Burden to others and the terminally ill

Existential aspects of breathlessness in serious disease

PURPOSE OF THE REVIEW

Breathlessness may evoke existential threat but may also affect the person with serious illness or their caregiver/s in other important ways which can be considered 'existential'. This review explores existential aspects of breathlessness in people with serious illness and presents recent studies of assessment and management of associated distress and suffering.

RECENT FINDINGS

Both existential distress and breathlessness are multidimensional and include a range of constructs, many of which have behavioural consequences. Existential distress tracks closely with distressing breathing potentially due to shared underlying neurobiological processing. Paradoxically 'contagious' and isolating effects of breathlessness and related distress have been recently highlighted. Approaches to screening and assessment vary. Preliminary studies have investigated novel approaches to breathing-related anxiety and existential distress.

SUMMARY

Studies with existential constructs as outcome measures in people with breathlessness are scarce. Interventions for existential distress developed for those with malignant disease may be beneficial for those with non-malignant conditions, but adaptations may be required. Recently proposed taxonomies of existential distress/concerns may guide assessment and direct novel therapeutic interventions in people living with serious illness and breathlessness-related distress. Neglecting existential aspects of breathlessness represents a missed opportunity to support holistic well-being in people with serious illness.

Psychodynamic psychotherapy in serious physical illness: A systematic literature review of approaches and techniques for the treatment of existential distress and mental disorders

Individuals with life-limiting physical illness experience lower mental health due to existential distress (e.g., demoralization, death anxiety) and mental disorders (e.g., depression, anxiety). Psychodynamic psychotherapy may be helpful in alleviating such distress by focusing patients' unconscious emotional and relational motivations. There is yet limited knowledge on the application of psychodynamic psychotherapies in this population. We systematically searched electronic databases and analyzed results using meta-ethnography. Of 15,112 identified records, we included 31 qualitative studies applying psychodynamic psychotherapies (n = 69, mean age: 49.3 [SD = 16.9)], 56% female). Psychodynamic treatment in this population can be beneficial when considering modification of the treatment setting to the illness reality, balancing needs for autonomy and separation in light of helplessness and death anxiety, and careful integration of supportive interventions and conflict-oriented interventions (e.g., exploring relational issues that interfere with mourning illness-related loss). We discuss future directions for the development and evaluation of treatments specific to serious physical illness.

Understanding caregiver burden from multiple perspectives: dyadic agreement between caregiver and care recipient

PURPOSE

Caregiver burden (CB) is typically self-assessed by caregivers. However, an emerging concept is assessment of CB by the recipients of care, i.e., the patient. The specific objectives are (1) to assess the level of agreement between care recipients' and caregivers' view on CB, across financial, physical, emotional, and social domains; (2) to explore two care recipient perspectives: their self-perceived burden (CR-SPB), and their interpretation of the caregiver's view (Proxy-CB).

METHODS

Data were collected from 504 caregiver-care recipient dyads in the U.S. using an online Qualtrics panel. The survey assessed caregiver burden using CarerQol and newly developed items. The level of agreement between responses was quantified using weighted kappa (κ) coefficients for individual items and intraclass correlation coefficients (ICC) for index/summary scores.

RESULTS

The average age of caregivers was 49.2 years, and 62.7 years for care recipients. Dyads most commonly consisted of spouses/partners (34.5%); 68.3% lived together. Proxy-CB aligned more closely with caregiver's view, with moderate to substantial agreement across CB domains (from κ = 0.48 for emotional to κ = 0.66 for financial). In the same perspective, the CarerQol-7D Index showed moderate agreement (ICC = 0.58) and the summary score of CB items substantial agreement (ICC = 0.76). Care recipients generally overestimated  CB in the Proxy-CB perspective, while they underestimated it in the CR-SPB perspective.

CONCLUSION

Results demonstrate there is a difference between perspectives. Strong agreement in Proxy-CB perspective suggests that care recipients can potentially substitute for caregivers depending on the domain. CR-SPB agrees less with caregivers and may provide complementary information.

A scoping literature review of factors influencing cancer patients' self-perceived burden

PURPOSE

A cancer diagnosis disrupts the peaceful lives and plans of patients and even their caregivers, and patients can easily feel burdened when they are being cared for by others. However, the influencing factors of self-perceived burden (SPB) have not been summarized, and related research is still in its infancy. This review explores factors related to the SPB of cancer patients and identifies future research directions.

METHOD

A systematic search, including trolling through six electronic databases, was conducted to identity articles published in English and Chinese from January 2003 to April 2022, using key terms related to cancer patients' burden on others; a manual search was also performed on the articles' reference lists.

RESULTS

Thirty-three articles were identified. The content was described into three groups: patient-related factors, caregiver-related factors, and family-related (financial) factors. Despite the heterogeneity, patients' physical/disease factors, psychological factors, social factors, caregiver type, quality of care provided, caregiver physical and psychological status, and financial factors were all correlated with SPB.

CONCLUSIONS

This literature review shows that SPB imposes a huge burden on cancer patients, and that SPB in cancer patients is influenced by patient-related factors, caregiver-related factors, and family factors. These influencing factors directly or indirectly affect SPB. In addition, SPB is complex and studies related to its factors deserve a further detailed analysis based on the actual situation of the patients in order to make the results more accurate and relevant.

Assessing Burdening Guilt and Its Correlates

Burdening guilt refers to the belief that one's emotions, needs, and ways of being are a burden to others, and is one type of interpersonal guilt proposed by the control-mastery theory (CMT). The aim of this article is to validate two new measures of burdening guilt. In the two studies conducted, we examined the psychometric properties of these scales and the relationship between burdening guilt and self-perceived burden (burdensomeness), self-esteem, shame, anxiety, depression, mental health, attachment insecurity, adverse childhood experiences, social desirability, empathy, and suicidal ideation. In Study 1, we presented a newly developed Burdening Guilt Rating Scale (BGRS) and its correlation with measures of the abovementioned dimensions. In Study 2 we verified, through confirmatory factor analysis and correlation techniques, the possibility of expanding the Interpersonal Guilt Rating Scale-15 with a shorter, 5-item burdening guilt scale derived from the BGRS, and showed that this shorter scale correlates similarly to the longer one. Findings allowed us to validate these new scales providing empirical measures of burdening guilt-a theoretical concept with important clinical implications.

Meaning of Life Therapy: A Pilot Study of a Novel Psycho-Existential Intervention for Palliative Care in Cancer

Intervention in Palliative Care aims to provide physical, psychosocial, and spiritual relief for patients and family members. Brief interventions with a psycho-existential approach have shown positive responses; however, cultural adaptations are needed. This pilot study aimed to develop the Meaning of Life Therapy (MLT), a novel psycho-existential intervention, rooted in the Dignity Therapy, Life Review, and Meaning-Centered Psychotherapy. MLT was culturally adapted to the Portuguese context to include questions about forgiveness, apology, reconciliation, farewell, and a legacy document, i.e., the Life Letter. Nine PC cancer patients answered a 14-question MLT protocol, intended to help patients find purpose and meaning in life. Eight themes emerged: Family, Preservation of Identity, Life Retrospective, Clinical Situation, Achievements, Socio-Professional Valorization, Forgiveness/Apology/Reconciliation, and Saying Goodbye. MLT has proved its ability to respond to the psycho-existential needs of PC patients. Further studies should be conducted to gain extensive knowledge of the effectiveness of culturally responsive interventions.

The impact of self-perceived burden, caregiver burden, and dyadic coping on negative emotions in colorectal cancer patient-spousal caregiver dyads: a dyadic analysis

Objective

To explore the correlation between dyadic coping, self-perceived burden, caregiver burden, and anxiety/depression in colorectal cancer patient-spousal caregiver dyads.

Methods

This study surveyed 200 colorectal cancer patient-spousal caregiver dyads from August 2022 to December 2022. It evaluated self-perceived burden (only for patients), caregiver burden (only for spousal caregivers), dyadic coping, anxiety, and depression. It analyzed data through Pearson's correlation and the actor-partner interdependence mediation model.

Results

Self-perceived burden and caregiver burden were significantly associated with the anxiety/depression of both individuals in colorectal cancer patient-spousal caregiver dyads; patients' dyadic coping was associated with self-perceived burden and caregiver burden; caregivers' dyadic coping was only associated with patients' dyadic coping and depression. There was an actor-partner mediating effect of self-perceived burden between dyadic coping and anxiety/depression, but there was only a partner-mediating effect of caregiver burden between dyadic coping and anxiety/depression.

Conclusion

This study confirmed the interrelationship between self-perceived burden, caregiver burden, dyadic coping, anxiety, and depression. Self-perceived burden and caregiver burden mediated the relationship between dyadic coping and anxiety/depression in colorectal cancer patient-spousal caregiver dyads. This suggests dynamic interventions for self-perceived burden and caregiver burden can be implemented to improve anxiety/depression in both partners based on maintaining healthy dyadic coping between colorectal cancer patient-spousal caregiver dyads.

Intervention and coping strategies for self-perceived burden of patients with cancer: A systematic review

Objective

Self-perceived burden (SPB) is a painful experience for patients with cancer and their caregivers. However, the intervention and coping strategies for SPB have not been systematically summarized. This work reviews the effects of interventions and coping strategies on SPB.

Methods

A systematic search, including trawling through six electronic databases, was performed to identify the articles published from January 2003 to February 2023, both in English and in Chinese. The key terms related to burden on others, intervention, and coping of patients with cancer were adopted. Manual search was also applied.

Results

Thirty articles were identified. Interventions were presented in three dimensions: physical, psychological, and financial/family. Coping strategies were presented in terms of coping attitudes and behaviors. Interventions such as functional exercise and psychological adjustment can improve SPB in the three dimensions mentioned above and thus alleviate SPB. Patients with different coping styles have different implications for prognosis. In addition, the impact of caregivers on patients and the coping they provided were worthy of attention.

Conclusions

This article reviewed interventions for SPB in patients with cancer and the coping strategies from patients and caregivers. The interventions targeting on SPB can alleviate SPB by improving patients' physical condition, psychological status, and financial/family situation. However, the coping attitudes and behaviors of both patients and caregivers were depending on the individual cognitions and perceptions; different coping strategies produced different outcomes. To achieve improvements in SPB, interventions should incorporate the coping strategies. Appropriate patient-caregiver dyad interventions should be constructed based on the commonalities in coping with SPB.

Self-perceived Burden for People With Life-threatening Illness: A Qualitative Systematic Review

CONTEXT

The perception of being a burden to others is a significant concern for people with life-threatening illness. It is unclear what underpins the concept of "self-perceived burden".

OBJECTIVES

To appraise and integrate primary evidence underpinning the concept of self-perceived burden (SPB) with respect to their informal caregivers among adult patients with life-threatening illness.

METHODS

This is a systematic review and a thematic synthesis of qualitative primary data. MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science were searched in September 2021, supplemented by hand searching of textbooks and web search engines, peer-review journals, and contact with experts. Qualitative studies were included if they provided primary data of adult patients' (with life-limiting illness) SPB toward their informal caregivers. Studies were appraised using the Critical Appraisal Skills Programme checklist.

RESULTS

Nine studies were included, reporting on 219 patients who mostly had advanced life-threatening illness and needed physical assistance for daily activities. SPB is a highly subjective perception contrasting self and/or informal caregivers in the past, present, and future. Patients develop SPB feeling uncertain about caregivers' perceptions and increasing future burden. SPB interacts with other factors of surrounding complex balances (such as care needs, reality, and identity) which would change over time, and patients' reactions to SPB at the sacrifice of their wishes may conversely increase the total suffering.

CONCLUSION

SPB is not a static perception but a fluctuating and complex 'process' based on uncertainty. More diverse understandings and following interventions to achieve a better balance of care should be sought.

A Systematic Review of Stakeholder Perspectives of Dignity and Assisted Dying

INTRODUCTION

The debate on assisted dying and its components, euthanasia and physician-assisted suicide has evolved with the emergence of the right to dignity and the wish to hasten death (WTHD). Whilst shaped by local legal and sociocultural considerations, appreciation of how patients, healthcare professionals and lawmakers relate notions of dignity to self-concepts of personhood and the desire for assisted dying will better inform and direct support of patients.

METHODS

Guided by the Systematic Evidence Based Approach, a systematic scoping review (SSR in SEBA) on perspectives of dignity, WTHD and personhood featured in PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Scopus databases and four key Palliative Care journals was conducted. The review hinged on the following questions: "what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?", "how is dignity conceptualised by patients with WTHD?" and "what are prevailing perspectives on the role of assisted dying in maintaining a dying patient's dignity?"

RESULTS

6947 abstracts were identified, 663 full text articles reviewed, and 88 articles included. The four domains identified include 1) concepts of dignity through the lens of the Ring Theory of Personhood (RToP) including their various definitions and descriptions; 2) the relationship between dignity, WTHD and assisted dying with loss of dignity and autonomy foregrounded; 3) stakeholder perspectives for and against assisted dying including those of patient, healthcare provider and lawmaker; and 4) other dignity-conserving measures as alternatives to assisted dying.

CONCLUSION

Concepts of dignity constantly evolve throughout the patient's end of life journey. Understanding when and how these concepts of personhood change and trigger the fear of a loss of dignity or intractable suffering could direct timely, individualised and appropriate person-centred dignity conserving measures. We believe an RToP-based tool could fulfil this role and further study into the design of this tool is planned.

Assessing the wellbeing of family caregivers of multimorbid and homebound older adults-A scoping literature review

BACKGROUND

The prevalence of homebound older adults in the United States more than doubled during the COVID-19 pandemic with greater burden on family caregivers. Higher caregiver burden, more specifically higher treatment burden, contributes to increased rates of nursing home placement. There exist a multitude of tools to measure caregiver well-being and they vary substantially in their focus. Our primary aim was to perform a scoping literature review to identify tools used to assess the facets of caregiver well-being experienced by caregivers of persons with multiple chronic conditions (MCC) with a special focus on those caregivers of homebound adult patients.

METHODS

The search was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. After refining search terms, searches were performed of the peer-reviewed and gray literature.

RESULTS

After removal of duplicate studies, a total of 5534 total articles were screened for relevance to our study. After all screening and review were completed, 377 total articles remained for full review which included 118 different quantitative tools and 20 different qualitative tools. We identified the 15 most commonly utilized tools in patients with MCC. The Zarit Burden Interview was the most commonly used tool across all of the studies. Of the 377 total studies, only eight of them focused on the homebound population and included 13 total tools.

CONCLUSIONS

Building on prior categorization of well-being tools, our work has identified several tools that can be used to measure caregiver well-being with a specific focus on those caregivers providing support to older adults with MCC. Most importantly, we have identified tools that can be used to measure caregiver well-being of family caregivers providing support to homebound older adults, an ever-growing population who are high cost and high utilizers of health care services.

Distinctions between depression and anxiety with fear of being a burden in late life

Objectives: The perception of being a burden is a well-known risk factor for dying by suicide. Research on factors that precede the state of perceived burdensomeness, such as fearing being a burden, is necessary. We investigated the extent to which health status, elevated depressive symptoms, and elevated anxiety symptoms are associated with fear of being a burden in late life.Method: Older adult participants (N = 155) completed the Geriatric Anxiety Scale (GAS), Patient Health Questionnaire (PHQ-8), and demographic and health questions. Fear of being a burden, assessed with a supplemental item on the GAS, was categorically grouped as 'no fear' or 'some fear'. Using logistic regression, we examined predictors of fear of being a burden.Results: In the first step, elevated depression was associated with fear of being a burden (OR = 2.30, 95% CI: 1.09, 4.89, p = .03), but health status was not significant. In the second step, elevated anxiety was significant (OR = 2.63, 95% CI: 1.15, 5.99, p = .02); depression was no longer significant.Conclusion: Contrary to expectations, anxiety more strongly predicted fear of being a burden than depression. Future research should further investigate the role of anxiety in fear of being a burden and ways of intervening.

Exploring interpersonal theory of suicide typologies in patients with cancer: A latent profile analysis

The current study examined patterns of endorsement of Interpersonal Theory of Suicide constructs in a group of patients with cancer (N = 133) via Latent Profile Analysis. Four profiles were identified: (1) Interpersonally Distressed (n = 7; 5.2%), (2) Burdened (n = 11; 8.3%), (3) Fearless About Death (n = 40; 30.1%), (4) Non-Distressed (n = 75; 56.4%). Profiles with higher levels of thwarted belongingness, perceived burdensomeness, and hopelessness were associated with greater suicide ideation. Results also suggest there may be characteristics of patients with cancer that require unique consideration about the potential meaning and relevance of such constructs.

Guilt for perceiving oneself as a burden in healthy older adults. Associated factors

METHODS

Participants were 317 community-dwelling people over 60 years without cognitive or functional limitations. A path model that explores the role of self-perceived burden in the relationship between negative self-perception of aging, perceived control, depressive symptoms and guilt associated with self-perception as a burden was analyzed.

RESULTS

The model presented excellent fit to the data, explaining 41% of the depressive symptomatology and 45% of guilt for perceiving oneself as a burden. Negative self-perceptions of aging, lower sense of control, and a perception of being a burden were significantly associated with depressive symptoms and guilt for perceiving oneself as a burden.

DISCUSSION

This study documents potential correlates of psychological distress in older adults with no explicit physical or cognitive problems, suggesting paths through which feelings of guilt for perceiving oneself as a burden may be reported by this population.

Prevalence and Factors Associated With Will-to-Live in Patients With Advanced Disease: Results From a Portuguese Retrospective Study

CONTEXT

Will-to-live (WtL) is a complex and multifactorial dimension of end-of-life experience. Health care decisions on assisted suicide and euthanasia are rarely based on WtL evidence-based discussions.

OBJECTIVES

To inform the debate, we aimed to evaluate the prevalence of WtL and its associations within a tertiary home-based palliative care unit.

METHODS

Retrospective analysis of all WtL entries registered in our anonymized clinical registry, from October 2018 to September 2020.

RESULTS

One-hundred and twelve patients were included: 53% were male, average age was 66 years old; 88% had malignancies, with a mean performance status of 55%. Mean for WtL of was 3.26 (SD = 3.87) with a prevalence of 60.7% strong, 8.9% moderate and 30.4% weak WtL. Weaker WtL was observed among patients who were not well adapted to their disease (P = .001), felt a burden to others (P< .001), were depressed (P = .001), anxious (P< .001) and endorsed a desire for death (P< .001). Weaker WtL was associated with pain (P = .002) and lower well-being (P = .001). Results from the logistic regression model found that the adaptation to disease emerged as a significant predictor of WtL (P = .025), and burden to others remained marginally significant (P = .087).

CONCLUSION

The factors associated with lower WtL scores are consistent with previous studies, indicating that these patients experience a myriad of physical, psychological and existential symptoms requiring an interdisciplinary palliative care approach. These factors pertaining to WtL should be made known, as Portugal considers how to navigate death-hastening legislation.

Investigating the Added Value of the EQ-5D-5L With Two Bolt-On Items in Patients With Hemophilia

Objective: This study examined the impact of adding two condition-specific bolt-on items to the EQ-5D-5L and assessed their psychometric properties in patients with hemophilia.

Methods: The data were obtained from a nationwide cross-sectional online survey of patients with hemophilia in China. Self-reported and proxy-reported data were analyzed separately. Ceiling effect, informativity, and discriminatory power of the EQ-5D-5L with two bolt-on items, dignity (DG), and bleeding (BL), were examined. Spearman's rank correlation (rho) was used to assess the associations of the EQ-5D-5L and two bolt-on items with the Hemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL) and SF-12. Multiple regression analysis was performed to evaluate the explained variance of the EQ-5D-5L and bolt-on items in predicting EQ-VAS scores.

Results: A total of 895 patients and 222 caregivers completed the questionnaire. The ceiling effect decreased from 1.9 to 0.6% and 5.9 to 0.9% when using the EQ-5D-5L and the EQ-5D-5L with two bolt-on items among participants with both self- and proxy-completed questionnaires. Both DG and BL were strongly correlated with Haem-A-QoL sum score [rho: DG = 0.64 (patient) vs. 0.66(proxy); BL = 0.49 (patient) vs. 0.31 (proxy)], SF-12 mental component [rho: DG = −0.36 (patient) vs. −0.41 (proxy); BL = −0.53 (patient) vs. −0.57(proxy)], and SF-12 physical component [rho: DG = −0.61 (patient) vs. −0.61 (proxy); BL = −0.35 (patient) vs. −0.39 (proxy)]. Known-group comparisons confirmed that the two bolt-on items had satisfactory discriminatory power. Multiple regression analysis indicated that adding two bolt-on items significantly increased the ability to predict EQ-VAS scores. The adjusted R² increased by 8.2 and 8.8% for reports completed by the patients or patients' proxy respondents, respectively.

Conclusion: Adding the DG and BL bolt-on items can increase performance on the EQ-5D-5L in patients with hemophilia. A future valuation study will be carried out.

"I want to go home": How location at death influences caregiver well-being in bereavement

OBJECTIVES

Goal concordant or congruent care involves having expressed wishes upheld. Yet, the preferred location for end-of-life care may be unaddressed. Caregiver-patient congruence between preferred and actual locations of care may influence the quality of life in bereavement. The study aimed to explore how the congruence between caregiver-patient preferred and actual locations of death influenced well-being in bereavement.

METHODS

Mixed methods were employed. In-depth in-person interviews were conducted with 108 bereaved caregivers of a hospice patient about 4 months after the death. An interview guide was used to collect quantitative and qualitative data: demographics, decision-making, Core Bereavement Items (CBI), Health Related Quality of Life, and perspectives on the end-of-life experiences. Data were analyzed with a convergent mixed methods one-phase process.

RESULTS

Patient preference-actual location congruence occurred for 53%; caregiver preference-actual location congruence occurred for 74%; caregiver-patient preference and location of death occurred for 48%. Participants who reported some type of incongruence demonstrated higher levels of distress, including more days of being physically and emotionally unwell and more intense bereavement symptoms. The Acute Separation subscale and CBI total scores demonstrated significant differences for participants who experienced incongruence compared with those who did not. Preference location congruence themes emerged: (1) caregiver-patient location congruence, (2) caregiver-patient location incongruence, and (3) location informed bereavement.

CONCLUSIONS

Congruence between a dying person's preferred and actual locations at death has been considered good care. There has been little focus on the reciprocity between caregiver-patient wishes. Discussing preferences about the place of end-stage care may not make location congruence possible, but it can foster shared understanding and support for caregivers' sense of coherence and well-being in bereavement.

A Pilot Randomized Trial of Engage Psychotherapy to Increase Social Connection and Reduce Suicide Risk in Later Life

BACKGROUND

Targeting social connection to prevent suicide in later life shows promise but requires additional study to identify the most effective and acceptable interventions. This study examines acceptability, feasibility, and efficacy of Engage Psychotherapy to improve subjective disconnection (target mechanisms: low belonging and perceived burden), and improve clinical and functional outcomes (depression, suicide ideation, quality of life).

METHODS

Pilot randomized trial with adults age 60 and older who reported feeling lonely and/or like a burden. Participants were randomly assigned to 10 sessions of 'Social Engage' (S-ENG; n = 32) or care-as-usual (CAU; n = 30), with follow-up assessments at 3 weeks, 6 weeks, and 10 weeks.

RESULTS

S-ENG is feasible to deliver over 10 sessions and acceptable to older adults who report social disconnection-a population at risk for suicide. Participants were willing and able to focus each session on social engagement and demonstrated high levels of compliance. Social Engage did not show preliminary evidence of impact on belonging or perceived burden but was effective in reducing depressive symptoms and improving social-emotional quality of life.

DISCUSSION

S-ENG holds promise for improving social-emotional quality of life and depressive symptoms. Future research is needed to identify and measure target mechanisms that account for clinical and functional improvement.

Existential distress in patients with advanced cancer and their caregivers: study protocol of a longitudinal cohort study

INTRODUCTION

At the end of life, patients with advanced cancer and their informal caregivers may confront multiple existential concerns. Despite the strong potential to alleviate existential distress through psychosocial interventions, existential distress and its impact on healthcare outcomes have not yet been studied systematically. We aim to investigate the frequency, longitudinal trajectory and predictive impact of existential distress on end-of-life outcomes. We further aim to determine patients' and caregivers' specific need for and utilisation of psychosocial support for existential distress.

METHODS

This longitudinal cohort study will consecutively recruit 500 patients with advanced cancer and 500 caregivers from oncological outpatient and inpatient clinics. Participants will complete self-report questionnaires (sociodemographic and disease-related characteristics, existential distress, end-of-life outcomes, resources and support needs) at five points of assessment (at baseline and after 3, 6, 9 and 12 months). At baseline and 6-month follow-up, we will conduct structured diagnostic interviews to assess mental disorders. Statistical analyses will include descriptive statistics to determine the prevalence of existential distress, mental disorders and end-of-life outcomes; multiple linear and logistic regression analyses to calculate the predictive impact of existential distress on end-of-life outcomes; and growth mixture models to analyse longitudinal trajectories of existential distress.

DISCUSSION

This study will provide comprehensive knowledge about patients' and caregivers' existential concerns. The longitudinal empirical data will allow for conclusions concerning the frequency and course of existential distress throughout 1 year. This important extension of existing cross-sectional research will contribute to further develop targeted psychosocial interventions. Profiles of existential distress may be applied by clinicians from multiple professions and help to address existential concerns effectively.

ETHICS AND DISSEMINATION

The study was approved by the institutional research ethics committee (reference number LPEK-0177). Results will be presented at scientific conferences and published in peer-reviewed journals. Other forms of dissemination will include sharing results on the psychometric properties of the structured demoralisation interview with international research groups and communication with healthcare professionals providing psychosocial treatment for patients and caregivers. Following scientific standards, our progress will be regularly updated on ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT04600206.

Assessing the Will to Live: A Scoping Review

CONTEXT

The will to live (WTL) is an important factor to consider in the context of providing resource-oriented palliative care. Until now, there has been no major review of the existing research on this subject.

OBJECTIVES

The primary objective of this study is to summarize the state of research concerning instruments that assess the WTL. The secondary objective is to explore the theoretical models and psychometric properties of these instruments, in studies where these instruments were initially presented. The tertiary objective is to identify, among all studies where these instruments have been used, the intensity of the WTL, and factors associated with it.

METHODS

We conducted a scoping review, including studies that were designed to assess the WTL among participants in all settings. Records were systematically searched from seven bibliographic databases with no date limitations up to August 2020.

RESULTS

Of the 3078 records screened, 281 were examined in detail and 111 were included in the synthesis. A total of 25 different instruments quantitatively assessing the WTL are presented. Most are single-question tools and rate intensity. The underlying concepts and psychometric properties are incompletely explained. Lack of crossreferencing is apparent. The intensity of the WTL is high, even among people with significant health impairment, and is frequently associated with different factors, such as resilience and quality of life.

CONCLUSION

A considerable yet unconnected body of studies assesses the WTL. Its assessment in clinical routine could promote resource-oriented and patient-centered care.

Community nurses' experiences of the Swedish Dignity Care Intervention for older persons with palliative care needs - A qualitative feasibility study in municipal home health care

OBJECTIVES

The Swedish Dignity Care Intervention (DCI-SWE) is an intervention for people with palliative care needs to enhance their dignity. The original DCI was developed in Scotland, where it was tested by nurses in municipal care. In this study, the DCI has been tested for the first time in a Swedish home health care context. The aim was to describe experiences of the DCI-SWE from the perspectives of community nurses (CNs).

METHODS

This was a feasibility study with a qualitative design. Three focus group interviews and one individual interview were performed with CNs (n = 11). Reflective diaries and field notes were written by the CNs and researchers, respectively. Data were analysed using inductive content analysis.

RESULTS

Two main categories and six subcategories were identified. The first main category, 'Practising the palliative approach while responding to palliative care needs', consisted of the subcategories: gives structure while providing palliative care; gives older people opportunities to be confirmed; and responding to existential and sensitive needs. The second main category, 'Aspects influencing the use of the DCI-SWE' had two subcategories about facilitators and barriers to the use of the DCI-SWE, and another about how to establish the DCI-SWE in the context of home health care.

CONCLUSION

The DCI-SWE offers CNs an overview of older people's concerns while providing palliative care, and gives the older people opportunities to be listened to. Essential prerequisites for using the DCI-SWE in municipal home health care are that CNs are comfortable holding conversations and are given time and space for these by the organisation. Other aspects facilitating the use of the DCI-SWE are managers' engagement and support, continuing training for CNs and CNs' opportunities for reflection.

Looking Behind the Fear of Becoming a Burden

As they age, many people are afraid that they might become a burden to their families and friends. In fact, fear of being a burden is one of the most frequently cited reasons for individuals who request physician aid in dying. Why is this fear so prevalent, and what are the issues underlying this concern? I argue that perceptions of individual autonomy, dependency, and dignity all contribute to the fear of becoming a burden. However, this fear is misplaced; common conceptions of these values should be re-framed and re-examined. Practices that support a more community-centered type of autonomy can be found in dependency and dignity. This paper offers some practical examples of how to address common end-of-life situations that may cause anxiety to patients who are worried about being a burden. These practices include discussing expectations, both for care and how the relationship among the participants might change, and modeling respectful caregiving behaviors. Most difficult of all, though, includes cultural and societal attitude changes so that people recognize the good in receiving care and get used to the idea that they do not need to do anything to be valuable.

Self-perceived burden and its associations with health-related quality of life among urologic cancer patients

OBJECTIVE

This study examined the prevalence of self-perceived burden (SPB) and its association with health-related quality of life (HRQoL) among urologic cancer patients.

METHODS

This was a prospective, cross-sectional study. A total of 429 respondents diagnosed with urologic cancers (prostate, bladder and renal cancer) from Sarawak General Hospital and Subang Jaya Medical Centre in Malaysia were interviewed by using a structured questionnaire. SPB and HRQoL were measured by the Self-perceived Burden Scale and the Functional Assessment of Cancer Therapy-General 7 Item Scale respectively.

RESULTS AND CONCLUSION

Self-perceived burden was experienced by 73.2% of the respondents. Respondents who had a lower education level, a monthly household income <MYR 5,000, monthly household expenditures <MYR 3,000 or whose Eastern Cooperative Oncology Group performance status (ECOG-PS) rating was higher and who faced medium to high subjective financial toxicity (FT) were more likely to experience low HRQoL, but not SPB, after adjustment for covariates. As medium to high subjective FT is significantly associated with high SPB and low HRQoL, future interventions should be prioritised to address subjective FT, which, in turn, would reduce SPB and improve HRQoL.

Dignity-conserving care for persons with palliative care needs — identifying outcomes studied in research: An integrative review

Objectives

With people living longer, palliative care may be required for lengthier periods of time. This puts demands on healthcare organizations to provide optimal palliative care. Maintaining dignity is central for any person's health and quality of life, but especially for a person with palliative care needs. Dignity-conserving care needs to be evaluated to increase knowledge about outcomes and how to assess these. The purpose of this integrative review was to identify outcomes studied within dignity-conserving care and how these have been operationalized.

Methods

An integrative review was conducted in 26 quantitative or mixed-method studies and study protocols. Thematic synthesis with an abductive approach was used for analysis.

Results

Seven themes of studied outcomes were identified, as well as four cluster themes: themes related to Illness-Related Concerns, themes related to the Dignity-Conserving Repertoire, themes related to the Social Dignity Inventory, and themes regarding Overarching Dignity Issues. Most outcomes studied dealt with Illness-Related Concerns within the themes of “Performance, symptoms and emotional concerns” and “End-of-life and existential aspects”. Themes linked to the Social Dignity Inventory had the lowest number of outcomes studied. Outcomes regarding overarching dignity issues such as “Dignity-related distress” and “Quality of life” were common. However, the results lacked concrete communication outcomes.

Significance of results

The results will underpin future research in which dignity-conserving care is implemented and evaluated, and contribute to the provision of evidence-based palliative care. A greater focus on outcomes within cluster themes related to the Dignity-Conserving Repertoire and the Social Dignity Inventory is needed, as is more focus on communication outcomes.

US Hospice Structure and its Implications for the "Right to Die" Debate : An Interdisciplinary Study of the "Feeling of Being a Burden to Others"

This article is an analysis of the relationship between US hospice structure and the feeling of being a burden to others (FBO). A goal of US hospice care is to reduce the FBO. But in America, hospice is limited in its ability to do so because of the high caregiver burden it places on family members of dying people. Through a historical study, I show that this burden was excessive when the hospice system was created and has worsened over time. Through three ethnographic vignettes, I demonstrate how this burden inculcates in dying people the FBO. I then examine the bioethical implications of this finding for the existing US debate about physician-assisted suicide (PAS). The presence of FBO due to insufficient hospice care supports arguments made by PAS opponents about the social pressure placed on dying people. This finding is not itself sufficient to resolve the "right to die" debate. But it provides the ground for a compromise, across the debate, to reduce the FBO by changing US hospice structure. The resulting consensus will further the goals of both PAS proponents and opponents.

A Philosophical View on the Experience of Dignity and Autonomy through the Phenomenology of Illness

In the context of the end of life, many authors point out how the experience of identity is crucial for the well-being of patients with advanced disease. They define this identity in terms of autonomy, control, or dependence, associating these concepts with the sense of personal dignity. From the perspective of the phenomenology of embodiment, Kay Toombs and other authors have investigated the ways disease can impact on the subjective world of patients and have stressed that a consideration of this personal world can promote understanding and recognition of their experience. Based on the findings of qualitative studies of the perception of dignity and autonomy in patients at the end of life, this analysis assesses concepts such as being-in-the-world in illness, embodiment, lived body versus objective body or the gaze of the other from a Toombsian phenomenological perspective.

The Correlation between Respecting the Dignity of Cancer Patients and the Quality of Nurse-Patient Communication

Context:

Nurse–patient communication is one of the important factors affects the promotion and maintenance of the dignity of cancer patients in the hospital settings.

Aims:

This study aimed to determine the perceptions of cancer patients regarding respecting their dignity and its correlation with nurse–patient communication in the hospital settings.

Subjects and Methods:

This correlational study was conducted on 250 cancer patients admitted to the Oncology Departments of Tabriz Shahid Ghazi University Hospital, Iran. These patients were selected using a convenience sampling method. The Patient Dignity Inventory and Nurse Quality of Communication with Patient Questionnaire were used for collecting the data.

Statistical Analysis Used:

Descriptive and inferential statistics were applied to the data.

Results:

The score of nurse–patient relationship is significantly correlated with patient's dignity score (R = −0.21, P = 0.001).

Conclusions:

Due to the importance of nurse–patient communication on maintenance of the dignity of cancer patients, it is a necessary requirement to take proper actions in this area, particularly by promoting “nurse's communication skills.”

Validity and reliability of the Mandarin version of Patient Dignity Inventory (PDI-MV) in cancer patients

Nurses play an important role in maintaining patients’ dignity. How to measure patients’ dignity and dignity-related distress is an important issue in nursing care. Use of a reliable and valid tool assessing dignity-related distress in patients is necessary. The study investigated the validity and reliability of the Mandarin Version of the Patient Dignity Inventory (PDI-MV) in cancer patients. The Patient Dignity Inventory (PDI) was translated into the Mandarin language using forward and back translation. A convenience sample of 125 adult cancer patients was recruited from the oncology ward of a medical center in southern Taiwan. Factor analysis with principal axis factoring extraction method and oblique rotation (promax) was used to assess the construct validity. Concurrent validity was established using the Patient Health Questionnaire-9 (PHQ-9), Mandarin version of Demoralization Scale (DS-MV) and the Rosenberg Self-Esteem Scale (RSES). Internal consistency was used to examine the reliability. Data were collected from February to May 2016. As a result of the factor analysis, four factors, including existential distress, loss of support and sense of meaning, symptom distress, and loss of autonomy. Concurrent validity showed that the PDI-MV was significantly correlated with the PHQ-9 (r = 0.25–0.54), DS-MV (r = 0.30–0.58) and the RSES (r = - 0.08 to—0.30), Cronbach’s alpha coefficients for the PDI-MV and four factors were 0.95, 0.95, 0.84, 0.83, and 0.89 respectively. The PDI-MV is a psychometrically sound instrument assessing a broad range of dignity-related distress issues in cancer patients.

Neuroticism confers vulnerability in response to experimentally induced feelings of thwarted belongingness and perceived burdensomeness: Implications for suicide risk

OBJECTIVE

This study investigated the role of individual differences in neuroticism in conferring increased reactivity to the interpersonal antecedents for suicide proposed by the interpersonal theory of suicide.

METHOD

Undergraduate students (N = 113) were screened and selected to form high (n = 58) and low (n = 55) neuroticism groups, and an experimental computer task was used to manipulate participants' experience of thwarted belongingness and perceived burdensomeness. Participants' self-reported desire to persist in the face of this induced interpersonal adversity was measured.

RESULTS

Results indicate that high neuroticism confers increased reactivity to the experimental induction of the interpersonal antecedents of suicidal ideation: Thwarted belongingness and perceived burdensomeness. Furthermore, this vulnerability corresponds to a diminished desire to persist with the task in the face of interpersonal adversity.

CONCLUSIONS

Neuroticism confers vulnerability for suicidal desire via an increased reactivity to the proximal, causal risk factors proposed by the interpersonal theory of suicide. This has implications for considering how personality risk factors such as neuroticism may interact with proximal interpersonal risk factors to increase suicidal ideation.

Advanced Cancer Patients’ Perceptions of Dignity

Purpose:

The present study assesses the relationship between patient dignity in advanced cancer and the following variables: psychological distress, preparatory grief, and sociodemographic and clinical characteristics.

Methods:

The sample consisted of 120 patients with advanced cancer. The self-administered questionnaires were as follows: the Preparatory Grief in Advanced Cancer Patients (PGAC), the Patient Dignity Inventory–Greek (PDI-Gr), the Greek Schedule for Attitudes toward Hastened Death (G-SAHD), and the Greek version of the Hospital Anxiety and Depression Scale (G-HADS).

Results:

Moderate to strong statistically significant correlations were found between the 4 subscales of PDI-Gr (psychological distress, body image and role identity, self-esteem, and social support) with G-HADS, G-SAHD, and PGAC ( P < .005), while physical distress and dependency was moderately correlated with depression. Multifactorial analyses showed that preparatory grief, depression, and age influenced psychological distress, while preparatory grief, depression, and performance status influenced body image and role identity.

Conclusions:

Preparatory grief, psychological distress, and physical symptoms had significant associations with perceptions of dignity among patients with advanced cancer. Clinicians should assess and attend to dignity-distressing factors in the care of patients with advanced cancer.

Self-perceived burden, perceived burdensomeness, and suicidal ideation in patients with chronic pain

Background: Self-perceived burden and perceived burdensomeness are two apparently related constructs that have arisen independently from research in physical and mental health, respectively. Although both are associated with suicidal ideation in individuals with chronic pain, they have yet to be examined concurrently in the same group of patients.

Aims: The aim of this study was to investigate the relationship between the two constructs and their differential prediction of suicidal ideation.

Methods: Participants were 260 outpatients of an interdisciplinary chronic pain treatment program. Each participant completed the Self-Perceived Burden Scale (SPBS), the Interpersonal Needs Questionnaire Perceived Burdensomeness Scale (INQPBS), the Beck Scale for Suicide Ideation, and the thoughts of self-harm item of the Patient Health Questionnaire-9.

Results: The SPBS and the INQPBS were both unifactorial measures with good internal consistency. They correlated significantly with one another (r = 0.50, P < 0.001), as well as with scores on the two measures of suicidal ideation (rs ranging from 0.29 to 0.62, Ps < 0.001). However, the INQPBS correlated more highly with suicidal ideation than did the SPBS. In regression analyses, the INQPBS predicted unique variance in suicidal ideation after adjusting for the SPBS. Conversely, the SPBS did not contribute uniquely when the INQPBS was entered first.

Conclusions: Patients with chronic pain who believe that they have become “a burden to others” are at increased risk for suicidal ideation. The conceptual similarities and differences between the constructs of self-perceived burden and perceived burdensomeness are reviewed to explain why perceived burdensomeness is the stronger predictor of this increased risk.

[The acceptability of the intervention Revie ⊕ : the nurses’ perceptions and experiences]

Persons with advanced cancer experience high levels of existential distress due to being confronted with their mortality, which leads to feelings of lack of sense, or discouragement. It is important to develop interventions to relieve existential distress to promote the dignity of persons with advanced cancer in order to help them live this difficult experience in the best possible way. A new intervention, called Revie ⊕ and conducted by nurses, was developed. A feasibility study was conducted with 41 patients with advanced cancer in the ambulatory and hospital sector of a university hospital in Switzerland to determine the acceptability of Revie ⊕. The purpose of this article is to present the intervention’s acceptability from the perspective of the nurses. Nurses conducting the intervention were asked to complete a questionnaire, maintain personal notes, and to participate in one focus group. Descriptive statistics were used to analyze the questionnaire. Thematic analysis was applied to analyze the nurses’ personal notes and focus group data. Results indicate that nurses consider Revie ⊕ to be a beneficial intervention for the patients and also for their professional posture. As a consequence, the nurses wish for its implementation into practice. Recommendations are proposed to promote further implementation.

The Relationship Between Poor Quality of Life and Desire to Hasten Death: A Multiple Mediation Model Examining the Contributions of Depression, Demoralization, Loss of Control, and Low Self-worth

CONTEXT

The risk of suicide is elevated in palliative care patients compared with the general population. Various psychological factors, including depression, demoralization, loss of control, and low self-worth, have been associated with a desire to hasten death.

OBJECTIVES

The aim of this study was to investigate whether depression, demoralization, loss of control, and low self-worth mediated the relationship between global quality of life and desire to hasten death.

METHODS

A sample of 162 palliative care patients completed measures of global quality of life, depression, demoralization, perceived control, self-worth, and desire to hasten death. A multiple mediation model with bootstrapping sampling tested the total (combined) indirect effect and individual indirect effects of depression, the two subscales of demoralization (Meaning and Purpose, and Distress and Coping Ability), perceived control, and self-worth.

RESULTS

Depressive symptoms, loss of meaning and purpose, loss of control, and low self-worth mediated the direct effect of global quality of life on desire to hasten death. The Distress and Coping Ability component of demoralization was not a significant mediator.

CONCLUSION

Depression, loss of meaning and purpose, loss of control, and low self-worth are strong clinical markers for desire to hasten death. Targeting these symptoms through existentially oriented therapies, such as meaning-centered therapy, may ameliorate suicidal thinking.

Impact of high self-perceived burden to others with preferences for end-of-life care and its determinants for terminally ill cancer patients: a prospective cohort study

BACKGROUND/OBJECTIVE

Self-perceived burden to others (SPB) is a major concern of terminally ill cancer patients and is frequently factored into end-of-life (EOL) care decision-making. However, changes in and determinants of SPB and its longitudinal impact on preferences for EOL care over the dying process have not been investigated. Our study was aimed at filling this gap in knowledge.

METHODS

A convenience sample of 325 cancer patients was followed until death. High SPB was identified as scoring >20 on the Self-perceived Burden Scale. Preferences for EOL care included EOL-care goals, life-sustaining treatments, and hospice care. Factors potentially precipitating/minimizing patients' high SPB included demographics, disease characteristics and burden, and social support and were examined by multivariate logistic regression modeling with the generalized estimating equation.

RESULTS

Prevalence of high SPB increased as death approached (51.78%, 58.26%, 62.66%, and 65.38% for 181-365, 91-180, 31-90, and 1-30 days before death, respectively). High SPB was precipitated by women, younger age, having inadequate financial resources, without religious affiliation, and suffering from severe symptom distress and heavy functional dependence but was independent of time proximity to patient death, disease characteristics, and social support. Furthermore, high SPB was not associated with EOL-care preferences, whether aggressive life-sustaining treatments or hospice care.

CONCLUSIONS

High SPB was prevalent among terminally ill cancer patients but independent of preferences for EOL care. Cancer patients' SPB may be lessened by adequate symptom relief to facilitate functional independence. These strategies to ease SPB may improve the quality of death and dying. Copyright © 2016 John Wiley & Sons, Ltd.

Factors associated with self-perceived burden to the primary caregiver in older patients with hematologic malignancies: an exploratory study

OBJECTIVE

Although cancer patients frequently experience self-perceived burden to others, this perception has not been enough studied. The aim of this study was to investigate the prevalence of self-perceived burden to the primary caregiver (SPB-PC) and associated factors in an older patient population with hematologic malignancies at the time of chemotherapy initiation.

METHODS

In total, 166 consecutive patients with hematologic malignancies aged ≥65 years were recruited at the time of chemotherapy initiation. Patients' SPB-PC was assessed using a 100-mm visual analogue scale (VAS). Characteristics potentially associated with SPB-PC, including sociodemographic and medical characteristics, physical functioning status (Karnofsky performance score, activities of daily living (ADL)/instrumental ADL), symptoms (fatigue, pain, nausea, quality of life), psychological distress (Hospital Anxiety and Depression Scale (HADS)), perceived cognitive function (Functional Assessment of Cancer Therapy Cognitive (FACT-Cog) Scale), and patients'/primary caregivers' personal relationship characteristics (family tie, support), were assessed.

RESULTS

Thirty-five percent of patients reported moderate to severe SPB-PC (VAS ≥ 50 mm). Patients' SPB-PC was associated with lower Karnofsky performance (β = -0.135, p = 0.058) and ADL (β = -0.148, p = 0.037) scores, and higher HADS (β = 0.283, p < 0.001) and FACT-Cog perceived cognitive impairments subscale (β = 0.211, p = 0.004) scores. The proportion of explained variance was 23.5%.

CONCLUSIONS

Health care professionals should be aware that about one third of older cancer patients experience moderate to severe SPB-PC at the time of chemotherapy initiation. They should adapt their support of patients who report such a feeling. Copyright © 2016 John Wiley & Sons, Ltd.

Associations between advanced cancer patients' survival and family caregiver presence and burden

We conducted a randomized controlled trial (RCT) of an early palliative care intervention (ENABLE: Educate, Nurture, Advise, Before Life Ends) for persons with advanced cancer and their family caregivers. Not all patient participants had a caregiver coparticipant; hence, we explored whether there were relationships between patient survival, having an enrolled caregiver, and caregiver outcomes prior to death. One hundred and twenty‐three patient‐caregiver dyads and 84 patients without a caregiver coparticipant participated in the ENABLE early versus delayed (12 weeks later) RCT. We collected caregiver quality‐of‐life (QOL), depression, and burden (objective, stress, and demand) measures every 6 weeks for 24 weeks and every 3 months thereafter until the patient's death or study completion. We conducted survival analyses using log‐rank and Cox proportional hazards models. Patients with a caregiver coparticipant had significantly shorter survival (Wald = 4.31, HR = 1.52, CI: 1.02–2.25, P = 0.04). After including caregiver status, marital status (married/unmarried), their interaction, and relevant covariates, caregiver status (Wald = 6.25, HR = 2.62, CI: 1.23–5.59, P = 0.01), being married (Wald = 8.79, HR = 2.92, CI: 1.44–5.91, P = 0.003), and their interaction (Wald = 5.18, HR = 0.35, CI: 0.14–0.87, P = 0.02) were significant predictors of lower patient survival. Lower survival in patients with a caregiver was significantly related to higher caregiver demand burden (Wald = 4.87, CI: 1.01–1.20, P = 0.03) but not caregiver QOL, depression, and objective and stress burden. Advanced cancer patients with caregivers enrolled in a clinical trial had lower survival than patients without caregivers; however, this mortality risk was mostly attributable to higher survival by unmarried patients without caregivers. Higher caregiver demand burden was also associated with decreased patient survival.

Goal Communication in Palliative Care Decision-Making Consultations

CONTEXT

Palliative care (PC) promotes patient-centered outcomes, but the mechanisms underlying these effects remain poorly understood. Identifying, clarifying, and prioritizing patients' goals are conceptually fundamental to the process of patient-centeredness and are the main reasons for PC referral. However, very little is empirically known about the content or process of goal expression in the natural setting of PC.

OBJECTIVES

To describe the frequency, types, and determinants of goal expression in PC consultations.

METHODS

This was a cross-sectional direct observational study of 72 audiorecorded PC consultations with hospitalized patients (and families) referred for PC goals of care clarification or end-of-life decision making. We coded digital audio files using reliable methods and linked conversation codes to clinical record and brief clinician interview data.

RESULTS

Goal expressions occurred frequently in PC consultations and addressed both length-of-life and quality-of-life domains. The presence of existential suffering in the conversation was associated with substantially more expressions and types of goals.

CONCLUSION

Goal communication is common in PC decision-making settings and strongly influenced by existential suffering.