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Bjornsdottir EA, Sigurdardottir S, Halldorsdottir S. Excruciating existential suffering and complicated grief: The essence of surviving the suicide of a son or daughter. Scand J Caring Sci 2024. [PMID: 39221616 DOI: 10.1111/scs.13289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 07/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Suicide is the fourth most common cause of death for the 15-29 age group. Research on the impact of suicide on parents is scarce and, therefore, poorly understood. AIM To explore parents' experiences who have lost a son or a daughter due to suicide and their experience of the services available to them. METHODS This phenomenological study involved 1-2 interviews with ten parents aged 40-65, seven mothers and three fathers in all 13 interviews. The age range of their sons and daughters was 17-37 years when they died. RESULTS For the parents, losing a son or a daughter to suicide is an overwhelming life experience characterised by Excruciating existential suffering and complicated grief where they are confronted with deep meaning-making and existential questions without answers since the person who can answer most of them is no longer alive. They, therefore, felt stuck in their grief for up to 4 years. The initial experience was an immense paralysing shock and sense of unreality. The subsequent period was a blur, and they were numb. Then, their psyche and bodies collapsed, and for a long time, they felt no grief processing was taking place. They sorely needed long-term professional trauma-informed support and felt that, in too many cases, they had to reach out for help themselves. They would have liked to see the healthcare system embrace them with more open arms, offer help and be met with information and individualised support. CONCLUSIONS Standard operating procedures must be installed to support suicide-bereaved parents better. Long-term professional support and trauma-focused care are required following such major trauma, and providing such support could help to reduce their adverse health impacts. Nurses and other health professionals must be better educated on existential suffering in this context.
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Affiliation(s)
- E A Bjornsdottir
- The Health Care Institution of North Iceland [Heilbrigðisstofnun Norðurlands], Reykjahlíð, Iceland
| | - S Sigurdardottir
- Faculty of Graduate Studies in Health Sciences, School of Health, Business and Natural Sciences, University of Akureyri, Akureyri, Iceland
| | - S Halldorsdottir
- Faculty of Graduate Studies in Health Sciences, School of Health, Business and Natural Sciences, University of Akureyri, Akureyri, Iceland
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Illueca M, Bradshaw YS, Carr DB. Spiritual Pain: A Symptom in Search of a Clinical Definition. JOURNAL OF RELIGION AND HEALTH 2023; 62:1920-1932. [PMID: 36083524 PMCID: PMC9461389 DOI: 10.1007/s10943-022-01645-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 06/15/2023]
Abstract
We conducted a literature search to identify and compare definitions of the experiential dimension of spiritual pain. Key databases were searched, up to the year 2021 inclusive, for papers with a definition of "spiritual" or "existential" pain/distress in a clinical setting. Of 144 hits, seven papers provided theoretical definitions/descriptions; none incorporated clinical observations or underlying pathophysiological constructs. Based on these findings, we propose a new definition for "spiritual pain" as a "self-identified experience of personal discomfort, or actual or potential harm, triggered by a threat to a person's relationship with God or a higher power." Our updated definition can inform future studies in pain assessment and management.
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Affiliation(s)
- Marta Illueca
- The Episcopal Diocese of Delaware, 913 Wilson Rd, Wilmington, DE, 19806, USA.
| | - Ylisabyth S Bradshaw
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave, Boston, MA, 02111, USA
| | - Daniel B Carr
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave, Boston, MA, 02111, USA
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Arshinoff R, Roldan C, Balboni T. Spirituality and spiritual distress in neurologic illness. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:221-234. [PMID: 36599510 DOI: 10.1016/b978-0-12-824535-4.00004-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Neurologic illnesses present multiple challenges to patients and their families from the time of initial diagnosis and throughout their illness trajectory, including challenges related to accepting the diagnosis and its various impacts and anxiety about future living with their illness. Often patients and their families rely on their spirituality to cope with and to maintain meaning and dignity in the midst of disease. As a result, spiritual care provision is a critical component of holistic medical care to patients with neurologic illness. Spiritual care provision follows a generalist-specialist model, which requires all healthcare professionals involved in the care of patients facing serious illness to play a role in recognizing and addressing spiritual needs. This model is characterized by generalist spiritual care providers (e.g., nurses, physicians, social workers) who perform spiritual screenings through history taking. Chaplains function as specialist spiritual care providers and can address spiritual care more deeply. In addition, several developed psychotherapeutic approaches may be useful for patients with neurologic disease, and chaplains are especially trained to offer supportive spiritual care to patients with neurologic illnesses and their families and to work together with physicians and other members of the healthcare team as part of a holistic approach to care.
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Affiliation(s)
- Rena Arshinoff
- Department of Spiritual Care, Baycrest Center for Geriatrics, Division of Palliative Care, University of Toronto, Toronto, ON, Canada.
| | - Claudia Roldan
- Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Tracy Balboni
- Departments of Radiation Oncology and of Psychosocial Oncology and Palliative Care, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, United States
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Ann-Yi S, Bruera E. Psychological Aspects of Care in Cancer Patients in the Last Weeks/Days of Life. Cancer Res Treat 2022; 54:651-660. [PMID: 35790196 PMCID: PMC9296948 DOI: 10.4143/crt.2022.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/25/2022] [Indexed: 11/30/2022] Open
Abstract
Palliative care is comprised of an interdisciplinary team (IDT) approach with members from different disciplines who collaboratively work together to reduce multidimensional components of pain and suffering and improve quality of life for patients coping with a terminal illness. Psychosocial team members are integral to the palliative care IDT and provide expertise in assessment and empirically validated interventions to address psychological distress. The following paper will provide a review of different facets of psychological distress experienced by advanced cancer patients such as psychological disorders, existential distress, spiritual distress, caregiver distress, parental distress, and grief. Finally, an overview of commonly used screening and assessment tools as well as psychological interventions relevant for the palliative care population is presented.
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Kukla H, Herrler A, Strupp J, Voltz R. "My life became more meaningful": confronting one's own end of life and its effects on well-being-a qualitative study. Palliat Care 2022; 21:58. [PMID: 35484588 PMCID: PMC9050349 DOI: 10.1186/s12904-022-00950-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/15/2022] [Indexed: 11/22/2022] Open
Abstract
Background The perception of being closer to death can be experienced due to old age or life-limiting diseases, and can pose profound existential challenges. Actively confronting death-related issues and existential questions may increase psychosocial comfort and stimulate personal growth, whereas dysfunctional coping may lead to existential distress. To date, research on individual and (semi-)professional approaches to confronting the own end of life and the effects on one’s well-being remain scarce. Therefore, the aim of this study was to explore individual strategies and wishes in order to derive ideas for appropriate support concepts. Methods Twenty semi-structured interviews were conducted with people over the age of 80 (n = 11) and with a life-limiting disease (n = 10). The interviews were transcribed verbatim and independently coded by two researchers according to Braun and Clarke's thematic analysis approach. Results While the use of (semi-)professional approaches (e.g., therapeutic support) to confronting existential questions in the shape of one’s impending death was rare, individual coping strategies did have a positive impact on psychosocial comfort. There were hardly any significant differences between the participants aged 80 and over and those with a life-limiting disease in terms of individual coping strategies or how they approached the ends of their lives. Both groups reported that theoretical education, preparing for the ends of their lives (e.g., funerals), talking about death-related topics, reflecting on death-related topics, and contemplating death in a spiritual sense had positive effects on their assurance, self-determination and relief. The necessity of confrontation and a desire for low-threshold, accessible and flexible services to meet their existential and spiritual needs were highlighted. Conclusions There is both a desire and a need for the addressing of existential questions. Outside of private contexts, however, the participants possessed little awareness of support services that focused on confronting end-of-life issues, and rarely used such services. Efforts to raise awareness for psychosocial and spiritual needs should be implemented within the care system, together with low-threshold support concepts, in order to increase psychosocial well-being. More research evaluating individual approaches to confronting the own end of life are needed to better understand this determinant of well-being and its mechanisms of action. Trial registration www.germanctr.de, DRKS-ID: DRKS00020577. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00950-3.
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Affiliation(s)
- Helena Kukla
- Faculty of Human Sciences and Faculty of Medicine, Graduate School GROW - Gerontological Research on Well-being, University of Cologne, Albertus-Magnus-Platz, 50931, Cologne, Germany. .,Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany.
| | - Angélique Herrler
- Faculty of Human Sciences and Faculty of Medicine, Graduate School GROW - Gerontological Research on Well-being, University of Cologne, Albertus-Magnus-Platz, 50931, Cologne, Germany
| | - Julia Strupp
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany.,Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany.,Faculty of Medicine and University Hospital, Clinical Trials Center Cologne (ZKS), University of Cologne, Cologne, Germany.,Faculty of Medicine and University Hospital, Center for Health Services Research (ZVFK), University of Cologne, Cologne, Germany
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Abstract
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.
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De Hert M, Loos S, Sterckx S, Thys E, Van Assche K. Improving control over euthanasia of persons with psychiatric illness: Lessons from the first Belgian criminal court case concerning euthanasia. Front Psychiatry 2022; 13:933748. [PMID: 35928783 PMCID: PMC9343580 DOI: 10.3389/fpsyt.2022.933748] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/30/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Belgium is one of very few countries that legally allow euthanasia for suffering caused by psychiatric illness. In the first criminal trial in Belgium of physicians involved in euthanasia, three physicians recently faced the accusation of "murder by poisoning," for allegedly having failed to comply with several requirements of the Belgian Euthanasia Law in granting the euthanasia request a woman suffering from psychiatric illness. Although all three physicians were acquitted, the case generated much debate among policy makers, medical professionals, and the general public. METHOD We use this trial as the starting point for a critical analysis of the adequacy of the three-level control system established in the Euthanasia Law, as it is applied in the evaluation of euthanasia requests from persons who suffer unbearably from a psychiatric illness. This analysis is based on information presented during the criminal trial as well as information on the euthanasia that was published in the press. RESULTS Our analysis highlights substantial problems in the assessment and granting of the euthanasia request. The patient was euthanized without it having been substantiated that her psychiatric illness had no prospect of improvement and that her suffering could not be alleviated. The three-step control system enshrined in the Law and promoted by the Federal Control and Evaluation Commission for Euthanasia appears to have failed at each level. CONCLUSION To evaluate requests for euthanasia for mental suffering caused by psychiatric illness, the requirements of the Belgian Euthanasia Law should be complemented by mandating the advice of two psychiatrists, and face-to-face discussions between all physicians involved. In parallel with the process of evaluating the euthanasia request, a treatment track should be guaranteed where reasonable evidence-based treatments and recovery-oriented options are tried.
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Affiliation(s)
- Marc De Hert
- University Psychiatric Centre, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Neurosciences, Centre for Clinical Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium.,Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium
| | - Sien Loos
- Research Group Personal Rights and Property Rights, Faculty of Law, University of Antwerp, Antwerp, Belgium.,Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sigrid Sterckx
- Bioethics Institute Ghent, Department of Philosophy and Moral Sciences, Ghent University, Ghent, Belgium
| | - Erik Thys
- University Psychiatric Centre, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Neurosciences, Centre for Clinical Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Kristof Van Assche
- Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium.,Research Group Personal Rights and Property Rights, Faculty of Law, University of Antwerp, Antwerp, Belgium
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Palmer PK, Wehrmeyer K, Florian MP, Raison C, Idler E, Mascaro JS. The prevalence, grouping, and distribution of stressors and their association with anxiety among hospitalized patients. PLoS One 2021; 16:e0260921. [PMID: 34871325 PMCID: PMC8648119 DOI: 10.1371/journal.pone.0260921] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
Anxiety is prevalent among hospital inpatients and it has harmful effects on patient well-being and clinical outcomes. We aimed to characterize the sources of hospital distress and their relationship to anxiety. We conducted a cross-sectional study of inpatients (n = 271) throughout two Southeastern U.S. metropolitan hospitals. Participants completed a survey to identify which of 38 stressors they were experiencing. They also completed the State Trait Anxiety Inventory six-item scale. We evaluated the prevalence of stressors, their distribution, and crude association with anxiety. We then used multivariate logistic regression to estimate the association between stressors and clinically relevant anxiety, with and without adjusting for demographic variables. We used factor analysis to describe the interrelationships among stressors and to examine whether groups of stressors tend to be endorsed together. The following stressors were highly endorsed across all unit types: pain, being unable to sleep, feelings of frustration, being overwhelmed, and fear of the unknown. Stressors relating to isolation/meaninglessness and fear/frustration tend to be endorsed together. Stressors were more frequently endorsed by younger, female, and uninsured or Medicaid-insured patients and being female and uninsured was associated with anxiety in bivariate analysis. After controlling for the sources of distress in multivariate linear analysis, gender and insurance status no longer predicted anxiety. Feelings of isolation, lack of meaning, frustration, fear, or a loss of control were predictive. Study results suggest that multiple stressors are prevalent among hospital inpatients and relatively consistent across hospital unit and disease type. Interventions for anxiety or emotional/spiritual burden may be best targeted to stressors that are frequently endorsed or associated with anxiety, especially among young and female patients.
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Affiliation(s)
- Patricia K. Palmer
- Department of Spiritual Health, Emory University Woodruff Health Sciences Center, Atlanta, Georgia, United States of America
- * E-mail:
| | - Kathryn Wehrmeyer
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Marianne P. Florian
- Graduate Division of Religion, Emory University, Atlanta, Georgia, United States of America
| | - Charles Raison
- Department of Spiritual Health, Emory University Woodruff Health Sciences Center, Atlanta, Georgia, United States of America
- School of Human Ecology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Ellen Idler
- Department of Sociology and Rollins School of Public Health, Emory University; Atlanta, Georgia, United States of America
| | - Jennifer S. Mascaro
- Department of Spiritual Health, Emory University Woodruff Health Sciences Center, Atlanta, Georgia, United States of America
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
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Increasing our understanding of nonphysical suffering within palliative care: A scoping review. Palliat Support Care 2021; 20:417-432. [DOI: 10.1017/s1478951521001127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Objective
Nonphysical suffering is emotional, psychological, existential, spiritual, and/or social in nature. While palliative care is a discipline dedicated to the prevention and relief of suffering — both physical and nonphysical — little is known about existing research specific to nonphysical suffering within the context of palliative care. This scoping review helps to fill this gap.
Method
Three hundred and twenty-eight unique records were identified through a systematic search of three databases (MEDLINE, CINAHL, and PsycINFO). The following keywords were used: (suffering) AND (palliative OR “end of life” OR “end-of-life” OR hospice OR dying OR terminal* ill*). Thirty studies published between 1998 and 2019 met the inclusion criteria.
Results
Losses, worries, and fears comprise patients’ primary sources of nonphysical suffering. Patients face numerous barriers in expressing their nonphysical suffering to healthcare providers. The idea that patients can choose how they perceive their circumstances, thereby minimizing their nonphysical suffering, is pervasive in the research. The nature of nonphysical suffering experienced by family caregivers and palliative care clinicians is revealed in the review. The unique and sensitive interplay between nonphysical suffering and both palliative sedation and requests for hastened death is also evident. Overall, seven themes can be identified: (i) patients’ experiences of nonphysical suffering; (ii) patient coping mechanisms; (iii) efforts to measure nonphysical suffering; (iv) palliative sedation; (v) requests for hastened death; (vi) family suffering; and (vii) clinician suffering.
Significance of results
This is the first scoping review to map palliative care's research specific to suffering that is social, emotional, spiritual, psychological, and/or existential in nature. Its findings expand our understanding of the nature of nonphysical suffering experienced by patients, families, and palliative care clinicians. The review's findings have significant implications for front-line practice and future research.
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Expression of existential suffering in two patients with advanced cancer in an acute palliative care unit. Palliat Support Care 2020; 18:748-750. [PMID: 33118907 DOI: 10.1017/s1478951520001121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Recognizing and managing existential suffering remains challenging. We present two cases demonstrating how existential suffering manifests in patients and how to manage it to alleviate suffering. CASE DESCRIPTION Case 1: A 69-year-old man with renal cell carcinoma receiving end-of-life care expressed fear of lying down "as he may not wake up." He also expressed concerns of not being a good Christian. Supportive psychotherapy and chaplain support were provided, with anxiolytic medications as needed. He was able to express his fear of dying and concern about his family, and Edmonton Symptom Assessment System scores improved. He died peacefully with family at bedside. Case 2: A 71-year-old woman presented with follicular lymphoma and colonic obstruction requiring nasogastric drain of fecaloid matter. Initially, she felt that focusing on comfort rather than cure symbolized giving up but eventually felt at peace. Physical symptoms were well-controlled but emotionally she became more distressed, repeatedly asking angrily, "Why is it taking so long to die?." She was supported by her family through Bible readings and prayers, but she was distressed about being a burden to them. An interdisciplinary approach involving expressive supportive counseling, spiritual care, and integrative medicine resulted in limited distress relief. Owing to increasing agitation, the patient and family agreed to titrate chlorpromazine to sedation. Her family was appreciative that she was restful until her death. CONCLUSION Existential suffering manifests through multiple domains in each patient. A combination of pharmacologic and non-pharmacologic techniques may be needed to relieve end-of-life suffering.
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Fürst P, Lundström S, Strang P. Methadone in Swedish specialized palliative care-Is it the magic bullet in complex cancer-related pain? PLoS One 2020; 15:e0230845. [PMID: 32275723 PMCID: PMC7147740 DOI: 10.1371/journal.pone.0230845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
CONTEXT Despite being associated with dependence and social stigma, methadone is a potential end-of-life option in complex cancer pain. OBJECTIVES To explore attitudes and opinions about methadone and its potential role and current use in complex end-of-life pain. METHODS Semi-structured interviews (n = 30) with physicians in specialized palliative care, transcribed and analyzed with conventional qualitative content analysis. RESULTS According to the physicians, patients and relatives expressed unexpectedly few negative attitudes, not affecting methadone's use as an analgesic. Complex pain in bone-metastatic cancer of the prostate, breast and kidney, as well as pancreatic cancer and sarcomas were recurrent suggestions of appropriate indications. Most of the informants stated that they applied a mechanism-based treatment and mainly prescribed low-dose methadone as an add-on to an existing opioid therapy to benefit from methadone´s proposed NMDA-receptor inhibiting properties, e.g. in cases with reduced opioid sensitivity. Despite its complex pharmacokinetics with a long half-life, most informants expressed defined strategies to avoid side-effects such as respiratory depression, especially when initiating treatment in the home-care setting. While many palliative care physicians expressed an overly enthusiastic attitude, others stressed the risks of overconfidence, low precision in use, and overlooked treatment options. Besides the obvious physical pain-relieving effects, they stated that effective pain relief could result in a reduced workload and emotional empowerment, both for physicians and staff. CONCLUSION Methadone, especially in the form of low-dose add-on to other opioids is widely advocated in Swedish specialized palliative care as a practical and safe method with rapid onset in complex pain situations at the end of life.
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Affiliation(s)
- Per Fürst
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
- * E-mail:
| | - Staffan Lundström
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Peter Strang
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Palliative Medicine, Stockholms Sjukhem Foundation, Stockholm, Sweden
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Tarbi EC, Meghani SH. A concept analysis of the existential experience of adults with advanced cancer. Nurs Outlook 2019; 67:540-557. [PMID: 31040052 PMCID: PMC6764914 DOI: 10.1016/j.outlook.2019.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/04/2019] [Accepted: 03/22/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Attention to the existential dimension of an individual's experience during serious illness is important. However, existential concerns continue to be poorly defined in literature, leading to neglect in the clinical realm. PURPOSE This concept analysis seeks to clarify the concept of the existential experience within the context of adults with advanced cancer. METHODS Rodgers' evolutionary method of concept analysis was used. DISCUSSION Existential experience in adults with advanced cancer is a dynamic state, preceded by confronting mortality, defined by diverse reactions to shared existential challenges related to the parameters of existence (body, time, others, and death), resulting in a dialectical movement between existential suffering and existential health, with capacity for personal growth. Personal factors and the ability to cope appear to influence this experience. CONCLUSION These findings can drive future research and enhance clinician ability to attend to the existential domain, thereby improving patient experience at end-of-life.
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Affiliation(s)
- Elise C Tarbi
- University of Pennsylvania School of Nursing, Philadelphia, PA.
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Kioko PM, Requena Meana P. The nature of suffering and its relief: a proposal for a redefinition. BMJ Support Palliat Care 2019; 10:e1. [DOI: 10.1136/bmjspcare-2019-001796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/03/2019] [Accepted: 04/22/2019] [Indexed: 12/16/2022]
Abstract
Recent advances in our understanding of the nature of suffering and its different dimensions have exposed certain deficits in the current definition of suffering. These shortcomings have impacted negatively on the appropriate formulation of precise treatment objectives for each dimension of suffering within the overall framework of the goals of medicine. Existential suffering offers a clear example where the lack of a universally accepted definition has led to confusion regarding what should constitute appropriate relief for this particular dimension of suffering. In this thought piece, we propose a redefinition of suffering based on three elements: first, suffering refers to a specific state of a person (the essence of suffering); second, this state is characterised by a specific psychosomatic anguish reaction (the manifestation of suffering) and third, this reaction is in response to a perceived threat to the integrity of the person (the cause of suffering). The proposed definition allows for an important and clear distinction to be made between the primary and symptomatic relief of suffering and the role of medicine in each form of relief. The terms of the proposed definition and the distinction between primary and symptomatic relief provide useful tools for further research regarding the different dimensions of suffering and its relief.
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Gaignard ME, Hurst S. A qualitative study on existential suffering and assisted suicide in Switzerland. BMC Med Ethics 2019; 20:34. [PMID: 31088444 PMCID: PMC6515594 DOI: 10.1186/s12910-019-0367-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/17/2019] [Indexed: 11/16/2022] Open
Abstract
Background In Switzerland, people can be granted access to assisted suicide (AS) on condition that the person whose wish is to die performs the fatal act, that he has his decisional capacity and that the assisting person’s conduct is not selfishly motivated. No restrictions relating to the ground of suffering are mentioned in the act. Existential suffering as a reason for wanting to die, however, gives raise to controversial issues. Moreover, existential suffering lacks definition and no consensus exists on how to evaluate and manage it. This study explores the perspectives of care professionals and volunteers from a “right-to-die organization” on existential suffering as a motive for assisted suicide requests. Methods A qualitative study based on face-to-face interviews was conducted with twenty-six participants: palliative care and primary care providers as well as EXIT right-to-die organization volunteers. Elements from the grounded theory approach were used. Results The twenty-six participants described existential suffering in a multiplicity of individual ways. In total, sixty-three stories were recounted. Their representations were grouped into eight categories: physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden and loss of pleasurable activities. According to all participants, suffering coming from the loss of self-identity was always linked to physical decline, as if one’s image completely defined someone’s identity. Society’s perception of old people and vulnerable people were also often questioned. Another interesting point was that only four stories referring to a “pure” existential suffering were found. This suffering was related to a feeling that life has come to an end, without identification of any other related restriction or suffering. Conclusions Existential suffering is multifaceted. Legislators and right-to-die organisations have to address the question of what make a AS acceptable. The plurality of existential suffering implies the need of a very personalized care. A better understanding of what it is made of could provide a “toolbox” to people concerned by these requests, helping them to explore it in order to offer suffering people a wider range of alternatives. Electronic supplementary material The online version of this article (10.1186/s12910-019-0367-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marie-Estelle Gaignard
- Institute for Ethics, History, and the Humanities, Institute for Biomedical Ethics, Geneva University Medical School, Rue Michel-Servet, 1, 1211, Geneva, Switzerland. .,Department of Oncology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
| | - Samia Hurst
- Institute for Ethics, History, and the Humanities, Institute for Biomedical Ethics, Geneva University Medical School, Rue Michel-Servet, 1, 1211, Geneva, Switzerland
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Black HK, Demichele KA, Rubinstein RL. Conceptualizations of Dying by an Elderly Man. J Palliat Care 2019. [DOI: 10.1177/082585970702300204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Helen K. Black
- Thomas Jefferson University, Center for Applied Research on Aging and Health, Philadelphia, Pennsylvania
| | - Kimberly A. Demichele
- University of Maryland, Baltimore County Gerontology Program, Baltimore, Maryland, USA
| | - Robert L. Rubinstein
- University of Maryland, Baltimore County Gerontology Program, Baltimore, Maryland, USA
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18
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Affiliation(s)
- Peter Strang
- Karolinska Institutet and Stockholms Sjukhem Foundation, Stockholm, Sweden
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19
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Affiliation(s)
- Alicia Krikorian
- A Krikorian (corresponding author): Faculty of Psychology, Universitat Autònoma de Barcelona, Barcelona, Spain, and Pain and Palliative Care Group, School of Health Sciences, Universidad Pontificia Bolivariana, Calle 78B No. 72A–109, Medellín, Colombia
| | - Joaquin T. Limonero
- JT Limonero: Research Group on Stress and Health, Faculty of Psychology, Universitat Autònoma de Barcelona, Barcelona, Spain
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Rattner M. Navigating the Intangible: Working With Nonphysical Suffering on the Front Lines of Palliative Care. OMEGA-JOURNAL OF DEATH AND DYING 2018; 81:670-684. [DOI: 10.1177/0030222818797171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
While relieving suffering is palliative care’s primary aim, how palliative care providers navigate patients’ nonphysical suffering in their day-to-day work and the impact of working with nonphysical suffering on the clinician have been understudied. This exploratory study aims to begin to fill this gap in the literature. Results revealed that palliative care clinicians face several challenges in their efforts to navigate patients’ nonphysical suffering in their day-to-day work, including (a) the intangible nature of nonphysical suffering, (b) systemic barriers (e.g., lack of time and adequate resources), (c) clinician helplessness or suffering, and (d) a lack of education, training, and support for clinicians specific to their work with patients’ nonphysical suffering. Study outcomes have the potential to improve frontline clinical care with patients and support and education for clinicians.
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Affiliation(s)
- Maxxine Rattner
- Faculty of Social Work, Wilfrid Laurier University, Kitchener, Ontario, Canada
- Kensington Hospice, Toronto, Ontario, Canada
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22
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Rosa WE. Transcultural Pain Management: Theory, Practice, and Nurse-Client Partnerships. Pain Manag Nurs 2018; 19:23-33. [DOI: 10.1016/j.pmn.2017.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 10/04/2017] [Accepted: 10/06/2017] [Indexed: 11/25/2022]
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Improved Pain Control in Terminally Ill Cancer Patients by Introducing Low-Dose Oral Methadone in Addition to Ongoing Opioid Treatment. J Palliat Med 2018; 21:177-181. [DOI: 10.1089/jpm.2017.0157] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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24
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Khoshnood Z, Iranmanesh S, Rayyani M, Dehghan M. Getting Out or Remaining in the Cage of Inauthentic Self: The Meaning of Existential Challenges in Patients' with Cancer. Indian J Palliat Care 2018; 24:131-138. [PMID: 29736113 PMCID: PMC5915877 DOI: 10.4103/ijpc.ijpc_179_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Context: Cancer as a life-threatening disease develops a range of existential challenges in persons. These challenges cause the patients to encounter some existential questions and tensions. This study method focuses on a person's experience about them. Aims: The aim of this study is to illuminate the meaning of existential challenges in patients with cancer in Iran. Subjects and Methods: A hermeneutic phenomenological approach, influenced by the philosophy of Ricoeur, was used to analyze the experiences of 10 Iranian patients with cancer. Data analysis was based on three stages of simple and fast understanding, structural analysis, and comprehensive understanding. Results: The present study showed that existential challenges in patients with cancer can be considered as getting out or remaining in the cage of inauthentic self. This theme consists of two subthemes “Being exposed to the light of awareness that revealed the cage of inauthentic self” and “The tension between getting out of the cage or remaining.” First, being exposed to the light of awareness revealed the cage of inauthentic self which subjectively refers to the emergence of existential questions, the past, the fear of future, and the collapse of physical body identity. Second, the tension between getting out of the cage or still staying which is characterized by anger, denial, sense of loneliness, and depression. Conclusions: According to the results of this qualitative study, it is possible to form discussion groups with peers or have self-reflective practice teaching groups to reflect patients' questions and existential challenges. In this way, participants can express themselves, share their experiences, challenges, learn, and find the answers.
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Affiliation(s)
- Zohreh Khoshnood
- Nursing Research Center, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Sedigheh Iranmanesh
- Nursing Research Center, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Masoud Rayyani
- Nursing Research Center, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Mahlegha Dehghan
- Nursing Research Center, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
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Harstäde CW, Blomberg K, Benzein E, Östlund U. Dignity-conserving care actions in palliative care: an integrative review of Swedish research. Scand J Caring Sci 2017; 32:8-23. [DOI: 10.1111/scs.12433] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Carina Werkander Harstäde
- Centre for Collaborative Palliative Care; Department of Health and Caring Sciences; Linnaeus University; Växjö Sweden
| | - Karin Blomberg
- Faculty of Medicine and Health; School of Health Sciences; Örebro University; Örebro Sweden
| | - Eva Benzein
- Centre for Collaborative Palliative Care; Department of Health and Caring Sciences; Linnaeus University; Kalmar Sweden
| | - Ulrika Östlund
- Centre for Collaborative Palliative Care; Department of Health and Caring Sciences; Linnaeus University; Växjö Sweden
- Centre for Collaborative Palliative Care; Department of Health and Caring Sciences; Linnaeus University; Kalmar Sweden
- Centre for Research & Development; Uppsala University/Region Gävleborg; Gävle Sweden
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26
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Hemberg J. The dark corner of the heart - understanding and embracing suffering as portrayed by adults. Scand J Caring Sci 2017; 31:995-1002. [DOI: 10.1111/scs.12424] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 11/29/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Jessica Hemberg
- Department of Caring Sciences; Faculty of Education and Welfare Studies; Åbo Akademi University; Vaasa Finland
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27
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Grech A, Marks A. Existential Suffering Part 1: Definition and Diagnosis #319. J Palliat Med 2017; 20:93-94. [DOI: 10.1089/jpm.2016.0422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Björkman B, Lund I, Arnér S, Hydén LC. The meaning and consequences of amputation and mastectomy from the perspective of pain and suffering. Scand J Pain 2016; 14:100-107. [PMID: 28850422 DOI: 10.1016/j.sjpain.2016.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/09/2016] [Accepted: 09/30/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The concepts 'pain' and 'suffering' are frequently treated as synonymous. However, they are clearly distinct phenomena. Phantom phenomena including pain and sensory disturbances are still recognized as long-lasting problems after limb amputation and after mastectomy. The complex nature of phantom phenomena makes the interpretation of its results ambiguous, regarding the prevalence of pain, sensory disturbances and the accompanying suffering. There is clinical experience that suffering is a great burden for the individual but there is a lack of systematic studies of patients' own evaluations of the suffering caused by their phantom phenomena. OBJECTIVES The overall aim of this study was to identify and describe patients' suffering related to, and as a part, of their post-amputation situation. METHODS The present study constitutes a part of a prospective, two-year follow up project investigating interviews of 28 men and women in different ages and who have undergone a limb amputation or mastectomy. The reason for amputation or mastectomy varied among the patients and included vascular diseases, cancer (sarcoma and breast-cancer) and trauma. Our ambition was to extract as much variations as possible in different, individualized aspects of the actual pain and suffering producing situation. The participants were, here, invited to open-ended, narrative-oriented interviews one month after the surgery. The interviews were transcribed verbatim and analyzed within qualitative methodology: thematic content analysis. RESULTS Twenty-two of 28 interviewees experienced phantom pain and phantom sensations. The two surgical processes amputation and mastectomy meant for a majority of the interviewees a critical event with threatening consequences for everyday life such as loss of function and personal integrity. Nine interviewees felt even stigmatized as a result of their lost body part. Numerous inter-related factors following the amputation/mastectomy, which can inflict severe suffering on the amputee, were uncovered. The context in which the interviewees were informed about the decision to amputate proved to be one such critical and important factor. CONCLUSION To understand potential suffering in relation to phantom phenomena, it will never be enough merely to have knowledge of the underlying physiological or neurological mechanisms and/or the intensity of phantom pain and phantom sensations. Rather, it is necessary to find out how the loss of the body part and its everyday consequences are experienced by patients. IMPLICATIONS It is important to create time for real dialogue with the patients both during pre-operative preparation and post-operative rehabilitation in order to clarify and verbalize elements that constitute the patients individual suffering. Hopefully this strategy can alleviate future chronic pain problems, severe psycho-social distress and suffering. Such an approach ought to have impact also for perceived suffering after other types of surgery or different invasive treatments.
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Affiliation(s)
- Berit Björkman
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet, SE-171 77Stockholm, Sweden
| | - Iréne Lund
- Department of Physiology and Pharmacology, Karolinska Institutet, SE-171 77Stockholm, Sweden
| | - Staffan Arnér
- Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care, Karolinska Institutet, SE-171 77Stockholm, Sweden
| | - Lars-Christer Hydén
- Center for Dementia Research(CEDER) Department of Medical and Health Sciences, Linköping University, SE-581 83Linköping, Sweden
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Cripe LD, Perkins SM, Cottingham A, Tong Y, Kozak MA, Mehta R. Physicians in Postgraduate Training Characteristics and Support of Palliative Sedation for Existential Distress. Am J Hosp Palliat Care 2016; 34:697-703. [PMID: 27432319 DOI: 10.1177/1049909116660516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Palliative sedation for refractory existential distress (PS-ED) is ethically troubling but potentially critical to quality end-of-life (EOL) care. Physicians' in postgraduate training support toward PS-ED is unknown nor is it known how empathy, hope, optimism, or intrinsic religious motivation (IRM) affect their support. These knowledge gaps hinder efforts to support physicians who struggle with patients' EOL care preferences. METHODS One hundred thirty-four postgraduate physicians rated their support of PS for refractory physical pain (PS-PP) or PS-ED, ranked the importance of patient preferences in ethically challenging situations, and completed measures of empathy, hope, optimism, and IRM. Predictors of PS-ED and PS-PP support were examined using binary and multinomial logistic regression. RESULTS Only 22.7% of residents were very supportive of PS-ED, and 82.0% were very supportive of PS-PP. Support for PS-PP or PS-ED did not correlate with levels of empathy, hope, optimism, or IRM; however, for residents with lower IRM, greater optimism was associated with greater PS-ED support. In contrast, among residents with higher IRM, optimism was not associated with PS-ED support. CONCLUSIONS Comparing current results to published surveys, a similar proportion of residents and practicing physicians support PS-ED and PS-PP. In contrast to practicing physicians, however, IRM does not directly influence residents' supportiveness. The interaction between optimism and IRM suggests residents' beliefs and characteristics are salient to their EOL decisions. End-of-life curricula should provide physicians opportunities to reflect on the personal and ethical factors that influence their support for PS-ED.
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Affiliation(s)
- Larry D Cripe
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Susan M Perkins
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Ann Cottingham
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA
| | - Yan Tong
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA
| | - Mary Ann Kozak
- 3 Purdue University School of Pharmacy, West Lafayette, IN, USA
| | - Rakesh Mehta
- 1 Indiana University (IU) School of Medicine, Indianapolis, IN, USA.,2 IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
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Tan SB, Loh EC, Lam CL, Ng CG, Lim EJ, Boey CCM. Psychological processes of suffering of palliative care patients in Malaysia: a thematic analysis. BMJ Support Palliat Care 2016; 9:e19. [PMID: 27098972 DOI: 10.1136/bmjspcare-2015-001064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/25/2016] [Accepted: 04/04/2016] [Indexed: 11/04/2022]
Abstract
Although suffering in palliative care has received increasing attention over the past decade, the psychological processes that underpin suffering remain relatively unexplored. OBJECTIVE To understand the psychological processes involved in the experiencing of suffering at the end phase of life. METHODS Semistructured interviews were conducted with 20 palliative care inpatients from an academic medical centre in Kuala Lumpur, Malaysia. The transcripts were thematically analysed with NVIVO9. RESULTS 5 themes of psychological processes of suffering were generated: (1) perceptions, (2) cognitive appraisals, (3) hope and the struggles with acceptance, (4) emotions and (5) clinging. A model of suffering formation was constructed. CONCLUSION The findings may inform the development of mechanism-based interventions in the palliation of suffering.
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Affiliation(s)
- Seng Beng Tan
- Unit of Palliative Medicine, Faculty of Medicine, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Ee Chin Loh
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Chee Loong Lam
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Chong Guan Ng
- Department of Psychological Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Ee Jane Lim
- Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
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Skarstein S, Lagerløv P, Kvarme LG, Helseth S. High use of over-the-counter analgesic; possible warnings of reduced quality of life in adolescents - a qualitative study. BMC Nurs 2016; 15:16. [PMID: 26949372 PMCID: PMC4778359 DOI: 10.1186/s12912-016-0135-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/24/2016] [Indexed: 12/22/2022] Open
Abstract
Background Use of over-the-counter analgesics among adolescents has increased markedly. High consumption of over-the-counter analgesics among adolescents is associated with frequent pain, lower self-esteem, reduced sleep, lower educational ambition, binge drinking, higher caffeine consumption, and part-time employment. Knowledge about life experiences of adolescents who frequently use over-the-counter analgesics may be useful to prevent health problems. The purpose of the study was to increase knowledge about adolescents who suffer from frequent pain and have a high consumption of over-the-counter analgesics. Methods A qualitative study, employing one-on-one, in-depth interviews using a thematic interview guide. Data were collected in Norway in 2013–2014. Three boys and sixteen girls; aged 14–16 years, who continuously consumed over-the-counter analgesics were recruited from ten high schools in urban and suburban districts. Candidate participants were excluded if they were medically diagnosed with an acute or chronic illness, requiring extended use of over-the-counter analgesics within the last year. The interviews were taped, transcribed and analysed as text according to Kvale’s three contexts of interpretation: self-understanding, common sense and theory. Results All participants disclosed unresolved physical and psychosocial distress characterized as pain. Frequent pain from various body parts made everyday life challenging. Methods of pain self-appraisal and over-the-counter analgesics use often mimicked maternal patterns. Participants reported being raised under unpredictable circumstances that contributed to long lasting family conflicts and peer-group problems. Participants wanted to feel appreciated and to be socially and academically successful. However, pain reduced their ability to manage everyday life, hampered experienced possibilities for success, and made social settings difficult. Conclusions Childhood experiences influence how adolescents experience pain and use over-the-counter analgesics. Coping with difficult situations or attempting to mask symptoms with over-the-counter analgesics can perpetuate and amplify underlying problems. High consumption of over-the-counter analgesics and frequent pain may be warning signs of adolescents with possible health threatening conditions and reduced quality of life. These adolescent might be in need of support from school nurses and General Practitioners. This study identifies new perspectives that may lead to novel approaches to identify, guide, and support adolescents with frequent pain and high consumption of over-the-counter analgesics.
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Affiliation(s)
- Siv Skarstein
- Department of Nursing, Oslo, and Akershus University College of Applied Sciences, 4, St. Olavsplass, Oslo, NO-0130 Norway
| | - Per Lagerløv
- Department of General Practice/Family Medicine, Institute of Health and Society, The Medical Faculty, University of Oslo, Oslo, Norway
| | - Lisbeth Gravdal Kvarme
- Department of Nursing, Oslo, and Akershus University College of Applied Sciences, 4, St. Olavsplass, Oslo, NO-0130 Norway
| | - Sølvi Helseth
- Department of Nursing, Oslo, and Akershus University College of Applied Sciences, 4, St. Olavsplass, Oslo, NO-0130 Norway
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Ruijs CD, van der Wal G, Kerkhof AJ, Onwuteaka-Philipsen BD. Unbearable suffering and requests for euthanasia prospectively studied in end-of-life cancer patients in primary care. BMC Palliat Care 2014; 13:62. [PMID: 25587240 PMCID: PMC4292985 DOI: 10.1186/1472-684x-13-62] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/17/2014] [Indexed: 11/29/2022] Open
Abstract
Background An international discussion about whether or not to legally permit euthanasia and (or) physician assisted suicide (EAS) is ongoing. Unbearable suffering in patients may result in a request for EAS. In the Netherlands EAS is legally permitted, and unbearable suffering is one of the central compulsory criteria. The majority of EAS is performed in cancer patients in the primary care practice. In around one in every seven end-of-life cancer patients dying in the primary care setting EAS is performed. The prevalence of unbearable symptoms and overall unbearable suffering in relationship to explicit requests for EAS was studied in a cohort of end-of-life cancer patients in primary care. Methods A prospective study in primary care cancer patients estimated to die within six months was performed. Every two months suffering was assessed with the State-of-Suffering V (SOS-V). The SOS-V is a comprehensive instrument for quantitative and qualitative assessment of unbearable suffering related to 69 physical, psychological and social symptoms in five domains. Results Out of 148 patients who were asked to participate 76 (51%) entered the study. The studied population were 64 patients who were followed up until death; 27% explicitly requested EAS, which was performed in 8% of the patients. The final interview per patient was analyzed; in four patients the SOS-V was missing. Unbearable symptoms were present in 94% of patients with an explicit request for EAS and in 87% of patients without an explicit request. No differences were found in the prevalence of unbearable suffering for physical, psychological, social and existential symptoms, nor for overall unbearable suffering, between patients who did or who did not explicitly request EAS. Conclusions In a population of end-of-life cancer patients cared for in primary care no differences in unbearable suffering were found between patients with and without explicit requests for EAS. The study raises the question whether unbearable suffering is the dominant motive to request for EAS. Most patients suffered from unbearable symptoms, indicating that the compulsory criterion of unbearable suffering may be met a priori in most end-of-life cancer patients dying at home, whether they request EAS or not.
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Affiliation(s)
- Cees Dm Ruijs
- Department of Public and Occupational Health, VU University Medical Center, EMGO+ Institute, Expertise Center for Palliative Care, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands ; Primary Care Center De Greev, Grevelingenstraat 10, 3522 PR Utrecht, The Netherlands
| | - Gerrit van der Wal
- Department of Public and Occupational Health, VU University Medical Center, EMGO+ Institute, Expertise Center for Palliative Care, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Ad Jfm Kerkhof
- Department of Clinical Psychology, VU University, EMGO+ Institute, van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, VU University Medical Center, EMGO+ Institute, Expertise Center for Palliative Care, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
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Existential encounters: nurses' descriptions of critical incidents in end-of-life cancer care. Eur J Oncol Nurs 2014; 18:636-44. [PMID: 24996512 DOI: 10.1016/j.ejon.2014.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 05/12/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED Nurses working with cancer patients in end of life care need to be prepared to encounter patients' psychosocial and spiritual distress. AIM The aim of this study was to describe nurses' experiences of existential situations when caring for patients severely affected by cancer. METHODS AND SAMPLE Nurses (registered and enrolled) from three urban in-patient hospices, an oncology clinic and a surgery clinic and a palliative homecare team were, prior to the start of a training program, invited to write down their experiences of a critical incident (CI), in which existential issues were featured. RESULTS Eighty-eight CIs were written by 83 nurses. The CIs were analyzed with qualitative content analysis. Two main themes were found: Encounters with existential pain experiences, which concerned facing death and facing losses; and Encountering experiences of hope, which concerned balancing honesty, and desire to live. CONCLUSIONS This study points out that health care professionals need to be aware of patients' feelings of abandonment in exposed situations such as patients' feelings of existential loneliness. That there are some patients that express a desire to die and this makes the nurses feel uncomfortable and difficult to confront these occurrences and its therefore important to listen to patients' stories, regardless of care organization, in order to gain access to patients' inner existential needs.
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Yodchai K, Dunning T, Savage S, Hutchinson AM, Oumtanee A. HOW DO THAI PATIENTS RECEIVING HAEMODIALYSIS COPE WITH PAIN? J Ren Care 2014; 40:205-15. [DOI: 10.1111/jorc.12073] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kantaporn Yodchai
- School of Nursing and Midwifery, Faculty of Health; Deakin University; Victoria Australia
| | - Trisha Dunning
- Centre for Nursing and Allied Health Research; Deakin University and Barwon Health; Victoria Australia
| | - Sally Savage
- Centre for Nursing and Allied Health Research; Deakin University and Barwon Health; Victoria Australia
| | - Alison M Hutchinson
- Centre for Nursing Research - Deakin University and Monash Health Partnership, Monash Health; Clayton Victoria Australia
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35
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A palliative care intervention for pain refractory to a percutaneous cordotomy. Palliat Support Care 2014; 13:395-8. [DOI: 10.1017/s1478951514000157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AbstractBackground:Intrathecal analgesia and radiofrequency techniques for tumor ablation are employed for palliation of symptoms. These interventions are efficacious in a select number of patients for controlling pain and improving quality of life. Careful selection of an appropriate candidate must be performed to prevent needless, invasive, and costly interventions, as interventional pain management alone will not treat total pain in cancer patients. We describe here a patient who experienced intractable pain and unsuccessfully underwent cordotomy but responded to the interdisciplinary (IDT) palliative care approach in an acute palliative care unit (APCU).Case:A middle-aged female with ovarian cancer metastatic to the left psoas muscle and the supraclavicular and retroperitoneal lymph nodes was admitted with severe left thigh and flank pain. She had been unsuccessfully treated with different opioid regimens, hypogastric nerve block, epidural steroid injection, and cordotomy. The palliative care team was consulted while awaiting placement of an intrathecal pump. The patient was subsequently transferred to the APCU for symptom management and transition to hospice. On admission, her morphine equivalent daily dose (MEDD) was 660 mg. Our IDT—composed of a physician, fellow, nurse practitioner, counselor, chaplain, social worker, and physical and occupational therapists—was able to identify several sources of distress that likely contributed to her expression of pain. Our IDT focused on frequent counseling, improving her function, provided medication education, discussed goals of care, and educated about hospice. She was discharged to hospice care with good pain control and an 85% reduction in her MEDD.Conclusion:An APCU approach involving an IDT alleviated the need for invasive interventions by diagnosing and treating the psychosocial, emotional, and spiritual distress contributing to the patient's total pain expression. Successful management must be reflective of rigorous assessment of the physical, psychological, spiritual, social, and practical aspects before consideration of more invasive treatments.
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Midwifing distress at end of life: Missed opportunities? Palliat Support Care 2014; 12:81-9. [DOI: 10.1017/s1478951512000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Birth and death are rites of passage, and preparation is important (Richards, 2007). Palliative care clinicians describe end of life as a meaningful stage of life filled with opportunity and mystery. However, in palliative care, we have a tendency to overlook dying as a means of spiritual awakening, and there is little understanding, and little or no demand, among palliative care patients, or in the broader culture, to learn the skills of dying.
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Abstract
There is one concept in medicine which is prominent, the symptom. The omnipresence of the symptom seems, however, not to be reflected by an equally prominent curiosity aimed at investigating this concept as a phenomenon. In classic, traditional or conventional medical diagnostics and treatment, the lack of distinction with respect to the symptom represents a minor problem. Faced with enigmatic conditions and their accompanying labels such as chronic fatigue syndrome, fibromyalgia, medically unexplained symptoms, and functional somatic syndromes, the contestation of the symptom and its origin is immediate and obvious and calls for further exploration. Based on a description of the diagnostic framework encompassing medically unexplained conditions and a brief introduction to how such symptoms are managed both within and outside of the medical clinic, we argue on one hand how unexplained conditions invite us to reconsider and re-think the concept we call a "symptom" and on the other hand how the concept "symptom" is no longer an adequate and necessary fulcrum and must be enriched by socio-cultural, phenomenological and existential dimensions. Consequently, our main aim is to expand both our interpretative horizon and the linguistic repertoire in the face of those appearances we label medically unexplained symptoms.
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Affiliation(s)
- Thor Eirik Eriksen
- Department of Occupational and Environmental Medicine, University Hospital of North Norway, Box 6060, 9038, Tromsø, Norway,
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Ford DW, Koch KA, Ray DE, Selecky PA. Palliative and end-of-life care in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e498S-e512S. [PMID: 23649453 DOI: 10.1378/chest.12-2367] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In the United States, lung cancer is a major health problem that is associated with significant patient distress and often limited survival, with some exceptions. The purpose of this article is to address the role of palliative and end-of-life care in the management of patients with lung cancer and to address the need for good communication skills to provide support to patients and families. METHODS This article is based on an extensive review of the medical literature up to April 2012, with some articles as recent as August 2012. The authors used the PubMed and Cochrane databases, as well as EBESCO Host search, for articles addressing palliative care, supportive care, lung neoplasm, and quality of life in cancer or neoplasm, with no limitation on dates. The research was limited to human studies and the English language. RESULTS There was no "definitive" work in this area, most of it being concurrence based rather than evidence based. Several randomized controlled trials were identified, which are reviewed in the text. The article focuses on the assessment and treatment of suffering in patients with lung cancer, as well as the importance of communication in the care of these patients over the course of the disease. The aim of medical care for patients with terminal lung cancer is to decrease symptom burden, enhance the quality of remaining life, and increase survival benefit. A second objective is to emphasize the importance of good communication skills when addressing the needs of the patient and his or her family, starting at the time of diagnosis, which in itself is a life-changing event. Too often we do it poorly, but by using patient-centered communication skills, the outcome can be more satisfactory. Finally, the article addresses the importance of advance care planning for patients with lung cancer, from the time of diagnosis until the last phase of the illness, and it is designed to enhance the physician's role in facilitating this planning process. CONCLUSIONS This article provides guidance on how to reduce patient distress and avoid nonbeneficial treatment in patients with lung cancer. The goal is to decrease symptom burden, enhance quality of life, and increase survival benefit. Good communication and advance care planning are vital to the process.
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Affiliation(s)
- Dee Walker Ford
- Division of Pulmonary, Critical Care Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, SC.
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Southall D. The patient's use of metaphor within a palliative care setting: theory, function and efficacy. A narrative literature review. Palliat Med 2013; 27:304-13. [PMID: 22833473 DOI: 10.1177/0269216312451948] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The modes of communication which patients use are seen as important within the sphere of palliative care and have been the focus of much research. AIM This literature review aims to identify and analyse one particular mode of patient expression, namely that of the figure of speech (trope) 'metaphor', and ask questions regarding metaphor's therapeutic usefulness when engaging with the life-limited patient. DATA SOURCES The investigation revolves around a literature review of academic papers which focus on the metaphorical ways in which patients speak of their condition. RESULTS This paper provides the theoretical foundations for the patient's metaphoric utterances. It also delineates the variety and diversity of metaphors used by patients and categorises them into broad groupings which encompass metaphors of war, journeying, personhood, the natural world and existential concepts. CONCLUSIONS The papers reviewed suggest that metaphoric communication allows sensitive subjects to be dealt with and provides benefits for patients. The results suggest that engaging with patients at the metaphoric level enables them to create new ways of viewing their situation and opens up the possibilities of new coping strategies. Finally, some developmental trajectories emanating from the reviewed papers are suggested, which will allow the efficacy of metaphor to be explored further within a palliative care setting.
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Affiliation(s)
- David Southall
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK.
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Exline JJ, Prince-Paul M, Root BL, Peereboom KS. The spiritual struggle of anger toward God: a study with family members of hospice patients. J Palliat Med 2013; 16:369-75. [PMID: 23406532 DOI: 10.1089/jpm.2012.0246] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Anger toward God is a common form of spiritual struggle, one that people often experience when they see God as responsible for severe harm or suffering. The aim of this study was to assess the prevalence, correlates, and preferred coping strategies associated with anger toward God among family members of hospice patients. METHODS Teams from a large hospice in the midwestern United States distributed surveys, one per household, to family members of home-care patients. The survey assessed feelings toward God (anger/disappointment and positive feelings), depressive symptoms, religiosity, and perceived meaning. Participants also rated their interest in various strategies for coping with conflicts with God. RESULTS Surveys (n=134) indicated that 43% of participants reported anger/disappointment toward God, albeit usually at low levels of intensity. Anger toward God was associated with more depressive symptoms, lower religiosity, more difficulty finding meaning, and belief that the patient was experiencing greater pain. Prayer was the most highly endorsed strategy for managing conflicts with God. Other commonly endorsed strategies included reading sacred texts; handling the feelings on one's own; and conversations with friends, family, clergy, or hospice staff. Self-help resources and therapy were less popular options. CONCLUSION Anger toward God is an important spiritual issue among family members of hospice patients, one that is commonly experienced and linked with depressive symptoms. It is valuable for hospice staff to be informed about the issue of anger toward God, especially because many family members reported interest in talking with hospice team members about such conflicts.
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Affiliation(s)
- Julie J Exline
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH 44106, USA.
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"To cherish each day as it comes": a qualitative study of spirituality among persons receiving palliative care. Support Care Cancer 2013; 21:1445-51. [PMID: 23288396 DOI: 10.1007/s00520-012-1690-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 12/10/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Spirituality is one of the main aspects of palliative care. The concept is multidimensional and encompasses the existential realm as well as value-based and religious considerations. The aim of this study was to explore spirituality from the perspective of persons receiving palliative care and examine their experience of spirituality and its influence on their lives and well-being. METHODS Qualitative interviews were conducted with ten persons receiving palliative care from Palliative Care Services in Iceland. The interviews were tape-recorded, transcribed and analysed. The study is in the field of practical theology and used the theoretical approach of hermeneutical phenomenology. RESULTS Thematic analysis found that the spiritual dimension was of significance for the participants who understood it as a vital element connected to seeking meaning, purpose and transcendence in life. Religious and non-religious aspects of spirituality were expressed including strong spiritual components of family relationships, the meaning of God/a higher being and spiritual practices which served as a key factor in giving strength, activating inner resources and motivating hope. Nine of the participants expressed their spirituality as faith. CONCLUSIONS Spirituality was experienced broadly as an important dimension of how participants lived with terminal illness. Religious and non-religious characteristics were recognised which reveals the complex nature of the phenomenon. Faith was a significant part of the participants' spirituality indicating the importance of attending to this aspect of palliative care. The study suggests the potential contributions of theological approaches which are relevant for palliative care research and practice.
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Beng TS, Guan NC, Seang LK, Pathmawathi S, Ming MF, Jane LE, Chin LE, Loong LC. The Experiences of Suffering of Palliative Care Patients in Malaysia. Am J Hosp Palliat Care 2012; 31:45-56. [DOI: 10.1177/1049909112458721] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A qualitative study was conducted with semi-structured interviews to explore the experiences of suffering in 20 adult palliative care inpatients of University Malaya Medical Centre. The results were thematically analyzed. Ten basic themes were generated (1) loss and change → differential suffering, (2) care dependence → dependent suffering, (3) family stress → empathic suffering, (4) disease and dying → terminal suffering, (5) health care staff encounters → interactional suffering, (6) hospital environment → environmental suffering, (7) physical symptoms → sensory suffering, (8) emotional reactions → emotional suffering, (9) cognitive reactions → cognitive suffering, and (10) spiritual reactions → spiritual suffering. An existential–experiential model of suffering was conceptualized from the analysis. This model may inform the development of interventions in the prevention and management of suffering.
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Affiliation(s)
- Tan Seng Beng
- Department of Medicine, Faculty of Medicine, University Malaya Medical Center, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Ng Chong Guan
- Department of Psychological Medicine, Faculty of Medicine, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Lim Kheng Seang
- Department of Medicine, Faculty of Medicine, University Malaya Medical Center, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Subramaniam Pathmawathi
- Department of Nursing Science, Faculty of Medicine, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Moy Foong Ming
- Department of Social and Preventive Medicine, Faculty of Medicine, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Lim Ee Jane
- Department of Medicine, Faculty of Medicine, University Malaya Medical Center, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Loh Ee Chin
- Department of Medicine, Faculty of Medicine, University Malaya Medical Center, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Lam Chee Loong
- Department of Medicine, Faculty of Medicine, University Malaya Medical Center, Lembah Pantai, Kuala Lumpur, Malaysia
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Mindfulness and psychosocial care in cancer: historical context and review of current and potential applications. Palliat Support Care 2012; 10:287-94. [PMID: 22612897 DOI: 10.1017/s1478951511001015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mindfulness-based interventions and mindfulness techniques have become increasingly popular in psychosocial care. These interventions have also been increasingly used with cancer patients and survivors. However, more attention is due to issues such as how these techniques may be specifically relevant for an oncology population and whether the religious derivation of mindfulness should be considered by frontline psychosocial clinicians. This article provides a history and overview of the use of mindfulness in psychosocial cancer care.
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Duraisamy BP, Dighe MP, Muckaden MA. Neuropathic pain: a personal case reflection on a critical incident. Indian J Palliat Care 2011; 17:155-8. [PMID: 21976858 PMCID: PMC3183607 DOI: 10.4103/0973-1075.84539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Neuropathic pain is a distressing symptom for the patient and a difficult symptom for the physician to treat. There is lack of evidence-based clinical guidelines for the management of malignant neuropathic pain. The case reflection is a personal account of what has been learnt from a critical incident in a particular patient in the management of neuropathic pain. Psychological issues are known to increase pain percetion and affect the quality of life. The case reflection explores problem areas, defines lacunae in knowledge, and demonstrates active learning of the management of neuropathic pain through reflective practice.
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Affiliation(s)
- Balaji P Duraisamy
- Palliative Care Services, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
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Mehnert A, Vehling S, Höcker A, Lehmann C, Koch U. Demoralization and depression in patients with advanced cancer: validation of the German version of the demoralization scale. J Pain Symptom Manage 2011; 42:768-76. [PMID: 21592722 DOI: 10.1016/j.jpainsymman.2011.02.013] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2010] [Revised: 02/05/2011] [Accepted: 02/06/2011] [Indexed: 10/18/2022]
Abstract
CONTEXT The concept of demoralization has been widely used to describe states of existential distress and a self-perceived incapacity to deal effectively with a specific stressful situation. OBJECTIVES To evaluate the psychometric properties of the German adaptation of the Demoralization Scale (DS) in patients with advanced cancer. METHODS Participants with heterogeneous tumor sites were recruited in several treatment and rehabilitation facilities. Concurrent and divergent validity of the DS was analyzed through associations with and group differences between measures of distress, depression, anxiety, and meaning-related life attitudes. RESULTS From a total sample of 1102 patients, 516 individuals (45%) with advanced cancer were enrolled (male 53%, median age 58 years [range 18-88], breast cancer 21%, prostate cancer 17%). The total mean score of the DS was 29.8 (SD=10.41). Four factors were extracted by exploratory factor analysis, which accounted for 59% of the variation (Cronbach α=0.84): loss of meaning and purpose (α=0.88), disheartenment (α=0.88), dysphoria (α=0.80), and sense of failure (α=0.76). DS dimensions shared between 12% and 62% of the variance. Demoralization was significantly associated with anxiety (r=0.71), depression (r=0.61), and distress (r=0.42). Fifty-seven percent of patients had high distress, 24% depression, and 11% high anxiety. According to different cutoff values, between 16% and 39% were seriously demoralized and 73% had moderate levels of demoralization. Between 5% and 20% of patients were seriously demoralized but not clinically depressed; 60% of patients with moderate levels of demoralization had no depression. CONCLUSION Results provide further evidence that the DS is a valid and reliable instrument of high clinical relevance in patients with advanced cancer.
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Affiliation(s)
- Anja Mehnert
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Bruce A, Boston P. Relieving existential suffering through palliative sedation: discussion of an uneasy practice. J Adv Nurs 2011; 67:2732-40. [DOI: 10.1111/j.1365-2648.2011.05711.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
No law in any jurisdiction that permits physician assisted dying offers individuals a medically assisted death without the need to comply with certain criteria. The Netherlands is no exception. There is evidence to suggest that physicians are averse to providing an assisted death even when the Dutch ‘due care criteria’ have been met and the unbearable pain and suffering requirement is especially difficult to satisfy. Some individuals with an enduring desire to die who do not meet the ‘due care’ criteria under the Dutch legislation turn to other means of achieving a self-appointed death. This paper explores two alternative methods of securing a self-determined death (an assisted death involving lay assistors or a self-hastened death by stopping eating and drinking), and raises the question of how far the law should recognise autonomy in the context of physician assisted death.
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Affiliation(s)
- Suzanne Ost
- Law School, Bowland North, Lancaster University, Lancaster LA1 4YN, UK
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Boston P, Bruce A, Schreiber R. Existential suffering in the palliative care setting: an integrated literature review. J Pain Symptom Manage 2011; 41:604-18. [PMID: 21145202 DOI: 10.1016/j.jpainsymman.2010.05.010] [Citation(s) in RCA: 215] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 05/26/2010] [Accepted: 05/28/2010] [Indexed: 11/29/2022]
Abstract
CONTEXT Existential and spiritual concerns in relation to palliative end-of-life care have received increasing attention over the past decade. OBJECTIVES To review the literature specifically related to existential suffering in palliative care in terms of the significance of existential suffering in end-of-life care, definitions, conceptual frameworks, and interventions. METHODS A systematic approach was undertaken with the aim of identifying emerging themes in the literature. Databases using CINAHL (1980-2009), MEDLINE (1970-2009), and PsychINFO (1980-2009) and the search engine of Google Scholar were searched under the key words existential suffering, existential distress, existential pain, palliative and end of life care. RESULTS The search yielded a total of 156 articles; 32% were peer-reviewed empirical research articles, 28% were peer-reviewed theoretical articles, and 14% were reviews or opinion-based articles. After manually searching bibliographies and related reference lists, 64 articles were considered relevant and are discussed in this review. Overall analysis identifies knowledge of the following: 1) emerging themes related to existential suffering, 2) critical review of those identified themes, 3) current gaps in the research literature, and 4) recommendations for future research. Findings from this comprehensive review reveal that existential suffering and deep personal anguish at the end of life are some of the most debilitating conditions that occur in patients who are dying, and yet the way such suffering is treated in the last days is not well understood. CONCLUSION Given the broad range of definitions attributed to existential suffering, palliative care clinicians may need to be mindful of their own choices and consider treatment options from a critical perspective.
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Affiliation(s)
- Patricia Boston
- Division of Palliative Care, Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.
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Bruce A, Schreiber R, Petrovskaya O, Boston P. Longing for ground in a ground(less) world: a qualitative inquiry of existential suffering. BMC Nurs 2011; 10:2. [PMID: 21272349 PMCID: PMC3045972 DOI: 10.1186/1472-6955-10-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 01/27/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Existential and spiritual concerns are fundamental issues in palliative care and patients frequently articulate these concerns. The purpose of this study was to understand the process of engaging with existential suffering at the end of life. METHODS A grounded theory approach was used to explore processes in the context of situated interaction and to explore the process of existential suffering. We began with in vivo codes of participants' words, and clustered these codes at increasingly higher levels of abstractions until we were able to theorize. RESULTS Findings suggest the process of existential suffering begins with an experience of groundlessness that results in an overarching process of Longing for Ground in a Ground(less) World, a wish to minimize the uncomfortable or anxiety-provoking instability of groundlessness. Longing for ground is enacted in three overlapping ways: by turning toward one's discomfort and learning to let go (engaging groundlessness), turning away from the discomfort, attempting to keep it out of consciousness by clinging to familiar thoughts and ideas (taking refuge in the habitual), and learning to live within the flux of instability and unknowing (living in-between). CONCLUSIONS Existential concerns are inherent in being human. This has implications for clinicians when considering how patients and colleagues may experience existential concerns in varying degrees, in their own fashion, either consciously or unconsciously. Findings emphasize a fluid and dynamic understanding of existential suffering and compel health providers to acknowledge the complexity of fear and anxiety while allowing space for the uniquely fluid nature of these processes for each person. Findings also have implications for health providers who may gravitate towards the transformational possibilities of encounters with mortality without inviting space for less optimistic possibilities of resistance, anger, and despondency that may concurrently arise.
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Affiliation(s)
- Anne Bruce
- School of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Rita Schreiber
- School of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Olga Petrovskaya
- School of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Patricia Boston
- Director, Division of Palliative Care, Department of Family Practice, University of British Columbia, Vancouver, British Columbia
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