Posttraumatic growth in palliative care settings: A scoping review of prevalence, characteristics and interventions

BACKGROUND

Posttraumatic growth refers to positive psychological change following trauma. However, there is a need to better understand the experience of posttraumatic growth in the palliative care setting as well as the availability and efficacy of interventions that target this phenomenon.

AIMS

To provide a review of the prevalence, characteristics and interventions involving posttraumatic growth in adults receiving palliative care and to collate recommendations for future development and utilisation of interventions promoting posttraumatic growth.

DESIGN

We performed a systematic scoping review of studies investigating posttraumatic growth in palliative care settings using the Arksey and O'Malley six-step scoping review criteria. We used the PRISMA guidelines for scoping reviews.

DATA SOURCES

Articles in all languages available on Ovid Medline [1946-2022], Embase [1947-2022], APA PsycINFO [1947-2022] and CINAHL [1981-2022] in November 2022.

RESULTS

Of 2167 articles located, 17 were included for review. These reported that most people report low to moderate levels of posttraumatic growth with a decline towards end-of-life as distress and symptom burden increase. Associations include a relationship between posttraumatic growth, acceptance and greater quality-of-life. A limited number of interventions have been evaluated and found to foster posttraumatic growth and promote significant psychological growth.

CONCLUSION

Posttraumatic growth is an emerging concept in palliative care where although the number of studies is small, early indications suggest that interventions fostering posttraumatic growth may contribute to improvements in psychological wellbeing in people receiving palliative care.

Positive Psychological Well-Being in Early Palliative Care: A Narrative Review of the Roles of Hope, Gratitude, and Death Acceptance

In the advanced cancer setting, low psychological functioning is a common symptom and its deleterious impact on health outcomes is well established. Yet, the beneficial role of positive psychological well-being (PPWB) on several clinical conditions has been demonstrated. Early palliative care (EPC) is a recent value-based model consisting of the early integration of palliative care into standard care for solid tumors and hematologic malignancies. While the late palliative care primary offers short-term interventions, predominantly pharmacological in nature and limited to physical symptom reduction, EPC has the potential to act over a longer term, enabling specific interventions aimed at promoting PPWB. This narrative review examines nine English studies retrieved from MEDLINE/PubMed, published up to October 2023, focusing on EPC and three dimensions of PPWB: hope, gratitude, and death acceptance. These dimensions consistently emerge in our clinical experience within the EPC setting for advanced cancer patients and appear to contribute to its clinical efficacy. The choice of a narrative review reflects the novelty of the topic, the limited existing research, and the need to incorporate a variety of methodological approaches for a comprehensive exploration.

Benefit finding and well-being over the course of the COVID-19 pandemic

This study focuses on understanding benefit finding, the process of deriving growth from adversity, and its relationship to well-being amidst the COVID-19 pandemic. Participants (n = 701) completed online surveys at 1, 3, 6, and 12 months after a shelter-in-place mandate was announced in California, USA. Identifying as female or of Asian descent, having a supportive social network, and reporting more distress were associated with higher levels of general benefit finding at all data collection points, while other demographics were not. Benefit finding exhibited small but statistically significant associations with two measures of well-being. Understanding the extent to which various groups of people experience benefit finding during ongoing adversity and how such benefit finding is associated with well-being may help to promote mental health during a collective trauma like the COVID-19 pandemic.

Posttraumatic growth in palliative care patients and its associations with psychological distress and quality of life

OBJECTIVES

Posttraumatic growth (PTG) refers to positive psychological changes resulting from individuals' inner struggles with traumatic events such as life-threatening illness. Although palliative care patients are confronted with their own mortality, little is known about their PTG experience. This study investigates whether PTG is an empirically relevant concept for palliative patients by assessing the prevalence and areas of growth, and examining associations with psychological distress and quality of life.

METHODS

Participants were recruited in Switzerland. Using validated questionnaires, we assessed PTG (Posttraumatic Growth Inventory, PTGI), psychological distress (Hospital Anxiety and Depression Scale), and quality of life (McGill-Quality of Life Questionnaire - Revised). We performed descriptive analyses, Spearman correlations, and linear regressions.

RESULTS

Fifty-five patients completed the PTGI, 44% of whom experienced no/low growth, 47% moderate growth, and 9% high/very high growth. Participants experienced the greatest positive changes in terms of appreciating life and relating to others. We found significant negative bivariate correlations between PTG and psychological distress (r = -0.33) and between PTG and depression (r = -0.47). Linear regressions showed that PTG is associated with depression (β = -0.468; p = 0.000), but not with anxiety or quality of life (adjusted R² = 0.219).

SIGNIFICANCE OF RESULTS

Over half of our patients experienced moderate to very high growth, indicating that PTG is an empirically relevant psychological process in palliative care. PTG is associated with lower levels of depression, possibly as those experiencing growth are more able to process past traumas and build a more positive outlook on one's life and self. By contrast, the relative independence of anxiety and PTG points to the likely coexistence of positive and negative psychological responses to trauma. The lack of association between PTG and quality of life points to the uniqueness of the PTG concept in capturing how people access deeper meaning and greater appreciation of life along the path toward posttraumatic self-reconstruction.

The end of life experiences of people living with socio-economic deprivation in the developed world: an integrative review

Background

Those experiencing socioeconomic deprivation have poorer quality of health throughout their life course which can result in poorer quality of death – with decreased access to palliative care services, greater use of acute care, and reduced access to preferred place of care compared with patients from less deprived populations.

Aim

To summarise the current global evidence from developed countries on end-of-life experience for those living with socio-economic deprivation.

Design

Integrative review in accordance with PRISMA. A thorough search of major databases from 2010–2020, using clear definitions of end-of-life care and well-established proxy indicators of socio-economic deprivation. Empirical research describing experience of adult patients in the last year of life care were included.

Results

Forty studies were included from a total of 3508 after screening and selection. These were deemed to be of high quality; from a wide range of countries with varying healthcare systems; and encompassed all palliative care settings for patients with malignant and non-malignant diagnoses. Three global themes were identified: 1) multi-dimensional symptom burden, 2) preferences and planning and 3) health and social care interactions at the end of life.

Conclusions

Current models of healthcare services are not meeting the needs of those experiencing socioeconomic deprivation at the end-of-life. Further work is needed to understand the disparity in care, particularly around ensuring patients voices are heard and can influence service development and delivery.

"Now I keep my feet on the ground. Earlier, I was arrogant and felt too big for my boots." Perspectives of people with cancer and oncology nurses on the psychological empowerment process

PURPOSE

A deeper understanding of the psychological empowerment process of people with cancer can provide improved practical strategies for healthcare professionals to assist the patients in maintaining hope and overcoming difficulties. This study aimed to describe, interpret, and understand the phenomenon of the psychological empowerment process related to cancer from the perspectives of people with cancer and oncology nurses.

METHOD

The present descriptive qualitative design study was conducted between May 2017 and August 2017, in the oncology clinics of a university hospital. A purposive sampling method was applied to recruit adult patients diagnosed with different types and stages of cancer. The semi-structured interviews were conducted with thirteen patients and sixteen nurses. The data were transcribed, themes were identified, and the COREQ (Consolidated criteria for Reporting Qualitative Research) Checklist was used to ensure quality reporting in this study.

RESULTS

This study categorized quotes of patients and nurses into four main themes including "gains and losses", "meaning of life", "presence and contact", and "need to be understood". Both patients and nurses shared similar thoughts toward the factors associated with the psychological empowerment process during the cancer experience.

CONCLUSION

Being aware of patients' requirements along with raising effective support to help them grow stronger while preventing the disparity between the support that patients require and receive are some of the aspects that need to be considered for the provision and organization of healthcare services related to the psychological empowerment of people with cancer.

Measuring positive psychosocial sequelae in patients with advanced cancer

OBJECTIVE

Posttraumatic growth and benefit finding describe the potential for positive changes resulting from traumatic experiences, including cancer. In oncology, these constructs are increasingly examined concurrently using the Posttraumatic Growth Inventory (PTGI) and the Benefit Finding Scale (BFS). However, distinctions between these constructs and their corresponding scales are not altogether clear, and the burden of administering 2 lengthy questionnaires is evident, particularly for patients at end-of-life.

METHOD

Baseline data from 209 participants enrolled in a randomized controlled trial evaluating the efficacy of a psychosocial intervention were analyzed. We assessed the structure and covariance of all PTGI and BFS items using item response theory to determine the extent to which these measures overlap and the potential value of their concurrent administration in patients with advanced cancer.

RESULTS

Despite conceptual differences in posttraumatic growth and benefit finding, results indicated that these measures address the same underlying construct. We subsequently analyzed 3 abbreviated scales (7, 11, and 16 items) that combine items from both scales to identify an optimal briefer combined scale. Results supported all 3 versions, with the 7- and 16-item measures appearing to have the best balance of content and concurrent validity and the 11-item version optimizing information gained with brevity.

CONCLUSIONS

These findings indicate that concurrent administration of the PTGI and BFS may be unnecessary given the high degree of overlap between these 2 measures and that a brief subset of items may adequately evaluate positive change among patients with advanced cancer while reducing participant burden. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

End-of-Life Dreams and Visions and Posttraumatic Growth: A Comparison Study

Background: End-of-life dreams and visions (ELDVs) can provide both meaning and comfort to individuals nearing death. While research has examined the prevalence and content of ELDVs, little is known on how dreaming at end of life may affect psychological processes. Objective: This study aimed to explore differences in posttraumatic growth (PTG) between hospice patients who experience ELDVs and hospice patients who do not experience this phenomenon. Design: This is a multimethod cross-sectional comparison study. Settings/Subjects: 70 hospice patients (35 with ELDV experiences and 35 without ELDV experiences) were recruited after being admitted to a hospice inpatient unit. Measurements: PTG was assessed using a modified version of the Posttraumatic Growth Inventory (PTGI). Demographic information, ELDV occurrence, and a brief description of ELDVs were also collected. Results: Significant differences emerged between groups in terms of personal strength (p = 0.012), spiritual change (p = 0.002), and overall PTG (p = 0.019). Patients with ELDV experiences had higher scores on all subscales as well as overall PTG compared to nondreaming patients. Conclusions: Dreams and visions at the end of life affect PTG of dying individuals in hospice care. Further research should be conducted between groups to examine the effects ELDVs may have on other psychological processes.

The Affect Regulation in Cancer framework: Understanding affective responding across the cancer trajectory

Affective dimensions of cancer have long been a central concern in the field of psycho-oncology. Recent developments in the field of affective science suggest the value of incorporating insights from the burgeoning literature on affect regulation. Accordingly, the objective of this article is to build on prior work in this area by applying a process-oriented affect regulation framework to the various phases of the cancer trajectory. The Affect Regulation in Cancer framework is adapted from Gross' process model of emotion regulation, and its aim is to integrate recent advances in affective science with work in the field of psycho-oncology. The basic elements of the affect generative and affect regulatory processes are outlined across the various phases of the cancer trajectory. Our proposed model provides a useful heuristic framework in advancing research on the ways people manage their affective responses throughout the cancer trajectory.

Posttraumatic growth among head and neck cancer survivors with psychological distress

BACKGROUND

Information on posttraumatic growth (PTG) among head and neck cancer (HNC) survivors with a high level of distress is limited. The aim of this cross-sectional study was to investigate the occurrence of PTG among distressed HNC survivors and its association with anxiety, depressive, nicotine, and alcohol use disorders and health-related quality of life.

METHODS

Seventy-four HNC survivors with psychological distress (Hospital Anxiety and Depression Scale (HADS) anxiety > 7 and/or HADS depression > 7) completed the Posttraumatic Growth Inventory, which comprises five subscales: relating to others, new possibilities, personal strength, spiritual change, and appreciation of life, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. Anxiety, depressive, nicotine, and alcohol use disorders were measured using the Composite International Diagnostic Interview.

RESULTS

Moderate to high Posttraumatic Growth Inventory (PTGI) scores occurred in 10% of the HNC survivors with distress. The mean total PTGI score was 30.8 (SD = 19.7), with the highest mean score on the subscale relating to others. A multivariate regression model consisting of tumor stage, anxiety disorder, alcohol use disorder, and social functioning predicted total PTGI score best (F(4, 64) = 7.565, p < .000, R²  = .321).

CONCLUSIONS

The presence of PTG in this population of distressed HNC survivors was low. PTG occurred most in the domain of relating to others. Among distressed HNC survivors, higher PTG was associated with lower tumor stage, absence of an anxiety disorder, absence of an alcohol use disorder, and better social functioning. Copyright © 2016 John Wiley & Sons, Ltd.

Posttraumatic Growth Outcomes and Their Correlates Among Young Adult Survivors of Childhood Cancer

OBJECTIVE

This study aims to identify and examine posttraumatic growth (PTG) experiences, and their correlates, among young adult survivors of childhood cancer.

METHODS

602 long-term childhood cancer survivors between the ages of 18 and 39 participated. Their demographic (age, gender, race/ethnicity, education, relationship status, employment, and income), cancer-related (diagnosis, current health problem, age at diagnosis, and years since diagnosis), and psychosocial (social support and optimism) PTG correlates were examined using descriptive, correlational, and regression analyses.

RESULTS

PTG was significantly greater for females and nonwhite survivors, and for those diagnosed at older ages. Survivors diagnosed with solid/soft tissue tumors reported lower PTG. Optimism and social support were positively associated with PTG.

CONCLUSION

Study findings highlight potential intervention opportunities for increasing PTG by facilitating discussion around growth experiences within an optimistic framework among a supportive network of family members and peers.

Threading the cloak: palliative care education for care providers of adolescents and young adults with cancer

Medical providers are trained to investigate, diagnose, and treat cancer. Their primary goal is to maximize the chances of curing the patient, with less training provided on palliative care concepts and the unique developmental needs inherent in this population. Early, systematic integration of palliative care into standard oncology practice represents a valuable, imperative approach to improving the overall cancer experience for adolescents and young adults (AYAs). The importance of competent, confident, and compassionate providers for AYAs warrants the development of effective educational strategies for teaching AYA palliative care. Just as palliative care should be integrated early in the disease trajectory of AYA patients, palliative care training should be integrated early in professional development of trainees. As the AYA age spectrum represents sequential transitions through developmental stages, trainees experience changes in their learning needs during their progression through sequential phases of training. This article reviews unique epidemiologic, developmental, and psychosocial factors that make the provision of palliative care especially challenging in AYAs. A conceptual framework is provided for AYA palliative care education. Critical instructional strategies including experiential learning, group didactic opportunity, shared learning among care disciplines, bereaved family members as educators, and online learning are reviewed. Educational issues for provider training are addressed from the perspective of the trainer, trainee, and AYA. Goals and objectives for an AYA palliative care cancer rotation are presented. Guidance is also provided on ways to support an AYA's quality of life as end of life nears.