Dignity and loss of dignity: Experiences of older women living with incurable cancer at home

Effect of logotherapy counseling program on chronic sorrow, dignity, and meaning in life of palliative care patients: a randomized controlled trial

PURPOSE

Palliative care patients experience chronic sorrow with loss in dignity and meaning in life. Logotherapy is an effective way to cope with loss. This study aimed to evaluate the effect of logotherapy on chronic sorrow, dignity, and meaning in life of palliative care patients.

METHODS

This study was conducted with 58 adults hospitalized due to advanced cancer and assigned to either intervention or control group by simple randomization. Data were collected with descriptive information form, Palliative Performance Scale, Patient Dignity Inventory (PDI), Prolonged Grief Disorder Scale-Patient Form (PGDS-PF), and Meaning in Life Questionnaire (MIL) on admission, at the 4th and 8th weeks. The intervention group received eight sessions of logotherapy. The control group received routine care.

RESULTS

The mean scores of PGDS-PF (p = 0.01), PDI (p = 0.01), and searched meaning subdimension of MIL (MIL-SM) (p = 0.11) decreased in the intervention group compared to controls, both at the 4th and 8th week evaluation. The mean score of the present meaning subdimension of MIL (MIL-PM) (p = 0.02) increased at the 4th week evaluation but decreased at a non-statistically significant level at the 8th week. The mean scores of PGDS-PF and PDI increased in the control group while MIL-PM and MIL-SM decreased, both at the 4th and 8th week evaluation.

CONCLUSIONS

Logotherapy was found effective in decreasing the sorrow and dignity-related distress of palliative care patients, while increasing finding meaning in life. Logotherapy is recommended to be used by palliative care professionals to empower patients.

TRIAL REGISTRATION

Clinicaltrials registration number and date: NCT05129059, 19/01/2021.

Dignity enhanced through faith & family support in palliative care: a qualitative study

BACKGROUND

Dignity is integral to palliative care. Illness can diminish it, causing hopelessness and the wish to hasten death. Yet, dignity is a complex multidimensional phenomenon, influenced by values and context. Understanding its varying interpretations can inform practice and policy. The aim of the study is to explore the understanding of dignity in adult patients with palliative care needs from a Lebanese perspective and how it is preserved during illness and while receiving health services.

DESIGN

Qualitative interview study underpinned with a social constructionist lens. Fourteen patients recruited from home-based hospice and outpatient clinics in Lebanon. Data analysed using reflexive thematic analysis.

RESULTS

Four themes were developed across all the interviews: (a) Dignity anchored through faith in God and religious practices; (b) Family support in maintaining physical, psychological wellbeing, and social connectedness; (c) Physical fitness, mental acuity, and healthy appearance through which patients may escape the stigma of disease, (d) accessible, equitable, and compassionate healthcare.

DISCUSSION

Dignity is elusive and difficult to define but faith and religious beliefs play a significant contribution in this study. For the participants, illness is seen as a natural part of life that does not necessarily diminish dignity, but it is the illness related changes that potentially affect dignity. Findings show the importance of family and children in preserving dignity during illness and how their active presence provide a sense of pride and identity. Participants aspired to restore physical, social, and mental well-being to reclaim their dignity and normalize their lives. Challenges related to physical appearance, memory loss, vitality, and social stigma associated with illness diminished dignity. Accessible, equitable and compassionate healthcare services are also crucial in preserving dignity. Participants valued clear communication, respect, and empathy from healthcare providers and identified affordability of care essential for maintaining dignity.

CONCLUSION

Faith in God, and strong family ties are dominant elements to maintaining dignity in the Lebanese context. Relational connectedness with family, children or God is also a need in maintaining dignity in other communal countries with variations in emphasis. The study indicates that religious and cultural context shapes the needs and perceptions of dignity during illness. These findings are likely to be transferable to many Middle Eastern countries but also countries with strong religious and family ties globally.

Patients' experiences with shared decision-making in home-based palliative care - navigation through major life decisions

BACKGROUND

This study addresses the issue of shared decision-making (SDM) in a Norwegian home-based palliative care setting. The significance of patient involvement in SDM is widely acknowledged, and many patients want to participate in decisions about care and treatment. Yet, it remains a need for more knowledge regarding the initiators and approaches of SDM in the context of home-based palliative care, particularly from the patients' perspective. The aim of this study is to understand patients' experiences and preferences for SDM in home-based palliative care, seeking to enhance the quality of care and direct the planning of healthcare services.

METHODS

We used a qualitative explorative design. A hermeneutic approach was employed, and data was collected through in-dept interviews with 13 patients.

RESULTS

The study uncovered an overarching theme of "Navigating to reach own decisions," comprising three sub-themes: "To be trapped in life without decisions to act on"; "To surrender to others and let others deal with decisions"; "To continue to be oneself without focusing on disease and decision-making".

CONCLUSIONS

The findings underscore the need for flexible, person-centered approaches in SDM, tailored to the fluctuating health literacy and changing preferences of patients in palliative care settings. Our study contributes to the understanding of SDM in palliative care by highlighting how patients navigate the balance between autonomy and reliance on HCPs. Future research should explore how healthcare systems, including HCPs' roles in the system, can adapt to the patients' dynamic needs, to ensuring that SDM will remain a supportive and empowering process for patients at all stages of their disease.

Framework for Patient and Informal Caregiver Participation in Research (PAICPAIR) Part 2

Previously, we described the development of the first part of the framework of Patient and Informal Caregiver Participation in Research (PAICPAIR part 1) and how it was implemented in the empirical study Dying With Dignity . Currently, we present our choices and experiences gained in PAICPAIR part 2, highlighting how PAICPAIR guided us as a modifiable and adaptable framework, with a particular emphasis on identifying and meeting the individual needs of our vulnerable coresearchers. This framework can be used as a methodological approach and study design in future research and inspire researchers to include patients receiving palliative care and informal caregivers-as coresearchers.

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

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

Effectiveness of dignity therapy on well-being among patients under palliative care: A systematic review and meta-analysis

BACKGROUND

Dignity therapy is a psychotherapeutic intervention that is potentially effective in improving the well-being of patients receiving palliative care. However, the effects of dignity therapy are not well-understood.

OBJECTIVE

We attempted to determine the effectiveness of dignity therapy in palliative patients to provide evidence that dignity therapy could be used in their care.

DESIGN

Systematic review.

PARTICIPANTS

The number of participants from all the studies was 1202 (intervention group, 619 patients; control group, 583 patients).

METHODS

The review was reported according to the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020. Relevant studies were collected with database searching of PubMed, Scopus, ScienceDirect, ProQuest Health & Medical Complete, CINAHL, and Psych Info databases from the inception of dignity therapy in 2002 to 2022. Literature was selected to identify trials of dignity therapy in patients with palliative care needs including cancer and non-cancer condition. Critical appraisal was performed independently by two reviewers to assess the relevance, reliability, and quality of the included studies. Two independent reviewers extracted data from all the studies. Data were synthesized using Review Manager version 4.5.

RESULTS

A total of 16 studies involving 1202 participants were included. Most studies were rated as medium quality (n = 10, 62.5 %). The results showed a significant difference between the dignity and control groups in dignity-related distress (MD = -3.54, 95 % CI: [-4.66, -2.42], p < 0.00001), hope (MD = 2.27, 95 % CI: [1.32, 3.22], p < 0.0001), and quality of life (SMD = 0.45, 95 % CI: [0.15, 1.14], p = 0.00). However, no significant difference was observed in depression (MD = -0.44, 95 % CI: [-1.09, 0.20], p = 0.18); anxiety (MD = -0.21, 95 % CI: [-1.68, 1.27], p = 0.78), and spiritual well-being (MD = 2.41, 95 % CI: [-0.82, 5.64], p = 0.14).

CONCLUSIONS

Dignity therapy was effective in improving dignity-related distress, quality of life, and levels of hope. A meta-analysis found no significant differences in patients' psychological or spiritual well-being. Differences in the providers of dignity therapy in the included studies may be the cause of the different findings regarding the varying effects of dignity therapy. Professional health workers need to be trained as dignity therapists to enhance the visibility of dignity therapy for patients.

REGISTRATION

CRD42022375319.

TWEETABLE ABSTRACT

Dignity therapy is an effective and promising intervention in palliative care.

Development and psychometric properties of the Person-centered Palliative Care Nursing Instrument (PPCNI) in the Philippines

Background

Over the years, a few tools and instruments have been developed to assist in the assessment within a palliative care setting. However, many of these tools and instruments do not reflect a person-centered palliative care model.

Objective

This study aims to develop a Person-centered Palliative Care Nursing Instrument (PPCNI) in the Philippines.

Methods

An exhaustive search of the literature was conducted to develop a pool of items for the instrument. The validity of the instrument was evaluated using the content validity index (CVI), while the factor structure was assessed using exploratory factor analysis (EFA) using maximum likelihood estimation with Promax rotation. Also, the internal reliability was evaluated using Cronbach's alpha.

Results

EFA yielded three factors: 1) Caring as maintaining person's dignity (13 items), 2) caring as empowerment of person's autonomy (14 items), and 3) caring as understanding person's momentary concerns (10 items). Whereas the internal consistency reliability of these subscales appeared excellent (i.e., 0.95, 0.96, and 0.93, respectively), the Cronbach's alpha for the overall scale was 0.98. The item-total correlation coefficients were >0.30 for all items, ranging from 0.310 to 0.726.

Conclusion

Findings support a three-factor, 37-item PPCNI that can be used in clinical practice to ensure that nurses provide palliative care based on patient needs and preferences.

Lifeworld perspectives of people with dementia: a meta-aggregation of qualitative studies

OBJECTIVES

This meta-aggregation aims to interpret and synthesize present knowledge on the lifeworld perspectives of people with dementia and develop a model for guidance in clinical practice.

METHOD

The data consist of four meta-syntheses describing different lifeworld perspectives in accordance with van Manen's existentials: lived relations, lived space, lived time and lived body. The meta-aggregation summarizes a range of views expressed by people with dementia in qualitative, interview-based studies, with the aim of generating a reliable model based on the studies' findings.

RESULTS

In total, 88 studies among 1,191 persons with dementia were included. Sixteen areas of focus were found, representing four perspectives: (a) lived relations, consisting of connectedness, independence, equality and competence; (b) lived space, consisting of belonging, meaningfulness, safety and security, and autonomy; (c) lived time, consisting of being rooted in the past, being in the present, viewing the future and being in process; and (d) lived body, consisting of being functional, trustworthy, adaptable and presentable. A model shaped as a tree trunk captures the lifeworld perspectives of people with dementia.

CONCLUSION

Sixteen areas were revealed from this meta-aggregation and form the basis of a model. This model may be used as a guide for health care personnel to ensure the overall lifeworld-perspectives of people with dementia in care for the target group and conduct lifeworld-preserving care with a person-centred approach.

Dignity and psychosocial related variables in elderly advanced cancer patients

INTRODUCTION

Most cancers occur in older individuals, who are more vulnerable due to functional impairment, multiple comorbidities, cognitive impairment, and lack of socio-familial support. These can undermine patients' sense of dignity. This study seeks to compare dignity scores in older patients with advanced cancer on sociodemographic and clinical variables and analyze the predictive value of anxiety, depression, functional limitations, and social support on dignity scores.

METHODS

A prospective, multicenter, observational study conducted with participation of 15 hospitals in Spain from February 2020 to October 2021. Patients with newly-diagnosed, advanced cancer completed the dignity (PPDS), anxiety and depression (BSI), Social Support (Duke-UNC-11), and functional limitations (EORTC-C30) scales. Lineal regression analyses explored the effects of anxiety, depression, functional status, and social support on dignity, adjusting for sociodemographic and clinical variables.

RESULTS

A total of 180 subjects participated in this study. The results of the correlation analysis revealed that dignity correlated negatively with anxiety, depression, and sex, and positively with social support, functional status, and longer estimated survival. Thus, women, and more anxious and depressed individuals scored lower on the dignity scale, whereas patients with more social support, fewer functional limitations, and longer estimated survival scored higher.

CONCLUSION

In conclusion, being female, having a lower educational level, lower estimated survival, depression, anxiety, less social support, and limited functionality are correlated with less dignity in the elderly with advanced cancer. It is a priority to manage both physical and psychological symptoms in patients with unresectable advanced cancer to mitigate psychological distress and increase their sense of dignity.

Dignity in bodily care at the end of life in a nursing home: an ethnographic study

BACKGROUND

Nursing homes (NHs) are populated by the frailest older people who have multiple physical or mental conditions and palliative care needs that may convey the violation of dignity. Although dignity is a commonly used concept and a core value of end-of-life care, it is assumed to be complex, ambiguous, and multivalent. Thus, the aim of this study was to explore aspects of dignity in older persons' everyday lives in a NH.

DESIGN

A focused ethnographic study design.

METHODS

Data consisted of 170 h of fieldwork, including observations (n = 39) with residents (n = 19) and assistant nurses (n = 22) in a Swedish NH. Interviews were undertaken with residents several times (in total, n = 35, mean 70 min/resident). To study dignity and dignity-related concerns, we used the Chochinov model of dignity to direct the deductive analysis.

RESULTS

The study showed that residents suffered from illness-related concerns that inhibited their possibilities to live a dignified life at the NH. Their failing bodies were the most significant threat to their dignity, as loss of abilities was constantly progressing. Together with a fear of becoming more dependent, this caused feelings of agony, loneliness, and meaninglessness. The most dignity-conserving repertoire came from within themselves. Their self-knowledge had provided them with tools to distinguish what was still possible from what they just had to accept. Socially, the residents' dignity depended on assistant nurses' routines and behaviour. Their dignity was violated by long waiting times, lack of integrity in care, deteriorating routines, and also by distanced and sometimes harsh encounters with assistant nurses. Because the residents cherished autonomy and self-determination, while still needing much help, these circumstances placed them in a vulnerable situation.

CONCLUSIONS

According to residents' narratives, important dignity-conserving abilities came from within themselves. Dignity-conserving interventions did occur, such as emphatic listening and bodily care, performed in respect for residents' preferences. However, no strategies for future crises or preparing for death were observed. To protect residents' dignity, NHs must apply a palliative care approach to provide holistic care that comprises attention to personal, bodily, social, spiritual, and psychological needs to increase well-being and prevent suffering.

A systematic scoping review on patients' perceptions of dignity

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

How aging of the global population is changing oncology

Population aging is causing a demographic redistribution with implications for the future of healthcare. How will this affect oncology? First, there will be an overall rise in cancer affecting older adults, even though age-specific cancer incidences continue to fall due to better prevention. Second, there will be a wider spectrum of health functionality in this expanding cohort of older adults, with differences between “physiologically older” and “physiologically younger” patients becoming more important for optimal treatment selection. Third, greater teamwork with supportive care, geriatric, mental health and rehabilitation experts will come to enrich oncologic decision-making by making it less formulaic than it is at present. Success in this transition to a more nuanced professional mindset will depend in part on the development of user-friendly computational tools that can integrate a complex mix of quantitative and qualitative inputs from evidence-based medicine, functional and cognitive assessments, and the personal priorities of older adults.

Dignity of older home-dwelling women nearing end-of-life: Informal caregivers' perception

BACKGROUND

Most older people wish to live in the familiar surroundings of their own home until they die. Knowledge concerning dignity and dignity loss of home-dwelling older women living with incurable cancer should be a foundation for quality of care within municipal healthcare services. The informal caregivers of these women can help increase the understanding of sources related to dignity and dignity loss.

AIM

The aim of this study was to explore informal caregivers' perceptions of sources related to dignity and dignity loss in end-of-life of older home-dwelling women with incurable cancer.

RESEARCH DESIGN AND METHOD

The study was founded upon Gadamer's philosophical hermeneutics. In-depth interviews with 13 informal caregivers were carried out, and four participant observations were performed during home meetings.

ETHICAL CONSIDERATION

The study was based on voluntary participation, informed consent, confidentiality and the opportunity to withdraw at any time. The Norwegian Social Science Data Services approved the study.

RESULTS

Three main sources important in preserving the older women's dignity were identified: maintaining one's self-concept, remaining hopeful and sustaining freedom of choice. We also identified three main sources that lead to dignity loss: Sensing loss of human value, experiencing absence of gentleness and feelings of being treated as an object.

DISCUSSION AND FINAL CONSIDERATIONS

On the individual level, the opportunity to maintain one's self-concept and control in life, preserved dignity, while feelings of existential loneliness led to dignity loss. On the relational level, being confirmed as worthy human beings promoted the women's dignity, whereas dignity loss was related to uncaring behaviours from healthcare professionals. On the societal level, individual decisions concerning travel situations and the place to stay when nearing end-of-life were of crucial importance. Constituting these women's living space, these perspectives should be emphasized in healthcare professionals' educational training and in the municipal end-of-life care of these patients.

How patients with cancer experience dignity: An integrative review

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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