Why we need more poetry in palliative care

Designing and Delivering a Poetry Workshop for Clinician Well-Being During the COVID-19 Pandemic: A Case Study

CONTEXT

Facilitated poetry writing workshops are used in healthcare settings as a therapeutic approach to address stressful factors that negatively influence clinician well-being. However, owing to the novelty of this intervention and a tendency to combine poetry with other types of narrative-based techniques, proponents of poetic medicine are calling for harmonization across programs in the US. This would facilitate the study of poetry in medicine and the multiple facets of well-being it is said to promote. To address these points, we partnered with a well-established poetry center to develop and study a facilitated poetry writing workshop program for palliative care and emergency medicine clinicians during the COVID-19 pandemic.

OBJECTIVES

Our qualitative aim was to describe how the workshop provided a creative outlet for the sharing and processing of clinician experiences.

METHODS

We conducted a multiple-case study of six workshop sessions using transcripts, model poems, writing prompts, and participant-created poems to describe the program's structure and processes.

RESULTS

Our workshop contained the core components of reading, writing, and reflection; however, our program was unique in its inclusion of a website and a prewriting component. The facilitator's instruction on and fostering the use of poetic technique coupled with website interaction were key promoters of participant engagement with their peers in the processing of complex experiences and related emotions.

CONCLUSION

Healthcare systems seeking to incorporate poetry into their wellness programming may build upon our findings to create flexible workshops suited to their clinician audience and program intent.

The Palliative Arts: Envisioning a New Paradigm in Palliative Care

A growing body of evidence supports the effectiveness of arts-based interventions in nurturing human connection, healing, and reflection-for patients living with illness, their families, and their health care communities. Thus, we propose that these interventions, what we call the Palliative Arts-just as much as science-should be systematically integrated in clinical education, practice, research, wellness, leadership, and advocacy to impact person-centered outcomes. Our interprofessional team describes a variety of arts-based programming that its authors are leading to highlight the breadth of existing Palliative Arts work and point to future horizons for its integration in health care education and clinical settings. We propose that the Palliative Arts can inform a new paradigm, one with the potential to foster person-centered innovation and meaningful change in the field of palliative care-and health care at large.

Narrative Medicine in Hospice and Palliative Care: A Longitudinal Fellowship Curriculum Pilot

INTRODUCTION

Growing evidence suggests that clinician exposure to narrative medicine (NM) may help bolster resilience and mitigate burnout. The value of formal longitudinal training in NM for hospice and palliative medicine (HPM) trainees remains understudied.

METHODS

A 1-year longitudinal NM curriculum for HPM fellows was pilot-tested for feasibility, acceptability, and exploratory impact. Six monthly 45-minute sessions included reading literature, reflective writing, and sharing creative work. Quantitative and qualitative data were collected through a pre-intervention survey and post-intervention survey administered immediately upon completion of the curriculum. Longitudinal impact was assessed with a post-intervention survey administered three months after completion of the curriculum.

RESULTS

All HPM fellows (n = 6) attended at least 5/6 sessions during the 1-year pilot, suggesting intervention feasibility. Participant engagement and self-reported comfort with NM exercises supported intervention acceptability. Post-intervention, participants described the positive influence of NM practice on their clinical practice and stated an intention to integrate NM skills in their future HPM careers. Three months following the intervention, participants had a sustained increase in their comfort level with NM. All participants felt that the NM sessions had been relevant to their life as HPM fellows and anticipated using NM moving forward in their practice of HPM.

DISCUSSION

This novel NM curriculum was feasible and acceptable to implement in a 1-year HPM fellowship. Longitudinal impact showed sustained increase in trainee comfort and interest in using NM in their future clinical practice.

Writing to Keep on Living: A Systematic Review and Meta-Analysis on Creative Writing Therapy for the Management of Depression and Suicidal Ideation

PURPOSE OF REVIEW

The purpose of this review and meta-analysis was to explore the effectiveness of creative writing therapies for the management of depression and suicidal ideation.

RECENT FINDINGS

Twenty one of the 31 reviewed studies showed that creative writing significantly improved depressive symptoms, while five studies suggested improvement in other symptoms. The results of meta-analyses showed that narrative writing significantly reduced depression compared to those in neutral writing or treatment as usual condition in both post intervention and follow-up. However, the number of studies exploring the effects of creative writing in suicidal ideation was too low to perform a meta-analysis. A structured and well-targeted intervention using creative writing could have beneficial results for the management of depressive symptoms. More studies are needed to explore the potential benefits of creative writing for reducing suicidal ideation.

The Lawlessness of Loss: Poetry and Autoethnographic Writing as Therapy in Grief and Loss

This study seeks to locate and evaluate 'poetry therapy' as a form of therapeutic method for use by practitioners of humanistic psychotherapy especially when used in responding to the traumas associated with grief and loss. Following an initial survey of the literature, the study will explore some examples of the use of poetry therapy for grief, with an especial qualitative focus upon the insights to be gained from first-hand autoethnographic accounts. The study undertakes a literature review which also includes some consideration of peer-reviewed autoethnographic explorations authored by theorists and practitioners of psychotherapy in order to identify what additional insights, if any, may be gained from accessing these personal accounts of process. In particular, the humanist perspective upon grief should be tempered with pragmatism so as to avoid regarding poetry as a reductive sentimentalising of trauma: encountering loss may be seen as experiencing subjection to a 'lawless' world. The study confirms the use of poetry therapy and autoethnographic writing has significant utility and potential, whilst recognising the challenges for empirical confirmation, the need for practitioners to be sensitive to the nuances of the source materials and the subtlety of appropriate application for different client perspectives and groups.

Utilizing Poetry as Spiritual Care for Hospital Staff

This personal reflection emphasizes the potential benefits of poetry for interfaith spiritual and pastoral support of medical professionals. Details are provided for the implementation of several successful practices, including an Intensive Care Unit Poetry Basket, Portable Poetry with Aromatherapy Towelette Hand Blessings, and Presenting Poems to Nurse Practice Council. The references include the poetry used in the spiritual care activities and the author also provided a helpful "Further Resources" section.

Creating critical palliative hypnotic adjustments: temporality, hope, and meaning

When cure is not possible, suffering often takes form as pain and distressing symptoms, death anxiety, existential distress, and meaninglessness. This paper describes important elements connecting palliative care principles with hypnotic approaches designed to provide support, palliate symptoms, foster hope, and address existential and spiritual distress. We offer a developmental process for and examples of hypnotic suggestions customized to simultaneously ameliorate physical symptoms and address profound distress arising from physical, social, psychological, existential, and spiritual challenges commonly encountered in terminal illness. This process necessarily requires use of the patient's vernacular to hypnotically deepen inwardly focused attention in order to explore and access internal resources, reframe negative automatic thoughts, and create positive meanings for experiences that disinvite suffering. Effective delivery utilizes cognitive tools such as clinical and scientific principles, artistic forms such as poetry and haiku, and a thorough assessment of needs. This approach strategically addresses an overarching dimension of temporality through suggestions that sequentially address multiple sources of suffering that are layered throughout the various dimensions of self. This requires focus and presence in the present moment; it ultimately fosters a therapeutic relationship that can safely hold past painful experience as helpful new meanings emerge that build resiliency for that experience. This work benefits from inwardly focused concentration and a holding environment to identify and access helpful inner resources, which include an increasingly malleable relationship with temporal memories.

Nursing interventions in palliative care in the intensive care unit: A systematic review

CONTEXT

Patients in palliative care are found in different places where care is provided, including the intensive care environment with important role of the nursing staff.

OBJECTIVE

The aim of this systematic review was to answer the following question: which nursing interventions are aimed to the palliative care patients who are in the intensive care unit (ICU).

DATA SOURCES

US National Library of Medicine (PUBMED), Virtual Health Library (BVS), SciELO, The Cochrane Library (Cochrane) and Lilacs databases were used.

DATA EXTRACTION

After applying inclusion and exclusion criteria in accordance with the PRISMA method, a total of 36 entries published between 2010 and 2020 were used.

DATA ANALYSIS

The records extracted were analyzed from a qualitative approach, so no statistical analysis was carried out.

RESULTS

The findings demonstrated that the interventions that focus on promoting the patient's autonomy and respect their needs on ICU involves effective communication, promoting shared decision with patient and family, individualize care for each patient including the family on the daily care and decisions, maintaining basic nursing care as hygiene and comfort and encouraging self-care, as well as the involvement of nursing palliative care specialists the care is important. Other interventions included promoting a continuing education program for the nursing staff and other professionals involved in caring for patients in palliative care at ICU.

CONCLUSION

This review highlighted the need for specific nursing interventions aimed at palliative care patients at ICU to promote patient autonomy and the focus on patient needs, always sharing decisions with the patient and family. However, it showed that there is a need for the continuous training of the nursing staff because factors such as the nurses' lack of technical-scientific knowledge and, concomitantly, the absence of a standardized and specific intervention model linked to a bureaucratic system, make it difficult to carry out a specialized care for this type of patient.

Using poetry to elicit internal medicine residents' perspectives on wellness

PURPOSE

To elicit internal medicine residents' perspectives on wellness through poetry writing, examining (1) response rates, (2) the tone/sentiment of their submissions and (3) the primary thematic content.

STUDY DESIGN

In academic year 2019-2020, a random sample of 88 residents from four internal medicine residency programmes was invited to participate in a year-long study of wellness. In December 2019, an open-ended prompt asked residents to write a poem reflecting on their well-being. Responses were inductively coded using content analysis techniques.

RESULTS

The response rate for the poetry prompt was 94%. The tone of the entries was most often neutral or contradictory (42%), followed by negative (33%) and positive (25%). There were three main themes: (1) Mindsets: most residents simply wanted to make it through their programme; (2) wellness influencers: the main wellness supporters were external to the programme such as vacationing and exercise; within hospitals, friendships with colleagues and boosted wellness and (3) scheduling/repetition: difficult schedules drained energy as did the monotony of administrative tasks.

CONCLUSIONS

Poetry appears to be an innovative and effective vehicle to elicit residents' perspectives without compromising response rate. Poetry survey techniques allow medical trainees to provide powerful messaging to leadership. Most of what is known about trainee wellness is derived from quantitative surveys. This study showed medicine trainees' willingness to engage in poetry and add richness and personal detail to highlight key drivers of wellness. Such information provides context and brings attention in a compelling manner to an important topic.

Poetry as a Healing Modality in Medicine: Current State and Common Structures for Implementation and Research

In healthcare institutions across the country, the role of poetry continues to emerge within the liminal spaces between the medical humanities and clinical care. While the field of narrative medicine is well-developed generally, formal review of the state of poetry as a healing modality is limited. Poetry in the medical humanities literature has often been described by its indefinability as much as by its impact on healing. The power of poetry in healthcare is thought to be multi-faceted and deserves to be explored further. Poetry can be medicine for both patient and clinician. "Poetic Medicine" is a modality that has been utilized for the healing of grief, loss, wounds of the psyche and spirit, and as a process for expanding resiliency in healthcare-applications that are particularly relevant to the practice of hospice and palliative medicine-for patient and clinician alike. While numerous approaches share common themes, current programs bringing poetry into healthcare have been operating largely in isolation from each other-with a lack of national consensus on definitions or structures of interventions. Such isolation is a major restriction to the study and growth of Poetic Medicine. While it is not known with certitude, the number of Poetic Medicine programs in healthcare in the United States appears to be growing. In this paper, we propose an initial framework to define the role and impact of poetry in healthcare and then describe two different, well-established Poetic Medicine programs in the United States.

Poetry and Medicine

Poetry and medicine are related in multiple ways, including historical interests in healing, defined broadly, through words. More contemporary scholarship explores how poems, which include insights into the human condition, can enlarge our understanding of health, illness, mortality, and health care, including issues of diversity. Anesthesiology and poetry have particular affinities due to their structures, timeframes, and rhythms. Patients, physicians, and health care workers can benefit in terms of well-being by access to reading, reflecting on, and writing poetry.

Impact of poetry-based ethics education on the moral sensitivity of nurses: A semi-experimental study

BACKGROUND

The nurses' moral sensitivity is the first step to make right decisions in difficult moral situations. Therefore, its education and promotion is highly important.

RESEARCH OBJECTIVES

The aim of this study was to examine the impact of poetry-based ethics education on the nurses' moral sensitivity.

RESEARCH DESIGN AND METHODS

This was a semi-experimental study. The sample consisted of 108 nurses who were selected by convenience sampling method and randomly assigned to three groups: intervention with poetry (G1), who read a booklet about values and principles of professional ethics as well as poems related to these subjects for 1 month; intervention without poetry (G2), who only read the booklet without any poetry; and control group (G3), who did not receive any intervention. Data were collected by Moral Sensitivity Questionnaire that was completed by the participants prior to the intervention (T1), 1-month post-intervention (T2), and 2-month post-intervention (T3). Data were analyzed by SPSS 16 software.

ETHICAL CONSIDERATIONS

This study was conducted in accord with the principles of research ethics and regulations relating to informed consent.

FINDINGS

Changes in the mean score of total moral sensitivity were significantly higher in G1 than in G2, which was in turn significantly higher than in G3. This increase was significant from T1 to T2 and T2 to T3 (P < 0.001). In all subscales, there was a significant difference between the mean changes in the three groups, so that in these subscales, the mean changes in G1 were significantly higher than those in other groups.

DISCUSSION

In line with previous studies, our results showed the effectiveness of poetry-based education on the transfer of educational concepts and increase moral sensitivity scores with greater lasting effect.

CONCLUSION

The use of interdisciplinary subjects such as poetry, due to its entertaining, fun, and lasting effect on minds; level of awareness; and actions of nurses, can help raise nursing moral sensitivity.

Discourse of Folk Literature on Healthy Ageing: A Case Study in Sindh, Pakistan during the Pandemic Crisis

Due to COVID-19 and the repeated imposition of lockdowns in Pakistan’s Sindh province, the life of senior citizens has become challenging. Given the scarcity of health care policies targeted at Sindh’s aged persons, the use of folk literature as therapy has increased to support against isolation, depression, and distress caused by COVID-19 and lockdowns. Although research on healthy ageing from medical and health care perspectives has been increasingly conducted in different contexts, there is a need to explore how folk literature can contribute to psychological, spiritual, and social wellbeing. Therefore, this research, conducted by collecting data from 15 aged participants through interviews and conversations, seeks to explore how senior Sindhis have used folk literature such as poetry, proverbs, and tales as therapy for their healing. Findings show that the participants’ use of Sindhi folk literature contributes to their psychological (eudemonic, evaluative, and hedonic) wellbeing, spiritual healing, and social satisfaction.

Emotional disclosure in palliative care: A scoping review of intervention characteristics and implementation factors

BACKGROUND

Emotional disclosure is the therapeutic expression of emotion. It holds potential as a means of providing psychological support. However, evidence of its efficacy in palliative settings is mixed. This may be due to variation in intervention characteristics.

AIM

To derive a greater understanding of the characteristics of potentially effective emotional disclosure-based interventions in palliative care by:(1) Developing a taxonomy of emotional disclosure-based interventions tested in people with advanced disease and(2) Mapping and linking objectives, outcomes, underlying mechanisms, and implementation factors.

DESIGN

A scoping review drawing on Intervention Component Analysis to combine evidence from studies' methods, results, and discussion sections.

DATA SOURCES

Six databases were searched to May 2020 including CINAHL, PsycINFO, and MEDLINE. Studies of emotional disclosure in adults with advanced disease were included. Study quality was appraised using an established tool.

RESULTS

Seven thousand seven hundred ninety-two unique records were screened, of which 25 primary studies were included. Intervention characteristics were grouped into classes within three domains: topic of disclosure, format, and dose. Evidence was not available to determine which, if any, of the characteristics is most effective. Thematic synthesis of evidence from methods and discussion sections identified factors to consider in tailoring an emotional disclosure-based intervention to this setting, including: population characteristics (e.g. time since diagnosis), providing a safe environment, and flexibility in format.

CONCLUSIONS

This review approach facilitated a clearer understanding of factors that may be key in developing emotional disclosure-based interventions for palliative populations. Intervention Component Analysis has potential for application elsewhere to help develop evidence-based interventions.

Effect of palliative care on the anxiety, depression and sleep quality in primary caregivers of elderly patients with terminal cancer

OBJECTIVE

To explore the effect of palliative care on the psychological well-being and sleep quality of the primary caregivers of elderly patients with terminal cancer.

METHODS

In this prospective study, a total of 102 elderly patients with terminal cancer and their primary caregivers were randomly divided into a study group and a control group of 51 patients each by a random number table. The control group was given routine end-of-life care and the study group was given palliative care. In this study, we compared adverse mood, sleep quality, psychological stress and satisfaction with care among primary caregivers before and after the intervention, as well as changes in patients' quality of life.

RESULTS

The Hamilton Anxiety Scale (HAMA), the Hamilton Depression Scale (HAMD), the Pittsburgh Sleep Quality Index (PSQI), and RSS scores of the primary caregiver were significantly lower in both groups after the intervention, and significantly lower in the study group (all P<0.05). The Generic Quality of Life Inventory-74 (GQOLI-74) scores were significantly higher in both groups after the intervention, and significantly higher in the study group (all P<0.05). In addition, the primary caregiver's satisfaction with care was significantly higher in the study group than that in the control group (96.08% vs. 82.35%, P<0.05).

CONCLUSION

Palliative care for patients with terminal cancer can be effective in alleviating the poor psychological well-being of the primary caregivers, improving their sleep quality as well as improving nursing satisfaction and patients' quality of life.

Implementation of a Multi-Modal Palliative Care Curriculum for Pediatric Residents

OBJECTIVES

To evaluate the feasibility and efficacy of a new multi-modal pediatric palliative care curriculum. We sought to determine the effect on comfort in palliative care, knowledge, and change in behavior by utilizing these skills with patients, and determine which modalities were most effective for residents.

STUDY DESIGN

25 pediatric residents were exposed to the 4-part curriculum. The modalities utilized in this curriculum included didactics, role-play, videos, case-discussion, small group activities, simulation, poetry and reflection.

RESULTS

The pediatric residents self-reported an increase in comfort and knowledge of the components of pediatric palliative care after this curriculum. In addition, 74% of residents were able to identify a patient experience in which a component of the palliative care curriculum was utilized directly in patient care. The effectiveness of techniques utilized in this multimodal curriculum varied; residents reported that the poetry and reflection components were less effective, as compared with the role-play, simulation and other active learning components.

CONCLUSIONS

Implementation of a multi-modal palliative care curriculum was effective in increasing knowledge in palliative care, comfort in breaking bad news, and caring for patients with palliative care needs. This can be translated into a change in behavior to utilize these new skills in the care of various patients in pediatrics. Among the various techniques used to teach this curriculum, residents reported that the techniques that most incorporated active learning and were directly applicable to the professional role of the resident were rated most valuable. This curriculum was well received, feasible and effective for pediatric residents.

A Look Back and a Path Forward: Poetry's Healing Power during the Pandemic

This discussion seeks to highlight the ability of poetry to combat loneliness, a growing public health problem with significant negative health outcomes that potentially impact millions of Americans. We argue that poetry can play a very relevant role and have an impact in medicine. Through a brief literature review of previous studies on poetry in medicine, we demonstrate that poetry can not only combat loneliness but can also play important roles in helping patients, physicians, and other healthcare professionals/providers. Because of the COVID-19 pandemic, we believe now is the perfect opportunity to utilize poetry because the benefits can be experienced even in solitude, which is why this is such a timely and pertinent issue today.

Storytelling and poetry in the time of coronavirus

The coronavirus crisis occurs at a time when many clinicians have already experienced burnout. One in three Irish doctors were suffering from burnout in the 2019 National Study of Wellbeing of Hospital Doctors in Ireland; rates are also high in Irish Psychiatry. We present a perspective on the use of narrative in medicine and recognise that storytelling, and the patient history are very much at the heart of medicine. Clinician storytelling, such as Schwartz Rounds and Balint group work, has very much come to the fore in Irish Psychiatry and in training. Projects such as MindReading have explored overlaps between clinicians, humanities experts and experts by experience. We give an overview of some approaches from the movement around narrative in medicine to bolster this. We explore why clinicians write as ways to support identification, catharsis and a way to process experiences. Clinicians and patients may also use literature and poetry to promote coping. The historical context and practical strategies are highlighted, particularly with reference to poetry use during the current crisis.

Emotional disclosure as a therapeutic intervention in palliative care: a scoping review protocol

INTRODUCTION

Emotional disclosure (ED) is a term used to describe the therapeutic expression of emotion. ED underlies a variety of therapies aimed at improving well-being for various populations, including people with palliative-stage disease and their family carers. Systematic reviews of ED-based psychotherapy have largely focused on expressive writing as a way of generating ED. However, heterogeneity in intervention format and outcome measures has made it difficult to analyse efficacy. There is also debate about the mechanisms proposed to explain the potential effects of ED.We present a scoping review protocol to develop a taxonomy of ED-based interventions to identify and categorise the spectrum of interventions that could be classified under the umbrella term of 'emotional disclosure' in the palliative care setting. By mapping these to associated treatment objectives, outcome measures and explanatory frameworks, the review will inform future efforts to design and evaluate ED-based therapies in this population.

METHODS AND ANALYSIS

The review will be guided by Arksey and O'Malley's five-stage scoping review framework and Levac's extension. The following electronic databases will be searched from database inception: CENTRAL, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science and MEDLINE. We will include peer-reviewed studies and reviews. We will also check grey literature, including clinical trial registers, conference proceedings and reference lists, as well as contacting researchers. Articles will be screened by at least two independent reviewers and data charted using an extraction form developed for this review. Results will be analysed thematically to create a taxonomy of interventions, outcome measures and theoretical frameworks.

ETHICS AND DISSEMINATION

This review does not require ethical approval as it is a secondary analysis of pre-existing, published data. The results will inform future research in the development of ED-based interventions and evaluation of their efficacy in the palliative care setting. We will disseminate findings through peer-reviewed journals.

Palliative Sedation for the Terminally Ill Patient

Palliative sedation (PS) is performed in the terminally ill patient to manage one or more refractory symptoms. Proportional PS, which means that drugs can be titrated to the minimum effective dose, is the form most widely used. From a quarter to a third of all terminally ill patients undergo PS, with a quarter of these requiring continuous deep sedation. The prevalence of PS varies according to the care setting and case mix. The most frequent refractory physical symptoms are delirium and dyspnea, but PS is also considered for existential suffering or psychological distress, which is an extremely difficult and delicate issue to deal with. Active consensus from the patient and advanced care planning is recommended for PS. The decision-making process concerning the continuation or withdrawal of other treatments is not the same as that used for PS. The practice differs totally from euthanasia in its intentions, procedures, and results. The most widely used drugs are midazolam and haloperidol for refractory delirium, but chlorpromazine and other neuroleptics are also effective. In conclusion, some patients experience refractory symptoms during the last hours or days of life and PS is a medical intervention aimed at managing this unbearable suffering. It does not have a detrimental effect on survival.