A person-centred approach in medicine to reduce the psychosocial and existential burden of chronic and life-threatening medical illness

Grasping a new approach to older persons' dignity: A process evaluation of the Swedish Dignity Care Intervention in municipal palliative care

AIM

Dignity in older persons is a goal of palliative care. This study aimed to perform a process evaluation of the Swedish Dignity Care Intervention (DCI-SWE) in municipal palliative care in Sweden, focusing on implementation, context, and mechanism of impact.

METHODS

This study had a process evaluation design. The Knowledge to Action framework supported the implementation of the DCI-SWE. The intervention was used by community nurses with older persons (n = 18) in home healthcare and nursing homes. Data were collected by focus groups- and individual interviews with community nurses (n = 11), health care professionals (n = 5) and managers (n = 5), reflective diaries, and field notes.

RESULTS

Grasping the DCI-SWE was challenging for some community nurses. Enhanced communication training and increased engagement from managers were requested. However, the DCI-SWE was perceived to enhance professional pride in nursing. In terms of fidelity, dose and reach the project was not fully achieved. Regarding mechanism of impact the DCI-SWE contributes to address older persons' loneliness and existential life issues, as it put conversations with older persons on community nurses' agenda.

CONCLUSIONS

The DCI-SWE provided opportunities to maintain older persons' dignity and quality of life. However, with refinements of design and the DCI-SWE, the sustainability in the context may increase.

Psychotherapeutic approaches: hopefully, globally effective

Many patients have lasting disorders due, for example, to excessive and chronic childhood stress. For these patients, certain psychotherapeutic approaches may be maximally effective, and this may be universally the case. This piece is intended to give providers optimal tools for reaching and helping these patients who, otherwise, may remain among those worst off. These interventions should enhance patients' trust, the quintessential precondition for enabling these patients to change. Specific interventions discussed include anticipating ambiguity and clarifying this before ambiguity occurs, therapists indicating that they will support patients' and families' wants over their own views, feeling and disclosing their emotions, validating patients' anger, laughing, going beyond usual limits, explaining why, asking before doing, discussing religion and ethics, and informing whenever this could be beneficial.

The Risk and The Course of Cancer Among People with Severe Mental Illness

The paucity of data regarding patients with Serious Mental Illness (SMI) and cancer is alarming given the fact that people with SMI, especially schizophrenia, bipolar disorders and severe depressive disorders, have in general poorer access to physical health care and higher morbidity and mortality because of physical illnesses. The aims of this review were to examine the current evidence from existing literature on the risk of developing cancer and its course among people with SMI. Equivocal results emerge regarding the risk of developing some kind of cancer among people with SMI, with contrasting data on a possible higher, similar or lower risk in comparison with the general population. In contrast, a series of studies have pointed out that patients with SMI who develop cancer are less likely to receive standard levels of cancer care, both in terms of screening, diagnosis and treatment. Also, the mortality for cancer has been confirmed to be higher than the general population. A global sensitization about these problems is mandatory in an era in which community psychiatry has been developed in all countries and that policies of prevention, treatment, follow up, and palliative care should regard all the segments of the population, including people with SMI, through an interdisciplinary approach.

Pancreatic cancer, depression, and spirituality in therapy: "Unio Mystica" and "Achrayut," 2 case reports

OBJECTIVES

Pancreatic cancer is a major site of gastrointestinal tumors and remains a leading cause of cancer death in adults in the United States. There is also a strong association between pancreatic cancer and depression. When struggling with cancer, along the different phases of illness, a human being is confronted with manifold issues, which might profoundly interfere with their sense of meaning and purpose.

METHODS

From this standpoint, several different therapeutic techniques have been designed to manage the psychological needs of the patients. Here we provide 2 clinical scenarios, where there was a strong religious correlation to the therapeutic techniques employed with patients suffering from pancreatic cancer.

RESULTS

The 2 cases described showed some improvement in their overall life view and could recalibrate their expectations based on a strong religious foundation.

SIGNIFICANCE OF RESULTS

The role of religion and spirituality in health has also received increasing attention in literature. Religion and spirituality can help patients with cancer find meaning in their illness, provide comfort in the face of existential fears, and receive support from a community of like-minded individuals. In effect, they also provide evidence toward the scope of and integrating the domain of spirituality into holistic cancer care.

Phantosmia and psychogenic non-epileptic seizures in a patient with burning mouth syndrome suffering from severe depression

Burning mouth syndrome (BMS) is a rare but serious medical condition with important psychiatric comorbidity and specific psychological correlates. Psychopathology related with BMS represents a real challenge for clinical decision-making. In this case, depression is the leading psychiatric diagnosis associated with patient's BMS somatic pain and is driven by anxiety and a dissociative functioning. Facing a complex psychosomatic symptomatology, we offer new clinical perspectives for the screening of psychological traits of BMS. Moreover, we highlight the need to foster interdisciplinarity to improve differential diagnosis and defining an optimal care path. This case report stimulates a reflection on management challenges for the consultation-liaison psychiatry and shows the importance of a person-centred approach when communicating the diagnosis.

Depressive Disorders in HIV/AIDS: A Clinically Focused Narrative Review

After participating in this activity, learners should be better able to:• Assess strategies for diagnosing depressive disorders in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)• Identify factors that contribute to the development of depressive disorders in HIV/AIDS• Evaluate strategies for managing depressive disorders in HIV/AIDS ABSTRACT: Depressive disorders and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) are associated with major socioeconomic burdens. The negative impact of depressive disorders on HIV/AIDS is well known, including on treatment outcomes. Unfortunately, depressive disorders are underdiagnosed and undertreated in seropositive persons. This review summarizes clinically useful information on depressive disorders in HIV/AIDS. More specifically, we address assessment, differential diagnosis, contributing factors, management, and common challenges in the treatment of depressive disorders in seropositive individuals. Assessment and diagnosis of depression may be challenging in seropositive persons because of several biopsychosocial particularities associated with HIV/AIDS. One of the difficulties is the overlap between depression and HIV/AIDS symptoms, particularly in individuals with advanced AIDS, requiring consideration of a broad differential diagnosis. Several factors related to HIV/AIDS status contribute to the higher rates of depressive disorders, including infectious-immunological, psychosocial, and exogenous factors. The treatment of depressive disorders in HIV/AIDS involves three groups of interventions: (1) pharmacological interventions, (2) psychotherapeutic interventions, and (3) management of other contributing factors. Challenges in management include poor adherence to treatment and the risk of suicide. We provide evidence-based recommendations to improve assessment and management of depressive disorders in seropositive persons.

Knowledge about risk factors for cancer and cancer risk behavior among patients with severe mental illness

Objective

To examine knowledge about, perception of and current risk factors for cancer, among patients with severe mental illness (SMI) and to compare these variables with patients without SMI.

Methods

A series of patients affected by SMI (i.e., schizophrenia spectrum disorders, bipolar disorders and severe personality disorders) and a matched (gender, age) control group of primary care attenders were assessed, by using an ad hoc semi‐structured interview and a short true/false 17‐item questionnaire, about family history of cancer, cancer risk‐related lifestyles, personal perception and knowledge of risk for cancer.

Results

Patients with SMI (n = 185, mainly schizophrenia spectrum disorders, 48%, and mood disorders, 33%) significantly differed from primary care attenders (n = 173) for: lower participation to occult stool blood screening test, Pap smear test and mammography; higher prevalence of current and past smoking habits; lower awareness towards their own physical symptoms and their perception of risks for cancer; lower physical exercise practicing; lower knowledge about risk factors for cancer (e.g. familiarity for cancer, smoke‐habits, breast and uterine cancer).

Conclusions

Patients suffering from SMI had higher at‐risk behavior for cancer and showed fewer concerns and less knowledge about risk for cancer than primary care attendees. These findings can guide to implement screening for cancer (e.g., Pap test, blood) and to design evidence‐based interventions to reduce cancer risk (e.g., educational and behavioral change for smoking cessation, dietary habits) among patients with SMI.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

SIGNIFICANCE OF RESULTS

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

Patients' and oncologists' perspectives on a novel Clinician-led Fear of Cancer Recurrence (CIFeR) Intervention

PURPOSE

Despite strong demand from breast cancer survivors, there is a dearth of flexibly delivered, accessible psychological interventions addressing fear of cancer recurrence (FCR). This study aimed to explore patients' and clinicians' perspectives concerning the experience, utility and barriers to a novel clinician-led FCR intervention (CIFeR).

METHODS

Twenty female participants (mean age, 59.8, SD = 11.43), diagnosed with early-stage breast cancer (mean years since diagnosis = 2.8, SD = 1.37 years) participated in telephone interviews, and their five oncologists completed a semi-structured electronic survey. Thematic qualitative analyses were performed on interview transcripts and survey responses.

RESULTS

Findings indicated both patients and clinicians were positive about CIFeR with perceived cognitive, behavioural and emotional benefits of CIFeR most pronounced for patients with clinically significant FCR. All patients, however, found that receiving CIFeR (especially the tailored prognostic information) from their oncologists with whom they had a long-standing relationship added a much-needed human element to addressing FCR. Similarly, clinicians valued CIFeR as a clear and consistent way to address unmet needs around FCR, with some barriers around time, language and cultural issues noted.

CONCLUSION

Overall, all participants perceived CIFeR as strongly beneficial in reducing FCR and related worries, thus warranting further evaluation of its utility in clinical practice.

Potential Space in Hospitals: Insight From a Health Psychologist

OBJECTIVE

Humanization is a challenge for the future of healthcare. Architecture may play a major role in designing spaces that enhance communication and help the patient to maintain mental health during physical illness. Health psychologists struggle to find adequate space for taking care of their patients. There is an urgent need to better define how relational space, defined here as potential, can be guaranteed in everyday hospital psychological consultations.

BACKGROUND

The author relates to his work as a health psychologist and psychotherapist in a consultation-liaison psychiatry (CLP) service operating in a general hospital in Lugano (Switzerland).

METHODS

An autoethnographic method is applied through calling on childhood memories on architecture and analyzing insights regarding the healthcare space in everyday work as a psychologist. Photographs and drawings are employed as evocative material.

RESULTS

Autoethnographical data show that building interiors can be a metaphor for an inner dimension. Spaces can be perceived as depersonalized in hospital. Through psychoanalytical theory, it is argued that space becomes ideal for CLP if it can ensure the continuity of the patient's self during hospitalization. Proximity, confidentiality, and privacy are healthcare design requirements to be considered for favoring potential space and psychological intervention.

CONCLUSION

Fostering potential space represents an outstanding challenge for the hospital of tomorrow in order to humanize healthcare spaces and promote a person-centered approach.

Effectiveness of a brief manualized intervention, Managing Cancer and Living Meaningfully (CALM), adapted to the Italian cancer care setting: Study protocol for a single-blinded randomized controlled trial

Patients with advanced cancer suffer from psychosocial distress that may impair quality of life and that may be ameliorated by psychotherapeutic treatment. We describe here the methodology of a randomized controlled trial (RCT) to assess the effectiveness of a novel, brief, semi-structured psychotherapeutic intervention to reduce distress and increase well-being in patients with advanced or metastatic cancer. The intervention, called Managing Cancer and Living Meaningfully (CALM), was originally developed in Canada and we are now testing its Italian adaptation (CALM-IT).

The study is a single-blinded phase III RCT with assessment at baseline, 3 and 6 months with two conditions: CALM-IT versus a nonspecific supportive intervention (SPI). Eligibility criteria include: ≥ 18 years of age; fluency in the Italian language; no cognitive deficit, and diagnosis of advanced or metastatic cancer with an expected survival of 12–18 months. CALM-IT includes up to 12 sessions, delivered over 6 months and covers 4 domains: i) Symptom Management and Communication with Health Care Providers; ii) Changes in Self and Relations with Close Others; iii) Sense of Meaning and Purpose; and iv) the Future and Mortality. The primary outcome is difference in severity of depressive symptoms between treatment arm and the primary endpoint is 6 months. The secondary endpoint is 3 months and secondary outcomes are: generalized anxiety, distress about dying and death, demoralization, spiritual well-being, attachment security, posttraumatic growth, communication with partners, quality of life, and satisfaction with clinical care.

If shown to be effective, CALM-IT can be implemented nationally to relieve distress and to promote psychological well-being in patients with advanced cancer.

"Dying With Dignity": A Qualitative Study With Caregivers on the Care of Individuals With Terminal Cancer

This study aimed to examine family members' attitudes and perceptions regarding their choice of care in the event of terminal illness, based on their experience in a caregiver's role, while a loved one was terminally ill. All participants (N = 10) had cared for an immediate family member with terminal cancer. Snowball sampling was used. Qualitative data were collected through in-depth, semi-structured interviews. The data were transcribed verbatim and analyzed using thematic analysis. Five themes were identified from the data. These included two themes relating to participants' experience of care, two themes in relation to participants' attitudes toward the type of care they experienced and a final theme related to the role of religion and spirituality in dealing with loss. The findings of this study support the integration of multidisciplinary healthcare teams and the introduction of holistic care as early as possible within hospitals for individuals with terminal cancer, using the biopsychosocial-spiritual model.

Dignity-conserving care for persons with palliative care needs — identifying outcomes studied in research: An integrative review

Objectives

With people living longer, palliative care may be required for lengthier periods of time. This puts demands on healthcare organizations to provide optimal palliative care. Maintaining dignity is central for any person's health and quality of life, but especially for a person with palliative care needs. Dignity-conserving care needs to be evaluated to increase knowledge about outcomes and how to assess these. The purpose of this integrative review was to identify outcomes studied within dignity-conserving care and how these have been operationalized.

Methods

An integrative review was conducted in 26 quantitative or mixed-method studies and study protocols. Thematic synthesis with an abductive approach was used for analysis.

Results

Seven themes of studied outcomes were identified, as well as four cluster themes: themes related to Illness-Related Concerns, themes related to the Dignity-Conserving Repertoire, themes related to the Social Dignity Inventory, and themes regarding Overarching Dignity Issues. Most outcomes studied dealt with Illness-Related Concerns within the themes of “Performance, symptoms and emotional concerns” and “End-of-life and existential aspects”. Themes linked to the Social Dignity Inventory had the lowest number of outcomes studied. Outcomes regarding overarching dignity issues such as “Dignity-related distress” and “Quality of life” were common. However, the results lacked concrete communication outcomes.

Significance of results

The results will underpin future research in which dignity-conserving care is implemented and evaluated, and contribute to the provision of evidence-based palliative care. A greater focus on outcomes within cluster themes related to the Dignity-Conserving Repertoire and the Social Dignity Inventory is needed, as is more focus on communication outcomes.

Assessing demoralization in medically ill patients: Factor structure of the Italian version of the demoralization scale and development of short versions with the item response theory framework

OBJECTIVE

Demoralization has been mostly investigated in oncology but is also relevant for patients with other physical illnesses. Our aims were to investigate the psychometric properties of the 24-item Italian version of the Demoralization Scale (DS-24) among medically ill inpatients, and to develop shorter versions for screening.

METHODS

Four-hundred and seventy-three participants were recruited from medical wards of the University Hospital of Ferrara. Patients were assessed using the Diagnostic Criteria for Psychosomatic Research-Demoralization module (DCPR/D), Demoralization Scale (DS-24), Patient Health Questionnaire-9 (PHQ-9), Brief-Symptom Inventory-18, Anxiety subscale (BSI-Anx) and EuroQol Group (EQ-5D). Confirmatory factor analyses of previous structures and exploratory factor analyses were conducted using an Item Response Theory approach, including a bifactor model.

RESULTS

According to DCPR/D criteria, the prevalence of demoralization was 40%. Confirmatory analyses revealed that none out of seven factor structures from oncology studies adequately fitted data from hospital inpatients. Exploratory Item Factor Analysis uncovered a four-factor model comprising Disheartenment, Dysphoria, Sense of Failure, Loss of Meaning and Purpose, or a bifactor model, comprising similar factors with the addition of a general factor accounting for 45% of the variance. Moreover, we developed 13 and 6-item versions of the DS, both retaining high correlation with DS-24 scores (r = 0.98 and r = 0.95, respectively) and concordance with DCPR/D criteria (AUC-ROC 0.82 and 0.81).

CONCLUSION

The DS factor structure differs between general hospital and cancer patients. Differences may depend on intrinsic disease features and cultural-geographic factors. The short versions of the DS-24 may aid clinicians in identifying demoralized patients in hospital settings.

Hospitalized Patients with Medically Unexplained Physical Symptoms: Clinical Context and Economic Costs of Healthcare Management

Medically Unexplained Physical Symptoms (MUPS) are physical symptoms without a medical explanation. This study collected data from hospitalized patients presenting MUPS, aiming to draw a clinical and socio-demographic profile of patients with MUPS, to explore psychopathological correlations of Somatic Symptoms Disorder (SSD) diagnosis, and to estimate economic costs related to hospital management for MUPS. The cross-sectional study consisted in the evaluation of data referring to hospitalized patients admitted between 2008 and 2018 in a teaching hospital in Northern Italy. A total of 273 patients presenting MUPS have been hospitalized. The sample showed a prevalence of female, married and employed patients. The most frequent wards involved are Neurology, Internal Medicine and Short Unit Stay. The most common symptoms found are headache, pain, syncope and vertigo. There is no evidence that a history of medical disease is associated with a diagnosis of SSD. A personality disorder diagnosis in patients with MUPS was associated with increased probability of having a diagnosis of SSD. A marginally significant positive association emerged with anxiety disorders, but not with depressive disorder. The overall estimated cost of hospitalization for patients with MUPS is 475′409.73 €. The study provides the investigation of a large number of patients with MUPS and a financial estimate of related hospitalization costs.

Existential Meaning of Patients with Chronic Facial Pain

Coping strategies are necessary to deal with pain, one of the most disabling conditions. Treatments are often refractory, and the elaboration of existential meaning is necessary to live with residual pain. The objective of this study was to discuss the relevance of the meaning of life in coping with refractory chronic neuropathic facial pain according to singular cases. Each patient is unique and needs a singular approach to understand and treat the pain phenomenon. Self-transcendence, existential issues and philosophical values are central concepts to assess chronic conditions and should be highlighted in medical practice these days.

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.