Dignity-related existential distress in end-of-life cancer patients: Prevalence, underlying factors, and associated coping strategies

Preserving the integrity of personhood in people with advanced cancer: An in-depth qualitative study among patients, relatives, and care professionals

BACKGROUND

Every advanced cancer diagnosis brings enormous challenges to patients and their relatives on numerous levels: be it physical, practical, social challenges, or on a more personal level. While specific aspects have been researched before, an overarching approach is lacking.

AIM

To understand the lived experiences of people with advanced cancer, to identify gaps along the cancer care continuum, to identify potential opportunities for meaningful interventions and to develop a theoretical framework for practitioners and researchers.

DESIGN

A qualitative study using in-depth interviews with patients, relatives, and care professionals. Interviews were transcribed verbatim and analysed using a conventional content analysis.

SETTING/PARTICIPANTS

Fifty-four interviews with 17 patients from a university oncology department and palliative care service, 15 relatives and 22 care professionals from physicians to funeral directors. All interviewees were recruited by a German university hospital.

RESULTS

We developed a novel model describing the diagnosis with advanced cancer as a highly disruptive experience that threatens to challenge the integrity of personhood in cancer patients through four areas: communication, knowledge, relationships, and confidence. We were able to identify factors leading to disintegration in these areas and factors supporting a restoration of integrity of personhood.

CONCLUSIONS

The developed model provides a more thorough understanding of patients lived experiences. It can help to develop new interventions along the cancer care continuum to support patients in the complex challenges they face. These interventions should focus on supporting the integrity of personhood.

End-Of-Life Cancer Patients' Dignity Perception Before and During COVID-19 Pandemic

Background: The safety and restriction regulations implemented to contain the COVID-19 pandemic significantly impacted people's quality of life compromising the perception of dignity. Preserving dignity for end-of-life patients remains a paramount objective in palliative care. This study aimed to compare dignity levels in terminal cancer patients between pre- and during-pandemic periods. Methods: Dignity was assessed by the Italian version of the Patient Dignity Inventory (PDI-IT) in both pre- and during-pandemic groups of terminal cancer inpatients (hospitalized or admitted in hospice). The 2 groups were compared using non-parametric tests and a multivariate logistic regression analysis to estimate the association of the different dimensions of dignity with COVID-19 period, adjusting for other confounders. The study involved 2 groups of end-of-life cancer patients with a Karnofsky Performance Status (KPS) index less than 50. The first group included 506 patients before COVID-19, and the second group consisted of 156 patients enrolled during pandemic. Results: Existential Distress, Loss of Purpose and Meaning, Physical Symptoms and Dependency, Social Support PDI subscales and PDI Total score were higher in the during-pandemic group. The multivariate regression model partially supported the previous results as Loss of Purpose and Meaning, Social Support, and Existential Distress PDI subscales were associated with during-pandemic period, whereas PDI Physical Symptoms and Dependency and PDI Psychological Distress were not. Conclusion: Social isolation and other restrictions put in place to contain the COVID-19 pandemic may have had a negative impact on the perception of dignity in cancer patients at the end of life.

A Systematic Scoping Review on Dignity Assessment Tools

CONTEXT

The provision of person-centered dignity-conserving care is central to palliative care. It is important to reevaluate current methods of assessing dignity as the concept of dignity is multifaceted.

OBJECTIVES

The aim of this study is to understand the tools which are used to assess a patient's dignity and the elements of dignity evaluated in these tools.

METHODS

Two independent and concurrent Systematic Evidence-Based Approach guided systematic scoping reviews (SSR in SEBA) on existing dignity assessment tools and on accounts of assessments of dignity were carried out. The SSR in SEBA on dignity assessment tools involving PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Scopus, and CINAHL databases saw 22 full-text articles included from the 645 articles reviewed. The SSR in SEBA on accounts of assessments of dignity featured in the PubMed database identified 102 full-text articles which saw 46 articles included.

RESULTS

The domains identified were factors affecting patients' definition of dignity; elements of dignity-conserving care; and components of effective tools.

CONCLUSION

Current accounts to assess dignity and assessment tools fail to capture shifting self-concepts of dignity holistically. A portfolio-like appraisal of dignity is proposed to achieve assessments that are timely, longitudinal, and patient-specific. Portfolio-based assessments by members of the multidisciplinary team will better direct timely evaluations of relevant aspects of changing concepts of dignity, without losing the patient's holistic perception of dignity.

"My body is a cage": A qualitative investigation into the self-discrepancy experiences of young women with metastatic cancer

OBJECTIVES

The current study investigated self-discrepancy experiences of young women with metastatic cancer.

METHODS

Semistructured interviews were conducted. Data were analyzed through interpretative phenomenological analysis.

FINDINGS

Eight female patients with metastatic cancer aged between 27 and 38 years formed the sample. Three superordinate themes emerged: (1) compulsory changes in self-concept with ambivalent evaluations; (2) new ideals not on the agenda of a healthy young woman; and (3) so-called 'minimalist' expectations from others.

DISCUSSION

Findings indicated that diagnosis and treatment of metastatic cancer impose unique developmental challenges for young adult women. Advanced cancer disrupted the tasks and responsibilities of young adulthood, resulting in frustration, grief, isolation, and overcompensation. These findings suggest that a developmental perspective is crucial when working with self-discrepancy experiences of young women with metastatic cancer.

Characteristics and influencing factors of demoralization in patients with lung cancer: A latent class analysis

OBJECTIVE

Demoralization has garnered increasing attention in recent years as a significant psychological distress. This study aims to identify latent classes of demoralization in lung cancer patients using Latent Class Analysis (LCA) from a person-centered perspective and to explore the factors influencing the latent classes of demoralization.

METHODS

A cross-sectional study using convenience sampling was conducted among 567 lung cancer patients in three tertiary hospitals in China. LCA was employed to classify heterogeneous classes of demoralization. Multinomial logistic regression analyses were performed to explore the associations between demographic and clinical characteristics, as well as physical symptoms, resilience, family function, and coping strategies, with class membership in the identified heterogeneous subgroups of lung cancer patients.

RESULTS

Three latent classes of demoralization were identified: the high demoralization group (Class 1, 14.8%), the moderate demoralization-distress and helplessness group (Class 2, 37.2%), and the low demoralization group (Class 3, 48.0%). In comparison to Class 3, lung cancer patients with hypertension, higher core symptom burden, poorer resilience, dysfunctional family dynamics, and resignation coping were more likely to belong to Class 1 and Class 2.

CONCLUSIONS

The demoralization patterns in lung cancer patients were varied. Targeted intervention should be developed based on the characteristics of each class, and timely attention should be paid to high-risk patients.

Life beyond Loss: A Retrospective Analysis of the Impact of Meaning of Life Therapy on the Grieving Process of Cancer Patients' Family Caregivers

Oncological disease in the palliative stage is a huge challenge for patients and their family caregivers (FCs) due to the fact that it confronts them with death, as well as physical, psychological, and existential suffering. Meaning of Life Therapy (MLT) is a brief structured psycho-existential intervention aiming to help patients in a meaning-making life review process, promoting end-of-life adaptation. The Life Letter (LL) resulting from MLT is an element that facilitates communication between the patient and their caregivers. The goal of this study was to understand the impact of MLT on the grieving processes of eight FCs and to study their perceptions of the role of the LL on grief through semi-structured interviews. The results of our qualitative analysis indicate that MLT was perceived by the FCs as a positive experience despite the conspiracy of silence being identified as a drawback. The LL was interpreted as a communicational element, promoting emotional closeness with the cancer patients and serving as a valuable tool in the FCs' adaptation to loss. Our research findings show that the needs of FCs, especially after experiencing the loss of their relative, are dynamic and specific. This is why it is urgent to develop interventions that consider the idiosyncrasies of end-of-life cancer patients and their FCs in order to avoid frustrated farewells, lonely deaths, and maladaptive grieving processes. This is the direction in which MLT should evolve.

Symptoms and problems reported by patients with non-cancer diseases through open-ended questions in specialist palliative care: a national register-based study

PURPOSE

Since 2010, a comprehensive symptom/problem (S/P) assessment has been carried out in Danish specialist palliative care using the EORTC QLQ-C15-PAL questionnaire and the open-ended "Write In three Symptoms/Problems" (WISP) instrument. On WISP patients can report up to three S/Ps not included in the EORTC QLQ-C15-PAL. However, little is known about which S/Ps patients with non-cancer diseases report using WISP. Therefore, we investigated the prevalence and severity of S/Ps reported on WISP by non-cancer patients in specialist palliative care and compared these S/Ps with those previously reported by cancer patients.

METHODS

This register-based study collected data from the Danish Palliative Care Database. We included adult patients with non-cancer diseases answering the EORTC QLQ-C15-PAL at admittance to specialist palliative care between 2016 and 2021. WISP responses were qualitatively categorized, and their prevalence and severity calculated.

RESULTS

Of the 2323 patients with non-cancer diseases answering the EORTC QLQ-C15-PAL, 812 (34.9%) reported at least one S/P using WISP. A total of 1340 S/Ps were reported on WISP, of which 56.7% were not included in the EORTC QLQ-C15-PAL (i.e., were new). Edema, existential problems, dizziness, cough, and dysphagia were the most prevalent new S/Ps. Overall, 88.7% of the S/Ps were scored as moderate-severe. The prevalence of S/Ps reported on WISP did not significantly differ between cancer and non-cancer patients, except for existential problems, dysphagia, myoclonus, speaking problems, sweats, and vomiting.

CONCLUSION

The similarities and differences in the prevalence of the most common S/Ps reported on WISP confirm that WISP improves symptom assessment regardless of patient diagnosis.

Loss of Personal Autonomy and Dignity-Related Distress in End-Of-Life Cancer Patients

The objective of this cross-sectional study is to investigate Dignity-Related Loss of Personal Autonomy (DR-LPA) intended as loss of relational independence causing dignity-related distress. Moreover, it analyzes its possible relationships with demoralization, spirituality, quality of life, hope, and coping styles in a sample composed of 207 end-of-life cancer patients. These variables have been assessed through the following rating scales: Patient Dignity Inventory - Italian version, Demoralization Scale - Italian version, Functional Assessment of Cancer Therapy Scale - General Measure, Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being, Brief Coping Orientation to Problem Experienced, and Herth Hope Index. The results have shown that most of the DR-LPA items were considered a problem by most patients. Functional, social, emotional, and spiritual wellbeing, disheartenment, age, and sex emerged as significant predictors of DR-LPA. In conclusion, this study showed that DR-LPA can be a relevant concern for patients at the end-of-life and for this reason it becomes necessary for psychosocial provides to consider it to deliver better dignity conserving care.

Self-reported dignity and factors that influence dignity in hospitalised older adults: A cross-sectional survey

OBJECTIVE

This study examined levels of self-reported dignity and explored factors expected to influence dignity experienced by older adults during acute hospitalisation in Ghana.

BACKGROUND

Dignified care has been recognised as inseparable from quality nursing care and maintaining patients' dignity has been highlighted in professional codes of conduct for nurses. However, there is a lack of research on self-reported dignity and the factors that influence the dignity of older adults during acute hospitalisation in Africa.

SETTING

A large teaching hospital in the northern region of Ghana.

PARTICIPANTS

Hospitalised older adults.

METHODS

A cross-sectional survey was used to gather data from a convenience sample of 270 older inpatients, using the Hospitalized Older Adults' Dignity Scale. Data were analysed using descriptive statistics and stepwise ordinal logistic regression to investigate stratified dignity outcomes. The study was reported following the STROBE checklist.

RESULTS

More than half of the older adults surveyed reported low to moderate levels of dignity. Demographic characteristics such as age, marital status, religious status, occupation, level of education and type of hospital ward did not show any significant associations with dignity levels. However, there was a significant association found between dignity levels and sex and the number of hospitalisations.

CONCLUSION

Most older adults in a Ghanian hospital experienced loss of dignity during their acute hospitalisation. Male older adults reported higher dignity levels during acute hospitalisation than their female counterparts. Further, older adults who were admitted to hospital for the second time reported less dignity compared to those admitted three or more times.

RELEVANCE TO CLINICAL PRACTICE

The results emphasise the importance of healthcare professionals having the necessary knowledge and skills to provide gender-sensitive care, which ultimately promotes the dignity of all patients. Additionally, the results underscore the urgency of implementing measures that guarantee patients' dignity during all hospital admissions.

PATIENT OR PUBLIC CONTRIBUTION

Survey questionnaires were completed by hospitalised older adults at the study setting.

Prevalence, Associated Factors and Adverse Outcomes of Demoralization in Cancer Patients: A Decade of Systematic Review

Demoralization has been extensively studied in oncology and palliative care settings, and is characterized by a loss of meaning and purpose in life, a sense of powerlessness over life events, and a sense of helplessness. The objective of this systematic review is to synthesize the prevalence, associated factors, and adverse outcomes of demoralization in cancer patients by reviewing the literature of the last decade. Seven databases (PubMed, PsycINFO, Embase, Web of Science, Medline, CINAHL and Cochrane Library databases) were systematically searched from January 2012 to June 2022. Roughly speaking, the prevalence of demoralization in cancer patients ranges from 13.50% to 49.4%. A total of 45 factors are associated with demoralization, of which psychological factors have been studied more frequently in the last decade. There are nine outcomes related to demoralization, with the strongest evidence for the correlation between demoralization and suicidal ideation. The study emphasizes the complexity of factors associated with demoralization in cancer patients. There appears to be a intersection between the constructs of demoralization and depression, anxiety, and suicidal ideation, which may explain the correlation between them.

Neuroticism as a moderator of symptom-related distress and depression in 4 noncancer end-of-life populations

OBJECTIVES

Neuroticism is a significant predictor of adverse psychological outcomes in patients with cancer. Less is known about how this relationship manifests in those with noncancer illness at the end-of-life (EOL). The objective of this study was to examine the impact of neuroticism as a moderator of physical symptoms and development of depression in patients with amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), end-stage renal disease (ESRD), and frailty in the last 6 months of life.

METHODS

We met this objective using secondary data collected in the Dignity and Distress across End-of-Life Populations study. The data included N = 404 patients with ALS (N = 101), COPD (N = 100), ESRD (N = 101), and frailty (N = 102) in the estimated last 6 months of life, with a range of illness-related symptoms, assessed longitudinally at 2 time points. We examined neuroticism as a moderator of illness-related symptoms at Time 1 (∼6 months before death) and depression at Time 2 (∼3 months before death) using ordinary least squares regression.

RESULTS

Results revealed that neuroticism significantly moderated the relationship between the following symptoms and depression measured 3 months later: drowsiness, fatigue, shortness of breath, wellbeing (ALS); drowsiness, trouble sleeping, will to live, activity (COPD); constipation (ESRD); and weakness and will to live (frailty).

SIGNIFICANCE OF RESULTS

These findings suggest that neuroticism represents a vulnerability factor that either attenuates or amplifies the relationship of specific illness and depressive symptoms in these noncancer illness groups at the EOL. Identifying those high in neuroticism may provide insight into patient populations that require special care at the EOL.

Demoralization and spirituality in oncology: an integrative systematic review

OBJECTIVE

To synthesize the scientific findings on demoralization and spirituality in the oncology context.

METHODS

This is an integrative systematic review, in line with the PRISMA 2020 guidelines, as proposed by Whittemore and Knalf (2005). The MEDLINE via PubMed, Scopus, Web of Science, APA PsycNet, CINAHL, Cochrane Library, EMBASE, and LILACS databases were searched without limitations regarding language or year of publication. The studies were screened for inclusion according to the predefined eligibility criteria. Data extraction and evidence quality assessment were performed.

RESULTS

Out of the 1587 articles evaluated, 10 studies were included in this review. In general, it was found that demoralization tends to increase with the proximity of death and seems to be inversely related to spirituality, with spiritual well-being being a protective factor against demoralization, while the non-fulfillment of spiritual needs is related to increased demoralization in people with cancer. Furthermore, even among caregivers of people with advanced cancer, demoralization seems to be associated, among other factors, with spiritual suffering. These results should be analyzed with caution, considering that the studies included in this review are all observational studies, which prevents establishing cause and effect relationships.

CONCLUSIONS

Demoralization tends to increase with growing frailty and the proximity of death in people with cancer, and it seems to be inversely related to spirituality, both in these patients and in their caregivers.

Demoralization during the Italian quarantine due to 2019 coronavirus disease pandemic: prevalence and association with psychological well-being and coping strategies

The aims of the study were to investigate demoralization in a sample of Italian citizens during the Italian quarantine due to COVID-19 pandemic and to explore its associations with psychological well-being, coping strategies, participants' socio-demographic characteristics and COVID-19-related factors. Italian citizens aged over 18 and quarantined in Italy were recruited. A cross-sectional online survey was launched through a snow-ball sampling and 1123 surveys were collected. Participants answered ad hoc questions and completed the Psychological General Well-Being Index, the Demoralization Scale, and the Coping Orientation to Problems Experienced-New Italian Version. Disheartenment, dysphoria, and sense of failure were the subdimensions of demoralization with higher scores. Demoralization was associated with depressed mood, positive well-being, self-control, general health, vitality, problem-solving, and avoidance and religious coping strategies. Individuals who were female, older, without children and not working during quarantine had higher demoralization. Quarantine-related changes can elicit demoralization that is associated to lower psychological well-being. Problem-solving and religious coping can protect against demoralization, while avoidant coping strategies can exacerbate it. Assessing and treating demoralization, especially in the categories of citizens most at risk of developing it, could be useful to provide adequate care against COVID-19-related distress.

Methodological quality of dignity-related patient reported outcome measures used in acute hospital settings: A systematic review using the COSMIN methodology

AIMS AND OBJECTIVE

The aim of this systematic review was to examine the methodological quality of dignity-related patient reported outcome measures (PROMs) used to measure patients' dignity during acute hospitalisation using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology for systematic review of PROMs.

BACKGROUND

Previous scoping review studies on the methodological quality of dignity-related PROMs lack specificity for dignity during acute hospital admission. They included PROMs that were developed to measure constructs of care other than patient dignity or designed to measure dignity in contexts outside of the acute hospital setting.

STUDY DESIGN

A systematic review based on COSMIN methodology.

METHODS

A systematic search was undertaken using five databases (CINAHL Complete, Medline Complete, EMBASE, PsycINFo and AgeLine) for articles published between 2000 and 2022. Relevant papers were identified using strict adherence to eligibility criteria, and studies that included development of dignity-related PROMs for use in acute hospital settings were selected. Two reviewers independently screened the identified papers, extracted data and examined the quality of studies.

RESULTS

Six papers met the inclusion criteria. Two PROMs, the 25-item Patient Dignity Inventory and the 34-item Inpatient Dignity Scale, met the COSMIN quality criteria because of their sufficient quality of evidence for content validity and reliable internal consistency. None of the PROMs met the quality criteria for assessment of measurement error, criterion validity, cross-cultural validity and responsiveness.

CONCLUSION

We recommend the Patient Dignity Inventory and the Inpatient Dignity Scale as the PROMs of choice for evaluating patients' dignity and/or dignified care during acute hospital admissions. These PROMs were developed using robust procedures with sufficient overall quality for content validity, internal consistency reliability and other measurement properties, and with moderate to high quality of evidence for these measurement properties. Researchers and clinicians who wish to use other dignity-related PROMs identified in this review should consider the methodological limitations of these PROMs, as highlighted in the present systematic review.

RELEVANCE TO CLINICAL PRACTICE

The review findings will guide healthcare professionals about their choice of patient reported outcome measures for evaluating patients' dignity or dignified care during acute hospitalisation.

Patients' experiences and perceptions of dignity in end-of-life care in emergency departments: A qualitative study

AIMS

To explore and understand the experiences of patients with advanced illness in relation to dignity during end-of-life care in emergency departments.

DESIGN

Qualitative study based on Gadamer's hermeneutics.

METHODS

Between September 2019 and February 2020, 16 in-depth interviews were carried out with advanced illness patients who attended emergency departments. The participants were informed priorly and signed informed consent. The data were analysed using an inductive strategy for finding emerging themes. The Consolidated Criteria for Reporting Qualitative Research was used for writing the study's report.

RESULTS

In the data analysis process, two main themes emerged that glean the experiences of patients in relation to dignity during end-of-life care in emergency departments. 'Dignity as an individual's attribute' and 'Acting with dignity: Dignity as a behavioural attribute'.

CONCLUSION

Patient dignity in end-of-life care is centred around the principle of control (of oneself, one's death and one's emotions). The strategies required for patients to preserve their dignity can be somewhat incompatible with the dynamics and objectives of healthcare professionals who work in emergency departments.

IMPACT STATEMENT

The dignity of patients with advanced illness who attend emergency departments is a relevant issue that merits being addressed from the patients' perspective. Participants have identified that dignity is a way of being and behaving in the face of illness. Emergency departments need to respect end-of-life patients' desires by supporting and accompanying them, avoiding therapeutic obstinacy. We recommend care to be centred on patients' well-being, to respect their autonomy and decision-making processes, and to allow prompt referrals to palliative care services.

PATIENT OR PUBLIC CONTRIBUTION

Managers from the Emergency Departments participated in the study design and patients' recruitment. Patients' relatives were informed about the study's aim, and they contributed to the development of the interview protocol.

The Italian validation of the Death and Dying Distress Scale

OBJECTIVES

Death anxiety (DA), a condition characterized by fear, angst, or panic related to the awareness of one's own death, is commonly observed in advanced cancer patients. The aim of this study was to examine the psychometric properties of the Italian version of the Death and Dying Distress Scale (DADDS-IT) in a sample of patients with advanced cancer.

METHODS

The sample included 200 Italian advanced cancer patients meeting eligibility criteria to access palliative care. Patients' levels of DA were assessed by using the DADDS-IT, while the levels of depression, anxiety, demoralization, spiritual well-being, and symptom burden were assessed using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the Demoralization Scale, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale, and the Edmonton Symptom Assessment System, respectively; Karnofsky Performance Status was used to measure functional impairment. Confirmatory factor analyses (CFA) of previous structures and exploratory factor analyses (EFA) were conducted.

RESULTS

CFA revealed that none of the previous structures adequately fitted data from our sample. EFA revealed a 4-factor model comprising Finitude (α = 0.91), Regret (α = 0.86), Dying (α = 0.88), and Relational Burden (α = 0.73), accounting for the 77.1% of the variance. Dying subscore was higher in hospice patients than in those recruited in medical wards.

SIGNIFICANCE OF RESULTS

The present study provides further evidence that DA is a condition that deserves attention and that DADDS-IT shows good psychometric properties to support its use in research and clinical settings.

Self-report instruments for measuring patient dignity: A psychometric systematic review

AIMS

To synthesize and evaluate the psychometric properties of self-report instruments that measure patient dignity.

DESIGN

A psychometric systematic review.

DATA SOURCES

A comprehensive search of studies published from inception until February 17, 2022, was performed using PubMed, Embase, CINAHL, Web of Science, and Scopus.

REVIEW METHODS

The methodological quality of the psychometric studies was evaluated following the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.

RESULTS

Eleven self-report instruments that evaluate dignity were identified. For most instruments, psychometric properties, including reliability, cross-cultural validity, responsiveness, and measurement error, had not been adequately examined. The Patient Dignity Inventory (PDI), the Jacelon's Attributed Dignity Scale (JADS), and the Inpatient Dignity Scale (IPDS) had acceptable content validity, structure validity, and internal consistency to measure dignity among adult patients under palliative care, community-dwelling older adults, and inpatients receiving daily care.

CONCLUSION

The PDI, the JADS, and the IPDS are recommended for future clinical practice and research to measure dignity among adult patients under palliative care, community-dwelling older adults, and inpatients receiving daily care. Early identification of patients' dignity-related problems in nursing care can prevent negative health outcomes and help develop a timely intervention to promote patients' health and recovery.

IMPACT

Given that the psychometric properties of the existing self-report dignity instruments have not been systematically assessed, the present review utilized comprehensive methods according to COSMIN to evaluate and determine the most appropriate measure for research and practice. The PDI, the JADS, and the IPDS demonstrated satisfactory psychometric properties and are, thus, recommended for clinical and research applications. Nursing professionals can employ these instruments to assess and promptly identify dignity issues among both young and older adults in hospitals and communities.

Understanding factors influencing demoralization among cancer patients based on the bio-psycho-social model: A systematic review

OBJECTIVE

Demoralization is a prevalent psychological problem among cancer patients and reflects a sense of subjective incompetence. This systematic review aims to identify factors influencing demoralization among cancer patients.

METHODS

Eleven databases were systematically searched from database inception to 31 December 2020. Google Scholar and relevant reference lists were supplementarily searched. Studies reporting demoralization measured by Demoralization Scale and its influencing factors among cancer patients were included. A qualitative synthesis was conducted owing to the heterogeneity of the study outcome.

RESULTS

A total of 49 studies involving 10,712 participants were included in this review. The results showed substantial effect size variation, but the psychological factors showed the strongest magnitude of association. Among the biological factors, the number of physical symptoms (mean r values [rs]: 0.331) was associated with increased demoralization. Among the psychological factors, negative psychological factors include hopelessness (mean rs: 0.633), desire for death (mean rs: 0.620), dignity-related distress (mean rs: 0.595), depression (mean rs: 0.593), anxiety (mean rs: 0.589), psychological distress (mean rs: 0.465), and suicidal ideation (mean rs: 0.460) were related to increased demoralization; whereas positive psychological factors including hope (mean rs: -0.565), attachment security (mean rs: -0.530), and sense of coherence (mean rs: -0.453) were related to decreased demoralization. Among the social factors, social support (mean rs: -0.330) was negatively related to demoralization, and the demographic factors were still controversial. Quality of life was considered to be at the intersection of biopsychosocial factors and negatively associated with demoralization (mean rs: -0.599).

CONCLUSIONS

Demoralization is a consequence of the interaction of physical, psychological, and social factors among cancer patients. Factors with a significant effect should not be overlooked when designing an intervention to reduce demoralization. It is necessary to distinguish demoralization from other negative psychological states and further explore positive psychological factors influencing demoralization among cancer patients.

A systematic review of patient-reported dignity and dignified care during acute hospital admission

AIMS

To synthesize quantitative evidence on levels of dignity during acute hospital admission and identify barriers and facilitators to patients' dignity or dignified care from the perspective of hospitalized patients. The secondary aim was to examine the relationship between dignity and demographic, clinical and psychological characteristics of patients.

DESIGN

A systematic review based on the protocol of the Preferred Reporting Items for Systematic reviews and Meta-Analyses guideline for reporting systematic reviews.

DATA SOURCES

Five electronic databases (PubMed, CINAHL, Embase, PsycINFO, AgeLine) were searched in February 2021, followed by backward-forward searching using Web of Science and Scopus databases.

REVIEW METHODS

Potentially eligible articles were scrutinized by two reviewers. Articles that met the eligibility criteria were appraised for quality using the Critical Appraisal Tool for Cross-Sectional Studies. Two reviewers extracted data for the review and resolved differences by consensus.

RESULTS

Out of 3052 potentially eligible studies, 25 met the inclusion criteria. Levels of dignity for hospitalized patients vary widely across geographic locations. Patients' dignity is upheld when healthcare professionals communicate effectively, maintain their privacy, and provide dignity therapy. Patients' perceptions of dignity were, in some studies, reported to be associated with demographic (e.g. age, marital status, gender, employment, educational status), clinical (e.g. hospitalization, functional impairment, physical symptoms) and psychological (e.g. depression, anxiety, demoralization, coping mechanisms) variables whilst other studies did not observe such associations.

CONCLUSION

Patients in acute care settings experience mild to a severe loss of dignity across different geographic locations. Patients' dignity is influenced by several demographic, clinical and psychological characteristics of patients.

IMPACT

The findings of the review support impetus for improvement in dignified care for hospitalized patients, addressing factors that facilitate or impede patients' dignity. Measures aimed at alleviating suffering, fostering functional independence and addressing patients' psychosocial needs can be used to promote dignity.

Vulnerability and Resilience: Phenomenological Analysis of Cancer Patients Value Directives

CONTEXT

Personal values are individual conceptions of the desirable appraisals and actions that guide our attitudes and behaviour. Advance care planning (ACP) now emphasises the consideration of personal life goals and values expressed as a Values Directive (VD) to guide discussions concerning medical treatment.

OBJECTIVE

To investigate the diversity of values, experiences and adaptations expressed in cancer patients VDs.

METHODS

Contents of the VDs of ACPs of cancer patients who participated in a randomised control trial comparing a video intervention showing values communication between cancer patient-caregivers with usual care were analysed. Qualitative phenomenological content analysis was used to understand how participants made meaning of their lived experiences.

RESULTS

Forty-two participants completed an ACP (37.2% response rate), with 97.6% of these completing a VD (57.1% female, mean age 72 years, 30.1% gastrointestinal cancer). Participants described diverse adjustments to frailty and adaptive coping with deteriorating functionality. Emotional and financial concerns were eased through experiencing benevolence and trust established through family and friendship bonds and reciprocation of care. Death anxiety and ambivalence were expressed concurrently with the experiential acceptance of dying. Secular and sacred rituals featured as an affirmation of their faith or beliefs.

CONCLUSION

Cancer patients seek to make meaning of their experiences, concurrently posturing vulnerability and resilience, despite conflicting emotions and experiences. Given that the choices people make as they approach dying relate to their most deeply held values, ACP conversations should explore how patients draw from their values and life goals to optimise their adaptations to illness.

Death anxiety and its relationship with family function and meaning in life in patients with advanced cancer-A cross-sectional survey in China

OBJECTIVE

This study explores the factors influencing death anxiety in patients with advanced cancer, and to investigate the role of family function on death anxiety, and the correlation between meaning in life and death anxiety.

METHODS

Patients with advanced cancer who were hospitalized in three institutions from November 2020 to May 2021 were recruited in this cross-sectional study. The Chinese version of the Death and Dying Distress Scale, Meaning in Life Scale For Advanced Cancer Patients and Family APGAR Index were used to assess death anxiety, meaning in life and family function. Pain symptoms were evaluated by the Numeric Rating Scale. Karnofsky Performance Status, patients' socio-demographic and clinical variables were also recorded. Statistical analyses were performed using IBM SPSS Statistics for Windows (version 26.0). Multivariate regression analysis was performed to examine the correlations of social-demographic and clinical variables with family function and death anxiety.

RESULTS

Three hundred and twenty-eight patients with advanced cancer were included in this study. The results showed that 12.2% of patients experienced moderate to severe death anxiety. Meaning in Life Scale For Advanced Cancer Patients (acceptance of death, controlling one's life), types of institution (oncology department of tertiary hospitals), self-perceived economic burden (extreme), Karnofsky Performance Status score, age, and medical insurance status (self-paid, inter-provincial medical insurance) were identified as associated factors of death anxiety (R ² ​= ​0.335, F ​= ​20.072, P ​< ​0.001). Patients with good family function scores had significantly low level of death anxiety in univariate analysis (F ​= ​5.892, P ​= ​0.003). Multivariate analysis revealed no significant association between family function and death anxiety.

CONCLUSIONS

Our results demonstrated that the oncology department of a tertiary hospital, extremely high of self-perceived economic burden, self-pay, and inter-provincial medical insurance might be associated with higher death anxiety in patients with advanced cancer. Lower level death anxiety was associated with higher level acceptance of death, a greater sense of life control, better physical performance, and older age. Further confirmation about the association between family function and death anxiety in patients with advanced cancer is warranted in the future.

Prevalence and factors associated with demoralization in palliative care patients: A cross-sectional study from Hong Kong

OBJECTIVES

Although demoralization is common among palliative care patients, it has not yet been examined empirically in the Hong Kong Chinese context. This study aims to examine (1) the prevalence of demoralization among community-dwelling palliative care patients in Hong Kong; (2) the percentage of palliative care patients who are demoralized but not depressed and vice versa; and (3) the association of socio-demographic factors, particularly family support, with demoralization.

METHOD

A cross-sectional study targeting community-living palliative care patients in Hong Kong was conducted. A total of 54 patients were recruited by a local hospice and interviewed for completing a questionnaire which included measures of demoralization, depression, perceived family support, and demographic information.

RESULTS

The prevalence of demoralization was 64.8%. Although there was overlap between demoralization and depression (52.8% meeting the criteria of both), 7.5% of depressed patients were not demoralized, and 13.2% of demoralized patients were not depressed. Participants who were not single and had more depressive symptoms and less family support had a significantly higher demoralization level.

SIGNIFICANCE OF RESULTS

This is the first study which reports the prevalence of demoralization in Hong Kong. Demoralization was found common in community-living palliative care patients receiving medical social work services in Hong Kong. This study provides evidence of the importance of differentiating the constructs between demoralization and depression. It also provides an implication that those who are married, more depressed, and have the least family support could be the most vulnerable group at risk of demoralization. We recommend that early assessment of demoralization among palliative care patients be considered.

Dignity Conserving Therapy: An Intervention for Addressing Psychosocial and Existential Distress in Patients with Serious Illness

Patients with serious illnesses may experience existential and psychosocial distress contributing to their pain and suffering. Addressing existential distress is challenging and may require a multidisciplinary approach. Often, providers feel uncomfortable or ill equipped to care for patients suffering from this distress. In the sample case, the patient has a life-limiting disease and is concerned about his family forgetting him, experiencing loss of dignity and narrative foreclosure. Loss of dignity is sensing hopelessness and worthlessness and a loss of self-determination. Narrative foreclosure is the premature conviction that one's life story has effectively ended. Beneficial interventions include meaning-centered psychotherapy and dignity therapy (DT). Both have an underlying theme of attempting to reverse the narrative foreclosure for patients with serious illnesses and maintain a sense of meaning in life. In addition, patients can be referred to palliative care to enhance coping and decrease depressive symptoms. Dr. Harvey Chochinov has outlined a framework that clinicians can use to care for their patients in a compassionate manner to specifically combat meaninglessness. In DT, a generativity document is created for the patient and their loved ones as part of the treatment along with the opportunity to answer the dignity conserving question. Success of this route of intervention includes greater will to live, reductions in stress, and benefits perceived by family. This article aims to give a framework to treat patients with serious illnesses experiencing psychosocial and/or existential distress.

Is there a relationship between end-of-life cancer patients' dignity-related distress and caregivers' distress? An exploratory study

OBJECTIVES

The mutual influence between end-of-life cancer patients and their family caregivers is widely endorsed. The present study aimed to explore the relationship between end-of-life cancer patients' dignity-related distress and the distress of their caregivers.

METHOD

A cross-sectional approach was used. The sample consisted of 128 patients with a Karnofsky Performance Status (KPS) below 50 and a life expectancy of a few weeks, and their family caregivers. Personal and clinical data were collected and validated rating scales were administered: Patient Dignity Inventory (PDI) to terminal cancer patients; Hospital Anxiety and Depression Scale (HADS), Demoralization Scale (DS), Herth Hope Index (HHI), Caregiver Reaction Assessment (CRA), Short Form Health Survey 36 (SF-36), and Distress Thermometer (DT) to caregivers.

RESULTS

Findings highlighted significant correlations between patients' scores on the Psychological Distress PDI subscale and the PDI Total Score and caregivers' Emotional Role. Patients' Psychological Distress, PDI Total Score, and Loss of Purpose and Meaning were associated with caregivers' Disrupted Schedule. Finally, patients' Physical Symptoms and Dependency, Loss of Purpose and Meaning, and PDI Total Score were correlated with caregivers' Disheartenment.

SIGNIFICANCE OF RESULTS

The results highlighted the key role of dignity as a relational dimension during the end-of-life phase. Therefore, because of caregivers' distress could affect patients' dignity-related distress by influencing the interpersonal aspects of patients' autonomy, it would be important to relieve caregivers' distress in order to promote patients' autonomy and minimize their fear of being a burden.

A systematic scoping review on patients' perceptions of dignity

Background

A socioculturally appropriate appreciation of dignity is pivotal to the effective provision of care for dying patients. Yet concepts of dignity remain poorly defined. To address this gap in understanding and enhance dignity conserving end-of-life care, a review of current concepts of dignity is proposed.

Methods

To address its primary research question “How do patients conceive the concept of dignity at the end of life?”, this review appraises regnant concepts and influences of dignity, and evaluates current dignity conserving practices. To enhance accountability, transparency and reproducibility, this review employs the Ring Theory of Personhood (RToP) as its theoretical lens to guide a Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) of patient perspectives of dignity. Three independent teams of reviewers independently analysed included articles from a structured search of PubMed, Embase, PsycINFO, Scopus, CINAHL and Cochrane Databases using thematic and content analyses. The themes and categories identified were compared and combined using the Funnelling Process to create domains that guide the discussion that follows.

Results

Seventy-eight thousand five hundred seventy-five abstracts were identified, 645 articles were reviewed, and 127 articles were included. The three domains identified were definitions of dignity, influences upon perceptions of dignity, and dignity conserving care.

Conclusions

This SSR in SEBA affirms the notion that dignity is intimately entwined with self-concepts of personhood and that effective dignity conserving measures at the end of life must be guided by the patient’s concept of dignity. This SSR in SEBA posits that such personalised culturally sensitive, and timely support of patients, their family and loved ones may be possible through the early and longitudinal application of a RToP based tool.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01004-4.

Analysis of Hazard Factors Affecting the Quality of Life for Lung Cancer Patients after Chemotherapy

Objective

To explore the hazard factors affecting the quality of life for patients with lung cancer after chemotherapy, so as to provide evidence-based clinical proof to improve their quality of life.

Methods

The clinic data of lung cancer patients treated with chemotherapy from November 2020 to November 2021 in our hospital were selected for retrospective analysis. A questionnaire survey was administered to 74 patients who met the inclusion criteria. The general condition questionnaire made by the department was used to analyzed the patients' demographic characteristics and disease status. The quality of life questionnaire for Chinese cancer patients receiving chemobiotherapy (QLQ-CCC) was used to evaluate the patients' quality of life.

Results

The research objects selected for this study scored an average of (94.53 ± 22.65) points in the quality of life. It was found by logistic regression analysis that age, education level, marital status, pathological types, monthly family income, and metastasis were the independent influencing factors that lowered the quality of life of lung cancer patients after chemotherapy (P < 0.001).

Conclusion

Chemotherapy can lead to a decline in the quality of life of lung cancer patients, and there are many factors at play. Therefore, medical and nursing staff should focus on the overall condition of patients when carrying out clinical treatment.

Hypertonic packs to reverse blindness caused by facial lymphoedema in the setting of head and neck cancer - A case report

BACKGROUND

Severe, cancer-related facial oedema can impair vision. It can result from lymphatic and/or venous obstruction due to disease and/or treatment related fibrosis. There is very limited data on the use of directly applied hypertonic packs for the relief of periorbital oedema.

CASE

A 63 year old man with recurrent laryngeal squamous cell carcinoma developed functional blindness secondary to periorbital oedema in the setting of severe facial swelling. This was refractory to maximal facial lymphatic massage available in the community setting.

POSSIBLE COURSES OF ACTION

Management dilemmas included what non-medical interventions may relieve his periorbital oedema and thereby restore his vision outside of daily lymphatic massage from a qualified physiotherapist.

FORMULATION OF MANAGEMENT PLAN

The patient agreed to an initial dry hypertonic pack with a great functional improvement of his vision. He was taught how to do this so that he could repeat ad libitum.

OUTCOME

The patient had previously expressed that his most distressing thought was the prospect of becoming functionally blind prior to dying. The provision of an easy additional therapy to relieve his visual obstruction provided him with much comfort. He passed away peacefully a few weeks later.

LESSONS

The case demonstrates that application of a dry hypertonic pack can relieve periorbital oedema in the setting of facial oedema in cases which are refractory to the combination of self-massage, cold-compress application, and daily lymphatic massage by a certified physiotherapist.

RESEARCH AVENUES

A case series to define incidence of adverse effects and duration of treatment effectiveness.

Existential Distress in Cancer Patients: A Concept Analysis

BACKGROUND

Existential distress is a widely used concept used in describing cancer patients. However, this concept is vague and has failed to achieve a consensus. The lack of a recognized conceptual framework could hinder future research on existential distress.

OBJECTIVE

The aim of this study was to clarify and analyze the concept of existential distress in cancer patients.

METHODS

The Walker and Avant concept analysis approach was applied.

RESULTS

For cancer patients, the concept of existential distress included 5 core attributes: (a) lack of meaning; (b) loss of autonomy; (c) loss of dignity; (d) hopelessness; and (e) death anxiety. Existential distress is a key factor causing poor quality of life, a poor emotional state, demoralization, and even suicide. It is often underpinned by uncontrolled physical pain, serious psychological morbidity, and a perceived sense of being a burden on others.

CONCLUSION

The concept analysis provides a theoretical framework for healthcare providers to better understand existential distress in cancer patients, to improve patient well-being.

IMPLICATIONS FOR PRACTICE

On the basis of the antecedents of this concept, cancer patients experiencing uncontrolled physical pain, severe psychological morbidity, and a perceived sense of being a burden on others are at a high risk of existential distress. These factors should be eliminated in a timely manner to prevent cancer patients from being caught in a state of existential distress. The 5 defining attributes and empirical referents of this concept could be used to develop tools to screen for existential distress in cancer patients and distinguish it from similar concepts.

Existential Quality of Life and Associated Factors in Cancer Patients Receiving Palliative Care

CONTEXT

Enhancing quality of life (QoL) is a goal of palliative care. Existential QoL is an important aspect of this.

OBJECTIVES

This study sought to advance our understanding of existential QoL at the end of life through examining levels of Preparation and Completion, subscales of the QUAL-E, and their associated factors.

METHODS

We used data from a multi-site study of 331 older cancer patients receiving palliative care. We examined levels of Preparation and Completion and their association with demographic, religious, and medical factors, and with the Patient Dignity Inventory.

RESULTS

Preparation and Completion scores were moderately high. In adjusted models, being 10 years older was associated with an increase of 0.77 in Preparation (P = 0.002). Non-white patients had higher Preparation (1.03, P = 0.01) and Completion (1.56, P = 0.02). Single patients reported Completion score 1.75 point lower than those married (P = 0.01). One-point increase in intrinsic religiousness was associated with a 0.86-point increase in Completion (P = 0.03). One-point increase in terminal illness awareness was associated with 0.75-point decrease in Preparation (P = 0.001). A 10-point increase in symptom burden was associated with a decrease of 0.55 in Preparation (P < 0.001) and a decrease of 1.0 in Completion (P < 0.001). The total Patient Dignity Inventory score and all of its subscales were negatively correlated with Preparation (r from -.26 to -.52, all P < 0.001) and Completion (r from -.18 to -.31, all P < 0.001).

CONCLUSION

While most patients reported moderate to high levels of existential QoL, a subgroup reported low existential QoL. Terminal illness awareness and symptom burden may be associated with lower existential QoL.

Dignity and its related factors among older adults in long-term care facilities: A cross-sectional study

Objectives

This study aimed to explore the dignity and related factors among older adults in long-term care facilities.

Methods

Cross-sectional data were obtained from a sample of 253 Chinese older adults dwelling in long-term care facilities. Dignity among older adults was measured using the Dignity Scale, and its potential correlates were explored using multiple linear regressions.

Results

Results showed that the total score of the Dignity Scale is 151.95 ± 11.75. From high to low, the different factors of dignity among older adults in long-term care facilities were as follows: caring factors (4.83 ± 0.33), social factors (4.73 ± 0.41), psychological factors (4.66 ± 0.71), value factors (4.56 ± 0.53), autonomous factors (4.50 ± 0.57), and physical factors (4.38 ± 0.55). A higher score of the Dignity Scale was associated with higher economic status, fewer chronic diseases, less medication, better daily living ability and long-time lived in cities.

Conclusion

Older adults with low economic status, more chronic diseases, and poor daily living ability, taking more medications, or the previous residence in rural areas seem to be most at low-level dignity in long-term care facilities and thus require more attention than their peers.

Caregiver bereavement outcomes in advanced cancer: associations with quality of death and patient age

Purpose

We investigated relationships between domains of quality of dying and death in patients with advanced cancer and their caregivers’ bereavement outcomes and the moderating effect of patient age at death.

Methods

Bereaved caregivers of deceased patients with advanced cancer who had participated in an early palliative care trial completed measures of grief (Texas Revised Inventory of Grief [TRIG]), complicated grief (Prolonged Grief Inventory [PG-13]), and depression (Center for Epidemiologic Studies-Depression [CESD-10]). They also completed the Quality of Dying and Death measure (QODD), which assesses patients’ symptom control, preparation for death, connectedness with loved ones, and sense of peace with death.

Results

A total of 157 bereaved caregivers completed the study. When patient age × QODD subscale interactions were included, greater death preparation was related to less grief at patient death (past TRIG: β =  − .25, p = .04), less current grief (present TRIG: β =  − .26, p = .03), less complicated grief (PG-13: β =  − .37, p = .001), and less depression (CESD-10: β =  − .35, p = .005). Greater symptom control was related to less current grief (present TRIG: β =  − .27, p = .02), less complicated grief (PG-13: β =  − .24, p = .03), and less depression (CESD-10: β =  − .29, p = .01). Significant patient age × connectedness interaction effects for current grief (present TRIG: β = .30, p = .02) and complicated grief (PG-13: β = .29, p = .007) indicated that, with less connectedness, younger patient age at death was associated with greater caregiver grief.

Conclusion

Better end-of-life death preparation and symptom control for patients with cancer may attenuate later caregiver grief and depression. Less connectedness between younger patients and their families may adversely affect caregiver grief.

Existential Suffering in Palliative Care: An Existential Positive Psychology Perspective

The COVID-19 pandemic has exposed the inadequacies of the current healthcare system and needs a paradigm change to one that is holistic and community based, illustrated by the healing wheel. The present paper proposes that existential positive psychology (PP 2.0) represents a promising approach to meet the rising needs in palliative care. This framework has a twofold emphasis on (a) how to transcend and transform suffering as the foundation for wellbeing and (b) how to cultivate our spiritual and existential capabilities to achieve personal growth and flourishing. We propose that these objectives can be achieved simultaneously through dialectical palliative counselling, as illustrated by Wong's integrative meaning therapy and the Conceptual Model of CALM Therapy in palliative care. We then outline the treatment objectives and the intervention strategies of IMT in providing palliative counselling for palliative care and hospice patients. Based on our review of recent literature, as well as our own research and practice, we discover that existential suffering in general and at the last stage of life in particular is indeed the foundation for healing and wellbeing as hypothesized by PP 2.0. We can also conclude that best palliative care is holistic-in addition to cultivating the inner spiritual resources of patients, it needs to be supported by the family, staff, and community, as symbolized by the healing wheel.

Reflecting on meaning in an existential-reorientation group psychotherapy approach for cancer patients: A qualitative thematic analysis

OBJECTIVE

The objectives of this study were to evaluate, in the Italian cultural context, breast cancer patients' main meaning themes related to the experience of the disease, on the one side, and to be part of an existentially oriented group intervention, on the other.

METHOD

A short reorientation-existential (RET) group intervention, structured by using some tools and background from cognitive analytic therapy (CAT) and based on the meaning-centered psychotherapy (MCP) existential framework, was delivered to 29 breast cancer patients. The sessions were audio-recorded and transcribed verbatim, with the narratives from reflective exercises (meaning of the journey cancer, meaning of the journey of intervention) uploaded to computer software NVivo 11. Analysis of the transcripts emerged from reflective exercises on the personal meaning of cancer and the letters of meaning (goodbye letter) written by the patients to express the meaning of their experience in the group was conducted through the interpretative phenomenological analysis (IPA) framework.

RESULTS

Four superordinate themes were identified in the exercise meaning of the experience of cancer, namely "sense of stigma and loneliness (the foreigner)," "guilt (unjust guilt and anticipatory guilt)," "reconsidering one's own life and nostalgia," and "rebirth (a new life, life after life)." Three superordinate themes were found in the meaning of the group experience in the letters, namely "togetherness and gratitude," "legacy," and "acceptance."

SIGNIFICANCE OF RESULTS

The study confirmed that a short group intervention, based on the existentially oriented framework and delivered in a public clinical healthcare setting, was enriched by focusing on the personal meaning of cancer. Some themes, such as loneliness, nostalgia, and rebirth, emerged during reflection giving, in written letters to participants, the sense of the group therapeutic experience.

How patients with cancer experience dignity: An integrative review

BACKGROUND

A diagnosis of cancer and its treatments can be associated with a prominent issue of loss of dignity or an undermined sense of dignity for patients. Research is increasingly being conducted into how patients with cancer experience dignity, with the aim to build clinical foundations for care that preserves patients' sense of dignity.

AIM

This review summarises and synthesises the available empirical literature on the experience of dignity in patients with cancer regarding both the perception of dignity and associated factors.

METHOD

An integrative review method was used. A literature search was conducted in 11 databases using the search terms 'dignity' OR 'existential' OR 'existentialism' combined with 'cancer'. The Mixed Methods Appraisal Tool (version 2011) was adopted to appraise the methodological quality of the included studies.

RESULTS

Nine qualitative studies and 13 quantitative studies met the selection criteria and were included in the review. The ways that patients with cancer perceived dignity include autonomy/control, respect, self-worth, family connectedness, acceptance, hope/future and God/religious. Factors associated with dignity include demographics, physical and psychosocial distress, experiences of suffering and coping strategies.

CONCLUSION

Dignity-conserving care should respect patients' human autonomy to strengthen their sense of self-worth, acceptance, hope, reinforce family connectedness, and foster coping strategies to control the physical, psychosocial factors and experience of sufferings that threaten their sense of dignity.

Validation of the Patient Dignity Inventory in Mexican Cancer Patients

Introduction: The Patient Dignity Inventory (PDI) is a reliable screening instrument for a variety of problems (physical, existential, and social) that affect the dignity of patients during their end of life. The PDI has been translated into several different languages and has been validated in different settings. As such, it is important to validate the instrument in patients with cancer in Mexico to assess dignity in this population. The aim of this study was to translate and validate the Spanish version of the PDI in Mexican patients with cancer. Methods: This is a cross-sectional study that included patients with cancer, both those enrolled and not enrolled in palliative care, at the Instituto Nacional de Cancerología in Mexico City from September 2018 to August 2019. A translation and back translation were performed to obtain the Mexican version of the PDI (PDI-Mx) instrument. Patients completed the PDI-Mx, the Hospital Anxiety and Depression Scale (HADS), and functional scales (Eastern Cooperative Oncology Group [ECOG] and Karnofsky). Psychometric properties were evaluated by determining internal consistency, exploratory and confirmatory factor analysis (CFA), and concurrent validity with the HADS. Results: We included 290 participants with cancer (145 in palliative care and 145 not enrolled in palliative care). The Cronbach's alpha of the PDI-Mx was 0.95. There was a significant correlation with the HADS (rs = 0.757, p < 0.0001). The factor analysis showed four factors that explain 64.7% of the model. The CFA presented adequate indicators, which show the adjustment of the structure that indicates a balanced and parsimonious model. Conclusions: The Mexican version of the PDI shows adequate psychometric properties in patients with cancer. We suggest the use of PDI-Mx in clinical care and research. The study was approved by the Institutional Review Board and Ethics Committee with numbers (016/063/CPI) and (CEI/1115/16) respectively.

The Health Care Providers' Perspectives on End-of-Life Patients' Sense of Dignity. A Comparison Among Four Different Professionals' Categories

The studies on terminally ill patients' dignity as perceived by health care providers (HCPs) in palliative care are growing. The comparison of different HCPs' perspectives in particular is necessary to explore how HCPs perceive patients' dignity in order to promote reflection on this core issue. This study aimed to investigate the perspectives on end-of-life patients' sense of dignity among four different categories of professionals: nurse assistants, nurses, psychologists, and physicians. A sample of 306 HCPs completed the Patient Dignity Inventory-Italian Version (PDI-IT) adapted for them and an ad hoc semi-structured written interview. Their responses were then analyzed using frequencies of the answers to the PDI-IT, a multivariate analysis of variance, Pearson's correlation index, t tests, and content analysis. All HCPs scored the relevance to the dignity-related physical aspects highly, followed by the psychological distress. Nurse assistants and nurses provided higher scores on the psychological and existential and spiritual PDI subscales than the other HCP groups. The social sphere was evaluated as the least salient for the patients' sense of dignity. Physicians who attended a course on dignity considered the psychological and existential dignity dimensions more. Differences in role and expertise could lead to different HCPs' perspectives on dignity, while the multidisciplinary work could favor their aligning. Therefore, it is essential to encourage HCPs' communicative exchange and reflective awareness through training, i.e., courses, seminars, and focus groups. These developments could promote increasingly adequate patient-centered care.

Overcoming existential loneliness: a cross-cultural study

BACKGROUND

Moving into a long-term care facility (LTCF) can reduce the ability for older adults to engage in meaningful roles and activities and the size of their social network. These changes and losses can lead them to experience existential loneliness (EL)-the intolerable emptiness and lack of meaningful existence resulted from the losses they have experienced. While EL has often been understood as a universal human experience, it has primarily been studied in people from Western cultures; little is known about how EL may be experienced by and manifested in people from Eastern cultures. Hence, this qualitative study aimed to describe the experience and coping of EL in Hong Kong Chinese and Swedish older adults living in LTCFs.

METHODS

A qualitative study using Thorne's (2004) interpretive description was conducted. Thirteen Chinese and 9 Swedes living in LTCFs in Hong Kong, China and Malmo, Sweden, respectively were interviewed about their experience of EL in two series of semi-structured interviews. Data were analyzed using thematic analysis.

RESULTS

The core theme of "overcoming EL" described the participants' experience of EL, which came about through the combined process of "Feeling EL" and "Self-Regulating". Both Chinese and Swedish participants had similar experience with EL. Realizing that they did not want to living with EL anymore, they coped by reframing their experience and identifying new meaning in their life.

CONCLUSIONS

The study findings suggested that early and clear counselling support that help older adults to define new meaning in life may help them cope. In addition, more opportunities should be available at the LTCFs to promote quality relationships, enable older adults to reflect on their lives with pride, and support their ability to do the things they enjoy.

Dignity Therapy Helps Terminally Ill Patients Maintain a Sense of Peace: Early Results of a Randomized Controlled Trial

Introduction: Dignity Therapy (DT) is a brief, individualized, narrative psychotherapy developed to reduce psychosocial and existential distress, and promote dignity, meaning, and hope in end of life patients. Previous studies have shown that DT was effective in reducing anxiety and depression, and improving dignity-related distress. However, less is known about its efficacy on spiritual well-being. The aim of this study is to contribute to the existing literature by investigating the effects of DT on specific dimensions of spiritual well-being, demoralization and dignity-related distress in a sample of terminally ill patients. Methods: A randomized, controlled trial was conducted with 64 terminally ill patients who were randomly assigned to the intervention group (DT + standard palliative care) or the control group (standard palliative care alone). The primary outcome measures were Meaning, Peace, and Faith whereas the secondary outcome measures were (loss of) Meaning and purpose, Distress and coping ability, Existential distress, Psychological distress, and Physical distress. All measures were assessed at baseline (before the intervention), 7-10 and 15-20 days after the baseline assessment. The trial was registered with ClinicalTrials.gov (Protocol Record NCT04256239). Results: The MANOVA yielded a significant effect for the Group X Time interaction. ANOVA with repeated measures showed a significant effect of time on peace and a significant Group X Time interaction effect on peace. Post hoc comparisons revealed that, while there was a decrease in peace from pre-treatment to follow-up and from post-treatment to follow-up in the control group, there was no such trend in the intervention group. Discussion: This study provides initial evidence that patients in the DT intervention maintained similar levels of peace from pre-test to follow-up, whereas patients in the control group showed a decrease in peace during the same time period. We did not find significant longitudinal changes in measures of meaning, faith, loss of meaning and purpose, distress and coping ability, existential, psychological and physical distress. The findings of our study are of relevance in palliative care and suggest the potential clinical utility of DT, since they offer evidence for the importance of this intervention in maintaining peace of mind for terminally ill patients.

Defining the Roles and Research Priorities for Psychedelic-Assisted Therapies in Patients with Serious Illness: Expert Clinicians' and Investigators' Perspectives

Background: Recent and preprohibition studies show that patients with serious illness might benefit from psychedelic-assisted therapies for a range of symptoms, physical, psychosocial, and existential. Objective: To explore the potential roles and research priorities of these therapies in patients with serious illness. Design, Setting, and Participants: Qualitative study based on semistructured interviews with 17 experts in serious illness care and/or psychedelic research from the United States and Canada. Measurements: The interview guide elicited participants' perspectives on (1) the potential roles of psychedelic-assisted therapies in this setting, (2) research priorities relevant to this population, and (3) the potential for integrating psychedelic-assisted therapies into existing delivery models of serious illness care. We used thematic analysis until thematic saturation. Results: Domain I: Participants had polar views on the therapeutic potential of psychedelic-assisted therapies, ranging from strong beliefs in their medical utility to reluctance about their use in this patient population. They shared concerns related to the risks of adverse effects, such as delirium or worsening of psychological distress. Domain II: Research priorities primarily concerned patients with clinically diagnosed psychosocial distress, such as depression, anxiety, or demoralization. Participants also articulated potential roles extending beyond traditional medical diagnosis. Domain III: Participants emphasized essential safety and efficacy guidelines relevant to the integration of these therapies into existing models of care. Conclusion: This qualitative study highlights issues and priorities for research on psychedelic-assisted therapies in patients with serious illness and proposes a conceptual framework for integrating these therapies into existing delivery models of serious illness care.

Effectiveness of dignity therapy for patients with advanced cancer: A systematic review and meta-analysis of 10 randomized controlled trials

BACKGROUND

Dignity is a vitally important aspect of the lives of advanced cancer patients. We conducted a systematic review and meta-analysis of the effectiveness of dignity therapy in this patient population.

METHODS

We searched for randomized controlled trials comparing dignity therapy versus standard care for patients with advanced cancer in five comprehensive databases (March 2019), two clinical trial registries and one gray literature database (August 2019). The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Handbook Version 5.1.0. We used GRADE approach to assess the certainty of evidence. Meta-analysis was performed with RevMan version 5.3. Outcomes of interest included anxiety, depression, dignity-related distress and quality of life (QoL).

RESULTS

Ten trials evaluating 904 patients (control, 449; experimental, 455) were identified. Six trials included patients with different types of advanced cancer, and four trials included patients with a single advanced cancer (lung cancer [20%], breast cancer [10%], and hepatocellular carcinoma [10%]). Compared with the standard care, dignity therapy decreased the score of anxiety, depression, and dignity-related distress of the advanced cancer patients (SMD = -1.07, 95% CI: [-1.57, -0.58], p < .05; SMD = -1.31, 95% CI: [-1.92, -0.70], p < .05; MD = -7.30, 95% CI: [- 12.04, - 2.56], p < .05). In addition, no significant differences were found in the patient's QoL (p > .05).

CONCLUSION

Very low certainty evidence demonstrated that dignity therapy might be a promising treatment, especially in reducing anxiety and depression in advanced cancer patients.

Exploring demoralization in end-of-life cancer patients: Prevalence, latent dimensions, and associations with other psychosocial variables

Objective

Demoralization is an existential distress syndrome that consists of an incapacity of coping, helplessness, hopelessness, loss of meaning and purpose, and impaired self-esteem. It can affect cancer patients, and the Demoralization Scale is a valid instrument to assess it. The present study aimed to investigate the prevalence of demoralization in end-of-life cancer patients and its associations with the medical and psychosocial variables. In addition, the latent dimensions of demoralization emerging in this distinctive population were explored.

Method

The study is cross-sectional. The sample consisted of 235 end-of-life cancer patients with a Karnofsky performance status (KPS) lower than 50 and a life expectancy of a few weeks. For each patient, personal and medical data was gathered by a palliative physician and a set of validated rating scales, assessing demoralization, anxiety, depression, physical symptoms, pain, spiritual well-being, and dignity, was administered by a psychologist during the first consultation.

Result

Sixty-four participants (27.2%) had low demoralization, 50.2% (n = 118) had medium demoralization, and 22.6% (n = 53) had high demoralization. Factor analysis evidenced a five-factor solution that identified the following demoralization factors: Emotional Distress and Inability to Cope, Loss of Purpose and Meaning, Worthlessness, Sense of Failure, and Dysphoria. All the considered variables were associated with demoralization, except for pain, nausea, breathing problems, and sociodemographic and clinical variables.

Significance of results

End-of-life cancer patients showed higher levels of demoralization than has been reported in other studies with advanced cancer. These data could suggest that demoralization could increase in proximity to death and with impaired clinical condition. In particular, the five demoralization dimensions that emerged could represent the typical concerns around which the syndrome evolves in end-of-life cancer patients. Finally, spiritual well-being could play a protective role with respect to demoralization.