The clinical role refers to the duties of providing psychological support along with VR interventions. As the field of psychology has been widely acknowledged for its crucial contribution to the development and advancement of high-quality VR for various purposes (29), we agree on the need for professional backgrounds in psychology, counseling, or other relevant mental health disciplines for the competency of VR therapists. First, we propose psychological assessments before VR to screen out patients with high risks of adverse effects. Prior psychological assessment refers to evaluations of the patient's (1) current mood state, as patients with depressive mood may appraise neutral events or stimulation in a negative and biased way and be prone to additional emotional disturbances; (2) current needs, i.e., physical, psychological, social, or spiritual; (3) degree of acceptance towards palliative status; and (4) psychological readiness for VR exposure to experience a favorable identity. Psychological assessment can be conducted through clinical interviews with patients to identify the individual's needs and evaluate the degree of illness acceptance. Assessment on mood state can be performed through clinical observations, collecting collateral information from ward staff or significant others, and data from a medical file as well. Second, relevant knowledge on psychology or related mental health disciplines may help select or design VR interventions that are specifically tailored to the unique needs and preferences of individual patients, upon assessment of one's psychological states, specific concerns and goals. Third, professional trainings on psychological interventions support their delivery following VR exposure to reduce negative impact and enhance therapeutic effect. Examples of psychological interventions are psychoeducation, emotional and cognitive processing, validation, acceptance and commitment therapy. Similar to the use of VR in exposure therapy for patients with posttraumatic stress disorder, we recommend VR not be in a “self-help” format but with available treatment options for potential therapeutic benefits, which was advocated by Rizzo et al. (30). Fourth, clinical training in psychology may contribute to a therapeutic alliance that helps foster trust and facilitates patients’ willingness to engage fully in VR. Lastly, professional trainings in psychology or related disciplines uphold ethical standards that help safeguard patient privacy, provide informed consent, manage potential risks, and ensure that patients’ psychological well-being and safety are prioritized throughout the VR interventions.

A good attitude from VR therapists is considered important for the quality delivery of VR as well. We advise VR therapists to have reasonable expectations for the efficacy of VR interventions. VR may help patients fulfill their last wishes virtually; however, it is important to note that exposing vulnerable patients to an ideal virtual environment has implications and potential psychological risks. We advocate the importance of clinical sensitivity to the patients’ mental state, psychological readiness for VR intervention, imminent needs, and existential challenges, with a professional demeanor that respects their needs and vulnerability. As patients at their end-of-life stage are particularly vulnerable when facing existential challenges, VR exposure may be an apparent trigger for emotional disturbances. We therefore consider VR therapists’ preparedness and readiness to deliver timely psychological interventions paramount.

The technical dimension refers to the technical skills of VR delivery, i.e., the operation of the VR hardware and software. Basic technical skills include operating the VR headset, the remote control, VR apps, products, and content, and an internet connection. As most patients under palliative care are physically fragile, we suggest special precautions to minimize potential physical harm. For instance, we advise VR therapists to locate an appropriate time or private space for VR session to minimize fatigue or exhaustion (i.e., avoiding time right after rehabilitation exercises, medical treatment, or late of the day); to ensure patient in a comfortable lying or sitting position to minimize discomfort due to prolonged posture; to verbally check if patients are feeling uncomfortable on-and-off during VR exposure; to alert patients the possible adverse effects, and prepare them for a “stop” sign if experiencing any discomfort; to minimize risk of cybersickness by limiting VR exposure (31) to about ten minutes, which are observed to be an optimal duration to minimize risk while maintaining therapeutic effect in our palliative care setting; to hold the VR headset for patients in front of their heads to minimize its weight, which was associated with subjective discomfort (32); to screen out patients who may be prone to physical risks, e.g., patients with visual and hearing impairment, epilepsy or having a seizure in the past six weeks, hypersensitivity to motion, active nausea or vomiting, and physical injuries including head wounds, neck pain.

To ensure quality delivery of VR interventions, we suggest VR therapists have basic knowledge of VR technology (i.e., hardware and software), safety measures, ethics concerning data privacy and security, as well as the latest research on VR in palliative care. We consider the following attitudes important: readiness and open-mindedness to keep abreast of updated knowledge and skills of VR in palliative care; adaptability in the face of quick changes in technology; and continual learning, which involves a commitment to ongoing professional development and self-reflection.

The supervisory dimension refers to the duties of a trainer of VR therapists and VR assistants. As VR has been increasingly practiced in various settings (12, 13, 33, 34), professional trainings for future VR therapists are important to ensure its wide adoption and accessibility. The supervisory role of a VR therapist involves providing guidance, support, and feedback to future VR therapists. The goal of supervision is to help the supervisees develop relevant knowledge, skills, and attitudes for quality VR delivery. We recommend the supervisors to have basic knowledge and skills in VR technology, adequate clinical experiences with VR interventions, and counseling experience in palliative care. Favorable attitudes for a VR therapist include openness, supportiveness, respect, and reflectiveness.

Our clinical experiences show that support from a patient care assistant in operating the VR can improve the efficiency of VR delivery. The trained assistant can perform technical tasks that leave capacity for a VR therapist to focus on clinical tasks, such as clinical observations or interaction with patients. Technical tasks include sanitizing the VR headset for infection control, locating the VR content, and holding the VR headset for the patient to minimize weight during VR exposure. We propose VR therapists to have adequate supervisory skills for both future VR therapists and VR assistants.