Validation of the Death and Dying Distress Scale in patients with advanced cancer

Feasibility of online managing cancer and living meaningfully (CALM) in Chinese patients with metastatic breast cancer: a pilot randomized control trial

Metastatic breast cancer could cause various psychological symptoms. Managing Cancer and Living Meaningfully (CALM) is a brief, manualized psychotherapy that has been validated for advanced cancer patients. We conducted a pilot randomized control trial (RCT) to verify the feasibility and preliminary efficacy of CALM therapy in this population. Patients who met the inclusion criteria were randomly assigned into CALM or Wait-list Control (WLC) groups. Patients in the CALM group received CALM therapy and usual care; patients in WLC group first received usual care and then underwent CALM therapy after completing all assessments. All patients were asked to complete three assessments: T0(baseline), T1(3 months), and T2(6 months). The primary outcomes was death anxiety; other outcomes were depression, distress, suicide ideation, attachment security, spiritual well-being and quality of life at the end of life. Analysis of Covariance (ANCOVA) and t-test were used for statistics analysis. Thirty-six patients were randomly assigned to either of the two groups, with 34 patients completing the three assessments. At six months, we found significant between group differences in suicide ideation, distress, and life completion between the CALM and WLC groups. At T2, patients in CALM group reported lower levels of depression (F = 5.016, p = 0.033, partial η2 = 0.143), distress (F = 7.969, p = 0.010, partial η2 = 0.257), attachment avoidance (F = 4.407, p = 0.044, partial η2 = 0.128), and better sense of life completion (F = 5.493, p = 0.026, partial η2 = 0.155) than patients in the WLC group. Compared with results of the T0 assessments, we found significant differences in socres for depression (T2&T0, t = - 2.689, p = 0.011, Cohen's d = 0.940) and distress (T2&T0, t = - 2.453, p = 0.022, Cohen's d = 0.965) between the two groups. CALM therapy was well received by the study population, and CALM therapy can reduce depression, distress, attachment avoidance while improving quality of life in Chinese metastatic breast cancer patients. A Phase III RCT was recommended to verify the impact of CALM therapy on psychological burden and survival in this population.Trial registration: This study is part of the "Preliminary application study for Managing Cancer and Living Meaningfully (CALM) therapy in Chinese advanced cancer patients" clinical trial, with the Trial Registration Number of ChiCTR1900023129 (13/05/2019) in the Chinese Clinical Trial Registry (ChiCTR) website. ( https://www.chictr.org.cn/index.html ).

Clinical evaluation questionnaire in advanced cancer: a psychometric study of a novel measure of healthcare provider interactions

OBJECTIVES

The Clinical Evaluation Questionnaire (CEQ) is a patient-reported experience measure (PREM) that assesses the perceived benefit of therapeutic interactions of patients with advanced cancer with their healthcare providers concerning issues relevant to their illness. It was developed for a randomised controlled trial of Managing Cancer and Living Meaningfully (CALM), a brief supportive-expressive therapy for patients with advanced cancer. The present study evaluates the preliminary psychometric properties of the CEQ.

METHOD

Patients in the CALM and usual care groups completed the CEQ 3 (n=195) and 6 (n=186) months after randomisation. The CEQ's internal consistency, factor structure and concurrent validity were evaluated, and CEQ scores in the treatment groups were compared.

RESULTS

The CEQ demonstrated high internal consistency for both treatment arms (Cronbach's α=0.94 to 0.95), and a single factor was consistently found in exploratory factor analyses. CEQ scores correlated significantly with satisfaction with the relationship with healthcare providers (r=0.23 to 0.61, p≤0.02) and life completion (r=0.24 to 0.37, p≤0.02) in both groups and with spiritual well-being in the CALM group (meaning: r=0.23 to 0.24, p=0.01 to 0.02; faith: r=0.24 to 0.34, p=0.001 to 0.02). The CALM group showed higher CEQ total scores than usual care at 6 months (CALM: 18.19±6.59; usual care: 14.36±7.67, p<0.001).

CONCLUSIONS

The CEQ is a reliable and valid PREM of the benefit perceived by patients with advanced cancer from their interactions with healthcare providers. Further study is needed to establish its value as a measure of perceived intervention benefit across different clinical and research settings.

Managing cancer and living meaningfully (CALM): Implementation in Dutch cancer care

OBJECTIVE

Managing Cancer and Living Meaningfully (CALM) is a brief, evidence-based psychotherapy tailored for patients with advanced cancer that has not yet been implemented routinely in Dutch cancer care. The aim of this study was to assess the feasibility, acceptability, sustainability and effectiveness of CALM in different clinical settings in the Netherlands.

METHODS

In 2019 and 2020 a multi-center, intervention-only study was performed in three Dutch cancer care settings. Professionals were trained to provide CALM under supervision. Patients diagnosed with advanced cancer were included and filled out questionnaires to measure depression (Patient Health Questionnaire-9), death anxiety (Death and Dying Distress Scale), and anxiety (hospital anxiety and depression scale-anxiety) at baseline, 3 and 6 months. The Clinical Evaluation Questionnaire was used to assess acceptability of CALM at 3 and 6 months.

RESULTS

Sixty-four patients (55% of the eligible patients) were included in the study and 85% of the included patients received 3 or more CALM sessions. Of the 24 trained therapists, 15 (63%) started providing CALM. Two years post-study, CALM was provided in each center by a total of 19 therapists. On average, patients perceived CALM to be at least somewhat helpful. A significant decrease in severity of depression (p = 0.006), death anxiety (p = 0.008), and anxiety (p = 0.024) was observed over time.

CONCLUSIONS

This study shows that CALM therapy is feasible, acceptable, and sustainable in three Dutch cancer care settings, although not all predefined feasibility criteria for therapists were met. CALM can be effective in decreasing feelings of depression, anxiety, and death anxiety in patients with advanced cancer.

Measuring double awareness in patients with advanced cancer: A preliminary scale development study

BACKGROUND

Individuals with advanced cancer face the challenge of living meaningfully while also preparing for end of life. The ability to sustain this duality, called "double awareness," may reflect optimal psychological adaptation, but no psychometric scale exists to measure this construct.

OBJECTIVES

The purpose of this study was to develop a novel scale to measure double awareness in patients living with advanced cancer.

METHODS

Guided by best practices for scale development, this study addresses the first three of nine steps in instrument development, including domain clarification and item generation, establishment of content validity of the items, and pre-testing of the items with patients.

RESULTS

Instrument development resulted in a 41-item measure with two dimensions titled "life engagement" and "death contemplation." Items retained in the measure displayed face validity and were found to be both acceptable by patients and relevant to their lived experience.

SIGNIFICANCE OF RESULTS

The results of this scale development study will allow for full validation of the measure and future use in clinical and research settings. This novel measure of double awareness will have clinical utility and relevance in a variety of settings where patients with advanced cancer are treated.

Death anxiety predicts fear of Cancer recurrence and progression in ovarian Cancer patients over and above other cognitive factors

Death anxiety is understudied in people with cancer, especially in relation to fear of cancer recurrence (FCR) and fear of progression (FOP). The present study aimed to identify if death anxiety can predict FCR and FOP over and above other known theoretical predictors. One hundred and seventy-six participants with ovarian cancer were recruited for an online survey. We included theoretical variables, such as metacognitions, intrusive thoughts about cancer, perceived risk of recurrence or progression, and threat appraisal, in regression analyses to predict FCR or FOP. We investigated whether death anxiety added to the variance over and above these variables. Correlational analyses demonstrated that death anxiety is more strongly associated with FOP than FCR. The hierarchical regression including the theoretical variables described above predicted 62-66% of variance in FCR and FOP. In both models, death anxiety predicted a small but statistically significant unique variance in FCR and FOP. These findings draw attention to the importance of death anxiety in understanding FCR and FOP in people with a diagnosis of ovarian cancer. They also suggest that elements of exposure and existentialist therapies may be relevant in treating FCR and FOP.

Measuring and understanding death anxiety in caregivers of patients with primary brain tumor

OBJECTIVE

Caregivers of patients with primary brain tumor (PBT) describe feeling preoccupied with the inevitability of their loved one's death. However, there are currently no validated instruments to assess death anxiety in caregivers. This study sought to examine (1) the psychometric properties of the Death and Dying Distress Scale (DADDS), adapted for caregivers (DADDS-CG), and (2) the prevalence and correlates of death anxiety in caregivers of patients with PBT.

METHODS

Caregivers (N = 67) of patients with PBT completed the DADDS-CG, Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), Fear of Cancer Recurrence (FCR-7), and God Locus of Health Control (GLHC). Caregivers' sociodemographic information and patients' medical characteristics were also collected. Preliminary examination of the psychometric properties of the DADDS-CG was conducted using exploratory factor analysis, Cronbach's alpha, and correlations. The prevalence and risk factors of death anxiety were assessed using frequencies, pair-wise comparisons, and correlations.

RESULTS

Factor analysis of the DADDS-CG revealed a two-factor structure consistent with the original DADDS. The DADDS-CG demonstrated excellent internal consistency, convergent validity with the PHQ-9, GAD-7, and FCR-7, and discriminant validity with the GLHC. Over two-thirds of caregivers reported moderate-to-severe symptoms of death anxiety. Death anxiety was highest in women and caregivers of patients with high-grade PBT.

SIGNIFICANCE OF RESULTS

The DADDS-CG demonstrates sound psychometric properties in caregivers of patients with PBT, who report high levels of death anxiety. Further research is needed to support the measure's value in clinical care and research - both in this population and other caregivers - in order to address this unmet, psychosocial need.

Developing a supportive and palliative care intervention for patients with allogeneic stem cell transplantation: protocol of a multicentre mixed-methods study (allo-PaS)

INTRODUCTION

Although allogeneic stem cell transplantation (allo-SCT) is a curative treatment for many haematological malignancies, it is often associated with a high morbidity and mortality. Yet, little is known about the needs for supportive and palliative care among allo-SCT recipients. Moreover, targeted interventions that reduce symptom burden and suffering are still lacking. The present study aims to inform a supportive-palliative care intervention for patients with allo-SCT and their informal carers by exploring their experience and assessing their needs, especially their existential concerns, regarding four research topics: symptom burden and quality of life; coexistence of a chance for cure and a relevant risk of dying; change in goals of care; dying phase.

METHODS AND ANALYSIS

This is a descriptive mixed-methods study in progress with a convergent parallel design. Data on the four research topics will be collected and analysed separately in three steps: (1) qualitative semi-structured interviews among 20 patients, 20 informal carers and 12 healthcare providers (HCPs) and focus groups among 12-24 HCPs; (2) a quantitative cross-sectional survey with validated questionnaires and self-developed questions among 100 patients, 100 informal carers and 50 HCPs; (3) a retrospective case analysis of all deceased patients who underwent an allo-SCT between 2010 and 2019, with collection of quantitative and qualitative data. The qualitative and quantitative data sets will be finally merged for comparison and interpretation. Results will serve to develop a supportive-palliative care intervention.

ETHICS AND DISSEMINATION

The Ethics Commission of the Faculty of Medicine of the University of Cologne approved this study (20-1370_2). The study results will be published in peer-review journals, be presented at congresses and will be translated into clinical practice through the development of the palliative-supportive care intervention.

TRIAL REGISTRATION NUMBER

DRKS00027290 (German Clinical Trials Register).

Evaluation of Managing Cancer and Living Meaningfully (CALM) in people with advanced non-small cell lung cancer treated with immunotherapies or targeted therapies: protocol for a single-arm, mixed-methods pilot study

INTRODUCTION

People with advanced non-small cell lung cancer (NSCLC) treated with immunotherapies (IT) or targeted therapies (TT) may have improved outcomes in a subset of people who respond, raising unique psychological concerns requiring specific attention. These include the need for people with prolonged survival to reframe their life plans and tolerate uncertainty related to treatment duration and prognosis. A brief intervention for people with advanced cancer, Managing Cancer and Living Meaningfully (CALM), could help people treated with IT or TT address these concerns. However, CALM has not been specifically evaluated in this population. This study aims to evaluate the acceptability and feasibility of CALM in people with advanced NSCLC treated with IT or TT and obtain preliminary evidence regarding its effectiveness in this population.

METHODS AND ANALYSIS

Twenty people with advanced NSCLC treated with IT or TT will be recruited from Peter MacCallum Cancer Centre, Melbourne, Australia. Participants will complete three to six sessions of CALM delivered over 3-6 months. A prospective, single-arm, mixed-methods pilot study will be conducted. Participants will complete outcome measures at baseline, post-intervention, 3 months and 6 months, including Patient Health Questionnaire, Death and Dying Distress Scale, Functional Assessment of Cancer Therapy General and Clinician Evaluation Questionnaire. The acceptability of CALM will be assessed using patient experiences surveys and qualitative interviews. Feasibility will be assessed by analysis of recruitment rates, treatment adherence and intervention delivery time.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Peter MacCallum Cancer Centre Human Research Ethics Committee (HREC/82047/PMCC). Participants with cancer will complete a signed consent form prior to participation, and carers and therapists will complete verbal consent. Results will be made available to funders, broader clinicians and researchers through conference presentations and publications. If CALM is found to be acceptable in this cohort, this will inform a potential phase 3 trial.

Death Anxiety and Correlates in Cancer Patients Receiving Palliative Care

Background: Death anxiety is powerful, potentially contributes to suffering, and yet has to date not been extensively studied in the context of palliative care. Availability of a validated Death Anxiety and Distress Scale (DADDS) opens the opportunity to better assess and redress death anxiety in serious illness. Objective: We explored death anxiety/distress for associations with physical and psychosocial factors. Design: Ancillary to a randomized clinical trial (RCT) of Dignity Therapy (DT), we enrolled a convenience sample of 167 older adults in the United States with cancer and receiving outpatient palliative care (mean age 65.9 [7.3] years, 62% female, 84% White, 62% stage 4 cancer). They completed the DADDS and several measures for the stepped-wedged RCT, including demographic factors, religious struggle, dignity-related distress, existential quality of life (QoL), and terminal illness awareness (TIA). Results: DADDS scores were generally unrelated to demographic factors (including religious affiliation, intrinsic religiousness, and frequency of prayer). DADDS scores were positively correlated with religious struggle (p < 0.001) and dignity-related distress (p < 0.001) and negatively correlated with existential QoL (p < 0.001). TIA was significantly nonlinearly associated with both the total DADDS (p = 0.007) and its Finitude subscale (p ≤ 0.001) scores. There was a statistically significant decrease in Finitude subscale scores for a subset of participants who completed a post-DT DADDS (p = 0.04). Conclusions: Findings, if replicable, suggest that further research on death anxiety and prognostic awareness in the context of palliative medicine is in order. Findings also raise questions about the optimal nature and timing of spiritual and psychosocial interventions, something that might entail evaluation or screening for death anxiety and prognostic awareness for maximizing the effectiveness of care.

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.

Death anxiety as general factor to fear of cancer recurrence

OBJECTIVE

Fear of cancer recurrence or progress is strongly related to death anxiety in cancer patients, but due to lack of conceptualization and measurement methods, the relationship was not analyzed quantitatively before. The aim of the present study was to investigate the conceptual relationship of both constructs, with death anxiety expected to be the general construct.

METHODS

Cancer patients (N=121) participated in an online study. They provided information on socio-demographical, medical and psychological measures including death anxiety (DADDS-G) and fear of cancer recurrence or progression (FoP-Q-SF). Relation of constructs was assessed using a two-step process: Confirming individual construct structure with CFA, including correlation of constructs and modification of measurement model, followed by structural equation modeling and comparison of structure models for best model fit.

RESULTS

The measurement model was modified to include three residual correlations within and between constructs. Comparison of structure models supported a bifactor structure with death anxiety as general factor and fear of recurrence or progression as group factor: SBχ² (173)=207.74 (p<.05), SB=1.538, relative χ² =1.2, rRMSEA=0.05[.01,0.07] (p>.05), SRMR=0.07, CFI=0.94, AIC=7543.60.

CONCLUSIONS

Death anxiety can be interpreted as general factor to fear of cancer recurrence or progression. Psychological interventions to reduce emotional burden of cancer patients need to focus additionally on existential threat and individual fears regarding death anxiety. This article is protected by copyright. All rights reserved.

Systematic Review of Common Refractory Symptoms in the End-Of-Life Situation and Its Relation With Euthanasia

AIM

To analyse the available evidence regarding refractory symptoms to treatment in patients receiving palliative/terminal healthcare.

DESIGN

A systematic review of various databases between September and December 2020; Pubmed; Cochrane; Scopus and ScienceDirect. Study eligibility criteria: Studies published between 1st January 2015 and 31st of March 2020, in Spanish, English or Catalan conducted in elderly people or terminal patients. The study included systematic reviews, clinical trials and interventions.

RESULTS

The search returned 782 articles, of which 22 articles were finally reviewed. Of the selected articles, 16 were systematic reviews and three were clinical trials. Three refractory symptoms are notable; breathlessness, delirium and existential suffering. There are various therapeutic approaches for the first two symptoms, but palliative sedation seems to be most effective for existential suffering.

CONCLUSIONS

Although palliative care enables controlling these symptoms effectively, and following a multidisciplinary approach, there remains a group of patients for whom euthanasia could save foreseeable suffering that is difficult to manage.

Validation of the Death and Dying Distress Scale (DADDS-Sp) in a population with advanced cancer in Chile

Introduction

Developing instruments to screen for relevant aspects of advanced illness is key to identifying palliative needs and evaluating the effectiveness of interventions in this population. The objective of this project is to validate the Death and Dying Distress Scale in Spanish (DADDS-Sp) for screening anxiety about death and evaluating psychometric properties for people with advanced cancer.

Methods

DADDS is a 15-item self-administered questionnaire that assesses thoughts and feelings related to death and the process of dying. A cross-sectional, descriptive, psychometric validation study was conducted in two cancer centres in Santiago de Chile. Included were patients over 18 years of age with incurable and/or metastatic cancer, fluent in Spanish, and a life expectancy of more than 3 months. Reliability was analysed using Cronbach's alpha, and confirmatory factor analysis was performed following the model of the original scale.

Results

Seventy four patients participated in the study. The median age was 63 years. Of the sample, 59% identified themselves as women. On average, participants reported low anxiety about death (mean = 21, SD = 18). Women have more death anxiety. The reliability analysis yielded a value of α = 0.93 (IC = 0.91-0.95). Factor analysis with a one-factor structure yielded Comparative Fit Index (CFI) = 0. 0.972, Root Mean Square Error of Approximation (RMSEA) = 0.092, Standardized Root Mean Square Residual (SRMR) = 0.085 and Tucker-Lewis Index (TLI) = 0.968. The model with a two-factor structure yielded CFI = 0.989, RMSEA = 0.059, SRMR = 0.075 and TLI = 0.987, suggesting that the two-factor model has a better fit for the data studied.

Conclusions

DADDS-Sp is psychometrically valid for use in a Spanish-speaking population, yielding high reliability and internal consistency. A majority of the Chilean patients reported a low level of anxiety about death although about 10% presented with severe anxiety, so their identification for adequate clinical management is fundamental.

Testing terror management theory in advanced cancer

Death anxiety is common in advanced cancer due to heightened mortality salience. We tested terror management theory (TMT) in this population (N = 305) by evaluating the buffering effect of the distal defenses (attachment security, meaning, self-esteem) on the impact of physical impairment (a proxy for mortality salience) on death anxiety. Patients with greater numbers of strong distal defenses reported lower death anxiety than those with no strong defenses or one strong defense. These findings support the relevance of TMT in individuals facing the actual threat of death and the need for further TMT research in such populations.

Medical Assistance in Dying in patients with advanced cancer and their caregivers: a mixed methods longitudinal study protocol

BACKGROUND

The legal criteria for medical assistance in dying (MAiD) for adults with a grievous and irremediable medical condition were established in Canada in 2016. There has been concern that potentially reversible states of depression or demoralization may contribute to the desire for death (DD) and requests for MAiD. However, little is known about the emergence of the DD in patients, its impact on caregivers, and to what extent supportive care interventions affect the DD and requests for MAiD. The present observational study is designed to determine the prevalence, predictors, and experience of the DD, requests for MAiD and MAiD completion in patients with advanced or metastatic cancer and the impact of these outcomes on their primary caregivers.

METHODS

A cohort of patients with advanced or metastatic solid tumour cancers and their primary caregivers will be recruited from a large tertiary cancer centre in Toronto, Ontario, Canada, to a longitudinal, mixed methods study. Participants will be assessed at baseline for diagnostic information, sociodemographic characteristics, medical history, quality of life, physical and psychological distress, attitudes about the DD and MAiD, communication with physicians, advance care planning, and use of psychosocial and palliative care interventions. Measures will subsequently be completed every six months and at the time of MAiD requests. Quantitative assessments will be supplemented by qualitative interviews in a subset of participants, selected using quota sampling methods.

DISCUSSION

This study has the potential to add importantly to our understanding of the prevalence and determinants of the DD, MAiD requests and completions in patients with advanced or metastatic cancer and of the experience of both patients and caregivers in this circumstance. The findings from this study may also assist healthcare providers in their conversations about MAiD and the DD with patients and caregivers, inform healthcare providers to ensure appropriate access to MAiD, and guide modifications being considered to broaden MAiD legislation and policy.

Validation of Death and Dying Distress Scale-Chinese Version and Prevalence of Death Anxiety Among Patients With Advanced Cancer

Purpose: Death anxiety is commonly experienced by individuals with advanced cancer who have a limited life expectancy. The Death and Dying Distress Scale (DADDS) is a validated measure that was created to capture this experience; but no Chinese version is available to date. We conducted a cross-sectional study to explore the psychometric properties of a Chinese version DADDS (DADDS-C) and address prevalence of death anxiety among patients with advanced cancer. Methods: Patients with advanced cancer were recruited from Peking University Cancer Hospital. Measures administered included: DADDS-C, Patient Health Questionnaire (PHQ-9), General Anxiety Disorder-7(GAD-7), Quality of Life at End of Life in Cancer (QUAL-EC), Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-sp). McDonald's Omega, Cronbach's alpha, Exploratory Factor Analysis and Confirmatory Factor Analysis were used to test DADDS-C's reliability and validity. Logistic regression analysis was used to identify risk factors for death anxiety. Results: Of 300 patients approached, 256 (85%) provided informed consent and completed the questionnaires. Of these participants, 43 (16.8%) had moderate death anxiety based on scores of ≥45 on the DADDS-C. Three factors (feeling shortness of time, dying and death distress, being a burden to others) explained 71.643% of shared variation with factor loadings ranging from 0.629 to 0.822. Cronbach's alpha was 0.939; Omega total was 0.959. DADDS-C had acceptable convergent and discriminant validity. Logistic regression analysis indicated that two factors (better relationship with healthcare providers and preparation for end of life) protected patients from death anxiety. Conclusion: DADDS-C is a valid tool for measuring death anxiety in Chinese patients with advanced cancer. The presence of at least moderate death anxiety in a substantial minority of these patients calls for screening for this symptom and for more routine psychological interventions to alleviate and prevent such distress in this population.