Background: Gratitude has sparked interest in the world of health. It is considered as a personality characteristic or as an emotion. However, little has been explored in the context of the interpersonal relationship of caring. An exploration in the context of end of life is ground-breaking. Objectives: This study analyses and reflects on the object of gratitude from the perspective of both the persons being cared for and the professionals providing health care. What are patients and their family members grateful for in palliative care? What is the reason for gratitude? What do these health professionals perceive when there is gratitude? These questions were answered considering the gratitude generated in health care encounters, not gratitude as personality trait. Methods: The phenomenological approach was used starting from lived clinical experiences. In the light of the dialogue between clinical experiences and philosophy, this study proposes an explanation of the 'real' or essential object of gratitude in palliative care. It was conducted within the context of palliative care. The study materials were manifestations of gratitude expressed or felt in clinical encounters and published in newspapers or shared in daily encounters. These were the basis for analysis and reflection and interdisciplinary dialogue. Findings: The analyses performed indicated healing or deep relief in serious diseases as objects of gratitude according to patients' perspective, and professional self-affirmation until the end according to the professionals' perspective. Conclusion: The two perspectives shared an important common fact, namely, the need to consider the persons in their entirety, and the importance of not losing sight of the value they have. This concept would characterize the nature of gratitude, its object being the 'objective good' for patients, family members, and palliative care professionals.

Background: Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries. Methods: This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis. Discussion: The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.

In this context, Erasmus + has promoted a project (RESPACC 2020-1-R001-KA202-080128) involving four countries: Romania (Hospice Casa Sperantei and the University of Transylvania), Spain (University of Navarra), Greece (Hospice Galillee), and Belgium (European Association for Palliative Care EAPC). The project research Competencies for Palliative Care Clinicians (RESPACC). (RESPACC) makes reference letter to Research (research) Expertise, Selfdevelopment Palliative Care, Attitude, Communication and Competence (skill).

Objectives: To explore the expressions of gratitude (EoG) received from patients and relatives and their influence on palliative care professionals (PCPs). Methods: A national online survey was sent to a representative of PCPs of each service listed in the national directory of palliative care (PC) services (n=272) (ie, hospital PC support team, hospice, paediatrics, etc). The questionnaire was pilot tested with experts. It comprised three sections: the overall perspective of receiving gratitude in the service, the staff experience of its influence and sociodemographic questions. A mailing schedule was designed to enhance the response rate. Results: 186 representatives from all over Spain completed the questionnaire (68% response rate). 79% of service representatives reported that they almost always received EoG. These came mainly from families (93%). These EoG were very often put on display (84%) and shared with other health professionals (HPs) involved in care (45%). EoG evoked positive feelings in the team members. Based on their experience, respondents attributed different functions to these EoG: increased professional satisfaction (89%), a source of support in difficult times (89%), mood improvement, encouragement to continue and rewards for effort (88%). Services, where gratitude was more frequently received, were associated with PCPs who more frequently reported being proud of their work (p=0.039, Pearson's correlation test). Conclusions: Gratitude from patients and relatives was frequent and significant to those who work in PC. HPs considered that EoG offer multiple beneficial effects and also a protective role in their practice against distress and an increase in resilience skills.

Providing palliative care can be both challenging and rewarding. It involves emotionally demanding work and yet research shows that burnout is lower than in other fields of healthcare. Spontaneous expressions of gratitude from patients and family members are not uncommon and are highly valued. This study explored the experience of Spanish palliative professionals who received expressions of gratitude from their patients and families. A phenomenological approach was used to better understand the role of receiving gratitude in participants¿ lives. Interviews were transcribed verbatim and a phenomenological approach to analysis was undertaken using macro-thematic and micro-thematic reflection. Two team members independently engaged in this reflection with an inductive approach. The analysis was shared and discussed at periodic meetings to identify the key themes and sub-themes of the gratitude experience. Ten palliative professionals were interviewed. Participants engaged in a process of recognizing, internalizing and treasuring the expressions of gratitude which they then used for reflection and growth. These expressions were a powerful and deeply meaningful resource that the palliative professionals revisited over time. Receiving expressions of gratitude invited a stronger sense of the value of one¿s self and one¿s work that was motivational and protective, particularly during challenging times.

Entering the world of work is costly and one of the first obstacles is the competence deficit that university students sometimes present. To remedy the excess of a decontextualised theory, the EHEA (European Higher Education Area Education ) has sponsored a methodological change that promotes a teaching more internship, since the most effective learning is active and connected to experience. Thus, the university teaching focuses, among other aspects, on the achievement of learning outcomes in the form of competences associated with the labour market. In this context, more practical and applied methodologies are being tested in [Spanish] universities, including Service-Learning. The goal of this work is to find out whether, for the employers participating in our study, university students who take part in Service-Learning activities develop the profile competences they are looking for, making them more attractive candidates in selection processes, thus improving their employability. To this end, a generic qualitative research was developed. Three focus groups were conducted with a purposive sample of thirteen employers of graduates from different Schools of the university, belonging to different sectors. The thematic guide included questions on the competences most in demand by employers, Service-Learning and its influence on the professional profile .

OBJECTIVE:Cultural backgrounds and values have a decisive impact on the phenomenon of the wish to die (WTD), and examination of this in Mediterranean countries is in its early stages. The objectives of this study were to establish the prevalence of WTD and to characterise this phenomenon in our cultural context. METHODS:A cross-sectional study with consecutive advanced inpatients was conducted. Data about WTD (Assessing Frequency & Extent of Desire to Die (AFFED) interview) and anxiety and depression (Edmonton Symptom Assessment System-revised (ESAS-r)) were collected through two face-to-face clinical encounters. Data were analysed with descriptive statistics, ¿2 and analysis of variance. RESULTS:201 patients participated and 165 (82%) completed both interviews. Prevalence of WTD was 18% (36/201) in the first interview and 16% (26/165) in the second interview (p=0.25). After the first interview, no changes in depression (p=0.60) or anxiety (p=0.90) were detected. The AFFED shows different experiences within WTD: 11% of patients reported a sporadic experience, while 7% described a persistent experience. Thinking about hastening death (HD) appeared in 8 (22%) out of 36 patients with WTD: 5 (14%) out of 36 patients considered this hypothetically but would never take action, while 3 (8%) out of 36 patients had a more structured idea about HD. In this study, no relation was detected between HD and frequency of the appearance of WTD (p=0.12). CONCLUSIONS:One in five patients had WTD. Our findings suggest the existence of different experiences within the same phenomenon, defined according to frequency of appearance and intention to have death. A linguistically grounded model is proposed, differentiating the experiences of the 'wish' or 'desire' to die, with or without HD ideation.

Education in palliative care is a required competence for the nursing degree.Pedagogical strategies in palliative care are mainly aimed at promoting an understanding of patients with advanced disease. Phenomenological texts are stories intended to evoke lived experiences and help understand these complex situations. However, there is no evidence regarding the experience of reading phenomenological texts in nursing. The aim of this study is to determine what impact nursing students have when reading a phenomenological text about the experience of people living with advanced cancer. The students¿ writings showed that reading the phenomenological text caused them to reflect and feel moved and challenged. The impact on the students is grouped into three categories: the experience of the corporeality of patients makes students aware of the importance of the body; the disease as an individual transformative process challenges students; and the experiences of advanced cancer patients make students aware of the importance of how they care for patients and their families. The reading of a phenomenological text on the experience of living with advanced cancer is innovative and may be a teaching method that promotes care focused on the person with advanced illness, key aspect for student¿s competency in clinical practice.

Emotional exhaustion is a problem many palliative care professionals face during their activity. Art therapy is emotionally beneficial for palliative patients that experience suffering, but its impact on professionals¿ experience of suffering has not been researched. Aim:To examine the immediate reactions of professionals after an art therapy workshop focused on personal self-care, also considering previously used coping strategies. Design: A four-hour art therapy workshop was designed including a generic qualitative study of participants. Participants were palliative care professionals and their reactions were examined using an ad hoc questionnaire with open-ended questions. Descriptive analysis of quantitative variables and thematic analysis of open-ended questions were conducted. Results: Seventeen professionals participated voluntarily. They rated the workshop positively, using words like ¿calm¿ and ¿relaxation¿ to express the effects of the workshop, which they considered therapeutic and a source of self-awareness. For some, it allowed them to release emotions; for others, it enabled introspection and opened up a more elaborated emotional response. They thought artistic expression would be useful for their colleagues, or even for their own personal development. In the workshop, professionals opened up and explained how they face intense moments on a day-to-day basis: how they approach the situation, or how they try to control their surroundings; how they disconnect/distract from the situation, or how they try to control their surroundings.

PC continues to be misunderstood within the world of healthcare. PC professionals are key agents for promoting a greater understanding of their field. It aims to examine the messages, both implicit and explicit, that PC professionals transmit about themselves and their work within their teams and to other health professionals. Methods: Focused ethnographic secondary analysis, exploring the interactions of PC professionals as it happens at everyday work. An inductive thematic analysis was developed from 242 h of observation of the daily work practices of palliative care professionals, focusing on their interactions with others. The data was coded without predefined categories, and the analysis was performed independently by two researchers. Results: Palliative professionals communicate that they are part of an active team working in an organised manner. They value and feel proud of their work. Despite the intensity of their work, these professionals are always available to others, to whom they demonstrate a clear professional identity. They convey their expertise in alleviating suffering, respectful behaviour and collaborative ability. Conclusion: Professionals, in their daily work, communicate through their messages the essence of palliative care. It is essential that PC professionals perceive themselves as potential influencers and explicitly transmit the reasons for their intervention. Otherwise, others will perpetuate myths, misunderstandings, lack of positive PC reputation

SECTION 1: PALLIATIVE CARE AND GRATITUDE ........................................ Chapter I: Gratitude in palliative care (Carlos Centeno) ................................ Chapter II: Nuances of gratitude in palliative care (María Arantzamendi) ..... Chapter III: Culture, gratitude and palliative care. A reflection staff (José Pereira) ............................................................................................................... SECTION 2: THE CONCEPTUALIZATION OF GRATITUDE .......................................... Chapter IV: Gratitude and its etymology (Alicia Hernando) ....................................... Chapter V: What subject of experience is gratitude? (Josef Seifert) ................... Chapter VI: Gratitude: the possibility of recognizing the good (Mariana Riojas) .... SECTION 3: THE OBJECT OF GRATITUDE ............................................................... Chapter VII: On the object of gratitude (Mariano Crespo) ......................... Chapter VIII: Gratitude, gift and interpersonal care (Anthony Steinbock) ............... Chapter IX: Gratitude in palliative care: what to be grateful for. A clinical and experiential approach. (Enric Benito) ..................................................................... SECTION 4: THE SUBJECT OF GRATITUDE ................................................................ Chapter X: Psychological factors favoring or inhibiting gratitude (Sergio Sánchez-Migallón). Sánchez-Migallón) ......................................................................................... Chapter XI: Obstacles and facilitators of gratitude (Paulina Taboada) ........ Chapter XII: A clinician's experience of gratitude with people at the end of his life (Julio Gómez). of life (Julio Gómez) ................................................................................. 8 Gratitude and palliative care SECTION 5: THE IMPACT OF GRATITUDE .................................................... Chapter XIV: The impact of gratitude (María Aparicio) ................................. Chapter XV: The culture of gratitude as care for human vulnerability (Luca Valera) .............................................................................................. Chapter XVI: Gratitude in palliative care patients and their families: where are we now (Mathieu Bernard) ............................................................ BIBLIOGRAPHICAL REFERENCES

Textbook of Palliative Care is a comprehensive, clinically relevant and state-of-the art book, aimed at advancing palliative care as a science, a clinical practice and as an art. Palliative care has been part of healthcare for over fifty years but we still find ourselves having to explain its nature and practice to colleagues and to the public in general. Healthcare education and training has been slow to recognise the vital importance of ensuring that all practitioners have a good understanding of what is involved in the care of people with serious or advanced illnesses and their families. However, the science of palliative care is advancing and our understanding concerning many aspects of palliative care is developing rapidly. The book is divided into separate sections for ease of use. Over 100 chapters written by experts in their given fields provide up-to-date information on a wide range of topics of relevance to those providing care towards the end of life no matter what the disease may be. We present a global perspective on contemporary and classic issues in palliative care with authors from a wide range of disciplines involved in this essential aspect of care. The Textbook includes sections addressing aspects such as symptom management and care provision, organisation of care in different settings, care in specific disease groups, palliative care emergencies, ethics, public health approaches and research in palliative care.