The Potential of Personalized Virtual Reality in Palliative Care: A Feasibility Trial

Experiences and perceptions of palliative care patients receiving virtual reality therapy: a meta-synthesis of qualitative studies

BACKGROUND

The combination of virtual reality (VR) and palliative care potentially represents a new opportunity for palliative care. Many previous studies have evaluated the application of VR therapy to patients with advanced disease receiving palliative care. However, patient-perspective reviews to comprehensively understand the actual experiences and feelings of patients and provide practical guidance for designing future studies are currently lacking. This review of qualitative evidence aimed to explore the experiences and perceptions of patients receiving VR therapy in palliative care.

METHODS

This study was conducted in accordance with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement guidelines. Ten databases, namely, PubMed, Web of Science, EBSCO, OVID MEDLINE, Scopus, John Wiley, ProQuest, CNKI, WANFANG DATA, and SinoMed, were searched, and qualitative and mixed studies from the establishment of each database to June 30, 2023 were included. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to assess the quality of the included studies. The data included in the literature were analyzed and integrated by "thematic synthesis" to formalize the identification and development of themes.

RESULTS

The nine selected studies altogether included 156 participants from seven hospice care facilities of different types and two oncology centers. Three key themes were identified: experiences of palliative care patients in VR therapy, the perceived value that palliative care patients gain in VR therapy, and perspectives of palliative care patients toward using VR therapy.

CONCLUSIONS

The patients' feedback covered discomfort caused by VR devices, good sense of experiences, and situations that affected the interactive experience. Some patients were unable to tolerate VR therapy or reported newer forms of discomfort. The findings indicated that VR therapy may be an effective approach to relieve patients' physical and psychological pain and help them gain self-awareness. Moreover, patients showed a preference for personalized VR therapy.

Virtual Reality for advanced cancer patients assisted at home: A randomized controlled interventional study

OBJECTIVE

Virtual Reality (VR) has been demonstrated to be an effective option for integrating psychological interventions in different therapeutic settings. This randomized controlled interventional study aims to assess the effects of VR, compared to tablet controlled intervention, on anxiety, depression, pain, and short-term psychophysical symptoms in advanced cancer patients assisted at home.

METHODS

Participants were provided with a VR headset or a tablet (TAB) for 4 days. On the first and last day, anxiety and depression were measured by Hospital Anxiety and Depression Scale and pain by Brief Pain Inventory. Before and after each VR and tablet session, symptoms were collected by the Edmonton Symptom Assessment Scale (ESAS).

RESULTS

Fifty-three patients (27 VR vs. 26 TAB) completed the study. Anxiety significantly decreased in the VR group after the 4-day intervention. The analysis of ESAS showed a significant improvement in pain (p = 0.013), tiredness (p < 0.001), and anxiety (p = 0.013) for TAB group, and a significant reduction in tiredness (p < 0.001) in the VR group.

CONCLUSIONS

Technological and user-friendly tools, such as VR and tablets, might be integrated with traditional psychological interventions to improve anxiety and cancer-related short-term symptoms. Further studies are needed to better consolidate the possible beneficial effects of VR.

Effectiveness of Virtual Reality Technology in Symptom Management of Patients at the end of life: A Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this review was to explore the effectiveness of virtual reality (VR) technology in symptom management of patients at the end of life.

DESIGN

This is a systematic review and meta-analysis, which has been registered on PROSPERO (CRD42022344679).

SETTING AND PARTICIPANTS

Patients at the end of life.

METHODS

PubMed, Embase, Web of Science, the Cochrane Library, JBI, EBSCO, CNKI, Wanfang, and SinoMed were searched from inception to July 31, 2023. Search terms included "virtual reality" and "end-of-life." Articles were screened according to the inclusion and exclusion criteria. The random effects model was used to calculate the standardized mean difference (SMD), and the fixed effects model was used to calculate the mean difference (MD). The Cochrane Risk of Bias Tool 2.0 and JBI Evaluation tool were used to assess the risk of bias. The I2 statistic was used to measure heterogeneity between studies. Forest plots were used for analysis.

RESULTS

A total of 234 patients at the end of life from 3 randomized controlled trials and 6 quasi-experimental studies were included. Compared with pre-VR intervention, the pain [standardized mean difference (SMD) -0.89, 95% CI -1.29 to -0.48, P < .05], shortness of breath [mean difference (MD) -0.98, 95% CI -0.98-0.51, P < .05], depression (MD -0.62, 95% CI -0.85 to -0.40, P < .05), and anxiety (SMD -0.93, 95% CI -1.50 to 0.36, P < .05) of patients at the end of life was significantly improved after VR intervention. However, there were no significant differences observed in tiredness, drowsiness, nausea, and lack of appetite.

CONCLUSIONS AND IMPLICATIONS

VR technology can be effective in improving pain, shortness of breath, depression, and anxiety in patients at the end of life. For tiredness, drowsiness, nausea, and lack of appetite, further research is required.

Personalised virtual reality in palliative care: clinically meaningful symptom improvement for some

OBJECTIVES

This study examined the effects of virtual reality (VR) among palliative care patients at an acute ward. Objectives included evaluating VR therapy benefits across three sessions, assessing its differential impact on emotional versus physical symptoms and determining the proportion of patients experiencing clinically meaningful improvements after each session.

METHODS

A mixed-methods design was employed. Sixteen palliative inpatients completed three personalised 20 min VR sessions. Symptom burden was assessed using the Edmonton Symptom Assessment Scale-Revised and quality of life with the Functional Assessment of Chronic Illness Therapy (FACIT-Pal-14). Standardised criteria assessed clinically meaningful changes. Quantitative data were analysed using linear mixed models.

RESULTS

Quality of life improved significantly pre-VR to post-VR with a large effect size (Cohen's d: 0.98). Total symptom burden decreased after 20 min VR sessions (Cohen's d: 0.75), with similar effect sizes for emotional (Cohen's d: 0.67) and physical symptoms (Cohen's d: 0.63). Over 50% of patients experienced clinically meaningful improvements per session, though substantial individual variability occurred.

CONCLUSIONS

This study reveals the nuanced efficacy of personalised VR therapy in palliative care, with over half of the patients experiencing meaningful benefits in emotional and physical symptoms. The marked variability in responses underscores the need for realistic expectations when implementing VR therapy.

Personalized virtual reality exposure for panic disorder and agoraphobia: A preliminary neurophysiological study

BACKGROUND

Personalization is considered an important principle in virtual reality (VR) exposure therapy. We aimed to identify whether personalized VR exposure could provoke increased anxiety in patients with panic disorder and agoraphobia as it is considered the first step in successful treatment for anxiety.

METHODS

We performed a double-arm, one-day preliminary study among 28 patients with panic disorder and agoraphobia. Three sessions of VR exposure, including a theater, train, and elevator scenario, were conducted in two groups. In the personalized group (n = 14), the brightness and crowd density were customized based on a pre-assessment. In the control group (n = 14), these conditions were fully randomized. Self-reported anxiety, heart rate, skin conductance, and electroencephalography were measured before, during, and after the VR sessions.

RESULTS

In the later VR sessions, higher self-reported anxiety levels measured by the Visual Analogue Scale were observed in the personalized exposure group. Increased heart rates during and after the VR sessions were observed in the personalized group. The changes in skin conductance peaks were not significantly different between the groups, but the increase in skin conductance was associated with the participants' perception of presence. The electroencephalogram showed widespread increases in alpha waves in the frontal and temporal areas of the brain in the personalized group than in the control group.

CONCLUSION

Personalized VR exposure elicits stronger anxiogenic effects in patients with panic disorder and agoraphobia as suggested by self-report and neurophysiological data. Personalization of VR exposure has the potential for effective behavioral therapy.

A Rapid Review of the Role of Virtual Reality in Care Delivery of Palliative Care and Hospice

Virtual reality (VR) is an emerging technology that can provide a nonpharmacological approach to symptom management for those with serious illnesses. The VR platform offers a unique perspective to connect patients with places and experiences they might otherwise miss. This rapid review aims to present the current literature on the uses and benefits of VR for palliative care and hospice patients. Through a systematic process, we identified 14 articles published between 2018 and 2023 that used VR as an interventional strategy for symptom management. The VR equipment includes a head-mounted display, such as the Oculus Go, and sometimes requires hand controllers or joysticks. Virtual reality software was contained exclusively in the head-mounted displays or required a laptop. Nature scenes, memorable locations, and the solar system are examples of options patients could select for the VR experience. Assessments of the intervention were measured before, during, after, and several hours afterward to evaluate benefits and potential adverse effects. Pain was the predominant symptom assessed in the studies. Overall, most of the studies focused on establishing the safety, efficacy, and feasibility of VR using a single-arm interventional method. Future research should implement randomized controlled trials, increase sample size, and expand to pediatric populations.

My virtual home: needs of patients in palliative cancer care and content effects of individualized virtual reality - a mixed methods study protocol

BACKGROUND

The desire to be at home is one of the most important needs of patients with advanced, incurable cancers. However, palliative cancer patients may require inpatient hospital care for medical reasons. Virtual reality (VR) could provide an approximation to the individuals' home environment.

METHODS

The project consists of 3 parts. All parts are supported by the patient advisory board. In the 1st part of the project, we interview patients, relatives, and the patient advisory board about their wishes and concerns regarding the project. In the 2nd part of the project, patients are offered to view 360° VR videos of their choice (their home, relatives, others if applicable). Effects and side-effects of the intervention are assessed with validated instruments (MIDOS, MDBF, SSQ, SPES). Diagnosis, treatment adherence, medication, and vegetative functionality is determined from the medical records of the patients. In the 3rd part of the project, the results of the study will be discussed with patients, relatives, health care professionals and the patient advisory board regarding implementation.

DISCUSSION

This study is the first to investigate whether individualized VR videos have additional benefits over generic VR nature videos on symptom relief, well-being, treatment satisfaction, and adherence in patients with palliative cancer care. A strength of the study is that we can incorporate the results of each part of the project into the subsequent project parts. However, the generalizability might be limited as this is a single-centred study.

TRIAL REGISTRATION

Registered at German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS); registration number: DRKS00032172; registration date: 11/07/2023 https://drks.de/search/de/trial/DRKS00032172 .

Integrating knowledge, skills, and attitudes: professional training required for virtual reality therapists in palliative care

Fully immersive virtual reality (VR) is an advanced technology increasingly studied and used in palliative care for symptom management. While the findings shed a positive light on its therapeutic potential, VR carries adverse effects, leading to ethical concerns. Based on the clinical experiences of a registered clinical psychologist who is also a certified thanatologist, we put forward a perspective on the importance of professional training for VR therapists in view of the possible risks posed by VR in palliative care. We propose professional trainings on knowledge, skills, and attitudes to ensure patients' safety while maximizing the therapeutic benefits of VR. Given the scarcity of reports on such an area, we hope this perspective article opens up discussions and contributes to current understanding and emerging future directions to ensure quality and ethical delivery of VR in palliative care.

Virtual reality reduces anxiety and pain in acute hospital palliative care: service evaluation

OBJECTIVES

Virtual reality (VR) might improve symptom management, but there is limited evidence regarding VR in palliative care. We evaluated the feasibility of VR and impact on anxiety and pain for patients in a hospital palliative care consultation service.

METHODS

Patients referred to a hospital specialist palliative care team, with anxiety or pain, were offered a VR intervention (a short audiovisual experience). Participants rated anxiety and pain on a 0-10 Likert severity scale pre intervention/post intervention and completed an evaluation form. Change in symptom scores was analysed by parametric statistics.

RESULTS

28 participants used VR a total of 42 times with no adverse events. Mean pain score reduced by 29% from 4.10 (SD=2.71) pre intervention to 2.93 (SD=2.45) post intervention (t(27)=5.150, p<0.001). Mean anxiety scores reduced by 40% from 4.43 (SD=2.56) to 2.65 (SD=2.24) (t(27)=5.058, p<0.001). Patients rated the experience on average 4.75/5 and all would recommend use to a friend. VR was described as absorbing and relaxing.

CONCLUSION

VR may improve anxiety and pain and was acceptable in this setting. Large-scale evaluation will generate important data on feasibility and implementation.

Virtual reality use and patient outcomes in palliative care: A scoping review

Objective

Virtual reality is increasingly used in healthcare settings. Potentially, it's use in palliative carecould have a positive impact; however, there is limited evidence on the scope, purpose and patient outcomes relating to virtual reality use in this context. The objective of this scoping review is to chart the literature on virtual reality use in palliative care, identifying any evidence relating to biopsychosocial patient outcomes which could support its use in practice.

Methods

A scoping review of the literature, involving . a systematic search across 10 electronic bibliographic databases in December 2021, . Eligibility criteria were primary research studies, of any research designwithin a 10-year timeframe, which reported on virtual reality use and patient outcomes in palliative care. A total of 993 papers were identified, andcomprehensive screening resulted in 10 papers for inclusion.

Results

This scoping review identified 10 papers addressing virtual reality in palliative care, published within a three-year timeframe 2019-2021. Research methodologies included mixed methods, quantitative and qualitative. The evidence highlightsvirtual reality use with patients receiving palliative care in a variety of settings, and data around useability, feasibility and acceptability is positive. However, the evidence regarding biopsychosocial patient outcomes linked to virtual reality use is limited.

Conclusion

Virtual reality is gathering momentum in palliative care and is potentially a helpful intervention; however more research is needed to underpin the evidence base supporting its application, particularly in understanding the impact on biopsychosocial patient outcomes and ascertaining the best approach for measuring intervention effectiveness.

Virtual reality reduces pain in palliative care-A feasibility trial

Background

Effective symptom control is a stated goal of palliative care (PC) to improve quality of life for terminally ill patients. Virtual reality (VR) provides temporary escapes from pharmacologically resistant pain and allows for experiences and journeys patients may not access in any other way. Enabling wishes through virtual worlds may also offer additional benefits such as controlling psychological and physical symptoms.

Aims

We investigated the feasibility of a single VR experience as a viable, satisfying, and effective tool for end-of-life pain relief for inpatients presenting palliative needs.

Design

This is an observational, single-arm and national single-center feasibility trial.

Methods

A one-time VR experience with a selection of several videos and games was offered to 45 inpatients receiving PC at Muenster University Hospital. Patients with brain tumors, brain metastases, seizures, motion sickness, claustrophobia, vertigo, hearing or visual impairment, or unable to consent were excluded. Primary outcome measured patient reported pain on a visual analogue scale (VAS). We also measured Karnofsky performance status, health-related quality of life (HRQOL) using the EQ-5D-5 L questionnaire, and the Pain Out Questionnaire for postoperative pain.

Results

We analyzed data from 21 women (52.5%) and 19 men (47.5%) at an average age of 51.9 (SD: 15.81) years. The mean Karnofsky score among the sample was 45.5 (SD: 14.97) and the HRQOL was 41.9 (SD: 23.08). While no serious side effects were reported during the intervention, three patients experienced nausea (7%), two headaches (5%), and three reported dry eyes (7%) afterwards. Significant pain reduction (baseline VAS 2.25 (SD: 0.4399)) was demonstrated during (VAS 0.7 (SD: 0.2983, p < 0.0001)), immediately after (VAS 0.9 (SD: 0.3354, p = 0.0001)) and one hour after the intervention (VAS 1.15 (SD: 0.4163, p = 0.0004)). More than 80% rated the VR experience as very good or good (85%, n = 34) and intended to make use of the device again (82.5%, n = 33). However, two participants (5%) also expressed sadness by becoming aware of old memories and previous opportunities that are gone.

Discussion

The present pilot study suggests that VR seems to be a feasible and effective tool for pain relief in PC. Its use encompasses the approach of a total pain and symptom therapy and enhances patients’ dignity and autonomy. Future research ought to include if and to what extent VR could reduce the necessity of pharmacological pain relief.

How effective is virtual reality technology in palliative care? A systematic review and meta-analysis

BACKGROUND

The efficacy of virtual reality for people living with a terminal illness is unclear.

AIM

To determine the feasibility and effectiveness of virtual reality use within a palliative care setting.

DESIGN

Systematic review and meta-analysis. PROSPERO (CRD42021240395).

DATA SOURCES

Medline, Embase, AMED, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science were searched from inception to March 2021. Search terms included 'virtual reality' and 'palliative care'. Eligibility: (1) adult (>18 years old) with a terminal illness (2) at least one virtual reality session and (3) feasibility data and/or at least one patient outcome reported. The ROB-2 and ROBINS tools assessed risk of bias. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool assessed the quality of the evidence. Standardised mean differences (Hedges's g) were calculated from the pre- and post-data. A DerSimonian-Laird random effects model meta-analysis was conducted.

RESULTS

Eight studies were included, of which five were in the meta-analysis. All studies had at least some concern for risk of bias. Virtual reality statistically significantly improved pain (p = 0.0363), tiredness (p = 0.0030), drowsiness (p = 0.0051), shortness of breath (p = 0.0284), depression (p = 0.0091) and psychological well-being (p = 0.0201). The quality of the evidence was graded as very low due to small sample sizes, non-randomisation methods and a lack of a comparator arm.

CONCLUSIONS

Virtual reality in palliative care is feasible and acceptable. However, limited sample sizes and very low-quality studies mean that the efficacy of virtual reality needs further research.

Virtual Reality in Palliative Care: A Systematic Review

Background: Virtual reality (VR) using head-mounted displays (HMDs) has demonstrated to be an effective tool for treating various somatic and psychological symptoms. Technological advances and increased affordability of VR technology provide an interesting option for delivering psychological interventions to patients in palliative care. The primary aim of this systematic review was to synthesise the available research on the use of VR for enhancing psychological and somatic outcomes for palliative care patients. Secondary aims included assessing general satisfaction and overall usability. Method: A pre-registered systematic literature search was conducted according to PRISMA guidelines using OVID Emcare, Cochrane Library, Embase, Medline, PsycINFO, and PubMed Care Search: Palliative Care Knowledge Network. Peer-reviewed experimental, quasi-experimental, observational, case, and feasibility studies consisting of single or multiple VR sessions using HMDs that reported psychological and/or somatic outcomes were included. Results: Eight studies published between 2019 and 2021 were included, representing 138 patients. While the reported quantitative psychological and somatic outcomes were ambiguous, the qualitative outcomes were largely positive. Participants were generally satisfied with VR, and most studies reported the VR interventions as usable, feasible, and acceptable. Conclusions: VR shows promise in palliative care and generally addresses a range of symptoms with few adverse effects. Future research should consist of adequately powered RCTs evaluating dosage and focusing on providing meaningful activities to enhance outcomes further.

Virtual Reality Therapy in Palliative Care: A Case Series

OBJECTIVES

Virtual reality (VR) opens a variety of therapeutic options to improve symptom burden in patients with advanced disease. Until to date, only few studies have evaluated the use of VR therapy in the context of palliative care. This case series aims to evaluate the feasibility and acceptability of VR therapy in a population of palliative care patients.

METHODS

In this single-site case series, we report on six palliative care patients undergoing VR therapy. The VR therapy consisted of a one-time session ranging between 20 to 60 minutes depending on the patient's needs and the content chosen for the VR sessions. A semi-structured survey was conducted and the Edmonton Symptom Assessment System (ESAS) and the Distress Thermometer were performed pre- and post-intervention.

RESULTS

Overall, VR therapy was well accepted by all patients. Five out of six patients reported having appreciated VR therapy. There were individual differences of perceived effects using VR therapy. The semi-structured survey revealed that some patients felt a temporary detachment from their body and that patients were able to experience the VR session as a break from omnipresent worries and the hospital environment ("I completely forgot where I am"). There was a considerable reduction in the total ESAS score post-treatment (T0 ESASTot = 27.2; T1 ESASTot = 18.8) and a slightly reduction in distress (T0 DTTot = 4.4; T1 DTTot = 3.8). However, two patients were more tired after the intervention.Significance of Results: Our preliminary results demonstrate that VR therapy is acceptable, feasible and safe for use within a palliative care population and appears to be a viable treatment option. Clinical trials are both warranted and necessary to confirm any therapeutic effects of VR therapy, as is the need to tailor VR systems better for use in palliative care settings.

[Digital Palliative Care]

Digital Palliative Care Abstract. Palliative care is becoming more and more digital. This article illuminates how digital approaches can help identify patients who qualify for palliative care offers and who wish to make use of them. Digital approaches can be used to monitor patients through apps and wearables, but digital methods are also becoming more important in psychosocial and spiritual support. One case demonstrates the therapeutic use of virtual reality. Work organization is digital, and teaching has also become digital during the corona crisis. In spite of all the advantages, however, the potential risks of digitization must also be considered.