Background There is growing interest in poetry as a healing modality within healthcare.[1,2] Poetic Medicine is a therapeutic process offering a defined and structured format in which participants listen to and write poetry in community.[3] Although widely practiced, few poetry-based interventions have been systematically evaluated for bereaved populations. This pilot aimed to address that gap by developing and studying a standardized Poetic Medicine model designed for grief support.[3] Objective To evaluate the feasibility, acceptability, and psychological impact of a virtual Poetic Medicine intervention for bereaved individuals. Methods Developed by an interprofessional team with expertise in palliative medicine and Poetic Medicine, the pilot included three cohorts of bereaved individuals from diverse communities. Participants attended three 60-minute virtual sessions following a structured format of listening, reflecting, and writing poetry, with the option to share aloud. All facilitators were trained by the UCSF MERI Center to ensure a consistent, supportive approach. Participants provided pre-intervention demographics, post-session Likert evaluations, and pre-/post-intervention validated scales assessing depression, anxiety, grief, loneliness, hope, resilience, and spiritual well-being. Paired analyses compared pre- and post-scores using two-tailed tests; qualitative feedback was reviewed for thematic insights. Results Forty-eight participants engaged; 41 completed post-evaluations and 37 completed pre-post scales. Ninety-seven percent were somewhat or extremely likely to recommend the workshops, and over 70% reported the sessions helped them cope with grief. Pre-post testing showed significant decreases in depression (PHQ-8, p=0.009) and anxiety (GAD-7, p=0.03), and increases in resilience (BRCS, p=0.005) and spiritual well-being (FACIT-Sp meaning p=0.04; peace p=0.02). Qualitative themes emphasized connection, shared humanity, and safe expression of emotion. Conclusions Poetic Medicine is a feasible, scalable, accessible, and creative intervention that meaningfully supports bereaved individuals from diverse settings and backgrounds. Findings demonstrate high satisfaction and measurable improvements in psychosocial outcomes, advancing evidence-based approaches to addressing grief and emotional suffering in palliative care.

Patients with serious medical illnesses may respond to the challenges of their illness in unique ways, shaped by personal, relational, and contextual factors. For many patients, depression and anxiety are common and may feature avoidance or withdrawal, negative expectations for outcomes, repetitive negative thinking (rumination and/or worry), sad mood, and/or irritability. These symptoms often arise from a complex and bidirectional interplay between a patient's emotions, thoughts, and behaviors. This dynamic system provides clinicians with multiple, clinically actionable entry points to foster patient engagement in treatment and coping with serious illness. This article illustrates how core principles from cognitive behavioral therapy (CBT) can inform serious illness communication, adapted for use by general palliative care clinicians in appropriate clinical contexts. Using a composite clinical case, we demonstrate the use of CBT principles as a way of organizing our clinical understanding of a patient who is feeling "stuck," from which CBT-informed techniques, such as guided discovery, cognitive restructuring, and behavioral experiments, can be implemented to reduce distress and promote adaptive coping.

Background/Rationale Psychological and psychiatric care is a core domain of palliative care. All team members have a responsibility to support this care domain, but training is variable for hospice and palliative medicine (HPM) physicians. Our recent project (1) delineated high-priority competencies within this domain using a two-phase modified Delphi process (interdisciplinary-expert-panel-generated initial competencies, prioritization by purposively-sampled-physician-panel 2-round voting). We observed a slightly higher proportion of prioritized competencies on psychiatric disorders (Category B) than on psychological foundations of serious illness (Category A). Objectives/Purpose We sought to determine whether senior voting panel members prioritized primary mental health competencies in a way that more highly represented normative psychological elements. Methods We dichotomized the voting panel into senior (>15 years post-training) and more-junior groups. We scored each group’s voting to compare their round-1 screened-in competency lists. Results Senior panelists (n=13) prioritized more Category-A items than more-junior panelists (n=23): 11 of 18 proposed Category-A items (61%) vs 3 of 18 (17%). Senior members also prioritized more items overall in Round-1 voting: 64% vs 32% of potential Category-B items and 75% vs 12.5% of potential Category-C items (system-based practice). Within Category B, senior panelists screened-in more items on psychotherapeutic interventions than junior panelists (6 vs 1), but similar numbers of pharmacologic-intervention items (5 vs 4). Many items highly prioritized in Round-1 voting by senior panelists were ultimately included in the final list after full-panel Round-2 voting (7 Category-A items [39%], 20 Category-B items [45%], and 5 Category-C items [62.5%]). Conclusion/Implications Secondary analysis of voting in an expert-developed, consensus-prioritized primary mental health competency project suggests that more-experienced HPM physicians are more likely to rate potential mental health competencies as high-priority on first-pass, particularly for items that related to psychological-mindedness and interdisciplinary-team collaboration. These differences could suggest priority-shifts during a career in HPM, potentially relevant to sustainable practice.

Serious illness threatens both the body and the self: the coherent, continuous sense of who one is, from bodily integrity to psychosocial identity. When illness disrupts identity and patients confront mortality and dependence, a range of responses may follow, including behaviors such as relentless demands, devaluation of clinicians, insistence on additional treatment, or rage at perceived care failures. These presentations are often labeled "narcissistic," yet such a formulation can foreclose clinical understanding. Heinz Kohut's self psychology offers a more generative framework: one that understands these behaviors as attempts to preserve self-cohesion when illness threatens identity, autonomy, competence, and roles. Because needs for recognition, connection, and reliable support persist throughout life, serious illness often exposes vulnerabilities that were previously stabilized through work, relationships, and social roles. Informed by self psychology's core concepts-self-object needs, mirroring, idealizing, twinship, and empathic attunement-this paper presents practical serious illness communication tools designed to reduce interpersonal conflict, strengthen therapeutic alliance, and support patients in maintaining a coherent sense of self as illness progressively reshapes what is possible.

Patients with serious illnesses and short prognoses often experience depression and suicidal ideation. Traditional antidepressants are limited by delayed onset, creating a need for rapidly acting therapies. In this Palliative Care Rounds, we examine the evidence for ketamine/esketamine's efficacy as antidepressants, including evidence specific to people with serious illnesses. In psychiatric studies, intravenous ketamine produces rapid (1-24 hours), moderate-to-large antidepressant effects lasting one to two weeks, with a number needed to treat of three in the first week. Esketamine nasal spray demonstrates similar early efficacy and is U.S. Food and Drug Administration-approved for treatment-resistant depression and major depression with suicidal ideation. Evidence in serious illness is limited to several perioperative cancer trials and small open-label studies, which show short-term reductions in depressive symptoms and suicidal ideation but do not address long-term management or maintenance dosing. Safety across serious illness studies is generally favorable, with transient dissociation, hypertension, and somnolence the most common adverse effects; serious adverse events remain rare. Ketamine and esketamine offer the strongest evidence among rapid-acting antidepressants and may be preferred when urgent symptom relief is needed. However, rigorous psychiatric trials in serious illness are lacking. Clinicians should consider prognosis, access to Risk Evaluation and Mitigation Strategies-certified esketamine programs or equivalent regulatory frameworks outside the U.S., and the need for an appropriate maintenance regimen when integrating ketamine into palliative care depression management.

Internal Family Systems (IFS) is a psychotherapeutic model that conceptualizes human experience as shaped by different internal "parts" that respond to stress, threat, and vulnerability in patterned ways. In the setting of serious illness, these parts may become increasingly polarized or extreme, contributing to rigidity, ambivalence, emotional narrowing, or disengagement. By integrating IFS principles with serious illness communication, palliative care clinicians can better understand these responses as protective rather than pathological. This article uses a clinical case to illustrate how an IFS-informed approach can help clinicians identify and work with protective and vulnerable parts, including Managers, Firefighters, and Exiles, while supporting access to the Self as a source of calm, curiosity, and clarity. Through techniques such as recognizing and exploring activated parts, relating to protective responses with greater compassion, and tracking multiple parts within a single encounter, clinicians may help reduce inner conflict, soften reactivity, and support more flexible, values-concordant coping in serious illness care.

Patients with relational trauma, including histories of maltreatment, abandonment, exploitation, or profound misattunement in caregiving relationships, may face unique psychological and interpersonal stressors when diagnosed with a serious illness. Because serious illness requires dependence on others, patients' past traumatic experiences with caregivers may be reactivated in medical relationships, manifesting in behaviors that can be confusing, contradictory, inconsistent, or difficult to understand. These dynamics may evoke intense countertransference responses in clinicians, at times making it difficult to offer therapeutically attuned care. By understanding relational trauma through the lens of psychodynamic and neuropsychological principles, palliative care clinicians can develop more empathic and clinically useful approaches to managing complex interpersonal dynamics. This article illustrates how these principles can be adapted to inform serious illness communication strategies for patients with relational trauma, including calibrating the treatment frame, validating emotions while maintaining boundaries, enhancing empathy to promote the therapeutic relationship, and repairing ruptures in the treatment relationship.

Existential concerns are common in serious illness and may include confronting questions about meaning, purpose, and mortality. The salience of these issues can vary between patients and throughout illness, and can oscillate between existential suffering, demoralization, normative processing, and even existential growth. Through analysis of a clinical composite case, this article illustrates dimensions and cues of existential suffering during serious illness. Recognizing the sources and manifestations of existential distress can help expand therapeutic imagination in serious illness care. Guided by existential principles, we draw on the tenets of Intensive Caring and Dignity in Care to offer practical language and psychotherapeutically informed communication strategies for general palliative care practice. These techniques aim to ease existential suffering, strengthen relational connection, and support patients in living meaningfully through the end of life.

Acceptance and commitment therapy (ACT) is a psychotherapeutic model that focuses on developing psychological flexibility by encouraging patients to attune to their present moment experience, cultivate openness to those experiences, and respond to those experiences with committed action that is rooted in their values. By combining the six core processes of ACT (attention to the present moment, self-as-context, defusion, acceptance, values, and committed action) with serious illness communication skills, palliative care clinicians can nurture psychological flexibility for patients facing uncertainty and difficult internal experiences common in serious illness. This article reviews a case study with examples of language and tools clinicians can use to bring these core processes into their work with patients.

Depression is common in serious illness, yet traditional antidepressants have a delayed onset. Psychostimulants offer potentially rapid symptom relief, but their evidence base for depression, especially in medically complex patients, remains unclear. In this Palliative Care Rounds, we review the evidence for the use of psychostimulants as monotherapy or augmentation for major depressive disorder, including trials enrolling patients with cancer or other serious illnesses. Evidence for monotherapy is weak: meta-analyses of small, methodologically limited trials suggest modest benefit compared with placebo. Augmentation studies demonstrate statistically significant but clinically small effects. Data on people with serious illnesses is limited to a small number of heterogeneous trials with inconsistent findings. Overall, psychostimulants have limited evidence for depression in serious illness, particularly as monotherapy. Given evidence for alternative rapid-acting interventions, such as ketamine/esketamine or second-generation antipsychotic augmentation, psychostimulants should be used sparingly and reserved for specific scenarios (e.g., comorbid attention-deficit/hyperactivity disorder or prior robust response).

Introduction Patients with serious illness often encounter distressing medical realities that challenge their ability to process information and make values-aligned decisions. In these moments, clinicians may struggle to strike a balance between honesty and psychological readiness. This interdisciplinary workshop introduces a novel framework of applying principles from exposure therapy to serious illness communication (SIC) in order to bolster coping, reduce avoidance, and support prognostic awareness. [1-3] Objectives Designed by an interdisciplinary, interprofessional team, this engaging and dynamic session draws from behavioral psychology and frontline clinical experience. We will translate core principles of exposure therapy [1], an evidence based intervention rooted in behavioral psychology that gradually increases a patient’s tolerance of feared stimuli through structured, individualized exposures. Participants will reconceptualize distressing medical information as a “feared stimulus,” allowing clinicians to apply the principles of titration, individualization, psychological safety, and coping enhancement to serious illness communication [4].Through case examples, reflective prompts, and skill-based demonstrations, participants will explore five SIC: Disclosure Breaking down difficult information into manageable, digestible segments.Potency Titration: Matching adjusting language intensity to align with patient readinessOne-Degree-Removed Framing: Using metaphor or indirect examples to reduce emotional or existential threat. [5]Talking About Talking About It: Allowing patients to contemplate future conversations without direct exposure.The “Box” Technique: Containing and temporarily setting aside difficult information in order to foster control and safety.All cases and teaching are rooted in culture humility with sensitivity and attunement to patients' unique diversity of identity, culture, background, and lived-experience. Conclusion By integrating exposure therapy principles into SIC, clinicians can reduce emotional flooding and support incremental integration of difficult realities [2,3]. This approach enables more adaptive decision-making and gradual prognostic awareness, preserving dignity and culturally concordant care [4,5]. Participants will acquire actionable tools to navigate emotionally charged conversations with nuance, inclusivity, and therapeutic presence.

Background Serious illness communication (SIC) is central to hospice and palliative medicine (HPM) training, yet psychotherapeutic concepts are rarely integrated.[1] In practice, clinicians frequently encounter complex emotional dynamics, moral distress, and case parameters that can influence communication and care. To address this gap, we piloted a half-day workshop applying foundational psychotherapeutic principles (e.g., formulation, countertransference) to HPM practice.[2] An optional longitudinal Process Rounds model was designed to reinforce skills.[3] Objective To evaluate the impact of a half-day psychological-skills workshop and complementary Process Rounds supervision model on diverse cohorts of HPM clinicians across settings and levels of training. Methods Using Kern’s curriculum development framework,[4] we implemented a 4-hour interactive workshop for four cohorts of palliative care clinicians (AAHPM, McGill International Congress, fellowship programs, and a social work summit). Pre-, post-, and 8-week follow-up surveys mapped to Kirkpatrick’s four evaluation levels were administered. A subset then joined four virtual, case-based Process Rounds sessions over 6–8 weeks. Outcomes included satisfaction, knowledge, comfort, application, and perceived impact. Quantitative data were analyzed with nonparametric statistics; facilitator qualitative feedback underwent content analysis.[3] Results Of 203 clinicians completing pre-surveys, 168 completed post-surveys and 79 completed 8-week follow-ups. Knowledge and use of formulation and countertransference improved significantly post-workshop and remained elevated (all p< 0.001). Satisfaction was high (95%). At 8 weeks, most reported a positive impact on clinical practice (87%), teaching (85%), and collaboration (83%). The 25 participants who enrolled in subsequent Process Rounds reported greater comfort teaching formulation (p=0.013) and higher clinical impact (p=0.028). Qualitative themes highlighted structured supervision, role modeling, and protected space to process difficult cases; scheduling was the primary barrier. Conclusions Integrating psychotherapeutic concepts into SIC training addressed a key educational gap and enhanced HPM clinicians’ knowledge, practice, and teaching.[1,2] Longitudinal Process Rounds reinforced learning and supported sustained integration of psychological skills into HPM education.[3,5]

Patients facing serious illness may respond to distressing medical information with avoidance or denial, limiting their ability to engage in values-based decision-making. Exposure therapy-an evidence-based psychological treatment for anxiety disorders-offers conceptual tools that can inform communication and therapeutic approaches with patients who struggle with avoidance in the context of serious illness. This article describes the care of a patient with advanced cancer who declined prognostic and hospice conversations due to death-related anxiety. Drawing on core exposure therapy principles-including safety, individualization, titration, and enhancement of coping-we illustrate how serious illness communication strategies can be intentionally adapted to support patient engagement, reduce distress, and strengthen psychological resilience. Through techniques such as progressive disclosure, calibration of language potency, and the "container" metaphor, clinicians can match communication to patients' emotional readiness, enhancing tolerance over time. Integrating exposures-informed approaches into palliative care practice helps bridge the gap between emotional avoidance and values-concordant care.

Introduction/Context Hospice and palliative medicine (HPM) clinicians frequently encounter patients who prioritize independence as a means of coping. This psychological stance—manifesting in behaviors such as refusing help, minimizing symptoms, or avoiding conversations about decline—can be rooted in complex personal, cultural, and existential dynamics. Yet, there is a notable gap in training on how to assess and therapeutically respond to this prevalent patient presentation, despite emerging consensus that such skills are foundational to high-quality palliative care communication and mental health competency in HPM. [1] Objectives This session, co-designed by interdisciplinary experts in psychiatry, psychotherapy, and palliative medicine, introduces a practical framework for identifying and responding to the “independent” patient. Drawing on contemporary psychotherapeutic and formulation-based approaches, learners will explore diverse psychological underpinnings for such patients, including: 1) loss of identity tied to self-sufficiency, 2) guilt about burdening others, 3) fear-driven control dynamics, 4) magical thinking about autonomy and survival, 5) lifelong “doer” traits, and 6) structurally justified independence, such as sole caregiving roles. [2,3] Participants will be guided in constructing “working hypotheses” for independence in order to inform personalized therapeutic strategies. Engagement Attendees will participate in dynamic, interactive case-based exercises. These include practicing psychological coping-assessments (i.e. formulations), exploring clinician reactions and countertransference (e.g., frustration, admiration, avoidance, helplessness), and developing tailored therapeutic responses that both affirm normative coping responses while gently expanding coping flexibility. [4,5] The session prioritizes patient-centered equity, recognizing how autonomy may be a survival strategy for marginalized patients, and emphasizes interdisciplinary collaboration in crafting personalized, culturally-attuned care plans. [2] Conclusion By enhancing HPM clinicians’ ability to assess and respond to independence as a coping style, this session addresses a critical training gap in serious illness care. Participants will leave with high-yield, immediately applicable tools that deepen therapeutic connection and advance equitable, transdisciplinary team-based care.

Introduction Hospice and palliative medicine (HPM) clinicians often encounter complex emotional dynamics in patient care, yet frequently lack structured training in integrating psychologically-informed skills and concepts. While skills workshops can introduce foundational psychotherapeutic concepts– such as case formulation, countertransference, and therapeutic interventions– learners often request longitudinal opportunities to deepen their ability to apply these tools to real-world practice[1,2]. To address this gap, as a longitudinal follow-up to a workshop on psychological skills, we piloted “Process Rounds” – a novel, longitudinal, case-based supervision model rooted in evidence-based psychotherapeutic educational principles[3,4] and tailored specifically to HPM clinicians. Objectives This session introduces “Process Rounds,” an educational model developed by an interdisciplinary, interprofessional HPM team. Process Rounds include a series of facilitated discussions that follow a structured format: case presentation, countertransference exploration[5], psychological formulation[2,3], and mindful/therapeutic communication strategies[1,3].Through interactive demonstration and discussion, attendees will learn the core, evidence-based components of traditional psychological clinical supervision[4], along with how those components were adapted for the needs of HPM clinicians. We will share insights learned from evaluation data of 25 HPM clinicians across four national and international cohorts who participated in Process Rounds to reinforce and consolidate learning from a half-day workshop on foundation psychological skills. We will explore the benefits of this model, including deepening psychological insight[3], reducing clinician distress[5], enhancing therapeutic communication[1,3], and increasing inclusivity and equity in serving diverse populations. The session will review implementation considerations across diverse institutional contexts, such as logistical constraints, facilitator preparation, and leveraging IDT expertise. Conclusions Process Rounds bridges the gap between introductory psychological training and sustained clinical transformation, elevating therapeutic efficacy in our work. This session offers a scalable, high-impact model that builds therapeutic capacity in everyday practice– equipping clinicians to more effectively meet the communication and coping needs of diverse patients and families facing serious illness[3,4].

Depression in serious illness is common, disabling, and often requires rapid improvement. Traditional antidepressants may take weeks to work, whereas second-generation antipsychotics (SGAs) have evidence for faster onset and robust augmentation effects in general psychiatric populations. In this Palliative Care Rounds, we review the general psychiatric and serious illness-specific evidence for the use of SGAs as monotherapy and augmentation therapy for depression. In the psychiatric literature, SGA augmentation improves response and remission rates (odds ratios 1.34-2.93; needed to treat 7-13), with onset of improvement within 1-2 weeks. Monotherapy is less well tolerated and not guideline-recommended. No randomized controlled trials have evaluated SGAs specifically for depression in serious illness, but numerous cancer trials support their safety for nausea, appetite, and other symptoms. Despite the absence of serious illness-specific psychiatric trials, SGAs have the strongest evidence base among augmentation options and may offer meaningful benefits when prognosis or symptom severity necessitates rapid improvement. Low-dose augmentation should be considered early, rather than only after multiple failed antidepressants, particularly when SGAs can also target co-occurring physical symptoms relevant to palliative care.

BACKGROUND:A half-day workshop improved palliative care clinicians' ability to integrate psychological concepts into serious illness communication but created demand for longitudinal learning. OBJECTIVE:To pilot "Process Rounds," a four-session, case-based, adapted psychotherapeutic supervision group reinforcing formulation, countertransference, and mindful intervention. METHODS:Workshop graduates from four cohorts were invited; 25/143 enrolled. Each cohort met for four 60-minute sessions over 6-8 weeks. Eight-week postworkshop surveys included specific items for Process Rounds participants. Facilitators were interviewed about their experiences and themes. RESULTS:Participants were highly satisfied with the Process Rounds. Compared with nonparticipants, Process Rounds attendees reported greater improvement in comfort teaching formulation (p = 0.013) and stronger clinical impact (p = 0.028). Participants and facilitators found value in the structured format; scheduling conflicts were the chief barrier. CONCLUSIONS:Process Rounds, an adapted model of psychotherapeutic supervision, was acceptable to palliative care clinicians and deepened learning about psychologically informed serious illness communication.