Participants
Of 494 patients admitted during the study period 184 suffered from incurable cancers, 83 were eligible, and 17 patients gave informed consent to participate (Figure 1). The mean age was 65.5 (SD±13.0, range 20-82 years), 9 were women (52.9 %). The number of days spent as an inpatient ranged from 1 to 75 days (mean 23.4, SD ±27.1). Two patients dropped out of the intervention because the relatives did not support their preferred video recordings at home (Figure 1). Demographic data are shown in Table 1.
(Figure 1. Flow chart of participation.) about here
Figure 1. Flow chart of participation. t0=baseline, t1=after the first VR, t2=after the intervention
IPOS, Integrated Palliative Outcome Scale; SSQ, Simulator Sickness Questionnaire; SPES, Spatial Presence Experience Scale
(Table 1. Demographic data of the entire sample.) about here
Table 1. Demographic data of the entire sample.
Patient choice of Virtual Reality content
Ten patients (66.6%) had no prior VR experience. For the individualized VR content, three patients (20%) chose to record their home, five (33.3%) their loved ones and four (26.7%) indicated other meaningful locations: their hometown (1), a specific mountain racetrack (1), a specific farm (1), and local forest trails (1). Three patients (20%) decided to watch the Heidelberg video. For standard VR, 12 patients (80%) chose a nature shot, and three (20%) preferred a city scene.
Effects of virtual reality on physical and psychosocial burden
Patient symptom burden did not differ between the individualized and the standard VR intervention. The mean IPOS total score was 17.7 (SD±6.44) after individualized VR and 17.5 (SD±6.30) after standard VR. Patients' symptom burden tended to decrease with each measurement time point from 20.8 (SD±7.15) to 17.0 (SD±6.27) before and after the VR intervention (Figure 2). This trend appears to be more pronounced regarding the physical symptom subscale of the IPOS (from 12.1, SD±5.54 to 8.47, SD±4.81) than the emotional symptom subscale (from 6.60, SD±2.56 to 6.40, SD±2.69) and communication (from 2.07, SD±1.39 to 2.13, SD±1.55) with intra-individual variation (Figure 2).
(Figure 2. Physical and psychosocial burden as reflected by the IPOS subscales. about here)
Figure 2. Physical and psychosocial burden as reflected by the IPOS subscales. Mean values ± SE (bar chart) and individual changes (spaghetti diagrams) across all measurement time points. Lines of the spaghetti diagram represent the scores of the individual patients. SE = standard error. t0 = baseline, t1 = after the first VR, t2= after the intervention. Higher scores are associated with a greater symptom burden.
Effects of virtual reality on well-being
The primary outcome well-being did not differ between the individualized and the standard VR-intervention. The mean MDBF-total score after the VR-presentation was 21.1 in both cases (SD ±4.79 for individualized VR; ±4.61 for standard VR). Also, the subscale results did not differ. The patients’ well-being tended to increase with each measurement time point from 19.9 (SD±5.54) to 21.2 (SD±4.25) before and after the VR-intervention (Figure 3). The trend seems to be mainly due to the mood-subscale of the MDBF (from 6.93±2.12 to 7.73±1.83), rather than the alertness subscale (from 5.67, SD±1.84 to 6.07, SD±1.44), and calmness-subscale (from 7.33, SD±2.19 to 7.40, SD±1.64) (Supplement 1). The intra-individual courses varied, with the greatest heterogeneity in the calmness subscale. These observations correlate with the results from the qualitative analysis of the post-interventional interviews.
(Figure 3. Well-being as reflected by the MDBF subscales. about here)
Figure 3. Well-being as reflected by the MDBF subscales. Mean values ± SE (bar chart) and individual changes (spaghetti diagrams) across all measurement time points. Lines of the spaghetti diagram represent the scores of the individual patients. SE = standard error, t0 = baseline, t1 = after the first VR, t2= after the intervention. Higher scores are associated with the positive pole of the scales bad-good mood, tiredness-alertness, restlessness-calmness.
Follow-up assessment after two weeks
Four participants used the opportunity to watch their individualized VR for two weeks with 1-3 repetitions. In the follow-up survey, the subjects' mean overall MDBF score remained stable compared to t2 (20.5, SD±4.80). However, the mean overall IPOS score had deteriorated to 35.3±9.60 at follow-up compared to 21.3±9.0 after the intervention.
“It was the biggest gift” - Post-interventional interviews
Most patients did not attribute the benefit of the VR to a state of calmness, but rather to feeling emotionally moved in a positive way, although the feelings fluctuated between joy and homesickness.
“So I thought that was good. I saw my home. (sobs). The family (......) The garden. The garden. [break]: Just the things, I'm missing. I think that’s it.” (R04w)
„I thought the video with the relatives was very, very good. It touched me deeply emotionally. All my family members, my little sister, my relatives were there too -- just emotional. It put me into a good mood.“ (A02m_ T1)
In this context, some patients welcomed the option to escape from their patient situation, one patient reported to be explicitly distracted from pain.
“It took me out of it a bit when I was in such enormous pain and made me forget a few other things, too. And I thought that was amazing and I thought that was very good. I would recommend it to everyone.“ (A08w_ T1)
„What I liked about the private video was that you can just be, where you like to be.“ (A10w_ T1)
The content analysis of the post-interventional interviews suggests that the experience of presence and memories to which the virtual reality is linked make up the patient perceived benefit.
“It was very realistic, especially in the video where I was at home. I thought, where have I ended up? I really thought I was at home in the living room. I have to say it was very realistic, simply in terms of the vibes.“ (A02m)
Overall participants rated their presence experience (SPES) very high for the individualized videos with 5.97 (SD±1.40), and 5.42 (SD±1.46) for the standardized videos (Table 2). The immersion was also observed by the study staff with patients’ expressions of joy and interest during most of the interventions, as well as numerous head and body movements.
Besides individual meaningful memories patients mentioned technical characteristics that supported the immersion like the 360° perspective, vivid colors, natural noises and music.
“The realism. It is really impressive that you can put yourself out there in the world like that, above all, 360 degrees ALL AROUND. So you can look in all directions and that's amazing.“ (A03m)
„Related to the first [individualized VR], it gives you a piece of home. (..) And with the second one [standard VR], also memories were brought back. And that was… I chose it so I could see the sea because I love the sea. And I really liked the sound of the waves and so on. And the colors, everything so realistic. And is, um, did not only evoked longing, but also a bit of hope [cries]“ (A08w)
Patients who participated in the follow-up preferred their individualized VR content. However, one patient explained different impacts of the two VR contents: his standard VR, a generic beach scenario that reminded him of his favorite holiday destination, calmed him down, the individualized conveyed motivation and a deep joy. Another patient even was afraid to be bored of repeated standard VR content.
“It wasn't boring [the standard VR], you could watch it, but it was a bit off compared to the first one [the individualized VR].” V01w
Headset Comfort
A clear suggestion of the patients was to improve the HMD in terms of weight and accumulated heat. Most patients needed support to install the HMD, in particular patients with glasses. Further, they wished for more interaction in terms of ease of use e.g. to fast forward, but also to interact with the VR.
Acceptance
On average, patients answered the statement "It helped me to watch the video" with 5.47 (SD±1.81) and "I think the use of such videos makes sense" with 6.10 (SD±1.42), indicating that they find the VR intervention beneficial both for themselves and in general. Some patients were grateful for the VR-intervention and encouraged the study staff to carry on.
“I like what you're doing, yes. And, um, it's very gratifying, yes, that you're offering something like that and all I can really say is, keep it up.“ (A09w )
We observed no serious side effects (Supplement 2) and no participant requested to stop the VR intervention.
(Table 2. Spatial Presence Experience Scale (SPES) about here)
(Figure 4 about here)
Figure 4. Thematic model of the Virtual Reality experience. The model based on the content analysis of the post-interventional interviews.