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Supplemental material, sj-pdf-2-pmj-10.1177_02692163221099584 for How effective is virtual reality technology in palliative care? A systematic review and meta-analysis by Jiping Mo, Victoria Vickerstaff, Ollie Minton, Simon Tavabie, Mark Taubert, Patrick Stone and Nicola White in Palliative Medicine

Supplemental material, sj-pdf-1-pmj-10.1177_02692163221099584 for How effective is virtual reality technology in palliative care? A systematic review and meta-analysis by Jiping Mo, Victoria Vickerstaff, Ollie Minton, Simon Tavabie, Mark Taubert, Patrick Stone and Nicola White in Palliative Medicine

Background: Patients treated in the community and in hospitals may be offered transfer to a hospice for symptom management . Many of these patients may be unfamiliar with this setting, and some may feel anticipatory fear of this unknown environment. Our cancer centre uses Virtual Reality headsets and 360 degree photo/video technology on a digital media pad (tablet computer) to give patients a digital tour of what the regional hospices look like, in order to help decision making.\udAims: To evaluate whether the use of a 360 degree visual tour of the local hospices, similar to what estate agents may offer for virtual house viewings, is useful to patients and whether it is easily implementable. To explore whether it impacts on palliative care patient perception. \udMethods: 360 degree filming and high resolution photography were undertaken as part of a quality improvement project in key areas of two local hospices, and uploaded to hospital and hospice websites, headsets and media pads. An online survey was created to assess the patient experience of the 360 degree digital views. Over a 6 month period, patients on the ward in the hospital who were willing to participate, known to the palliative care team, and/or who had an active hospice referral in place were offered a digital tour. \udResults: Of 25 patients, 90% felt more informed about hospices after seeing the 360 degree views. 95% of patients stated they would recommend the digital hospice tour to other patients. All preferred the electronic 360 degree tour to the paper patient information leaflets. Staff members felt the 360 degree photo tour was easily integrated into their day-to-day work.\udConclusions: The use of 360 degree hospice views can make a significant difference to patient perception of what hospices look like and addresses the fear of the unknown. Whilst this evaluation was conducted prior to Covid-19, the use of the electronic media tour of hospices went up significantly in our inpatient unit during the pandemic, due to patients and relatives not being able to visit the hospice prior to deciding on relocation to this setting.

Background: Simulation & high-fidelity simulation involves using manikins, clinical training suites, wards, computer programs and theatres in medical teaching. These teaching formats have established themselves in medical undergraduate and postgraduate education. Rated highly among students, they have also been shown to be effective learning tools.\ud Aims: To reduce the potential risk to patients and their proxy associated with learning ‘at the bedside’, which can pose a challenge in medical and in particular palliative settings. Education and training methods that do not expose patients to preventable communication blunders from less experienced practitioners are a priority. Simulation and high-fidelity simulation provides a way for students and doctors to train safely, before entering real-life scenarios.\ud Methods: We provide a summary review on the current literature and evidence for simulation and high-fidelity simulation in palliative and end-of-life care settings, and discuss potential uses of technologies including virtual and augmented reality in future training.\ud Results: The most common form of simulation in palliative medicine is often an actor-based role-play scenario with particular emphasis on communication skills. This is expensive and time-consuming to set up. Less evidence was found on the use of high-fidelity simulation in end-of-life care teaching.\ud Conclusion: Palliative medicine has been slow to adapt to an educational method and environment that now is widely used across other areas of healthcare. There has been less emphasis on training with manikins and even less on using computer simulation and virtual reality environments to recreate challenging end-of-life care scenarios. We provide some examples of where this could benefit the curriculum.

Aims: In Wales, the Advance & Future Care Planning (AFCP) strategic group oversees the national direction for advance care planning. The aim is to establish a peer-supported campaign to effectively inform people about AFCP. The group includes patient representation and has had a strong focus on promoting person-centred AFCP via new media.\ud Methods: Several social media campaigns, for instance #TalkCPR, #FutureCarePlanning & #WhatMattersMost, have been led & co-directed by technology-savvy patients & carers. YouTube videos on the complexities of resuscitation & AFCP education have been co-created by patients. Apps, websites, YouTube channels & hashtags were created including https://advancecareplan.org.uk, www.wales/nhs.uk/DNACPR, #TalkCPR & http://talkcpr.com. Patient groups helped write scripts for explanatory videos. A national conference in 2019 further helped to set direction. Resources have been accessed over a million times, including countries like Lesotho.\ud Results: The online content has had a worldwide reach & highlighted Welsh advance care planning materials. As an example, a patient wrote about the resources on a medical journal site, “Twitter helped me decide that I’m not for resuscitation” in the BMJ ‘What your patient is thinking’ series. The article was downloaded over 10,000 times, with readership breakdown of 61% members of public, 29% practitioners, 8% scientists & 1% journalists.

At the start of the pandemic there was a clear need to prepare and equip care settings with the knowledge, skillsets and in some cases the technology to allow patients to say “goodbye” to their loved ones and reduce feelings of social isolation. ‘Using Skype and video messaging apps during pandemic isolation’ was written by James Norris and Professor Mark Taubert and published on 15th March 2020. \udResults: The tutorial was highly accessed and received a positive response from care professionals. It was listed in the European Association for Palliative Care (EAPC)’s "Coronavirus and the palliative care response" resources. The International Association for Hospice and Palliative Care (IAHPC)’s ‘Resources relevant to Palliative Care and COVID-19’ also featured this step-by-step tutorial. The tutorial encouraged conversations around the importance of connecting virtually, when visits cannot take place a pandemic situation. A campaign called ‘Tablets Against Loneliness’ was launched to improve uptake in this area. The campaign’s aim was to raise awareness at the start of the pandemic about using video calling technologies, sharing a basic framework and to provide technical support for care settings when using video calling technologies. Social distancing guidelines meant that many funerals took place with a small number of attendees and some funerals in the UK were postponed. A framework for funeral directors and funeral director associations was launched by the Digital Legacy Association. Funeral director associations should include virtual funeral conversations as part of their service when severe social distancing measures are in place. Conclusion / lessons learned: A BMJ SPC tutorial acted as a snowball for advocacy, change and collaboration.

Background: Patients referred to a hospice may feel trepidation about this unknown environment, and the word hospice can carry stigma for some. Virtual Reality (VR) applications allow users to feel present and become immersed in a realistic computer-generated environment and are used for instance by estate agents for house viewings. Our cancer hospital in Cardiff uses 360◦ photo/video technology on tablet computers to give patients a ‘digital tour’ of two regional hospices.\ud Aims: To evaluate whether the use of these 360◦ walkthrough tours of local hospices is acceptable to patients/proxy and readily implementable within a clinical environment.\ud Methods: 360◦ filming/photography was undertaken in two local hospices & uploaded to hospital media pads. An online survey was created to assess patient experience. Patients on the ward for whom a hospice referral was suggested by the MDT were offered this digital tour and were included in this survey. Staff were asked whether it was easy to use.\ud Results: Of 25 patients, 90% felt the 360◦ tour improved their readiness for hospice transfer. Also, 95% of patients stated they would recommend it to other patients being referred to hospices. All patients/proxy found it acceptable. Staff felt the 360◦ tour was easily integrated into their work, and preferred using tablet computers over VR headsets.\ud Conclusion: The technological use of 360◦ hospice photographic views as an introduction to the hospice infrastructure can make a difference to patients and addresses the fear of an unknown environment. Integration of this innovative technology into the clinical environment is feasible and appears acceptable to patients. Creating 360◦ imagery in local hospices was not technologically difficult, but is aided by availability of staff interested in digital media. Furthermore, informal hospice visits ceased during the Covid-19 pandemic, driving up the usage of these virtual tours significantly.

Background Social media (SM) have altered the way we live and, for many, the way we die. The information available on even the rarest conditions is vast. Free from restrictions of mobility, time and distance, SM provides a space for people to share experiences of illness, death and dying, and potentially benefit from the emotional and practical support of others n similar positions. The communications that take place in these spaces also create large amounts of ‘data’ which, for any research centre, cannot be ignored. However, for a palliative care research centre the use of this ‘data’ comes with specific ethical dilemmas. \ud \ud \ud Methods This paper details the process that we, as a research, went through in constructing a set of ethical guidelines by which to work. This involved conducting two consensus days; one with researchers from within the centre, and one with the inclusion of external researchers with a specific interest in SM. \ud \ud \ud Results The primary themes that emerged from the consensus meetings includes; SM as a public or private space; the status of open and closed groups; the use of historical data; recruiting participants and obtaining informed consent and problems of anonymity associated with dissemination. \ud \ud \ud Conclusions These are the themes that this paper will focus on prior to setting out the guidelines that we subsequently constructed.

Background: Virtual reality immersive environments have been shown to be effective in medical teaching. Our university hospital received funding from our deanery to film teaching videos with a 360 degree camera.\ud \ud Aims: Evaluate whether Virtual Reality is an effective teaching environment. Virtual Reality headsets were set up for medical students who rotated through Velindre Cancer Hospital’s Palliative Care department.\ud \ud Methods: Students watched a 27 minute video on nausea & vomiting in palliative care settings in a virtual tutorial space. They subsequently viewed a radiotherapy treatment experience.\ud \ud Results: Of the 72 medical students who participated, 70 found the experience comfortable, with 2 students stating they found it uncomfortable (tight headset, blurry visuals). Numerical scoring on ability to concentrate in VR from 0-10 (0=worst, 10=best) scored an average of\ud 8.44 (range 7-10). Asked whether this format suited their learning style, average score was 8.31 (range 6-10). 97.2% (n=70) students stated that they would recommend this form of learning to a colleague, with 1 student saying he/she would not recommend and 1 student stating he/she was unsure. Students left positive & negative free text comments which helped frame future needs in this emerging area and will be presented.\ud \ud Discussion: This study indicates that there is room for exploring new ways of delivering teaching and expanding it more widely in palliative care, but also provides feedback on areas that need further careful attention. Comments from students included: “Might have been the novelty factor but I learned more from this 20 minute VR thing than I have from many lectures”\ud \ud Summary: The project has proved so popular in medical student feedback that the VR experience is now available on Youtube & has been expanded to routine teaching. It has been viewed worldwide incl Africa, so this format of teaching could prove valuable and promising in its potential for global reach.