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Context: The COVID-19 pandemic presented unique challenges for health care systems. Overcrowded units, extreme illness severity, uncertain prognoses, and mistrust in providers resulted in a "pressure cooker" where traditional communication strategies were often insufficient. Objectives: Building on well-studied traditional communication interventions, neurobiology principles were used to create a novel communication strategy designed in the COVID-ICU to respond to the unique communication needs of patients within the context of a high mistrust setting. Methods: The hierarchy of communication needs recognizes three specific levels of communication that are essential within high-emotion and low-trust settings. The first level is to establish trust. The second level is to resonate with patients' emotions, helping to reduce arousal and improve empathy. The third level includes the more traditional content of disclosing prognostic information and shared decision-making. When facing communication challenges, clinicians are taught to move back a level and reattune to emotions and/or reestablish trust. Discussion: The COVID pandemic revealed the shortcomings of a primarily cognitive communication style. The hierarchy of communication needs emphasizes trust building, and emotional resonance as prerequisites of effective cognitive discussions, resulting in more effective clinician-patient communication that more fully incorporates cultural humility and better meets the needs of diverse patient populations. Additional research is needed to further develop this strategy and evaluate its impact on patient experience and outcomes.

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Context: The majority of people with serious health-related suffering in low- and middle-income countries lack access to palliative care (PC). Increased access to PC education is greatly needed. Objectives: This paper describes the process to adapt an advanced PC training course for a Chilean context. Methods: A joint team of intercultural PC educators from the US and Chile conducted a series of key informant interviews and a target audience survey to iteratively design a PC training course in Chile. Results: Eight key informant interviews identified a strong need for formal PC education pathways, confirmed the five central learning domains, and helped to identify potential course sub-topics. A target audience survey of 59 PC providers from across Chile confirmed a strong desire to participate in such a course. Conclusion: Our team of intercultural PC educators adapted an advanced PC course to the unique context of Chilean providers.

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BACKGROUND: Using a validated instrument to measure palliative care (PC) educational needs of health professionals is an important step in understanding how best to educate a well-versed PC workforce within a national health system. The End-of-life Professional Caregiver Survey (EPCS) was developed to measure U.S. interprofessional PC educational needs and has been validated for use in Brazil and China. As part of a larger research project, this study aimed to culturally adapt and psychometrically test the EPCS among physicians, nurses, and social workers practicing in Jamaica. METHODS: Face validation involved expert review of the EPCS with recommendations for linguistic item modifications. Content validation was carried out by six Jamaica-based experts who completed a formal content validity index (CVI) for each EPCS item to ascertain relevancy. Health professionals practicing in Jamaica (n = 180) were recruited using convenience and snowball sampling to complete the updated 25-item EPCS (EPCS-J). Internal consistency reliability was assessed using Cronbach's [Formula: see text] coefficient and McDonald's [Formula: see text]. Construct validity was examined through confirmatory factor analysis (CFA) and exploratory factor analysis (EFA). RESULTS: Content validation led to elimination of three EPCS items based on a CVI < 0.78. Cronbach's [Formula: see text] ranged from 0.83 to 0.91 and McDonald's [Formula: see text] ranged from 0.73 to 0.85 across EPCS-J subscales indicating good internal consistency reliability. The corrected item-total correlation for each EPCS-J item was > 0.30 suggesting good reliability. The CFA demonstrated a three-factor model with acceptable fit indices (RMSEA = 0.08, CFI = 0.88, SRMR = 0.06). The EFA determined a three-factor model had the best model fit, with four items moved into the effective patient care subscale from the other two EPCS-J subscales based on factor loading. CONCLUSIONS: The psychometric properties of the EPCS-J resulted in acceptable levels of reliability and validity indicating that this instrument is suitable for use in measuring interprofessional PC educational needs in Jamaica.

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CONTEXT: The vast majority of people with serious health-related suffering in low- and middle-income countries lack access to palliative care (PC). In Latin America, this shortage is critical, and PC education is greatly needed. OBJECTIVES: This study aims to assess the effects of an advanced PC diploma course in Chile through assessment of participants' satisfaction, knowledge, behavior, and self-efficacy. METHODS: We developed and implemented a 12-day, hybrid-setting, advanced PC diploma course for Latin American clinicians and collected and analyzed pre course, immediate post course, and 6-month post course quantitative and qualitative data on satisfaction, knowledge, behaviors, and self-efficacy. RESULTS: Thirteen Latin American doctors participated in this advanced PC diploma course. Overall knowledge and self-efficacy increased post course. One hundred percent of participants described the course as "very high quality" or "high quality," described the course's teaching methods as "very easy to understand" or "easy to understand," and ranked role-play as a "very useful" tool. CONCLUSION: There is a critical shortage of PC in Latin America where PC education is greatly needed. The lessons learned from this pilot advanced PC diploma course will inform further PC educational development in Latin America. The results of our course assessments show that an advanced diploma course can increase participants' PC knowledge, behaviors, and self-efficacy with a goal of leveraging the Train the Trainer model to increase PC educational leadership and enable training at participants' home institutions.

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CONTEXT: The majority of people in need of palliative care (PC) in low- and middle-income countries lack access to it and suffer unnecessarily as a consequence. This unmet need is due, in part, to the lack of trained PC providers. OBJECTIVES: This study aims to assess the effects of regional training in PC for doctors, nurses, and pharmacists in the Caribbean through assessment of participant satisfaction, anticipated course impact on participants' clinical practice, barriers to changing practice, and perceived course impact on achievement of key PC milestones. METHODS: We created and taught a course in basic PC for clinicians from the Caribbean region and collected and analyzed postcourse quantitative and qualitative data on satisfaction and expected impact. RESULTS: Eighty-three clinicians from five Caribbean countries participated in this workshop. Thirty participants completed the post-course survey. One hundred percent of these participants ranked the quality of the course as "very high quality" or "high quality." The majority of participants anticipated changing their practice as a result of this course. Several barriers were reported, including lack of formal PC training in participants' home countries. Results of participants' retrospective pre- and postcourse self-assessment for achievement of key PC milestones showed a statistically significant mean increase of at least one point on the seven-point Likert scale for each milestone. CONCLUSION: Overall satisfaction with the course was high, and self-assessed competency in PC improved. These data suggest that an intensive training over several days is an effective format for increasing providers' perceived efficacy in delivering PC.

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BACKGROUND: Formal recognition of palliative medicine as a specialty has been one of the main drivers in the development of palliative care. AIM: To provide a comparative, comprehensive overview on the status of palliative medicine as medical specialty across Latin America. METHODS: We conducted a comparative study of 19 Latin American countries. Key informants and persons in charge of the specialization training programs were identified and interviewed. We collected data on general recognition as specialty (title, process of certification) and on training program characteristics (title, start year, requirements, training length, and type full time or part time). RESULTS: Eight of 19 countries (42%) Argentina, Brazil, Colombia, Costa Rica, Ecuador, Mexico, Paraguay and Venezuela reported palliative medicine as medical specialty. Thirty-five (sub)specialization training programs in palliative medicine were identified in the region (eight as a specialty and 27 as a subspecialty), the majority in Colombia (43.5%) and Brazil (33.7%). A total of 20% of the programs have yet to graduate their first cohort. Length of clinical training as specialty varied from two to four years, and from 520 hours to three years for a subspecialty. CONCLUSION: Despite long-standing efforts to improve quality of care, and significant achievements to date, most Latin American countries have yet to develop palliative medicine as medical specialty. Specialty and sub-specialty training programs remain scarce in relation to regional needs, and the programs that do exist vary widely in duration, structure, and content.

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Individuals in low-income and middle-income countries (LMICs) account for approximately two-thirds of cancer deaths worldwide, and the vast majority of these deaths occur without access to essential palliative care (PC). Although resource-stratified guidelines are being developed that take into account the actual resources available within a given country, and several components of PC are available within health care systems, PC will never improve without a trained workforce. The design and implementation of PC provider training programs is the lynchpin for ensuring that all seriously ill patients have access to quality PC services. Building on the Breast Health Global Initiative's resource-stratified recommendations for provider education in PC, the authors report on efforts by the Jamaica Cancer Care and Research Institute in the Caribbean and the Universidad Católica in successfully developing and implementing PC training programs in the Caribbean and Latin America, respectively. Key aspects of this approach include: 1) fostering strategic academic partnerships to bring additional expertise and support to the effort; 2) careful adaptation of the curriculum to the local context and culture; 3) early identification of feasible metrics to facilitate program evaluation and future outcomes research; and 4) designing PC training programs to meet local health system needs.

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