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Palliative care clinicians enhance the illness experiences of patients and their families through building therapeutic relationships. Many psychological concepts underlie a clinician's approach to a specific patient. Through high-yield tips, this article highlights ten selected psychological elements that palliative care clinicians often use to support patients. As we all (both clinicians and patients) bring our own histories and unique biographies to the work of palliative care, a more explicit focus on the psychological aspects of this work can enhance our own experience and efficacy as providers. With a thoughtful focus on the psychological aspects of how we engage with patients, palliative care clinicians can offer a more meaningful therapeutic encounter. [ABSTRACT FROM AUTHOR]

1. Describe how psychological concepts, such as formulation and countertransference, can inform and enrich therapeutic efficacy in palliative care. 2. Practice the application of concrete psychologically-informed strategies and techniques to elevate routine palliative care practice. This interactive workshop introduces practitioners to several high-yield psychological concepts that can be incorporated into daily palliative care practice. Participants will develop working knowledge in creating a formulation of a patient's and family's unique psychological composition, which guides interactions more effectively with patients and referring clinicians. This interprofessional workshop will employ diverse clinical vignettes to raise our self-awareness of countertransference (i.e. emotions and reactions toward our patients) to enhance inclusivity and sustainability of practice. Finally, participants will acquire several clinical techniques of therapeutic presence and using one's own self as a therapeutic tool. [ABSTRACT FROM AUTHOR]

1. List 5 mental health competencies in which they already have expertise. 2. Identify 2 potential sources for further learning when a physician has a relative lack of expertise in a mental health competency (i.e. a licensed clinical social worker on their existing clinical team, journal articles in the palliative medicine or mental health literature, a consult-liaison psychiatrist with shared patient populations, etc). Hospice and palliative medicine physicians aim to support patients' whole-person quality of life, but our training emphasizes physical symptoms. We used an expert panel to develop primary mental health competencies for palliative care physicians, which will undergo iterative rounds of voting from a larger stakeholder cohort for prioritization. Psychological and psychiatric care is a core domain of palliative care. Palliative care clinicians manage common psychological and psychiatric symptoms and use concepts from mental health in serious illness communication. Despite growing interest in the mental health aspects of palliative care, recent data demonstrate that training in mental health for hospice and palliative medicine (HPM) physician fellows is variable. Few guidelines exist to define scope of practice and educational goals. The lack of operationalized criteria to guide training of HPM physicians is a barrier to upskilling the HPM workforce and meeting the mental health needs of patients with serious illness. To delineate preliminary HPM physician competencies in the psychological and psychiatric aspects of palliative care. We used a purposive sampling strategy to convene a cohort of interdisciplinary experts in various domains of mental health and palliative care including experts in palliative care social work, psychology, bereavement, geriatric psychiatry, psycho-oncology, addiction medicine, and medical education. Our expert panel collaboratively created a framework and proposed competencies, which were then iteratively refined by the first and senior authors (LP, DS) through individual meetings with each group member. Leveraging the input of the expert panel, an organizational framework was developed. Competencies were organized into (A) psychological foundations of serious illness (18 competencies and sub-competencies), (B) diagnosis and management of mental health disorders in serious illness (44 competencies and sub-competencies), and (C) systems-based practice (8 competencies and sub-competencies). These proposed competencies will undergo vetting by a larger stakeholder cohort to identify those deemed most important. We present initial HPM physician competencies in psychological and psychiatric care, a highly significant but under-delineated domain of HPM practice. These competencies will undergo further vetting to identify priorities for developing educational content and to help define scope of practice. Workforce / Career Development / Scientific Research [ABSTRACT FROM AUTHOR]

Palliative care clinicians provide psychological support throughout their patients' journeys with illness. Throughout our series exploring the psychological elements of palliative care (PEPC), we suggested that the quality of care is enhanced when clinicians have a deeper understanding of patients' psychological experience of serious illness. Palliative care clinicians are uniquely poised to offer patients a grounded, boundaried, and uplifting relationship to chart their own course through a life-altering or terminal illness. This final installment of our series on PEPC has two aims. First, to integrate PEPC into a comfort-focused or hospice setting and, second, to demonstrate how the core psychological concepts previously explored in the series manifest during the dying process. These aspects include frame/formulation, attachment, attunement, transference/countertransference, the holding environment, and clinician wellness. [ABSTRACT FROM AUTHOR]

Palliative care supports referring colleagues in multiples ways. This support to referring colleagues is not often explored in the literature, yet the psychological concept that best describes it is the holding environment. The holding environment is the relational space palliative care offers referring clinicians for processing emotions and information. Using the case of Gloria, a patient living with cancer, this article discusses ways palliative care creates a holding environment for her referring oncologist, Dr. Ko. As palliative care clinicians, we create this relational space for referring clinicians when we change the dynamic, accompany the clinician, recognize challenges, establish expectations, and share a clinical second look. This article is the sixth in a series exploring the psychological elements of palliative care. [ABSTRACT FROM AUTHOR]

Attunement, the process of understanding and responding to another's spoken and unspoken needs, is a fundamental concept of human development and the basis of meaningful relationships. To specialize the concept of attunement for palliative care, this article introduces clinical attunement. This term accounts for how palliative care clinicians must repeatedly balance patients' readiness to talk about the future with the cadence of the illness and need for medical decision making. Using the case of Gloria, an example patient living with cancer, this article discusses three skills to foster clinical attunement: asking, repairing disconnections, and offering containment. It is the fourth in a series exploring the psychological elements of palliative care. [ABSTRACT FROM AUTHOR]

Establishing an empathic clinical relationship is a cornerstone of high-quality palliative care. More than simply approaching patients with a pleasant affect or "being nice," we propose that skilled clinicians routinely employ distinct psychological elements when creating effective bonds with seriously ill patients and their families. Palliative care involvement has been shown to improve a variety of outcomes for patients with serious cancer, and yet the components of this salutary effect are still becoming known in the literature. Many believe that a successful interpersonal relationship is the essential factor. In this article, we will apply the psychological constructs of transference and countertransference to the unique arena of palliative care communication. Although most palliative care clinicians are not mental health clinicians and have not received training or certification in psychotherapeutic techniques, there are elements from these frameworks that may be advantageously applied. We will draw on sources from psychology and psychiatry to explore the in-between spaces of clinical encounter. Using the case of Gloria, a patient living with cancer drawn from our clinical experience, we will offer adapted definitions and novel applications of these psychological concepts. Branching from the theory to everyday practice, we will then offer practical suggestions to guide the palliative care clinician in recognizing and managing strong countertransference reactions. This article is the third installment of a series on the psychological elements of palliative care. [ABSTRACT FROM AUTHOR]

Palliative care has been shown to help patients live well with serious illness, but the specific psychological factors that contribute to this benefit remain investigational. Although support of patient coping has emerged as a likely factor, it is unclear how palliative care helps patients to cope with serious illness. The therapeutic relationship has been proposed as a key element in beneficial patient outcomes, possibly undergirding effective patient and family coping. Understanding the distress of our patients with psychological depth requires the input of varied clinicians and thinkers. The complex conceptual model we developed draws upon the contributions of medicine, nursing, psychology, spiritual care, and social work disciplines. To elucidate these issues, we convened an interdisciplinary seminar of content experts to explore the psychological components of palliative care practice. "Healing Beyond the Cure: Exploring the Psychodynamic Aspects of Palliative Care" was held in May 2019 at Harvard University's Radcliffe Institute for Advanced Study. Over two days, the working group explored these essential elements of successful palliative care encounters through lecture and open discussion. This special report describes the key psychological aspects of palliative care that we believe underlie optimal adaptive coping in palliative care patients. We also outline key areas for further development in palliative care research, education, and clinical practice. The discussion held at this meeting became the basis for a planned series of articles on the psychological elements of palliative care that will be published in the Journal of Palliative Medicine on a monthly basis during the fall and winter of 2021–2022. [ABSTRACT FROM AUTHOR]

Relationships of care for those facing illness are inherent to the practice of medicine. Palliative care provides interpersonal space to patients and families that helps them face serious illness and dying. We consider therapeutic holding uniquely critical in palliative care but see it as applying in varied forms throughout medicine. Its optimization requires a deep understanding of its nature. We use theoretical foundations of psychodynamic therapy, which uses the therapeutic relationship as its sole intervention, to identify the key elements of palliative care's therapeutic holding. We draw together six major concepts to do so. Using a fairly typical case, we illustrate how a palliative care team that included a psychodynamic therapist created therapeutic holding. This article came as part of a discussion group about psychodynamic cases involving serious illness and evolved in discussion with the rest of the authors. Northwestern's Institutional Review Board (IRB) exempted this project. This case is anonymized; sociodemographic and specific illustrations are changed. This case exemplifies how psychodynamic theory discerns and describes elements of palliative care's therapeutic holding. The case further illuminates the important place of therapeutic holding in effective palliative care and shows how psychodynamic therapy can help. We urge further research on therapeutic holding in palliative care. [ABSTRACT FROM AUTHOR]

This is the second article in the psychological elements of palliative care (PEPC) series. This series focuses on how key concepts from psychotherapy can be used in the context of palliative care to improve communication and fine tune palliative care interventions. In this article, we introduce two foundational concepts: frame and formulation. The frame is the context in which care is delivered; it includes concrete aspects of clinical care such as where it takes place, for how long, and with what frequency. It also includes the conceptual aspects of care, including the specific roles of the clinician and the patient, emergency contingencies, and the extent to which emotion is invited within the clinical encounter. Defining and discussing the frame with patients are especially important in palliative care because of the strong emotions that arise when talking about serious illness and because many patients may not be familiar with palliative care before they are in care. Formulation is the process by which we make judgment-neutral psychological hypotheses to understand the feelings and behaviors of our patients. It is an ongoing, dynamic process whereby as we learn more about our patients, we integrate that data to improve our explanatory model of who they are. This helps us tailor our interventions to meet their unique needs and respect their life experiences, aptitudes, and vulnerabilities. Both concepts are foundational PEPC; understanding them will prepare readers to continue to the next four articles in the series. [ABSTRACT FROM AUTHOR]

Outcomes: 1. Upon completion, participants will be able to define psychodynamic concepts and describe the benefits of these principles for palliative medicine clinicians reflecting on cases at an interdisciplinary team meeting 2. Upon completion, participants will be able to identify strategies to enrich palliative care clinician clinical approaches and plans of care addressing psychosocial needs and concerns The interdisciplinary team (IDT) meeting is a weekly centerpiece for many palliative care groups and offers clinical and interpersonal support for complex patient care experiences. While there is substantial variability in location, duration, session components, and attendance, most palliative care teams use the IDT meeting to build community, create space for reflection, and provide high-quality clinical care through interdisciplinary inquiry. Coming from a rich intellectual tradition, the psychodynamic model considers the conscious and unconscious forces of the mind that interact to drive our feelings and behaviors. These concepts are particularly high-yield in emotionally charged encounters with seriously ill patients and their families. From our training in different disciplines within mental health, we find that applying concepts from the psychodynamic tradition can deepen the IDT encounter and add nuance to discussions of psychosocially complex patients and families. The entire structure of this session is a simulated IDT to demonstrate a psychodynamically informed case discussion. One clinician will present a typical case from inpatient palliative care consultation and two interdisciplinary colleagues will ask questions and offer suggestions based on the psychodynamic principles of frame, formulation, and countertransference. Prior to beginning the simulation, participants will break into small groups according to their interest in the three psychodynamic principles and engage with the simulation according to their chosen concept. The simulation will be punctuated by frequent pauses to explicate and apply the psychodynamic principles, while engaging audience participation. Both presenters and participants will be empowered to call a "time out" and "time in" to pause the simulation to discuss the concepts and their application. Through understanding the application of psychodynamic principles, participants will gain new psychologically informed knowledge and tools for IDT meetings bolstering care for patients and families. [ABSTRACT FROM AUTHOR]

This is the seventh entry in the Psychological Elements of Palliative Care (PEPC) series. Previous articles have focused on the psychological elements of the care we provide patients and the relationships we build with our referring clinician colleagues. In this entry, we focus on how the PEPC also impact clinician well being. The PEPC are bidirectional: we impact patients, but patients also impact us. The reactions that we have to patients and the boundaries we set around the care we provide are two examples of psychological factors of care that can influence our well being. Creating spaces to explore and reflect on the psychological impact of the clinical care we provide is a key component of wellness. Such spaces vary in their configuration, but all share the opportunity to self-reflect and to experience emotional validation, normalization, and reality testing from peers or mentors. In mental health training, clinical supervision is one common format for creating such a space. While this can be replicated in the palliative care setting, other strategies include integrating a psychological orientation into interdisciplinary team meetings, creating peer support or process groups, and creating small groups within teams for longitudinal self-reflection. [ABSTRACT FROM AUTHOR]

This is the fifth article in the psychological elements of palliative care series. This series focuses on how key concepts from psychotherapy can be used in the context of palliative care to improve communication and fine tune palliative care interventions. In this article, we discuss attachment—the system by which people form bonds in relationships. The different styles that people have in navigating relationships such as clinician-patient relationships develop from early life onward. Attachment styles are not pathological. But they are helpful to understand because they are a relatively stable factor that impacts how people relate to caregivers like clinicians. Our patients all express unique relational needs to us; some of our patients need closeness and reassurance to feel comfortable, others value independence and space. These needs are highly significant to palliative care clinicians; they inflect our patients' goals of care and values, they modulate our patients' psychosocial needs, and they elucidate the ways our patients respond to a range of therapeutic interventions. Understanding attachment gives us a window into these individual care needs and empowers us to tailor the care we provide for a wide range of patients. [ABSTRACT FROM AUTHOR]