Woldegiorgs, Julia Ambler, Lankoandé Martin, Lukas Radbruch, Lyubima Despotova-Toleva, Maria Cervantes, Maria M Fajardo, Mary Lynn McPherson, Matthias Brian, Michelle Mikus, Mitchell Scott, Mitsuru Sakitani, Mohamad Hamade, Mohammad Al-Shahri, Mukelabai Mukelabai, Nahla Gafer, Natalia Carafizi, Neil Nijhawan, Noreen Chan, Nshimirimana Mwadjuma, Pati Dzotsenidze, Regina Mc Quillan, Rosa Buitrago, Rui Carneiro, Rumana Dowla, Samy Alsirafy, Sefanit Gebreab, Sofia Bunge, Vanesa Rocio Orellana Caro, Victoria Hewitt., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Palliative sedation involves the intentional proportional lowering of the level of consciousness in patients with life-limiting disease who are experiencing refractory suffering. The efficacy of palliative sedation needs to be monitored to ensure patient comfort. The aim of this study was to evaluate the efficacy using discomfort levels combined with sedation/agitation levels., Methods: In this prospective observational study, adult patients with advanced malignancies were recruited from hospice units, palliative care units, and hospital wards in five European countries. Health care professionals used proxy observations of discomfort levels (Discomfort Scale-Dementia of Alzheimer Type, range 0-27) and sedation/agitation levels (Richmond Agitation-Sedation Scale modified for palliative care inpatients), range - 5 to + 4) to evaluate the efficacy of palliative sedation., Results: In 78 participants, discomfort levels were monitored during palliative sedation. The mean discomfort score before start was 9.4 points (95% CI 8.3-10.5), which showed a significant decrease of 6.0 points (95% CI 4.8-7.1) after start of sedation for the total sedation period. In the multivariable analysis, no significant factors influencing baseline discomfort levels were identified. The discomfort and depth of sedation scores were found to be positively correlated, with an r of 0.72 (95% CI 0.61-0.82). The internal consistency of the discomfort scale was good (0.83), but the "Noisy breathing" item was less informative of the total discomfort score., Conclusions: The efficacy of palliative sedation can be evaluated by measuring discomfort levels combined with sedation/agitation levels. The measurement of discomfort levels might provide a more specific and detailed evaluation of adequate sedation., Trial Registration: This study is registered at ClinicalTrials.gov since January 22, 2021, registration number: NCT04719702., Competing Interests: Declarations. Ethics approval and consent to participate: This study has been approved by the Research Ethics Committee (REC) of the Radboud University Medical Centre in Nijmegen (ref.nr. 2019/6016, June 2020), the REC of the University Hospital Navarra in Pamplona (ref.nr.2020.044, June 2020), the REC of the Rheinische Friedrich-Wilhelm’s University in Bonn (ref.nr. 300/20, July 2020), the REC of the University Hospital of Palermo (ref.nr. 7/2020, July 2020), and the REC of the University Hospitals in Leuven (ref.nr.S64008, August 2020). Written informed consent was obtained before participation in the study, both in the participants and in the relatives and health care professionals for completing questionnaires. All methods were conducted in accordance with relevant guidelines and applicable regulations. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Structures of palliative care, cross-sectoral transitions and care pathways of patients with palliative care needs were investigated at two sites. The systematic comparison of similarities and differences using the topic of 'pain' as an example is intended to provide information on the extent to which these are related to site-specific palliative care concepts (integrated and cooperative)., Methods: The study follows a mixed-methods design. In addition to a document analysis of anonymised patient records (n = 774), expert interviews (n = 20), as well as interviews with patients, relatives (n = 60) and focus groups (n = 12), were conducted., Results: The systematic comparative analysis provides evidence for concept-independent commonalities (e.g. sociodemographic distribution, aggravated pain treatment) as well as concept-dependent differences (e.g. care pathways, facilitated continuous symptom control through integrated care structures) in the context of integrated or cooperative palliative care., Discussion: Commonalities and differences with regard to the topic of pain, as focused on here, and its organisational management become tangible as effects of the respective organisational structure (= concept-dependent) as well as concept-independent external influencing factors., Competing Interests: Einhaltung ethischer Richtlinien Interessenkonflikt S. Peuten, B. Jaspers, I. Hainsch-Müller, C. Aulmann, W. Schneider, L. Radbruch und G. Ateş geben an, dass kein Interessenkonflikt besteht.Nach positivem Votum des Ethikrats des Universitätsklinikums Bonn (Lfd. Nr. 238/17) wurden nach Studieninformationsgesprächen und unterschriebenen Einwilligungserklärungen qualitative und quantitative Erhebungen durchgeführt., (© 2023. The Author(s).)

The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research., (© 2024. The Author(s).)

Context: Estimates of serious health-related suffering (SHS) demonstrate immense unmet need for palliative care, predominately in low- and middle-income countries (LMICs). Because opioids are essential medicines in palliative care (PC), measuring their availability can be used to evaluate the capacity of health systems to meet need., Objectives: Present the methodology for calculating Distributed Opioids in Morphine Equivalents (DOME)- introduced in the Lancet Commission on Global Access to Palliative Care and Pain Relief report - and how it can be used as a simple indicator to quantify unmet pain relief and PC need., Methods: Using International Narcotics Control Board (INCB) data, DOME applies relative potency estimates to convert the annualized quantities of clinically appropriate opioids procured by a country to oral morphine equivalent milligrams. To quantify unmet need, an expert group proposed health condition-specific estimates for opioid need and used available data on the burden of SHS to posit the annual opioid quantity required by country for symptomatic treatment of pain or breathlessness. Comparing this to DOME generates DOME%SHSNEED, the proportion of opioids needed for palliative care that can be fulfilled by the opioid procured by a country during a year., Results: DOME and DOME%SHSNEED can be used to measure, over time, the capacity of countries to meet PC need, as a key component of universal health coverage. Identifying access gaps disproportionately impacting LMICs can promote better health system performance and guide countries and institutions in policy making., Conclusion: DOME and DOME%SHSNEED can be used to monitor health system progress to redress disparities and promote access to medically indicated opioid therapy in palliative care., Competing Interests: Disclosure and Acknowledgments FMK reports research grant funding to the University of Miami from the U.S. Cancer Pain Relief outside the submitted work; ABC Global Alliance outside the submitted work; research grant funding from the Medical Research Council to FUNSALUD (Mexican Health Foundation) for work related to palliative care outside the submitted work; research grant funding from the University of Edinburgh to the University of Miami for work related to palliative care outside the submitted work; research grant funding to the University of Miami outside submitted work from Merck KGaA/EMD Serono; and personal fees from Merck KGaA/EMD Serono and Tecnológico de Monterrey. FMK is on the board of the IAHPC, Founding President of Tómatelo a Pecho, A.C, and Senior Economist for FUNSALUD. HAO reports research grants from MerckKGaA/EMD Serono via the University of Miami. XK and AB report consulting fees from the University of Miami Institute for the Advanced Study of the Americas for part of the submitted work and consulting fees through a research grant from the Medical Research Council to the University of Edinburgh for work related to palliative care outside the submitted work. AB also reports Honoraria from Memorial Sloan Kettering for presentation and Recipient of Fulbright U.S. Scholar Teaching and Research Award from the Bureau of Educational and Cultural Affairs, U.S. Department of State related to palliative care and outside of submitted work. SRC reports paid employment as executive director from Worldwide Hospice Palliative Care Alliance; Royalties from Routledge Publishing for book “Hospice and Palliative Care: The essential guide, 3rd ed” (2017 - present); Honoraria for Plenary at annual meeting 2023 from Hong Kong Jockey Club; Travel reimbursement for speaking 2023 from Hong Kong Jockey Club; International children's Palliative Care Network Board member (non-paid); Elisabeth Kubler-Ross Foundation Board member (non-paid); International Work Group on Death, Dying, & Bereavement Board member (non-paid); Mt Sinai Hospital, National Palliative Care Research Center Scientific Advisory Board member (non-paid); Journal of Pain & Symptom Management Editorial Board (non-paid); Public Health & Palliative Care International Member Ex-officio Board Member (non-paid). LDL reports Executive Director, International Association for Hospice and Palliative Care. WER partially supported by NCI/NIH Comprehensive Cancer Center Award P30CA008748; receives book royalties from Springer Publishing, Jones & Bartlett Learning, and Oxford University Press. LR reports Chair of the Board of Directors of the International Association for Hospice and Palliative Care. All other authors declare no competing interests. We would like to thank the participants in the expert panels who contributed to the estimates of opioid needs for adults and children. We are also grateful to Abigail Schcolnik and Paul Vila for their research support. We also thank The Tecnológico de Monterrey (Challenge-Based Research Funding Program, I036- IOR005-C5-T3-T) and the The Ibero-American General Secretariat (SEGIB) and the European Union (Memorandum of Cooperation: DJ-TM-GSL/ITESM-INV/2024-030) and the University of Miami Institute for Advanced Study of the Americas for financial support., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Context: Palliative care aims to improve the quality of life in patients with progressive diseases such as cancer. Effective cancer pain management is a major challenge of palliative treatment. Empirical data on the prevalence of cancer pain, the efficiency of pain treatment and influencing factors are scarce., Objectives: Here, we investigated pain in cancer patients treated on inpatient palliative care wards in Germany., Methods: N = 4779 data sets provided by the German Palliative Care Registry from yearly evaluation periods between 2015 and 2020 were included. Pain ratings were assessed by professionals through a checklist of symptoms and problems (HOPE-SP-CL)., Results: More than half of the included patients suffered from moderate/severe pain at the beginning of inpatient palliative care and in 71% of these patients, pain relief was achieved at the end of inpatient treatment. Pain intensity, depression and ECOG performance status at admission were weak predictors of later pain relief. The highest pain intensity at the beginning and least pain relief were found in patients with bone and cartilage cancer. The highest percentage of adequate pain control (81%) was seen in 2020., Conclusion: Data from the German Palliative Care Registry confirmed that although increasingly better addressed over the years, insufficiently controlled cancer pain remains a challenge for palliative care units. Patient-specific (e.g. psychological comorbidity) and cancer-related (e.g. bone or cartilage cancer) risk factors for poor pain treatment underline the need for individualized multimodal pain management including psychological support., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Palliative sedation aims to relieve refractory suffering in patients with life-limiting disease. The 2009 framework on palliative sedation of the European Association for Palliative Care (EAPC) has recently been updated. Recommendations have also been formulated by the research group SedPall in Germany. This article describes the social and ethical complexity of decision-making and summarises the recommendations. Patient autonomy is emphasised. Refractoriness of the suffering should be determined jointly by physician and patient. Sedation should be proportional, that is to say, its form and duration should be adapted to the patient's individual situation. The decision on palliative sedation and that on hydration involve two separate decision-making processes. Midazolam should be used as first choice. Particular attention should be paid to the patient's relatives/significant others and the treating team., (© 2024. The Author(s).)

Background: Heart failure is a substantial global health concern that severely affects patients' quality of life. We aimed to compare the effects of early integration of palliative care (EIPC) and standard cardiac care on health status and mood of patients with non-terminal heart failure., Methods: EPCHF was a multicentre, parallel, two-arm, open-label, randomised controlled trial carried out at University Hospital Bonn and University Hospital Düsseldorf in Germany. Eligible patients (aged 18 years or older) had heart failure, with New York Heart Association class II or more and NT-proBNP concentrations greater than or equal to 400 pg/mL. Patients were randomly assigned (1:1) to receive EIPC with standard cardiac care or standard cardiac care alone. Randomisation was computer-generated with allocation concealment, variable block sizes, and stratification by investigational site. The primary endpoints were health status and mood, measured every 3 months over 12 months using the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-PAL) and the Kansas City Cardiomyopathy Questionnaire (KCCQ), analysed by intention to treat. This trial is registered with DRKS.de, DRKS00013922., Findings: Between May 21, 2019, and Nov 15, 2021, 843 patients were assessed for eligibility, 205 of whom were enrolled (100 assigned to EIPC and 105 assigned to standard cardiac care). 143 (70%) patients were male and 62 (30%) were female. Over 12 months, both groups significantly improved in FACIT-PAL and KCCQ Overall Summary Score (OSS) with no significant differences between the groups (FACIT-PAL adjusted mean difference 0·98 points [95% CI -1·28 to 3·23]; p=0·40; KCCQ-OSS adjusted mean difference -2·06 points [-7·89 to 3·78]; p=0·49). Nine (9%) patients in the EIPC group and seven (7%) patients in the standard cardiac care group died from any cause, with no significant differences in time to death between the two groups (hazard ratio [HR] 1·32 [95% CI 0·49 to 3·54]; p=0·58). 22 (22%) patients in the EIPC group and 21 (21%) patients in the standard cardiac care group were hospitalised at least once due to heart failure, with no significant differences in time to heart-failure-related hospitalisation between the two groups (HR 1·09 [0·61 to 1·98]; p=0·77). 70 (70%) patients in the EIPC group and 62 (59%) in the standard cardiac care group had any adverse events (p=0·10)., Interpretation: In this open-label, randomised clinical trial, standard cardiac care, featuring guideline-directed optimisation of medical therapy and regular 3-monthly follow-ups was found to be as effective as when combined with EIPC in improving health status and mood in patients with non-terminal heart failure. Future clinical practices should consider EIPC based on individual patient needs., Funding: Federal Ministry of Education and Research., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Context: Inequities and gaps in palliative care access are a serious impediment to health systems especially in low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions., Objectives: In this paper, an updated methodology - SHS 2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions., Methods and Results: The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS., Conclusions: The methodology encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0., (Copyright © 2024. Published by Elsevier Inc.)

Background: Caring for terminally ill patients with minor children can be very stressful. The perceived quality of life is significantly influenced by the Meaning in Life (MiL). No studies were found that focus on the prioritized special needs of this patient group., Objectives: The aim is to compare and contrast terminally ill parents with minor children and palliative care patients in Germany, in order to provide appropriate support beyond medical, nursing or therapeutic interventions., Methods: Terminally ill parents diagnosed were surveyed using a validated instrument 'Schedule for Meaning in Life Evaluation (SMiLE)'. The study listed various areas that contribute to the MiL, followed by an evaluation of their importance and satisfaction levels. The researchers then compared these findings with data collected from palliative care patients., Results: In Germany, 54 patients, mostly female and with a mean age of 43, were included in this study between February 2017 and September 2020. The median age of the 96 children during the survey phase was 7 years. The comparison group consists of 100 palliative care patients in Germany; mostly aged 50 years and older. For terminally ill patients most important areas were in decreasing order family (100%), social relations (80%), leisure time (61%), nature/animals (39%) and home/garden (30%). Although the overall indices are close between both groups, there are significant and highly correlated differences between them. Parents felt limited by their illness in being a mother or father, as they wanted to be., Conclusion: The involvement with SMiLE led patients to consider their coping resources. The areas relevant to terminally ill parents differed from those relevant to palliative care patients. All participants identified family as the most important factor for MiL. The results suggest that evaluating MiL can serve as a coping strategy and help terminally ill parents with minor children., Competing Interests: The authors declare that there is no conflict of interest., (© The Author(s), 2024.)

Background: Resilience is an increasingly used term in medicine and subject to various definitions, often not easy to grasp. There are established core concepts for patients receiving palliative care, for example, meaning in life, that have already been researched a lot. Resilience, relative to these concepts, is a new object of research in palliative care, where it has so far been used predominantly with regard to the well-being of teams., Aim: To explore how experts in palliative care define the concept of resilience and its suitability for patients, significant others, and professionals., Design: Qualitative study using summarizing content analysis according to Mayring., Setting/participants: Twenty-one health and social care professionals with expertise caring for persons with life-threatening/limiting illnesses and their relatives were interviewed in three individual interviews and four focus groups. All conversations were recorded, transcribed, coded via MAXQDA, and validated by another researcher., Results: Resilience has been described as something procedural, dynamic, individual, and flexible. In connection with well-known concepts such as posttraumatic growth or terms from the field of mindfulness, social environment or personal factors have also been linked to resilience. Resources such as spirituality can contribute to resilience, and resilience itself can function as a resource, for example, by contributing to quality of life. An active use of the term in practical work with patients or relatives is rare, but it is used in education or team measures. Limited lifespan can pose a challenge to an active use of the concept of resilience., Conclusion: Resilience as a very individual approach provides added value to other core concepts of palliative care. Within the palliative context, the normative dimension of resilience must be well reflected. A broader definition of resilience is recommended, leaving room for everyone to find their own form of resilience. The concept of resilience in palliative care includes opportunities as well as risks and should, therefore, be implemented carefully, requiring specific training., Competing Interests: The authors declare that there is no conflict of interest., (© The Author(s), 2024.)

Competing Interests: Declaration of interests CEC reports grants from Breast Cancer Now, Cancer Research UK (CRUK), Addenbrooke's Charitable Trust, and the National Institute for Health and Care Research (NIHR); participation in the Independent Data Monitoring Committees for the UK PivotalBoost trial (chair), the PROTIS phase III sinonasal proton versus IMRT trial (member), the TORPEdO Proton Beam Therapy trial (member); and a leadership role for the Lancet Breast Cancer Commission (chair). CHB reports grants and research support from AbbVie, Nektar Therapeutics, Pfizer, Polyphor, Amgen, Daiichi Sankyo, Sanofi, Exelixis, Regeneron, Novartis, Henlius, Shanghai Henlius Biotech, GSK, Janssen, OBI Pharma, Eli Lilly, Seagen, Checkpoint Therapeutics, Roche, Bristol Myers Squibb, MSD, Merck Serono, AstraZeneca, Novocure, Aveo Oncology, Takeda Pharmaceuticals, TRIO Pharmaceuticals, PharmaMar, Celgene, Myovant, PPD, Syneos Health, DOCS, Labcorp, ICON, IQVIA, Parexel, Nuvisan, PSI, and Medpace; ownership or stocks in Tummi and MEDSir; and participation in advisory boards and consulting activities for Boehringer Ingelheim, GSK, Novartis, Pfizer, Genentech, Eisai, Bayer, MSD, AstraZeneca, Zodiac, Eli Lilly, Sanofi, and Daiichi Sankyo. DAC reports research grants and support from Exact Sciences and Novartis; consulting fees from Eli Lilly, Novartis, Seagen, Daiichi Sankyo, Erytech Pharma, Carnall Farrar, Sapience, and Sanofi; payment or honoraria for lectures and presentations from Exact Sciences, Gilead, Eli Lilly, and Pfizer; participation on data safety monitoring or advisory boards for Novartis, AstraZeneca, and Grail; unremunerated leadership roles for Make Seconds Count (chair of charity trustees) and the Breast International Group (chair of board of not-for-profit research organisation); and receipt of funding for analysis and medical writing for Eli Lilly and Novartis. FC reports payment or honoraria for lectures and presentations and support for attending meetings and travel from Amgen, Astellas/Medivation, AstraZeneca, Celgene, Daiichi Sankyo, Eisai, GE Oncology, Genentech, Gilead, GSK, IQVIA, Macrogenics, Medscape, MSD, Merus, Mylan, Mundipharma, Novartis, Pfizer, Pierre Fabre, prIME Oncology, Roche, Sanofi, Samsung Bioepis, Seagen, Teva Pharmaceuticals, and Touch Independent Medical Education; institutional financial support for clinical trials from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, Eisai, Fresenius, Genentech, Gilead, GSK, Ipsen, Incyte, Nektar Therapeutics, Nerviano, Novartis, Macrogenics, MediGene, MedImmune, MSD, Millenium, Pfizer, Pierre Fabre, Roche, Sanofi, Sonus, Tesaro, Tigris, Wilex, and Wyeth; a leadership role for the ABC Global Alliance and ABC Consensus Conference and Guidelines (president); and membership of ESMO, ESO, EORTC-BCG, IBCSG, SOLTI, ASCO, AACR, EACR, SIS, and ASPIC. WC reports honoraria from AstraZeneca, Pfizer, MSD, and Eisai. PAF reports a former role in the scientific advisory committee of Breast Cancer Trials Australia and New Zealand cooperative group (chair). RJ reports support from the Susan G Komen Foundation; grants from the National Institutes of Health (NIH), the Doris Duke Charitable Foundation, the Greenwall Foundation, and the American Cancer Society; serving as an expert witness for Kleinbard and Hawks Quindel Law; roles in the Board of Directors of ASCO (former member), ASTRO's Ethics Committee (chair), and the Women in Radiation Oncology Affinity Group (chair); membership on the Medical Advisory Board for Blue Cross Blue Shield Association; stock options for their advisory board role in Equity Quotient; and personal fees from the NIH, Doris Duke Charitable Foundation, and the Greenwall Foundation. FMK reports research grants from the ABC Global Alliance, Breast Cancer Now, Merck Serono WHO, MSD, Avon Cosmetics, the US Cancer Pain Relief Committee, and the Medical Research Council; consulting fees from Merck Serono and Instituto Tecnológico y de Estudios Superiores de Monterrey Mexico; and leadership roles for the Board of Directors of Women in Global Health (unpaid member), Tómatelo a Pecho (unpaid president and founder), the Mexican Health Foundation (unpaid Senior Economist), and the Board of Directors of the International Association for Hospice and Palliative Care (unpaid member). SAMcI reports grant funding from the NIHR, CRUK, and Breast Cancer Now; honoraria from Roche, MSD, AstraZeneca, Becton, Dickinson and Company; travel and conference support from Roche, Eli Lilly, and MSD; membership of advisory boards for Eli Lilly, MSD, Roche, and Novartis; and roles for the UK National Cancer Research Institute Breast Research Group (unpaid chair) and the Royal College of Surgeons Breast Surgical Specialty Lead (unpaid). K-AP reports clinical trial funding from AstraZeneca (paid to institution) and unremunerated previous participation in AstraZeneca advisory boards. LR reports grants from the European Commission Horizon 2020 and the German Research Foundation and a role in the International Association for Hospice and Palliative Care (Chair of Board of Directors). MKT reports grants from Addenbrooke's Charitable Trust and CRUK. FA reports grants from Novartis, Pfizer, AstraZeneca, Eli Lilly, Daiichi Sankyo, and Roche and consulting fees from MedImmune, Gilead, Relay Therapeutics, and Guardant Health. JEA reports speaker honoraria from AstraZeneca, Pfizer, Novartis, and Eisai and conference travel support from AstraZeneca. ISB reports participation in the Roche advisory board for ESMO. JMB reports research grants from Breast Cancer Now, AstraZeneca, MSD, Puma Biotechnology, Clovis Oncology, Pfizer, Janssen-Cilag, Novartis, Eli Lilly, Roche, CRUK, and the NIHR. MAF is funded by a Conquer Cancer Breast Cancer Research Foundation Career Development Award for Diversity and Inclusion supported by the Breast Cancer Research Foundation and reports financial support from the WeShare project. AF reports consultancy work for Oxford Immune Algorithmics; grants from Addenbrooke's Charitable Trust and the Ann McLaren Building Preclinical Imaging Suite of the University of Cambridge; and travel support from the University of Cambridge. DIR reports support from the University of Chicago Center for Global Health. DN reports research support from Cepheid; a grant from the US National Cancer Institute; and an unpaid leadership role with the WHO Global Breast Cancer Initiative. WER reports grants from the Cambia Health Foundation, the Robert Wood Johnson Foundation, and the Rita and Alex Hillman Foundation; and book royalties from Springer Publishing and Jones & Bartlett Learning. JR reports funding from the NIHR and support from AstraZeneca for attendance at a teaching event. DS reports a leadership role at the Jamaica Cancer Care and Research Institute (co-director). HS reports membership of the Breast Cancer Now Tissue Bank Advisory Board and voluntary patient membership of the Independent Cancer Patients' Voice charity; an honorarium from the CRUK Precision Grand Challenge; and support for travel expenses from Breast Cancer Now, CRUK, the Association of Breast Surgeons UK, and Breast International Group. IV-L reports grants from Resilience; consulting fees from Novartis, AstraZeneca, and Amgen; payment or honoraria for lectures and presentations from Novartis, Sandoz, Amgen, AstraZeneca, and Pfizer; and support for travel and attending meetings from Novartis. CV-G reports grants from AstraZeneca and Roche; consulting fees from Roche, Novartis, Pfizer, and Eli Lilly; honoraria from Roche, Myriad Genetics, and Novartis; and support for attending meetings and travel from Roche, MSD Oncology, and Pfizer. All other authors declare no competing interests.

Background: The COVID-19 pandemic presents a significant challenge to professional responders in healthcare settings. This is reflected in the language used to describe the pandemic in the professional literature of the respective professions. The aim of this multidisciplinary study was to analyze the linguistic imagery in the relevant professional literature and to determine the identification of different professional groups with it and its emotional effects., Method: A list of 14 typical, widespread and differing imageries for COVID-19 in form of single sentences (e.g., "Until the pandemic is over, we can only run on sight.") were presented to 1,795 healthcare professionals in an online survey. The imageries had been extracted from a qualitative search in more than 3,500 international professional journals in medicine, psychology and theology. Ratings of agreement with these imageries and feelings about them were subjected to factor analysis., Results: Based on the list of imageries presented, it was possible to identify three factors for high/low agreement by experiences, and two factors for high/low induced feelings. Broad agreement emerged for imageries on "fight against the crisis" and "lessons learned from the crisis", while imageries on "acceptance of uncontrollability" tended to be rejected. Imageries of "challenges" tended to lead to a sense of empowerment among subjects, while imageries of "humility" tended to lead to a sense of helplessness., Conclusion: Based on the qualitative and subsequential quantitative analysis, several factors for imageries for the COVID-19 pandemic were identified that have been used in the literature. Agreement with imageries is mixed, as is the assessment of how helpful they are., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Baranowski, Blank, Maus, Tüttenberg, Matthias, Culmann, Radbruch, Richter and Geiser.)

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.