Management model of caregiver’s grief in a tertiary oncological center Hospice: from anticipatory mourning to condolence conversation: preliminary observations

Management model of caregiver’s grief in a tertiary oncological center Hospice: from anticipatory mourning to condolence conversation: preliminary observations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Management model of caregiver’s grief in a tertiary oncological center Hospice: from anticipatory mourning to condolence conversation: preliminary observations Ivan Gallio, Marina Lorusso, Matilde Moscato, Chiara Miranti, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3969736/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Dec, 2024 Read the published version in BMC Palliative Care → Version 1 posted 4 You are reading this latest preprint version Abstract Background Bereavement is a physiological process of great importance in palliative care; grief-processing disorders can be diagnosed after at least 6 months after death and have severe clinical or psychological consequences. Aim of the study is to verify how adequate management of anticipatory mourning and condolence conversation in the early grief stages can be protective. Methods Patients and caregivers are supported by the multidisciplinary team by semi structured interviews. In condolence conversation within 1 month of the death, we identify elements of suspicion of psychological fragility that require support for an adequate processing of the loss. Results From condolence conversation, only 3% of the caregivers who had been psychologically supported during the hospital stay and demonstrated a good level of acceptance of their relative's end of life, showed problems in grieving within 1 month of death; none showed excessive avoidance of memories, difficulties with trust and feelings of emotional loneliness. Conclusions Despite the limitations, the preliminary data of our study clearly suggests the protective potential of multidisciplinary support, particularly in the risk of developing grief processing disorders. These considerations encourage us to implement our model of clinical and psychological support system and develop paths dedicated to caregivers in greater difficulty. palliative care multidisciplinary grief anticipatory mourning Hospice care psychological support Figures Figure 1 Figure 2 Figure 3 Simple Summary Processing the loss of a relative is a complex and painful experience, which can sometimes become complicated, with the appearance of grief processing disorders. In palliative care and particularly in Hospice a progressive path is possible to protect patients and caregivers, identifying their vulnerabilities. This leads to correct management of anticipatory grief, taking advantage of all the skills of the multidisciplinary team involved in taking charge. Furthermore, scheduling an interview within a month of the death (“condolence conversation”) allows the team to identify those most at risk for complicated grief and suggest strengthening strategies, directing the caregivers most in difficulty towards a dedicated psychological path. 1. Background Palliative care is an “ approach that improves the quality of life (QoL) of patients and their families, address the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and smart assessment and treatment of pain and other problems, physical, psychosocial and spiritual ” [ 1 , 2 ]. Global palliative care for terminal cancer patients can be managed at home or in Hospice, that is dedicated to the patients with a prognosis of 6 months or less: admission to Hospice allows greater support for the caregiver, who can also dedicate themselves to the processing of anticipatory grief, supported by the palliative care team. [ 3 – 5 ]. Grief processing is a matter that the palliative care team deals with every day: in fact, mourning is a natural response to the loss of a loved one and for most people the symptoms of grief begin to decrease over time. Despite most individuals having sufficient personal resources to adapt to this transition phase, there are more vulnerable subjects who are at risk of complicated bereavements [ 6 – 8 ]. Classically, according to Elizabeth Kübler Ross, the mourning process is divided into 5 phases: rejection and denial, anger, negotiation, depression, and acceptance [ 9 , 10 ]. The acceptance phase represents a crucial moment in the mourning process: during this phase, the grieving person begins to gradually integrate the awareness of the loss into their reality and find a new emotional balance. Acceptance of death requires time and energy as an individual goes through the various stages of processing the loss and must be correctly supported in case of need [ 10 ]. The literature clearly shows how, even in palliative care settings, guaranteeing an universal bereavement service is neither necessary nor beneficial and can sometimes be counterproductive in individuals with adequate individual resources [ 11 – 18 ]. Indeed, prolonged grief disorder (PGD) is characterized by this intense and persistent grief that causes problems and interferes with daily life and an estimated 7%-10% of bereaved adults will experience the persistent symptoms of prolonged grief disorder 19. The PGD is included in the International Classification of Diseases, 11th Revision (ICD-11), with diagnostic criteria also accepted for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5 TR) (identity disruption, such as feeling as though part of oneself has died; marked sense of disbelief about the death; avoidance of reminders that the person is dead; intense emotional pain related to the death; difficulty with reintegration, such as problems engaging with friends, pursuing interests, planning for the future; emotional numbness ; feeling that life is meaningless or intense loneliness) [ 19 – 26 ]. To be significant, symptoms must be present nearly every day during the prior month and the relative’s death had to have occurred for at least 6 months. The bereavement lasts longer than might be expected based on social, cultural, or religious norms. Factors that may increase the likelihood of developing PGD include the high burden of care on the part of the caregiver, social isolation, advanced age, the nature of the death, the number of losses and the psychiatric comorbidity [ 19 , 26 ]. Adequate management of the anticipatory grief phases could significantly reduce the risk of developing PGD, especially in hospice care settings [ 12 , 27 ], so monitoring for signs of severe grief in caregivers could be fundamental to increase preparation for death and to reduce caregiver burden [ 12 , 27 – 30 ]. The aim of our study is to demonstrate how, in the context of multidisciplinary management, offering semi-structured psychological support from the early stages of hospitalization in the Hospice and which continues during the condolence conversation can be useful and protective in developing mourning disorders. The care model that we propose has the aim of allowing a correct and gradual processing of anticipatory grief by the caregiver. 2. Methods We considered the patients admitted to our Tertiary Oncological Center Hospice in the period 2021–2023: 144 patients admitted to the Veneto Institute of Oncology (IOV) Hospice from November 2022 to November 2023; of the 144 patients, 30 were discharged with home care, while 114 died in Hospice. The decision of Hospice admission was formulated by the attending physician (oncologist, palliative care doctor, general practitioner) and approved by the palliative care team: according to the procedure in use, before entering the Hospice, the patient and caregiver are involved in a multidisciplinary interview (the pre-entry interview) to define the objectives of hospitalization and share decisions. The pre-entry interview involves the palliative care team composed by palliative physician, psychologist, and nurse. As part of the care taking process for patients admitted to our Hospice, a psycho-oncological assessment and possibly management of the patient, caregiver and family members is envisaged. The psychologist, starting from the pre-entry interview and based on the clinical evaluation of the physician and the analysis of the family's needs during the entry interview, proceeds with a specialized evaluation of the patient and the family members who take care of him for a more in-depth analysis of any emerging problems and needs. This evaluation will allow the setting up of a specific psychological-therapeutic intervention program for the family unit evaluated. During hospitalization, the patients and caregivers are supported by the multidisciplinary team and some semi-structured psychological interviews are offered to identify any critical issues and vulnerabilities, in the management of anticipatory grief. During the psycho-oncological interviews, the levels of awareness of diagnosis and prognosis (of the patient, caregiver, and family members), the type of functioning of the family and any fragility of the family context are assessed. All those elements that allow the team to understand whether a good job of anticipatory mourning processing is underway are also explored. For all caregivers of patients who died in Hospice, a condolence interview is planned within 1 month of the death, which can be performed in person or remotely based on the needs of the subjects. The timing and contents of the condolence interview are evaluated on the findings made thanks to the use of "observation grids”, as well as on the quality and necessity of the interventions carried out during hospitalization. The team warns the family members that they will receive a condolence phone call from the psychologist and/or palliative care doctor every few weeks to evaluate their emotional state and the emergence of any needs/frailties related to the loss. Alternatively, a condolence conversation in person with the entire palliative care team is agreed upon immediately. Through a semi-structured interview, defined as a "condolence interview", we try to identify early elements of suspicion of psychological fragility that require support for an adequate processing of the loss. If the need for a therapeutic path is identified, family members are helped to activate competent local services in an appropriate manner (Fig. 1). Figure 1. The figure shows the mourning process, starting from the anticipatory mourning phases up to the management of any mourning disorders. In the phases of anticipatory mourning, the support of the multidisciplinary palliative care team is essential for both the patient and the caregiver, to provide the appropriate tools also for the management of actual mourning. The mourning process is divided into 5 phases, not necessarily consequential but all indispensable: denial, anger, negotiation, depression, acceptance. The diagnosis of mourning disorder occurs at least 6 months after the loss of a loved one, in the presence of disturbing and persistent symptoms, which compromise the normal functioning of daily life. Condolence conversations, a natural continuation of taking charge of palliative care during the hospice stay, can make it possible to identify elements of vulnerability early and direct people to the competent local services for a targeted psychological path. In particular, the semi-structured psychological interview is based first of all on the clinical and demographic data shared with the palliative care doctor, who plays a fundamental role in the all-round management: the origin of the patient (home vs. hospital or other structure), the reporting methods and the figures involved in the interview prior to the proposal to enter the Hospice. During the pre-entry interview and any subsequent psycho-oncological interviews, the following are assessed for both the patient and the caregiver: adaptation difficulties: difficulties in accepting and dealing with the changes associated with illness, alterations in behavior and relationships due to the illness, problems relating to the state of information on the diagnosis, problems relating to the state of information on the prognosis, unrealistic expectations regarding the treatment process; emotional fatigue expressed in relation to the disease. We then go on to consider the types of family functioning: functional, i.e. elastic in its internal organization, good adaptation skills; mute or frozen: use of silence as a defense mechanism; asks not to inform the patient of his condition; tendency towards relational isolation; rigid: unable to express emotions; also controlling the therapies administered; poor tendency to adapt; asks for continuous explanations and reassurances; conflict • ual: aggression internal and external to the family context; difficulty relating and expressing requests; broken up: weak intra-family ties; puts the needs of individuals before those of family members and the patient; absent in providing assistance and company to the patient); rejecting: not cohesive; distrustful; devaluing the professionalism of the treatment team. As regards the management of anticipatory mourning, during the interviews with the patient, the patient's fears are assessed (fear of physical pain, of the unknown, of judgment, of separation from loved ones, of dependence on the help of others, of feeling of burden, of disfigurement, of loss of control, mental or physical, of loneliness and the fear of them being forgotten). The sense of fragility, anxiety and fear linked to the continuous questioning of one's health conditions, the general sense of helplessness and emotional loneliness are also explored. The patient's degree of acceptance is then assessed, with specific reference also to his wishes regarding the dying process and the post-mortem. Similarly, during the interview with the caregiver, the degree of awareness and acceptance is assessed, in particular in relation to the caregiver's attitude: actions of "premature abandonment", with delegation of all care and care to healthcare personnel, symbiotic attitude, denial of the reality of death, hope in the patient's death and feelings of guilt). As part of the condolence conversation, the timing of which is evaluated with the team based on the work done and the problems that have emerged, the presence of disorders that may indicate a difficulty in processing is assessed, partly borrowed from the items indicative of PGD of DSM V: ● Persistent longing/pervasive nostalgia for the deceased person; ● Sadness and intense emotional pain; ● Concern about the circumstances of the death; ● Marked difficulty accepting death; ● Feel disbelief; ● Difficulty in indulging in positive memories regarding the deceased; ● Bitterness or anger; ● Negative self-evaluation; ● Excessive avoidance of memories of the loss; ● Desire to die to remain close to the deceased; ● Difficulty trusting others; ● Feeling of being alone or detached; ● Feeling that life is empty or meaningless without the deceased; ● Confusion about one's role in life, or a diminished sense of one's identity; ● Difficulty or reluctance in pursuing one's interests or making plans for the future; ● Impairment in occupational, social, or other important areas of functioning. All patients and caregivers gave their consent to the collection of clinical and psychological data emerging during hospitalisation; the study was conducted in accordance with the principles of the Declaration of Helsinki. The Ethics Committee of IOV approved the study and the virtual consultation. Clinical data reported in eCRF were collected anonymously. Continuous data were reported as mean and standard error; proportions and rates were calculated for categorical data. Groups were compared with the chi-square test for categorical variables (the raw P values were adjusted with the Bonferroni method for multiple comparisons). The SPSS 24 software package for Windows (SPSS, Inc., Chicago, IL, USA) was used to manage the database and perform the statistical analysis. The significance level was set at p < 0.05 for all tests. 3. Results In the period November 2022-November 2023, our Hospice welcomed 144 patients, of which 30 were discharged home with the activation of an exclusive home palliative care programme. Of the 114 patients followed until death in our Hospice, 60% were male and 40% female. Table 1 describes the patients: malignancies of admission, age and the length of stay in the Hospice. Table 1 Neoplastic conditions of patients that died during Hospice recovery, their age class and duration of stay in Hospice. CNS: Central Nervous System. CANCER (n) % AGE range (n) % DURATION OF STAY (n) % CNS (7) 6,1 31–40 years (1) 0,9 < 7 days (51) 44,7 Lung (21) 18,4 41–50 years (6) 5,3 8–10 days (19) 16,7 Genitourinary (12) 10,5 51–60 years (12) 10,5 11–15 days (14) 12,3 Female genital system (5) 4,4 61–70 years (18) 15,8 16–20 days (10) 8,8 Gastrointestinal (31) 27,2 71–80 years (37) 32,5 > 21 days (20) 17,5 Pancreas (11) 9,6 > 81 years (40) 35,1 Skin (3) 2,6 Breast (6) 5,3 Blood (11) 9,6 Regarding caregivers, the majority were female (66%) moreover the 34% were male. The Fig. 2 shows their distribution based on role in the family unit: most caregivers were sons (51%) or spouses (31%). Only 9% were not first-degree relatives or did not belong to the nuclear family (2%). No significant differences in mourning emerge in relation to the family role or the gender of the caregiver. Figure 2. The figure shows distribution based on role in the family unit: most caregivers were sons (51%) or spouses (31%). Only 9% were not first-degree relatives or did not belong to the family (2%) None of the caregivers who had not participated in the pre-entry multidisciplinary interview showed difficulties in grieving during the condolence interview carried out within 1 month of the death of the relative. Instead, the 29% of caregivers who had participated in the pre-entry interview showed difficulties in grieving. Particularly, by evaluating the pathological mourning items according to the DSM V, significant correlations emerge with pervasive nostalgia and disbelief. From the analysis of the condolence conversation, as shown in the Fig. 3, among the caregivers who had been psychologically supported during the hospital stay and demonstrated a good level of acceptance of their relative's end of life, a small minority showed problems in grieving (3%) within 1 month of death. The 4% expressed pervasive nostalgia, intense emotional pain, disbelief, 2% perplexity about the circumstances of the death, lack of positive memories, feeling of an empty life, confusion about their role in life, maintaining their interests or identifying their role in the community. None showed excessive avoidance of memories, difficulties with trust and feelings of emotional loneliness. Figure 3. The figure shows the presence (blue columns) or absence (orange columns) of potential prolonged grief disorders in caregivers with good acceptance of relative's end of life phase, investigated one month after the death with the condolence conversation. Among caregivers with a good level of acceptance of their relative's end of life, a small minority showed problems in grieving (3%) within 1 month of death. The 4% expressed pervasive nostalgia, intense emotional pain, disbelief, 2% perplexity about the circumstances of the death, lack of positive memories, feeling of an empty life, confusion about their role in life, maintaining their interests or identifying their role in the community. None showed excessive avoidance of memories, difficulties with trust and feelings of emotional loneliness 4. Discussion Processing the loss of a loved one is a complex experience and always represents a moment of great fragility. Although everyone can count on their own personal resources and on the support of their own family, the risk of developing a mourning disorder must always be considered [ 3 – 5 , 19 , 27 ]. The model that we propose emphasizes the importance of a multidisciplinary approach: the palliative care physician and the psycho-oncologist co-participate in taking charge of the patient himself and his family unit, actively involving the other assistance figures (nurses and social-health workers). Especially in Hospice, the caregiver, in fact, can count on multidisciplinary support in the processing of anticipatory grief, regardless of the length of hospitalization. Our data support the hypothesis that, faced with the privilege of saying goodbye to relatives, denied to those who are faced with sudden death, everyone's personal resources can however be exhausted in the attempt to offer as much support as possible to the patient while they are alive [ 31 , 32 ]. Specific staff training, in a delicate and multifaceted context such as exclusive palliative care, represents the key to adequately taking care of the patient. Our preliminary data indeed, highlights how a specialized psychological support allows the team to focus on the problems of anticipatory mourning, significantly minimizing the caregivers' risk of pathological mourning. It will then be the team intervention that allows the patient and family to feel welcomed and listened to; furthermore, the possibility of interfacing with multiple professional figures allows us to highlight different facets and grasp a greater number of symptoms, taking advantage of different specific skills. The proposal of a condolence conversation within a month of death, borrowing a more classically used model in the management of sudden death, allows us to identify those most at risk and direct them towards specialist support. On the other hand, as evident for the caregivers who did not participate in the pre-entry interview without showing acceptance problems, psychological support must not be offered to everyone without distinction, but only to those who demonstrate the need for it. In summary, our model was created to evaluate the protective potential of psycho-oncological caregiver’s care from the early stages of hospitalization in the Hospice with respect to the risk of pathological bereavement. As suggested by our data, thanks to the support received from the entire team during the course of hospitalization, many families show excellent coping strategies at the time of death. We then proceed with reinforcement and, if necessary, a review of skills or anything else necessary to face the first days in the absence of your loved one. In the model we tested, each caregiver is offered psychological support through semi-structured interviews during the hospitalization of their family member, without however making the interview an obligatory moment or in which the family member must feel obliged to share their feelings and problems. This engagement system, which where possible starts before entering the Hospice with the pre-entry interview, allows coping skills to be assessed and greater support to be offered to those in greater difficulty. Furthermore, the analysis of the problems inherent to anticipatory mourning, conducted with evaluation interviews but without the use of predetermined scales, makes the interview perceived as more informal and therefore more spontaneous. Although the assessment with a condolence conversation within 1 month is not in itself sufficient to diagnose mourning disorder, it allows family members to maintain a channel of communication with the staff who assisted them in a delicate period such as that of the end life of their loved one. It also allows the team to identify the greatest difficulties or vulnerabilities, directing those at risk to competent external psychological support. As evident in our sample, the difficulty in formulating the prognosis explains why nearly 30% of hospice patients die in 7 days or less, so a fundamental step is certainly involvement in the care path right from the phases of life prolonging therapies, with early palliative care. From the perspective of early palliative care, in line with international literature [ 33 – 35 ], we hope to be able to expand this model of care also to patients in active care, also in relation to the difficulty of formulating the prognosis and the care burden growing of the caregiver. Our institute already offers dedicated support to family members, but not strictly connected to the outpatient palliative care unit, a context in which it would be desirable to have a dedicated psycho-oncologist. The involvement of the caregiver in the pre-entry interview is certainly an important step to allow an adequate process of anticipatory mourning [ 30 , 36 ]. Although our Hospice procedure, in the pandemic and post-pandemic period there are many factors that may have contributed to reducing these possibilities, in accordance with national and international regulations for the prevention of COVID. In accordance with the demographic distribution [ 37 ] the majority of patients of our Hospice are over 70 years old and the caregivers are in most cases the patients' sons, often with an active job and heavily burdened by assistance in the patient care process. This is a factor that could partly explain the greater difficulty in participating in pre-entry interviews. Moreover, given the heterogeneous basic training of physicians who deal with palliative care (oncologists, general practitioners, internal medicine specialists, geriatricians, neurologists and others), it is also worth considering the possibility that different basic trainings, despite the targeted specialist training, underlie different sensitivities and attitudes which may or may not lead to the valorization of the interview as a moment of care and therefore to push for the interviews to be as multidisciplinary as possible and involve the caregiver, even in the face of the organizational difficulties that may arise. The heterogeneity of the outcomes of the procedures based on specialist training is a fact already known in other settings, which would also be interesting to study in palliative care [ 38 ]. Surely, the objective of our working group is to make the care of the patient and his family as homogeneous as possible, to guarantee adequate support for everyone. 5. Conclusions Despite the numerous limitations (such as the small sample, the reduced involvement of caregivers in the pre-entry interview, the percentage of patients with hospital stays of less than a week) the preliminary data of our study clearly suggests the protective potential of multidisciplinary support, particularly in the risk of developing grief processing disorders. These considerations encourage us to implement our model of clinical and psychological support system and develop paths dedicated to caregivers in greater difficulty. Further studies are underway to create an ad hoc form for psycho-oncological management in Hospice and we hope there will be the possibility of implementing this model by also extending it to management in simultaneous palliative care, adequately preparing patients and their caregivers in the perspective of a shared path. Declarations Author Contributions: Conceptualization, I.G. and M.L; methodology, I.G, M.L, A.F.; software, M.L.; validation, M.L, A.F.; formal analysis, M.M.; investigation, I.G, M.L. M.M, C.M.; data curation, M.L and E.R; writing—original draft preparation, E.R, I.G, M.L.; writing—review and editing, E.R, A.F F.F; visualization, I.G, M.M, C.M, M.P.; supervision F.F.; project administration, E.R.; funding acquisition, M.P. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Dec, 2024 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 20 Feb, 2024 Submission checks completed at journal 20 Feb, 2024 Editor assigned by journal 20 Feb, 2024 First submitted to journal 19 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3969736","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":273829102,"identity":"dd197474-d0d2-435f-be9f-7657b0bf58fe","order_by":0,"name":"Ivan Gallio","email":"","orcid":"","institution":"Istituto Oncologico Veneto","correspondingAuthor":false,"prefix":"","firstName":"Ivan","middleName":"","lastName":"Gallio","suffix":""},{"id":273829103,"identity":"ba14ba9d-87d6-4cf5-9ed2-88a90f62198d","order_by":1,"name":"Marina Lorusso","email":"","orcid":"","institution":"Istituto Oncologico Veneto","correspondingAuthor":false,"prefix":"","firstName":"Marina","middleName":"","lastName":"Lorusso","suffix":""},{"id":273829104,"identity":"4f367a9f-3394-4946-99fa-726b665b3daa","order_by":2,"name":"Matilde Moscato","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Matilde","middleName":"","lastName":"Moscato","suffix":""},{"id":273829105,"identity":"95a7db14-e1d3-4ab0-b460-794ef32d1fae","order_by":3,"name":"Chiara Miranti","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Chiara","middleName":"","lastName":"Miranti","suffix":""},{"id":273829106,"identity":"9d1ce191-cd92-4479-95fe-304888d89f7c","order_by":4,"name":"Mirsad Pasalic","email":"","orcid":"","institution":"Istituto Oncologico Veneto","correspondingAuthor":false,"prefix":"","firstName":"Mirsad","middleName":"","lastName":"Pasalic","suffix":""},{"id":273829107,"identity":"26d72913-6701-4ca1-b77c-58d642df6c34","order_by":5,"name":"Fabio Formaglio","email":"","orcid":"","institution":"Istituto Oncologico Veneto","correspondingAuthor":false,"prefix":"","firstName":"Fabio","middleName":"","lastName":"Formaglio","suffix":""},{"id":273829108,"identity":"ac26b40e-0cbe-4268-a819-35321a5bfc2a","order_by":6,"name":"Alessandra Feltrin","email":"","orcid":"","institution":"Istituto Oncologico Veneto","correspondingAuthor":false,"prefix":"","firstName":"Alessandra","middleName":"","lastName":"Feltrin","suffix":""},{"id":273829109,"identity":"d9977346-5294-4377-bd6d-81e8dca55a0d","order_by":7,"name":"Elena Ruggiero","email":"data:image/png;base64,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","orcid":"","institution":"Istituto Oncologico Veneto","correspondingAuthor":true,"prefix":"","firstName":"Elena","middleName":"","lastName":"Ruggiero","suffix":""}],"badges":[],"createdAt":"2024-02-19 10:34:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3969736/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3969736/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-024-01620-2","type":"published","date":"2024-12-20T15:58:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51507123,"identity":"7aef301b-cbeb-49e7-a0bf-d46db7456ee2","added_by":"auto","created_at":"2024-02-22 19:36:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":424647,"visible":true,"origin":"","legend":"\u003cp\u003eThe figure shows the mourning process, starting from the anticipatory mourning phases up to the management of any mourning disorders. In the phases of anticipatory mourning, the support of the multidisciplinary palliative care team is essential for both the patient and the caregiver, to provide the appropriate tools also for the management of actual mourning. The mourning process is divided into 5 phases, not necessarily consequential but all indispensable: denial, anger, negotiation, depression, acceptance. The diagnosis of mourning disorder occurs at least 6 months after the loss of a loved one, in the presence of disturbing and persistent symptoms, which compromise the normal functioning of daily life. Condolence conversations, a natural continuation of taking charge of palliative care during the hospice stay, can make it possible to identify elements of vulnerability early and direct people to the competent local services for a targeted psychological path.\u003c/p\u003e","description":"","filename":"Figuer1Griefjourning.png","url":"https://assets-eu.researchsquare.com/files/rs-3969736/v1/7a1f50fccefee4eca65575fa.png"},{"id":51507122,"identity":"e1e1e8bb-2454-4f07-aa33-a235bbd946a6","added_by":"auto","created_at":"2024-02-22 19:36:56","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45289,"visible":true,"origin":"","legend":"\u003cp\u003eThe figure shows distribution based on role in the family unit: most caregivers were sons (51%) or spouses (31%). Only 9% were not first-degree relatives or did not belong to the family (2%)\u003c/p\u003e","description":"","filename":"Figure2IGallio.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3969736/v1/befb07ecb6eaa5d01fc4e2e6.jpg"},{"id":51507124,"identity":"6d00039f-aa6a-415b-a67a-d9f5af023db6","added_by":"auto","created_at":"2024-02-22 19:36:56","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":104243,"visible":true,"origin":"","legend":"\u003cp\u003eThe figure shows the presence (blue columns) or absence (orange columns) of potential prolonged grief disorders in caregivers with good acceptance of relative's end of life phase, investigated one month after the death with the condolence conversation. Among caregivers with a good level of acceptance of their relative's end of life, a small minority showed problems in grieving (3%) within 1 month of death. The 4% expressed pervasive nostalgia, intense emotional pain, disbelief, 2% perplexity about the circumstances of the death, lack of positive memories, feeling of an empty life, confusion about their role in life, maintaining their interests or identifying their role in the community. None showed excessive avoidance of memories, difficulties with trust and feelings of emotional loneliness\u003c/p\u003e","description":"","filename":"Figure3IGallio.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3969736/v1/4f6977570b70cc5946a0ccd8.jpg"},{"id":72202755,"identity":"547a7bca-a8e6-4634-a447-4271f78bbcd3","added_by":"auto","created_at":"2024-12-23 16:16:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":906913,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3969736/v1/a2a1f644-88d1-4856-a44a-1b96e25e69a1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management model of caregiver’s grief in a tertiary oncological center Hospice: from anticipatory mourning to condolence conversation: preliminary observations","fulltext":[{"header":"Simple Summary","content":"\u003cp\u003eProcessing the loss of a relative is a complex and painful experience, which can sometimes become complicated, with the appearance of grief processing disorders. In palliative care and particularly in Hospice a progressive path is possible to protect patients and caregivers, identifying their vulnerabilities. This leads to correct management of anticipatory grief, taking advantage of all the skills of the multidisciplinary team involved in taking charge. Furthermore, scheduling an interview within a month of the death (\u0026ldquo;condolence conversation\u0026rdquo;) allows the team to identify those most at risk for complicated grief and suggest strengthening strategies, directing the caregivers most in difficulty towards a dedicated psychological path.\u003c/p\u003e"},{"header":"1. Background","content":"\u003cp\u003ePalliative care is an \u0026ldquo;\u003cem\u003eapproach that improves the quality of life (QoL) of patients and their families, address the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and smart assessment and treatment of pain and other problems, physical, psychosocial and spiritual\u003c/em\u003e\u0026rdquo; [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Global palliative care for terminal cancer patients can be managed at home or in Hospice, that is dedicated to the patients with a prognosis of 6 months or less: admission to Hospice allows greater support for the caregiver, who can also dedicate themselves to the processing of anticipatory grief, supported by the palliative care team. [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGrief processing is a matter that the palliative care team deals with every day: in fact, mourning is a natural response to the loss of a loved one and for most people the symptoms of grief begin to decrease over time. Despite most individuals having sufficient personal resources to adapt to this transition phase, there are more vulnerable subjects who are at risk of complicated bereavements [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClassically, according to Elizabeth K\u0026uuml;bler Ross, the mourning process is divided into 5 phases: rejection and denial, anger, negotiation, depression, and acceptance [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The acceptance phase represents a crucial moment in the mourning process: during this phase, the grieving person begins to gradually integrate the awareness of the loss into their reality and find a new emotional balance. Acceptance of death requires time and energy as an individual goes through the various stages of processing the loss and must be correctly supported in case of need [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe literature clearly shows how, even in palliative care settings, guaranteeing an universal bereavement service is neither necessary nor beneficial and can sometimes be counterproductive in individuals with adequate individual resources [\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIndeed, prolonged grief disorder (PGD) is characterized by this intense and persistent grief that causes problems and interferes with daily life and an estimated 7%-10% of bereaved adults will experience the persistent symptoms of prolonged grief disorder 19. The PGD is included in the International Classification of Diseases, 11th Revision (ICD-11), with diagnostic criteria also accepted for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5 TR) (identity disruption, such as feeling as though part of oneself has died; marked sense of disbelief about the death; avoidance of reminders that the person is dead; intense emotional pain related to the death; difficulty with reintegration, such as problems engaging with friends, pursuing interests, planning for the future; emotional numbness ; feeling that life is meaningless or intense loneliness) [\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. To be significant, symptoms must be present nearly every day during the prior month and the relative\u0026rsquo;s death had to have occurred for at least 6 months. The bereavement lasts longer than might be expected based on social, cultural, or religious norms. Factors that may increase the likelihood of developing PGD include the high burden of care on the part of the caregiver, social isolation, advanced age, the nature of the death, the number of losses and the psychiatric comorbidity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdequate management of the anticipatory grief phases could significantly reduce the risk of developing PGD, especially in hospice care settings [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], so monitoring for signs of severe grief in caregivers could be fundamental to increase preparation for death and to reduce caregiver burden [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of our study is to demonstrate how, in the context of multidisciplinary management, offering semi-structured psychological support from the early stages of hospitalization in the Hospice and which continues during the condolence conversation can be useful and protective in developing mourning disorders. The care model that we propose has the aim of allowing a correct and gradual processing of anticipatory grief by the caregiver.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eWe considered the patients admitted to our Tertiary Oncological Center Hospice in the period 2021\u0026ndash;2023: 144 patients admitted to the Veneto Institute of Oncology (IOV) Hospice from November 2022 to November 2023; of the 144 patients, 30 were discharged with home care, while 114 died in Hospice.\u003c/p\u003e \u003cp\u003eThe decision of Hospice admission was formulated by the attending physician (oncologist, palliative care doctor, general practitioner) and approved by the palliative care team: according to the procedure in use, before entering the Hospice, the patient and caregiver are involved in a multidisciplinary interview (the pre-entry interview) to define the objectives of hospitalization and share decisions. The pre-entry interview involves the palliative care team composed by palliative physician, psychologist, and nurse. As part of the care taking process for patients admitted to our Hospice, a psycho-oncological assessment and possibly management of the patient, caregiver and family members is envisaged. The psychologist, starting from the pre-entry interview and based on the clinical evaluation of the physician and the analysis of the family's needs during the entry interview, proceeds with a specialized evaluation of the patient and the family members who take care of him for a more in-depth analysis of any emerging problems and needs. This evaluation will allow the setting up of a specific psychological-therapeutic intervention program for the family unit evaluated.\u003c/p\u003e \u003cp\u003eDuring hospitalization, the patients and caregivers are supported by the multidisciplinary team and some semi-structured psychological interviews are offered to identify any critical issues and vulnerabilities, in the management of anticipatory grief. During the psycho-oncological interviews, the levels of awareness of diagnosis and prognosis (of the patient, caregiver, and family members), the type of functioning of the family and any fragility of the family context are assessed. All those elements that allow the team to understand whether a good job of anticipatory mourning processing is underway are also explored.\u003c/p\u003e \u003cp\u003eFor all caregivers of patients who died in Hospice, a condolence interview is planned within 1 month of the death, which can be performed in person or remotely based on the needs of the subjects. The timing and contents of the condolence interview are evaluated on the findings made thanks to the use of \"observation grids\u0026rdquo;, as well as on the quality and necessity of the interventions carried out during hospitalization.\u003c/p\u003e \u003cp\u003eThe team warns the family members that they will receive a condolence phone call from the psychologist and/or palliative care doctor every few weeks to evaluate their emotional state and the emergence of any needs/frailties related to the loss. Alternatively, a condolence conversation in person with the entire palliative care team is agreed upon immediately.\u003c/p\u003e \u003cp\u003eThrough a semi-structured interview, defined as a \"condolence interview\", we try to identify early elements of suspicion of psychological fragility that require support for an adequate processing of the loss. If the need for a therapeutic path is identified, family members are helped to activate competent local services in an appropriate manner (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e\u003cb\u003eFigure 1.\u003c/b\u003e The figure shows the mourning process, starting from the anticipatory mourning phases up to the management of any mourning disorders. In the phases of anticipatory mourning, the support of the multidisciplinary palliative care team is essential for both the patient and the caregiver, to provide the appropriate tools also for the management of actual mourning. The mourning process is divided into 5 phases, not necessarily consequential but all indispensable: denial, anger, negotiation, depression, acceptance. The diagnosis of mourning disorder occurs at least 6 months after the loss of a loved one, in the presence of disturbing and persistent symptoms, which compromise the normal functioning of daily life. Condolence conversations, a natural continuation of taking charge of palliative care during the hospice stay, can make it possible to identify elements of vulnerability early and direct people to the competent local services for a targeted psychological path.\u003c/p\u003e \u003cp\u003eIn particular, the semi-structured psychological interview is based first of all on the clinical and demographic data shared with the palliative care doctor, who plays a fundamental role in the all-round management: the origin of the patient (home vs. hospital or other structure), the reporting methods and the figures involved in the interview prior to the proposal to enter the Hospice.\u003c/p\u003e \u003cp\u003eDuring the pre-entry interview and any subsequent psycho-oncological interviews, the following are assessed for both the patient and the caregiver:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eadaptation difficulties: difficulties in accepting and dealing with the changes associated with illness, alterations in behavior and relationships due to the illness, problems relating to the state of information on the diagnosis, problems relating to the state of information on the prognosis, unrealistic expectations regarding the treatment process;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eemotional fatigue expressed in relation to the disease.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eWe then go on to consider the types of family functioning:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003efunctional, i.e. elastic in its internal organization, good adaptation skills;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003emute or frozen: use of silence as a defense mechanism; asks not to inform the patient of his condition; tendency towards relational isolation;\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003erigid: unable to express emotions; also controlling the therapies administered; poor tendency to adapt; asks for continuous explanations and reassurances;\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003econflict\u003c/strong\u003e \u003cp\u003e\u0026bull; ual: aggression internal and external to the family context; difficulty relating and expressing requests;\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ebroken up: weak intra-family ties; puts the needs of individuals before those of family members and the patient; absent in providing assistance and company to the patient);\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003erejecting: not cohesive; distrustful; devaluing the professionalism of the treatment team.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAs regards the management of anticipatory mourning, during the interviews with the patient, the patient's fears are assessed (fear of physical pain, of the unknown, of judgment, of separation from loved ones, of dependence on the help of others, of feeling of burden, of disfigurement, of loss of control, mental or physical, of loneliness and the fear of them being forgotten).\u003c/p\u003e \u003cp\u003eThe sense of fragility, anxiety and fear linked to the continuous questioning of one's health conditions, the general sense of helplessness and emotional loneliness are also explored. The patient's degree of acceptance is then assessed, with specific reference also to his wishes regarding the dying process and the post-mortem.\u003c/p\u003e \u003cp\u003eSimilarly, during the interview with the caregiver, the degree of awareness and acceptance is assessed, in particular in relation to the caregiver's attitude: actions of \"premature abandonment\", with delegation of all care and care to healthcare personnel, symbiotic attitude, denial of the reality of death, hope in the patient's death and feelings of guilt).\u003c/p\u003e \u003cp\u003eAs part of the condolence conversation, the timing of which is evaluated with the team based on the work done and the problems that have emerged, the presence of disorders that may indicate a difficulty in processing is assessed, partly borrowed from the items indicative of PGD of DSM V:\u003c/p\u003e \u003cp\u003e● Persistent longing/pervasive nostalgia for the deceased person;\u003c/p\u003e \u003cp\u003e● Sadness and intense emotional pain;\u003c/p\u003e \u003cp\u003e● Concern about the circumstances of the death;\u003c/p\u003e \u003cp\u003e● Marked difficulty accepting death;\u003c/p\u003e \u003cp\u003e● Feel disbelief;\u003c/p\u003e \u003cp\u003e● Difficulty in indulging in positive memories regarding the deceased;\u003c/p\u003e \u003cp\u003e● Bitterness or anger;\u003c/p\u003e \u003cp\u003e● Negative self-evaluation;\u003c/p\u003e \u003cp\u003e● Excessive avoidance of memories of the loss;\u003c/p\u003e \u003cp\u003e● Desire to die to remain close to the deceased;\u003c/p\u003e \u003cp\u003e● Difficulty trusting others;\u003c/p\u003e \u003cp\u003e● Feeling of being alone or detached;\u003c/p\u003e \u003cp\u003e● Feeling that life is empty or meaningless without the deceased;\u003c/p\u003e \u003cp\u003e● Confusion about one's role in life, or a diminished sense of one's identity;\u003c/p\u003e \u003cp\u003e● Difficulty or reluctance in pursuing one's interests or making plans for the future;\u003c/p\u003e \u003cp\u003e● Impairment in occupational, social, or other important areas of functioning.\u003c/p\u003e \u003cp\u003e All patients and caregivers gave their consent to the collection of clinical and psychological data emerging during hospitalisation; the study was conducted in accordance with the principles of the Declaration of Helsinki. The Ethics Committee of IOV approved the study and the virtual consultation. Clinical data reported in eCRF were collected anonymously. Continuous data were reported as mean and standard error; proportions and rates were calculated for categorical data. Groups were compared with the chi-square test for categorical variables (the raw P values were adjusted with the Bonferroni method for multiple comparisons). The SPSS 24 software package for Windows (SPSS, Inc., Chicago, IL, USA) was used to manage the database and perform the statistical analysis. The significance level was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all tests.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eIn the period November 2022-November 2023, our Hospice welcomed 144 patients, of which 30 were discharged home with the activation of an exclusive home palliative care programme.\u003c/p\u003e \u003cp\u003eOf the 114 patients followed until death in our Hospice, 60% were male and 40% female. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e describes the patients: malignancies of admission, age and the length of stay in the Hospice.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNeoplastic conditions of patients that died during Hospice recovery, their age class and duration of stay in Hospice. CNS: Central Nervous System.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCANCER (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAGE range (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDURATION OF STAY (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCNS (7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u0026ndash;40 years (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 days (51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e44,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLung (21)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u0026ndash;50 years (6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026ndash;10 days (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGenitourinary (12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u0026ndash;60 years (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u0026ndash;15 days (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale genital system (5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u0026ndash;70 years (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u0026ndash;20 days (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGastrointestinal (31)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71\u0026ndash;80 years (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;21 days (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePancreas (11)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;81 years (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSkin (3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBreast (6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood (11)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding caregivers, the majority were female (66%) moreover the 34% were male. The Fig.\u0026nbsp;2 shows their distribution based on role in the family unit: most caregivers were sons (51%) or spouses (31%). Only 9% were not first-degree relatives or did not belong to the nuclear family (2%). No significant differences in mourning emerge in relation to the family role or the gender of the caregiver.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2.\u003c/b\u003e The figure shows distribution based on role in the family unit: most caregivers were sons (51%) or spouses (31%). Only 9% were not first-degree relatives or did not belong to the family (2%)\u003c/p\u003e \u003cp\u003eNone of the caregivers who had not participated in the pre-entry multidisciplinary interview showed difficulties in grieving during the condolence interview carried out within 1 month of the death of the relative. Instead, the 29% of caregivers who had participated in the pre-entry interview showed difficulties in grieving. Particularly, by evaluating the pathological mourning items according to the DSM V, significant correlations emerge with pervasive nostalgia and disbelief.\u003c/p\u003e \u003cp\u003eFrom the analysis of the condolence conversation, as shown in the Fig.\u0026nbsp;3, among the caregivers who had been psychologically supported during the hospital stay and demonstrated a good level of acceptance of their relative's end of life, a small minority showed problems in grieving (3%) within 1 month of death. The 4% expressed pervasive nostalgia, intense emotional pain, disbelief, 2% perplexity about the circumstances of the death, lack of positive memories, feeling of an empty life, confusion about their role in life, maintaining their interests or identifying their role in the community. None showed excessive avoidance of memories, difficulties with trust and feelings of emotional loneliness.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3.\u003c/b\u003e The figure shows the presence (blue columns) or absence (orange columns) of potential prolonged grief disorders in caregivers with good acceptance of relative's end of life phase, investigated one month after the death with the condolence conversation. Among caregivers with a good level of acceptance of their relative's end of life, a small minority showed problems in grieving (3%) within 1 month of death. The 4% expressed pervasive nostalgia, intense emotional pain, disbelief, 2% perplexity about the circumstances of the death, lack of positive memories, feeling of an empty life, confusion about their role in life, maintaining their interests or identifying their role in the community. None showed excessive avoidance of memories, difficulties with trust and feelings of emotional loneliness\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eProcessing the loss of a loved one is a complex experience and always represents a moment of great fragility. Although everyone can count on their own personal resources and on the support of their own family, the risk of developing a mourning disorder must always be considered [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe model that we propose emphasizes the importance of a multidisciplinary approach: the palliative care physician and the psycho-oncologist co-participate in taking charge of the patient himself and his family unit, actively involving the other assistance figures (nurses and social-health workers). Especially in Hospice, the caregiver, in fact, can count on multidisciplinary support in the processing of anticipatory grief, regardless of the length of hospitalization. Our data support the hypothesis that, faced with the privilege of saying goodbye to relatives, denied to those who are faced with sudden death, everyone's personal resources can however be exhausted in the attempt to offer as much support as possible to the patient while they are alive [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Specific staff training, in a delicate and multifaceted context such as exclusive palliative care, represents the key to adequately taking care of the patient.\u003c/p\u003e \u003cp\u003eOur preliminary data indeed, highlights how a specialized psychological support allows the team to focus on the problems of anticipatory mourning, significantly minimizing the caregivers' risk of pathological mourning. It will then be the team intervention that allows the patient and family to feel welcomed and listened to; furthermore, the possibility of interfacing with multiple professional figures allows us to highlight different facets and grasp a greater number of symptoms, taking advantage of different specific skills.\u003c/p\u003e \u003cp\u003eThe proposal of a condolence conversation within a month of death, borrowing a more classically used model in the management of sudden death, allows us to identify those most at risk and direct them towards specialist support. On the other hand, as evident for the caregivers who did not participate in the pre-entry interview without showing acceptance problems, psychological support must not be offered to everyone without distinction, but only to those who demonstrate the need for it.\u003c/p\u003e \u003cp\u003eIn summary, our model was created to evaluate the protective potential of psycho-oncological caregiver\u0026rsquo;s care from the early stages of hospitalization in the Hospice with respect to the risk of pathological bereavement. As suggested by our data, thanks to the support received from the entire team during the course of hospitalization, many families show excellent coping strategies at the time of death. We then proceed with reinforcement and, if necessary, a review of skills or anything else necessary to face the first days in the absence of your loved one.\u003c/p\u003e \u003cp\u003eIn the model we tested, each caregiver is offered psychological support through semi-structured interviews during the hospitalization of their family member, without however making the interview an obligatory moment or in which the family member must feel obliged to share their feelings and problems. This engagement system, which where possible starts before entering the Hospice with the pre-entry interview, allows coping skills to be assessed and greater support to be offered to those in greater difficulty. Furthermore, the analysis of the problems inherent to anticipatory mourning, conducted with evaluation interviews but without the use of predetermined scales, makes the interview perceived as more informal and therefore more spontaneous.\u003c/p\u003e \u003cp\u003eAlthough the assessment with a condolence conversation within 1 month is not in itself sufficient to diagnose mourning disorder, it allows family members to maintain a channel of communication with the staff who assisted them in a delicate period such as that of the end life of their loved one. It also allows the team to identify the greatest difficulties or vulnerabilities, directing those at risk to competent external psychological support.\u003c/p\u003e \u003cp\u003eAs evident in our sample, the difficulty in formulating the prognosis explains why nearly 30% of hospice patients die in 7 days or less, so a fundamental step is certainly involvement in the care path right from the phases of life prolonging therapies, with early palliative care. From the perspective of early palliative care, in line with international literature [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], we hope to be able to expand this model of care also to patients in active care, also in relation to the difficulty of formulating the prognosis and the care burden growing of the caregiver. Our institute already offers dedicated support to family members, but not strictly connected to the outpatient palliative care unit, a context in which it would be desirable to have a dedicated psycho-oncologist.\u003c/p\u003e \u003cp\u003eThe involvement of the caregiver in the pre-entry interview is certainly an important step to allow an adequate process of anticipatory mourning [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Although our Hospice procedure, in the pandemic and post-pandemic period there are many factors that may have contributed to reducing these possibilities, in accordance with national and international regulations for the prevention of COVID. In accordance with the demographic distribution [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] the majority of patients of our Hospice are over 70 years old and the caregivers are in most cases the patients' sons, often with an active job and heavily burdened by assistance in the patient care process. This is a factor that could partly explain the greater difficulty in participating in pre-entry interviews.\u003c/p\u003e \u003cp\u003eMoreover, given the heterogeneous basic training of physicians who deal with palliative care (oncologists, general practitioners, internal medicine specialists, geriatricians, neurologists and others), it is also worth considering the possibility that different basic trainings, despite the targeted specialist training, underlie different sensitivities and attitudes which may or may not lead to the valorization of the interview as a moment of care and therefore to push for the interviews to be as multidisciplinary as possible and involve the caregiver, even in the face of the organizational difficulties that may arise.\u003c/p\u003e \u003cp\u003eThe heterogeneity of the outcomes of the procedures based on specialist training is a fact already known in other settings, which would also be interesting to study in palliative care [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurely, the objective of our working group is to make the care of the patient and his family as homogeneous as possible, to guarantee adequate support for everyone.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eDespite the numerous limitations (such as the small sample, the reduced involvement of caregivers in the pre-entry interview, the percentage of patients with hospital stays of less than a week) the preliminary data of our study clearly suggests the protective potential of multidisciplinary support, particularly in the risk of developing grief processing disorders. These considerations encourage us to implement our model of clinical and psychological support system and develop paths dedicated to caregivers in greater difficulty. Further studies are underway to create an ad hoc form for psycho-oncological management in Hospice and we hope there will be the possibility of implementing this model by also extending it to management in simultaneous palliative care, adequately preparing patients and their caregivers in the perspective of a shared path.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization, I.G. and M.L; methodology, I.G, M.L, A.F.; software, M.L.; validation, M.L, A.F.; formal analysis, M.M.; investigation, I.G, M.L. M.M, C.M.; data curation, M.L and E.R; writing\u0026mdash;original draft preparation, E.R, I.G, M.L.; writing\u0026mdash;review and editing, E.R, A.F F.F; visualization, I.G, M.M, C.M, M.P.; supervision F.F.; project administration, E.R.; funding acquisition, M.P. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to partecipate:\u0026nbsp;\u003c/strong\u003eThe study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of\u0026nbsp;Veneto Institute of Oncology IOV\u0026ndash;IRCCS, Padua, Italy (L04P10). informed consent was obtained from all subjects and/or their legal guardian(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eall subjects and/or their legal guardian(s) give their informed consent for publication of identifying information/images in an online open-access publication\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSep\u0026uacute;lveda C, Marlin A, Yoshida T, Ullrich A. 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Laryngoscope. 2007;117(4):699\u0026ndash;705. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MLG.0b013e318031c817\u003c/span\u003e\u003cspan address=\"10.1097/MLG.0b013e318031c817\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"palliative care; multidisciplinary, grief, anticipatory mourning, Hospice care, psychological support","lastPublishedDoi":"10.21203/rs.3.rs-3969736/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3969736/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBereavement is a physiological process of great importance in palliative care; grief-processing disorders can be diagnosed after at least 6 months after death and have severe clinical or psychological consequences. Aim of the study is to verify how adequate management of anticipatory mourning and condolence conversation in the early grief stages can be protective.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients and caregivers are supported by the multidisciplinary team by semi structured interviews. In condolence conversation within 1 month of the death, we identify elements of suspicion of psychological fragility that require support for an adequate processing of the loss.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom condolence conversation, only 3% of the caregivers who had been psychologically supported during the hospital stay and demonstrated a good level of acceptance of their relative's end of life, showed problems in grieving within 1 month of death; none showed excessive avoidance of memories, difficulties with trust and feelings of emotional loneliness.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite the limitations, the preliminary data of our study clearly suggests the protective potential of multidisciplinary support, particularly in the risk of developing grief processing disorders. These considerations encourage us to implement our model of clinical and psychological support system and develop paths dedicated to caregivers in greater difficulty.\u003c/p\u003e","manuscriptTitle":"Management model of caregiver’s grief in a tertiary oncological center Hospice: from anticipatory mourning to condolence conversation: preliminary observations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-22 19:36:51","doi":"10.21203/rs.3.rs-3969736/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-02-20T08:29:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-20T06:07:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-20T06:07:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2024-02-19T10:30:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed019ea0-fd8c-4416-90ee-218340662d57","owner":[],"postedDate":"February 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:11:40+00:00","versionOfRecord":{"articleIdentity":"rs-3969736","link":"https://doi.org/10.1186/s12904-024-01620-2","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2024-12-20 15:58:05","publishedOnDateReadable":"December 20th, 2024"},"versionCreatedAt":"2024-02-22 19:36:51","video":"","vorDoi":"10.1186/s12904-024-01620-2","vorDoiUrl":"https://doi.org/10.1186/s12904-024-01620-2","workflowStages":[]},"version":"v1","identity":"rs-3969736","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3969736","identity":"rs-3969736","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}