The Patient Dignity Inventory: Just another evaluation tool? Experiences with advanced cancer patients

Poor Concordance Between Intensive Care Unit Patients' and Family Members' Patient Dignity Inventory Scores Despite Communication of Dignity-Related Distress

BACKGROUND

Promptly assessing and treating the distress of intensive care unit (ICU) patients may improve long-term psychological outcomes. One holistic approach to reduce patient distress is through dignity-centered care, traditionally used in palliative care. The 25-item Patient Dignity Inventory has construct validity and reliability for measuring dignity-related distress among ICU patients. Because family members often serve as ICU patients' surrogates and play an integral role in patients' dignity, we examined whether family members reliably recognized ICU patients' sources of distress.

METHODS

Two single-center observational studies of adult ICU patients were performed from May to June 2022. Inclusion criteria were ICU length-of-stay >48 hours, awake and alert, intact cognition, and no delirium. Study #1 evaluated concordance between patient and family for dignity-related distress. Both completed the Patient Dignity Inventory independently. The next Study #2 measured how many distressing items that the patient reported discussing with family members.

RESULTS

Study #1 of concordance had 33 patient-family dyads complete the Patient Dignity Inventory. The concordance correlation coefficient was small, 0.20 (99% confidence interval -0.21 to 0.55) and less than the inventory's test-retest reliability (r = .85). Study #2 examined sharing of Patient Dignity Inventory-related items between patients and family members. There were 12 of 19 patients who had severe distress based on an average Patient Dignity Inventory item score ≥1.92. The median patient shared multiple items of distress with their family (median 12, 99% 2-sided exact Hodges-Lehmann interval 4.0-17.5).

CONCLUSIONS

Although ICU patients often report sharing sources of distress with their loved ones, family members cannot accurately or reliably assess the extent to which patients experience psychosocial, existential, and symptom-related distress during critical illness. Treatments of distress should not be delayed by the absence of family members.

Lack of Useful Predictors of Dignity-Related Distress Among the Critically Ill as Assessed With the Patient Dignity Inventory

BACKGROUND

Many intensive care unit patients are awake (ie, alert and engaging in conversation), actively experiencing many facets of their critical care. The Patient Dignity Inventory can be used to elicit sources of distress in these patients. We examined the administrative question as to which awake intensive care unit patients should be evaluated and potentially treated (eg, through palliative care consultation) for distress. Should the decision to screen for distress be based on patient demographics or treatment conditions?

METHODS

This was a retrospective cohort study of 155 adult patients from 5 intensive care units of one hospital from 2019 to 2020. Each patient had ≥48 hours without delirium, dementia, or sedation. The Patient Dignity Inventory has 25 items to which patients responded on a 1 (not a problem) to 5 (an overwhelming problem) scale. Multiple complete, stepwise forward, and stepwise backward logistic regression models were created among patient and treatment variables for predicting thresholds of the mean among the 25 items.

RESULTS

There were 50% (78/155; 95% confidence interval [CI], 42-58) of patients with significant dignity-related distress (mean score ≥1.60). There were 34% (52/155; CI, 26-42) of patients with severe dignity-related distress (mean score ≥1.92; previously associated with often feeling like wanting to die). Models including combinations of vasopressor medication (protective of distress), tracheostomy (greater risk of distress), and female gender (greater risk of distress) had some predictive value. However, all combinations of potential predictors had misclassification rates significantly >20%.

CONCLUSIONS

Identification of subsets of patients with little potential benefit to screening for dignity-related distress would have a reduced workload of palliative care team members (eg, nurses or social workers). Our results show that this is impractical. Given that approximately one-third of critical care patients who are alert and without delirium demonstrate severe dignity-related distress, all such patients with prolonged intensive care unit length of stay should probably be evaluated for distress.

The Validation of the Chinese (Cantonese) Version of the Patient Dignity Inventory in a Hong Kong Palliative Care Setting

Context

To assess and address a patient's dignity and dignity-related distress would greatly benefit patients who have advanced stage disease. The Patient Dignity Inventory (PDI) allows clinicians to identify sources of dignity-related distress for patients. The PDI should be evaluated for use in a local Chinese setting.

Objectives

To validate the Patient Dignity Inventory Hong Kong-Chinese (Cantonese) version (PDI-HK) and assess the psychometric properties in patients in an inpatient palliative setting in Hong Kong.

Method

The English version of the PDI was translated and back translated, then reviewed by a panel including a clinician, clinical psychologist, and nurse clinician. Recruited patients would complete the PDI-HK, the Chinese version of Hospital Anxiety and Depression Scale (HADS), the McGill Quality of Life Questionnaire-Hong Kong (MQOL-HK), and the Edmonton Symptom Assessment Scale. Psychometric properties including internal consistency, concurrent validity, test-retest reliability, and factor analysis were tested.

Results

A total of 97 consecutive patients were recruited into the study. The mean PDI score was 51.85 (range 25-102). Cronbach's alpha was 0.953 (p < 0.001). Concurrent validity with the HADS and MQOL-HK questionnaire was established. Factor analysis showed four factors, namely Existential Distress, Physical Change and Function, Psychological Distress, and Support. These were similar to previous PDI validation studies.

Conclusion

The PDI was translated into Chinese (Cantonese) and applied in an inpatient palliative care unit in Hong Kong, with adequate validity. The PDI-HK version can be further used in a larger Chinese population to assess and address dignity-related issues.

Forecasting Caseload of Critically Ill Patients Who Are Alert and Without Delirium for at Least Two Consecutive Days for the Assessment of Their Psychological Distress

INTRODUCTION

One-quarter of alert, non-delirious patients in critical care units report significant psychological distress. Treatment of this distress depends upon identifying these high-risk patients. Our aim was to characterize how many critical care patients remain alert and without delirium for at least two consecutive days and could thus predictably undergo evaluation for distress.

METHODS

This retrospective cohort study used data from a large teaching hospital in the United States of America, from October 2014 to March 2022. Patients were included if they were admitted to one of three intensive care units, and for >48 hours all delirium and sedation screenings were negative (Riker sedation-agitation scale four, calm and cooperative, and no delirium based on all Confusion Assessment Method for the Intensive Care Unit scores negative and all Delirium Observation Screening Scale less than three). Means and standard deviations of means for counts and percentages are reported among the most recent six quarters. Means and standard deviations of means for lengths of stay were calculated among all N=30 quarters. The Clopper-Pearson method was used to calculate the lower 99% confidence limit for the percentages of patients who would have had at most one assessment of dignity-related distress before intensive care unit discharge or change in mental status.

RESULTS

An average of 3.6 (standard deviation 0.2) new patients met the criteria daily. The percentages of all critical care patients (20%, standard deviation 2%) and hours (18%, standard deviation 2%) meeting criteria decreased slightly over the 7.5 years. Patients spent a mean of 3.8 (standard deviation 0.1) days awake in critical care before their condition or site changed. In the context of assessing distress and potentially treating it before the date of change of condition (e.g., transfer), 66% (6818/10314) of patients would have zero or one assessment, lower 99% confidence limit of 65%.

CONCLUSIONS

Approximately one-fifth of critically ill patients are alert and without delirium and thus could be evaluated for distress during their intensive care unit stay, mostly during a single visit. These estimates can be used to guide workforce planning.

Logistic Regression and Machine Learning Models for Predicting Whether Intensive Care Patients Who Are Alert and Without Delirium Remain As Such for at Least Two More Days

Background Some intensive care unit patients are alert and without delirium for at least two consecutive days. These patients, like other critically ill individuals, are at risk for dignity-related distress. An interval of at least two days would provide for a palliative care multidisciplinary team to be consulted in the late morning or afternoon of day one and visit the next day. An assessment would include the administration of the validated Patient Dignity Inventory in a reflective manner. To determine whether dignity-related distress can be identified and treated during patients' intensive care unit stay, we evaluated whether a substantive fraction of such patients (≥5%) have a substantial (>90%) probability of remaining alert and without delirium in the intensive care unit for at least four consecutive days. Methods The retrospective cohort study used data from one large teaching hospital in the United States of America, from 2012 to June 2022. The inclusion criteria were: a) adults, b) present in an intensive care unit at 12 PM one day and continually so for the next 48 hours, c) during those two days had every Riker sedation-agitation scale score "4, calm and cooperative," and d) during those two days had all Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scores negative (i.e., no delirium) and all Delirium Observation Screening Scale (DOS) scores less than three (i.e., no delirium). Results Among the 10,314 patients alert and without delirium in an intensive care unit over two-day periods that included three successive 12 PMs, 3,826 (37%) maintained this status for at least two successive 12 PMs. Six patient characteristics (e.g., hemodynamic infusion or ventilatory support) had value in predicting those 37% of patients. However, logistic regression and classification models each predicted a few (≈0.2%) patients with >90% probability of maintaining these criteria. Forecasts were inaccurate for nearly all patients remaining alert and without delirium in the intensive care unit (≈37%) because the models predicted no patient alert, without delirium, and in the intensive care unit for two days would remain so for at least four days. That ≈63% accuracy was improved upon by random forest machine learning, but only with ≈3% improvement. Conclusion Although many intensive care unit patients remain alert and without delirium for several consecutive days, each patient has a high daily probability of intensive care unit discharge or deterioration in medical condition. Therefore, the results of our prediction modeling show that care models for the assessment and treatment of patients with intensive care unit-associated dignity-related distress should not rely solely on the intensive care unit team but instead should be taken from the perspective of the entire hospitalization.

Psychometric properties of the Patient Dignity Inventory in an acute psychiatric ward: an extension study of the preliminary validation

BACKGROUND

During the last decades, dignity has been an emerging issue in mental health since its ethical and therapeutic implications became known. This study is an extension of the preliminary validation of the Patient Dignity Inventory (PDI) in a psychiatric setting, originally designed for assessing perceived dignity in terminal cancer patients.

METHODS

From October 21, 2015 to December 31, 2016, we administered the Italian PDI to all patients hospitalized in an acute psychiatric ward, who provided their consent and completed it at discharge (n=165). We performed Cronbach's alpha coefficient and principal factor analysis. We administered other scales concomitantly to analyze the concurrent validity of PDI. We applied stepwise multiple linear regression to identify the patients' demographic and clinical variables related to the PDI score.

RESULTS

Our response rate was 93%, with excellent internal consistency (Cronbach's alpha coefficient=0.94). The factorial analysis showed three factors with eigenvalue >1, which explained >80% of total variance: 1) "loss of self-identity and anxiety for the future", 2) "concerns for social dignity and spiritual life", and 3) "loss of personal autonomy". The PDI and the three factor scores were positively and significantly correlated with the Hamilton Scales for Depression and Anxiety but not with other scale scores. Among patients' variables, "suicide risk" and "insufficient social and economic condition" were positively and significantly correlated with the PDI total score.

CONCLUSION

The PDI can be a reliable tool to assess patients' dignity perception in a psychiatric setting, which suggests that both social and clinical severe conditions are closely related to dignity loss.