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    September 06, 2024

    Hope in Holograms: Supporting Palliative and End-of-Life Care With Immersive Reality

    Dinesh Napal LL.M
    The PDF, which includes endnotes and footnotes, in which this article appears can be found in Bifocal, Vol. 45 Issue 6.

    Immersive reality was once thought of as a far-off, sci-fi goal. Now, you can go online, shop around for a headset and once it arrives, be transported to worlds and experiences both familiar and fresh. Whether discussion around immersive technology is worrying or exciting, many are interested in whether this technology can play a role in the lives of those experiencing extreme hardship or marginalization. In this context, immersive technology presents opportunities, and risks, for those receiving palliative or end-of-life care, which are essential to consider for anyone providing advice to patients or loved ones.

    What is Immersive Technology?

    Immersive technology allows communication or interaction with the environment through a visual or auditory experience. Two types of such technology include the following, which you may have heard of:

    1. (Virtual reality (VR), which involves a simulated three-dimensional (3D) environment that lets users explore or interact with a virtual world that approximates reality. Examples include ClassVR, a standalone virtual reality headset for use in classrooms that creates a virtual learning environment, and XRHealth, a virtual platform used to address neurological conditions by connecting patients with providers using a headset.
    2. Augmented reality (AR), involves an enhanced, interactive version of a real-world environment achieved through digital elements overlaid over the real-world space. One notable example is Microsoft’s HoloLens, which uses a headset to overlay virtual objects in the real world and allows users to interact with those objects through voice and motion.

    These forms of immersive technology are often discussed in the entertainment space, with video gaming being the primary context in which virtual or augmented reality headsets are enjoyed by consumers. At the same time, developers have found opportunities to investigate how their immersive technology works in different contexts, such as healthcare,  construction and hospitality, exploring more tailored experiences and uses for consumers. Under the healthcare umbrella, developers and researchers continue to appraise the effectiveness of immersive technology in the provision of palliative and end-of-life care.

    Opportunities presented by immersive reality in end-of-life and palliative care

    Pain Relief

    Immersive technology has been routinely discussed as an option for providing temporary relief from pharmacologically-resistant pain, by offering opportunities to patients to access virtual environments.[xi] In some cases, such as the National Institutes of Health’s HEAL Initiative, this involves using VR to immerse patients in a therapeutic experience that can either distract from their chronic pain, or educate them on ways of coping with pain later, without the aid of VR.

    A 2022 study found that VR could be a feasible and effective tool for pain relief, with researchers describing that its use “encompasses the approach of a total pain and symptom therapy, and enhances patients’ dignity and autonomy.” The 2024 study, on Flourishing-Life-of-Wish VR Relaxation Therapy (FLOW-VRT-Relaxation) for terminal cancer patients, found that symptoms of distress experienced in palliative care were significantly reduced through VR usage, and the technology enabled emotion-focused coping to manage physical and mental wellbeing.

    Emotional Fulfillment

    Patients in end-of-life or palliative care settings can often experience limited mobility or travel capacity. As a result, many express feelings of loneliness or sadness at the inability to access places of significance to them, or the inability to achieve personal ambitions in visiting locations they have wanted to during their lives.

    A 2017-18 study found that Google Earth VR software was efficacious and safe for terminal cancer patients who wished to “return home” or go to a “memorable place,” presenting significant improvements for pain, tiredness, depression, anxiety and other wellbeing metrics. In 2021, a study involved Lenovo’s Mirage Solo goggles with Day Dream software playing a continuous loop of audiovisual content designed to offer relaxation or relief to palliative care patients. The study found that the technology offered meaningful activity and enhanced quality-of-life as a “non-pharmacologic intervention,” allowing patients to achieve “bucket list” items such as going to the beach, going fishing and flying a plane. A 2022 study found that even a one-off VR session was able to offer hospice patients joy, relief from pain and anxiety, and connection with a meaningful reality outside of the hospice space.[xviii]

    Enhanced Person-Centered Decision Making

    Many patients wish to feel more control or autonomy, in collaboration with their healthcare providers and experts, on the delivery and management of their care. Immersive technology can, in some circumstances, offer the opportunity for some patients or loved ones to undertake advanced decisions on their care, through unique VR interventions.

    A 2020 study involved presentation of five medical options (CPR, life-sustaining treatments, antibiotics, blood transfusion and artificial nutrition/hydration) through a VR video to participants in palliative care. The study found that the proportion who expressed uncertainty around decision-making before participating in the VR intervention had significantly decreased. Furthermore, in 2021, a study using a 360-degree VR tour of a hospice facility investigated how comfortable patients were with deciding to transfer to a hospice for palliative care and symptom management. 90% of patients reported feeling more informed through the VR tour and 95% of patients recommended the tour to other patients to help alleviate the fear of the unknown. 

    Concerns around the use of immersive reality in end-of-life or palliative care

    Additional Emotional Distress

    Patients in palliative care often experience emotional discomfort or distress, which can be exacerbated in unfamiliar or strange circumstances. For many, this may include engaging with immersive reality technology. Sometimes, patients can experience additional emotional distress if the virtual experience triggers maladaptive or unhelpful ways of thinking.

    For example, some participants in VR experiences have worried whether they are abnormal if they cry during VR content that is intended to induce happiness. Some older adults have also experienced the triggering of unpleasant memories, which can be unpredictable given that, for many, the VR experience may already be unfamiliar or uncomfortable. Other older adults have expressed sadness during immersive experiences at the realization of old or repressed memories, or previous opportunities that they feel have passed them by.

    Sickness or Discomfort

    Some research has indicated that, on rare occasions, older adults or others in palliative care or end-of-life settings may experience nausea, headaches and dry eyes, and may have difficulty concentrating . While this may be normal to experience for many people in the first experiences with immersive technology, this may be particularly uncomfortable or distressing for those who are already managing chronic pain or other long-term health conditions. A 2023 interventional trial on the use of VR for oncology and palliative care patients suggested that drowsiness may be the most common effect of VR, despite there being no adverse effects reported in the study.

    Accessibility

    Some patients in palliative care settings may be socio-economically disadvantaged, or from a marginalized background, culture or have physical and mental disabilities. These aspects of their existence may make it exceptionally harder for them to enjoy the benefits presented by VR or other immersive technologies, whether this is because it is difficult for them to do so in conjunction with other conditions they may have, or if they simply cannot afford the high cost of devices associated with immersive technology. A 2020 comparative analysis suggested that the high cost of VR may be possible to outweigh with investment in immersive technology for long-term use, but outside of research trials or programs in the palliative or end-of-life setting, this may not be accessible to many people.

    How to Advise Patients or Loved Ones on Immersive Technology

    It is important to cover the following key points to those who may be exploring immersive technology as an option for managing end-of-life or palliative care:

    1. These technologies are constantly emerging and developing, and there is a lot we do not know about how they operate in end-of-life or palliative care spaces. With continuing innovation, technology could develop that can address different needs for different patients that may not exist today.
    2. Remind people of financial and accessibility considerations. So much of what is available to patients is only available to them as individual consumers, which means purchasing the technology themselves. They may consider asking their care provider if they are working on, or have considered, research projects on immersive technology. This can offer the opportunity for immersive devices to be piloted in their care environment, at least on a temporary basis.
    3. Encourage open-mindedness toward the available technology – many studies do indicate positive effects in different care contexts, particularly for pain relief and emotional fulfilment. It is important that, before patients consider immersive technology as an option, they think about what their specific needs are and what they want to achieve.

    Ultimately, while immersive technology is emerging, issues affecting patients in end-of-life and palliative care are ever-present. These opportunities and concerns will continue to be important as legal professionals, care providers, researchers, and loved ones seek to investigate the best possible ways of improving patient experiences.

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