Nancy Preston

Background: The burden of cancer is rising in low- and middle-income countries (LMICs), where social determinants, limited access to treatment, and inadequate palliative care amplify suffering. With most unmet palliative care needs concentrated in LMICs, strengthening palliative care in these settings is a moral and health systems imperative. This study aimed to develop a roadmap for palliative care development in LMICs. Methods: A theory of change framework was used to explore palliative care development in LMICs as it enabled mapping of complex, interacting elements and their impact on meaningful change. Stakeholders were recruited through purposive and snowball sampling via the research team’s professional networks, and included physicians, nurses, public health experts, and community participants. Eight virtual workshops addressed key elements of the theory of change framework: impact, outcomes, preconditions, interventions, and assumptions. Data from workshop transcripts, online chats, and facilitator meetings were analysed iteratively using consensus-driven theory-informed approach to map the causal pathway. Results: Twenty-one stakeholders from three continents participated in eight facilitated workshops. Stakeholders emphasised integration of palliative care into health systems as central to its development and essential for mitigating cancer-related suffering. The desired outcome was comprehensive, sustainable, and culturally relevant palliative care. Fourteen preconditions, 21 interventions, and 12 assumptions were identified and mapped onto the causal pathway. Conclusion: The theory of change approach facilitated the creation of contextually grounded stakeholder-informed roadmap for palliative care development in LMICs, achievable through integration within existing health systems. Future efforts should concentrate on testing the implementation, feasibility and impact of this roadmap across diverse LMICs.

Background: International adaptation of healthcare interventions requires sensitivity to local contexts, especially in palliative care, where healthcare systems and cultural expectations about end of life differ widely. Pal-Cycles is an intervention that aims to improve transitions in care for patients with advanced cancer. This intervention was adapted for implementation in a stepped wedge trial across seven European countries (Germany, Hungary, the Netherlands, Poland, Portugal, Romania and the UK). This paper aims to illustrate the process of adapting a palliative care intervention (Pal-Cycles) to meet the needs of those using healthcare settings across seven European countries. Methods: Adapted nominal group techniques (a structured group method that supports idea generation, discussion, and prioritisation) were used, involving both in-country and cross-country adaptation meetings focused on the five key components of the original intervention design, to ensure cultural sensitivity and best fit All countries established a group of clinicians and all except two countries (Portugal and Hungary) involved groups of patients and families. The adaptation process occurred in a series of 5 meetings, which were mostly held online to accommodate participants’ schedules. Results: A total of 36 clinicians, 14 patients or family members, and 16 facilitators participated in the adaptation process over a four-month period. Structured guidance and iterative consultation meetings ensured that the final intervention was both standardised and adaptable to each country’s healthcare setting. We produced a standardised intervention manual based on a theory of change model, ensuring consistency across countries while allowing for contextual flexibility. Conclusions: This paper provides guidance for future cross-cultural adaptation of palliative care interventions, illustrating the value of detailed methodological planning, structured guidance, and multi-stakeholder engagement in the adaptation process. Trial registration: ClinicalTrials.gov NCT06259136, registered on 6 February 2024.

Adapting complex healthcare interventions for use across diverse healthcare systems requires balancing fidelity to core components with responsiveness to l

Background: Since December 2022, the National Health Service (NHS) has experienced large-scale strikes by staff. The NHS cancels approximately 12 million elective care appointments each year, and around 1 million elective appointments were cancelled due to strikes between 2022 and 2024. During strikes, emergency care is prioritised, and it has been claimed that emergency departments (EDs) run ‘better than usual’. The aim of this study was to investigate changes in patient flow into hospitals through the ED during the strike periods. Methods: Cox proportional hazards modelling was applied to data from two different EDs in the north-west of England to model time between patient arrival at the ED and their subsequent admission. Systematic (linear temporal trend, yearly seasonality, daily seasonality, weekends, ED ‘heat’) and patient/presentation-level factors (urgency, service referred to, patient age, ethnicity and gender) were controlled for. The impact of different striking professions on patient time to admission was investigated using HRs, where a higher HR indicated faster admission. Results: Over the analysis period, we observed 61 separate strike days: 40 junior doctor strike days, 11 nursing days, 10 consultant days and 7 ambulance days. Junior doctor and consultant strikes coincided on 4 days. For the type 1 ED, median time to see a clinician was similar on strike and non-strike days (median 2 hours 27 min on strike days (IQR: 1 hour 2 min to 4 hours 53 min), 2 hours 27 min on non-strike days (IQR: 1 hour 5 min to 5 hours 14 min)). Patients were admitted through the ED more quickly on both the junior doctor and consultant strike days compared with non-strike days (HRs: 1.12, 1.28, both p≤0.001). This increased flow was only seen while consultants were striking in the type 2 smaller ED. Conclusions: These findings suggest that the improved patient flow observed on strike days could be driven by the additional inpatient capacity created through the postponement of elective care. This result indicates that NHS hospital systems could potentially be adjusted to enhance turnaround times and reduce ED crowding.

Background/Objectives: Conversations about end-of-life care or advance care planning are often difficult and emotionally challenging to initiate. Tailoring messages to the specific audiences can make these sensitive discussions more manageable and effective. The Evidence-based Model for the Transfer and Exchange of Research Knowledge (EMTReK), compromising six core components (message, stakeholders, processes, context, facilitation, and evaluation) offers a structured framework for research dissemination and knowledge transfer in palliative and long-term care settings. Knowledge translation bridges research and practice, with its effectiveness depending on stakeholder engagement, tailored communication, and systematic application of evidence in policy and practice. This study explores stakeholder perspectives on a dementia care intervention, using EMTReK as an analytical framework to examine how knowledge transfer and exchange (KTE) actions were implemented across long-term care settings. Methods: A qualitative analysis was conducted on primary data comprising case narratives from multinational research groups involved in the “Caregiver Decision Support” (mySupport) study (2019–2023). Teams from Canada, the Czech Republic, Ireland, Italy, the Netherlands, and the United Kingdom evaluated the mySupport intervention through interviews, with analysis guided by components of the EMTReK model. Results: Facilitated Family Care Conferences were found to be effective mechanisms for supporting knowledge transfer and intervention uptake in dementia care across nursing homes in Europe and Canada. Despite challenges posed by the COVID-19 pandemic, Family Care Conferences adapted through stakeholder engagement, interactive learning, and innovative communication methods. Using EMTReK as an analytical framework, the research team identified key elements that contributed to successful implementation, including the importance of flexibility to accommodate local contexts. Conclusions: The transnational application of the EMTReK model for advance care planning in long-term dementia care highlights the importance of tailored, culturally relevant knowledge translation strategies, which, despite challenges from the COVID-19 pandemic, were successfully implemented through local adaptations and diverse dissemination methods, emphasising the need for further research on their impact on resident and family outcomes.

Background: High-quality recommendations require rigorous methods based on strong evidence to improve clinical practice. In palliative and end-of-life care, expert consensus is sometimes achieved through nominal group techniques. However, its practical challenges are often underestimated, potentially compromising the rigour and the quality of the recommendations. Methodological reflections: The methodological reflections on developing recommendations using the nominal group technique are discussed in this paper. These reflections are drawn from its theoretical foundations and applications in palliative care research, including a Taiwanese study on preparing families for a relative’s death. We highlight key issues such as the omission of pilot meetings and the underestimation of practical challenges in conducting group meetings, including time constraints and real-world uncertainties, especially during the stages of listing, clarifying, voting and ranking recommendations. Cultural factors are often overlooked, as seen in the example study, where the moderator avoided interruptions to show respect and politeness during the meeting. Additionally, valuable data gathered during meetings is often underutilised. These factors collectively can undermine the quality of recommendations. Based on these insights, we offer suggestions for improvement. Key suggestions: Pilot meetings should be conducted and reported to demonstrate how they inform the main meeting, ensuring research rigour and recommendation quality. Sufficient time should be allocated for listing and clarifying recommendations and in societies with specific etiquettes (e.g. minimising interruptions to show politeness). Further qualitative analysis of meeting transcripts is suggested to better understand the context and rationale behind the recommendations and enhance their applicability and clarity.

Background/Objectives: Studies have shown that healthcare providers struggle to discuss difficult end-of-life issues, including palliative sedation (PS), with patients and relatives. This qualitative study aimed to evaluate communication challenges related to PS among healthcare providers in eight European countries. Methods: In each country, two clinical settings providing palliative care were selected. Two moral case deliberation (MCD) sessions were conducted, each with 3 to 9 palliative healthcare professionals (HCPs). They discussed patient cases involving PS and refractory symptom management. Sessions were audio-recorded, transcribed, anonymized, and analyzed using a framework analysis. Results: Key issues included core communication values—open, empathetic, and honest dialogue—which were consistent across countries but varied in practice. In The Netherlands, Germany, Belgium, and the UK, communication prioritized patient autonomy through timely discussions and family dialogue. In Spain and Italy, family-centered communication approaches predominated, while in Romania and Hungary, tendencies for selective disclosure were also evident, along with delegated decision-making and complex family dynamics. Certain challenges reflected professional experience rather than national culture. Nurses mediated across contexts, while terminology surrounding palliative sedation remained a source of ambiguity. Conclusions: This is the first study to present HCPs’ perceptions of communication issues related to PS across Europe. Despite variations between settings, consistently open dialogue among patients, families, and HCPs emerged as the most valued element. These findings highlight the need to better understand how end-of-life communication about PS varies in practice and underscore the importance of considering healthcare providers’ real-world experiences to improve communication with patients and families.