Background: Gratitude has sparked interest in the world of health. It is considered as a personality characteristic or as an emotion. However, little has been explored in the context of the interpersonal relationship of caring. An exploration in the context of end of life is ground-breaking. Objectives: This study analyses and reflects on the object of gratitude from the perspective of both the persons being cared for and the professionals providing health care. What are patients and their family members grateful for in palliative care? What is the reason for gratitude? What do these health professionals perceive when there is gratitude? These questions were answered considering the gratitude generated in health care encounters, not gratitude as personality trait. Methods: The phenomenological approach was used starting from lived clinical experiences. In the light of the dialogue between clinical experiences and philosophy, this study proposes an explanation of the 'real' or essential object of gratitude in palliative care. It was conducted within the context of palliative care. The study materials were manifestations of gratitude expressed or felt in clinical encounters and published in newspapers or shared in daily encounters. These were the basis for analysis and reflection and interdisciplinary dialogue. Findings: The analyses performed indicated healing or deep relief in serious diseases as objects of gratitude according to patients' perspective, and professional self-affirmation until the end according to the professionals' perspective. Conclusion: The two perspectives shared an important common fact, namely, the need to consider the persons in their entirety, and the importance of not losing sight of the value they have. This concept would characterize the nature of gratitude, its object being the 'objective good' for patients, family members, and palliative care professionals.

Abstract RESPACC was an Erasmus + funded project to develop a framework of core research competencies for palliative care (PC) clinicians and supporting education materials (http://www.studiipaliative.ro/projects/research-respacc/). The supporting materials included a self-assessment quiz to guide PC multidisciplinary team members on areas of research understanding that needed further development. The objective was to pilot the self-assessment quiz developed based on the research competency framework for PC clinical teams and test it for face validity and clarity. Methods: A pilot observational study was conducted to test the self-assessment quiz for face validity and clarity. The self-assessment quiz was developed between May-November 2021. It was structured to include questions about each of the competencies in the seven domains of the framework, using the examples. Items within the quiz were responded on a 5- points ordinal scale, with participants identifying their perceived competency as: Novice, Advanced Beginner, Competent, Proficient, Expert (each clearly defined). The quiz was developed in English and then translated into the national languages of partners (Greek, Romanian, Spanish). The quiz was piloted with Romanian PC professionals attending the National Palliative Care Conference. Questions about clarity of the quiz, suggestions for improvements were asked together with some demographic data about participants. Results: Multidisciplinary PC clinicians participated in the pilot testing (18 physicians, 4 nurses, 2 psychologists and 1 physiotherapist). Most (n=15) had less than one year of experience in PC. Participants identified themselves as: Novice (n=5), Advanced beginner (n=9), Competent (n=5), Proficient (n=3), Expert (n=3). All respondents answered all question without difficulties and considered the quiz to be clearly written, well structured and adequate. Conclusions: The self-assessment quiz is easy to use, and may be useful in helping members of PC teams assess their competencies and identify their research education needs. Keywords: pilot test, competency, research, palliative care https://www.paliatia.eu/new/wp-content/uploads/2023/05/Jurnalul-Paliatia_apr-2023_1-6.pdf

Background Palliative sedation involves the intentional lowering of consciousness at the end of life. It can be initiated to relieve a patient's burden caused by refractory symptoms at the end of life. The impact of palliative sedation needs to be clinically monitored to adjust the proper dose and regimen of sedative medication to ensure that patients are at ease and comfortable at the end of their lives. Although there is consensus among health care professionals and within guidelines that efficacy of palliative sedation needs to be closely monitored, there is no agreement about how, when, and by whom, this monitoring should be performed. The aim of this study is to evaluate the effects of palliative sedation by measuring the discomfort levels and sedation/agitation levels of the patients at regular timepoints. In addition, the clinical trajectories of those patients receiving palliative sedation will be monitored and recorded.Methods The study is an international prospective non-experimental observational multicentre study. Patients are recruited from in-patient palliative care settings in Belgium, Germany, Italy, Spain and the Netherlands. Adult patients with advanced cancer are monitored by using proxy observations of discomfort (DS-DAT) and depth of sedation/agitation levels (RASS-PAL) during palliative sedation. After the palliative sedation period, the care for the specific participant case is evaluated by one of the attending health care professionals and one relative via a questionnaire.Discussion This study will be the first international prospective multicenter study evaluating the clinical practice of palliative sedation including observations of discomfort levels and levels of sedation. It will provide valuable information about the practice of palliative sedation in European countries in terminally ill cancer patients. Results from this study will facilitate the formulation of recommendations for clinical practice on how to improve monitoring and comfort in patients receiving palliative sedation.

Background: Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries. Methods: This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis. Discussion: The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.

En este contexto, Erasmus + ha promovido un proyecto (RESPACC 2020-1-R001-KA202-080128) en el que participan cuatro países: Rumanía (Hospice Casa Sperantei y la Universidad de Transilvania), España (Universidad de Navarra), Grecia (Hospice Galillee) y Bélgica (European Association for Palliative Care EAPC). El proyecto ¿Competencias de Investigación para Clínicos de Cuidados Paliativos¿ (RESPACC) hace referencia a Research (Investigación) Expertise (Experiencia), Selfdevelopment (Autodesarrollo) Palliative Care (Cuidados Paliativos), Attitude (Actitud), Communication (Comunicación) y Competence (Competencia).

Objectives: To explore the expressions of gratitude (EoG) received from patients and relatives and their influence on palliative care professionals (PCPs). Methods: A national online survey was sent to a representative of PCPs of each service listed in the national directory of palliative care (PC) services (n=272) (ie, hospital PC support team, hospice, paediatrics, etc). The questionnaire was pilot tested with experts. It comprised three sections: the overall perspective of receiving gratitude in the service, the personal experience of its influence and sociodemographic questions. A mailing schedule was designed to enhance the response rate. Results: 186 representatives from all over Spain completed the questionnaire (68% response rate). 79% of service representatives reported that they almost always received EoG. These came mainly from families (93%). These EoG were very often put on display (84%) and shared with other health professionals (HPs) involved in care (45%). EoG evoked positive feelings in the team members. Based on their experience, respondents attributed different functions to these EoG: increased professional satisfaction (89%), a source of support in difficult times (89%), mood improvement, encouragement to continue and rewards for effort (88%). Services, where gratitude was more frequently received, were associated with PCPs who more frequently reported being proud of their work (p=0.039, Pearson's correlation test). Conclusions: Gratitude from patients and relatives was frequent and significant to those who work in PC. HPs considered that EoG offer multiple beneficial effects and also a protective role in their practice against distress and an increase in resilience skills.

Providing palliative care can be both challenging and rewarding. It involves emotionally demanding work and yet research shows that burnout is lower than in other fields of healthcare. Spontaneous expressions of gratitude from patients and family members are not uncommon and are highly valued. This study explored the experience of Spanish palliative professionals who received expressions of gratitude from their patients and families. A phenomenological approach was used to better understand the role of receiving gratitude in participants¿ lives. Interviews were transcribed verbatim and a phenomenological approach to analysis was undertaken using macro-thematic and micro-thematic reflection. Two team members independently engaged in this reflection with an inductive approach. The analysis was shared and discussed at periodic meetings to identify the key themes and sub-themes of the gratitude experience. Ten palliative professionals were interviewed. Participants engaged in a process of recognizing, internalizing and treasuring the expressions of gratitude which they then used for reflection and growth. These expressions were a powerful and deeply meaningful resource that the palliative professionals revisited over time. Receiving expressions of gratitude invited a stronger sense of the value of one¿s self and one¿s work that was motivational and protective, particularly during challenging times.

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

Introducirse en el mundo laboral es costoso y uno de los primeros obstáculos es el déficit competencial que, en ocasiones, presentan los universitarios. Para subsanar el exceso de una teoría descontextualizada, el EEES (Espacio Europeo de Educación Superior) ha auspiciado un cambio metodológico que fomenta una docencia más práctica, ya que el aprendizaje más efectivo es activo y está conectado con la experiencia. De este modo, la enseñanza universitaria se enfoca, entre otros aspectos, en la consecución de resultados de aprendizaje en forma de competencias asociadas al mercado laboral. En este contexto se están ensayando en la universidad [española] metodologías más prácticas y aplicadas, entre ellas, el Aprendizaje-Servicio. El objetivo de este trabajo es conocer si para los empleadores participantes en nuestro estudio, los universitarios que participan en actividades de Aprendizaje-Servicio desarrollan el perfil competencial que buscan, haciéndoles candidatos más atractivos en los procesos de selección, mejorando en consecuencia su empleabilidad. Para ello, se desarrolló una investigación cualitativa genérica. Se realizaron tres grupos focales en los que participaron por muestreo intencional trece empleadores de egresados de distintas facultades de la universidad, pertenecientes a distintos sectores. La guía temática incluía preguntas sobre las competencias más demandadas por los empleadores, el Aprendizaje-Servicio y su influencia en el perfil profesional.

OBJECTIVE:Cultural backgrounds and values have a decisive impact on the phenomenon of the wish to die (WTD), and examination of this in Mediterranean countries is in its early stages. The objectives of this study were to establish the prevalence of WTD and to characterise this phenomenon in our cultural context. METHODS:A cross-sectional study with consecutive advanced inpatients was conducted. Data about WTD (Assessing Frequency & Extent of Desire to Die (AFFED) interview) and anxiety and depression (Edmonton Symptom Assessment System-revised (ESAS-r)) were collected through two face-to-face clinical encounters. Data were analysed with descriptive statistics, ¿2 and analysis of variance. RESULTS:201 patients participated and 165 (82%) completed both interviews. Prevalence of WTD was 18% (36/201) in the first interview and 16% (26/165) in the second interview (p=0.25). After the first interview, no changes in depression (p=0.60) or anxiety (p=0.90) were detected. The AFFED shows different experiences within WTD: 11% of patients reported a sporadic experience, while 7% described a persistent experience. Thinking about hastening death (HD) appeared in 8 (22%) out of 36 patients with WTD: 5 (14%) out of 36 patients considered this hypothetically but would never take action, while 3 (8%) out of 36 patients had a more structured idea about HD. In this study, no relation was detected between HD and frequency of the appearance of WTD (p=0.12). CONCLUSIONS:One in five patients had WTD. Our findings suggest the existence of different experiences within the same phenomenon, defined according to frequency of appearance and intention to hasten death. A linguistically grounded model is proposed, differentiating the experiences of the 'wish' or 'desire' to die, with or without HD ideation.

SECCIÓN 1: LOS CUIDADOS PALIATIVOS Y LA GRATITUD ........................................ Capítulo I: La gratitud en cuidados paliativos (Carlos Centeno) ................................ Capítulo II: Matices de la gratitud en cuidados paliativos (María Arantzamendi) ..... Capítulo III: Cultura, gratitud y cuidados paliativos. Una reflexión personal (José Pereira) ............................................................................................................... SECCIÓN 2: LA CONCEPTUALIZACIÓN DE LA GRATITUD .......................................... Capítulo IV: La gratitud y su etimología (Alicia Hernando) ....................................... Capítulo V: ¿Qué tipo de vivencia es el agradecimiento? (Josef Seifert) ................... Capítulo VI: Agradecimiento: la posibilidad de reconocer el bien (Mariana Riojas) .. SECCIÓN 3: EL OBJETO DE LA GRATITUD ............................................................... Capítulo VII: Sobre el objeto del agradecimiento (Mariano Crespo) ......................... Capítulo VIII: Gratitud, don y cuidado interpersonal (Anthony Steinbock) ............... Capítulo IX: La gratitud en cuidados paliativos: qué se agradece. Una aproximación clínica y vivencial. (Enric Benito) ..................................................................... SECCIÓN 4: EL SUJETO DE LA GRATITUD ................................................................ Capítulo X: Factores psicológicos favorecedores o inhibidores de la gratitud. (Sergio Sánchez-Migallón) ......................................................................................... Capítulo XI: Obstáculos y facilitadores del agradecimiento. (Paulina Taboada) ........ Capítulo XII: La experiencia de la gratitud de un clínico junto a las personas al final de su vida (Julio Gómez) ................................................................................. 8 Gratitud y cuidados paliativos SECCIÓN 5: EL IMPACTO DEL AGRADECIMIENTO .................................................... Capítulo XIV: El impacto del agradecimiento (María Aparicio) ................................. Capítulo XV: La cultura de la gratitud en cuanto cuidado de la vulnerabilidad humana (Luca Valera) .............................................................................................. Capítulo XVI: Gratitud en los pacientes de cuidados paliativos y sus familiares: ¿dónde estamos ahora? (Mathieu Bernard) ............................................................ REFERENCIAS BIBLIOGRÁFICAS

Textbook of Palliative Care is a comprehensive, clinically relevant and state-of-the art book, aimed at advancing palliative care as a science, a clinical practice and as an art. Palliative care has been part of healthcare for over fifty years but we still find ourselves having to explain its nature and practice to colleagues and to the public in general. Healthcare education and training has been slow to recognize the vital importance of ensuring that all practitioners have a good understanding of what is involved in the care of people with serious or advanced illnesses and their families. However, the science of palliative care is advancing and our understanding concerning many aspects of palliative care is developing rapidly. The book is divided into separate sections for ease of use. Over 100 chapters written by experts in their given fields provide up-to-date information on a wide range of topics of relevance to those providing care towards the end of life no matter what the disease may be. We present a global perspective on contemporary and classic issues in palliative care with authors from a wide range of disciplines involved in this essential aspect of care. The Textbook includes sections addressing aspects such as symptom management and care provision, organization of care in different settings, care in specific disease groups, palliative care emergencies, ethics, public health approaches and research in palliative care.