Psychological interventions in palliative care

Psychological interventions for emotional well-being in adults with advanced progressive life-limiting illness

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To determine the benefits and harms of psychological interventions compared to treatment as usual, waiting list, active control, or another psychological intervention to improve emotional well-being in adults with an advanced progressive life-limiting illness.

Fluctuations in core depressive symptoms in colorectal cancer patients. A prospective, population-based PROFILES-registry study

PURPOSE

Research investigating depressive symptoms among cancer patients rarely distinguish between core symptoms of depression (motivational and consummatory anhedonia, and negative affect). This distinction is important as these symptoms may show different trajectories during the course of the illness and require different treatment approaches. The aim of the present study is to investigate fluctuations in core depressive symptoms in patients with colorectal cancer (CRC). It is hypothesized that these core depressive symptoms fluctuate differently during the course of the illness and depend on the phase of the illness (diagnostic, treatment, recovery and palliative phase).

METHOD

This study is based on data from the PROCORE study. PROCORE is a prospective, population-based study aimed to examine the longitudinal impact of CRC and its treatment on patient-reported outcomes. Eligible patients completed self-report questionnaires (i.e. Multifactorial Fatigue Index, Hospital Anxiety and Depression scale, EORTC-C30) after diagnosis, after surgery and at one and two years after diagnosis.

RESULTS

In total, 539 patients participated of whom 68 have died until March 1ste 2021. Core depressive symptoms fluctuated differently during the course of the illness with higher levels of motivational anhedonia during treatment and palliative phase (P<.001), consummatory anhedonia at the palliative phase (p < .001) and negative affect at the diagnostic and palliative phase (P<.001).

CONCLUSION

It is important to distinguish between different core depressive symptoms as they fluctuate differently during the course of an illness like CRC. The various depressive symptoms may require a different treatment approach at specific moments during the illness process.

Preserving the integrity of personhood in people with advanced cancer: An in-depth qualitative study among patients, relatives, and care professionals

BACKGROUND

Every advanced cancer diagnosis brings enormous challenges to patients and their relatives on numerous levels: be it physical, practical, social challenges, or on a more personal level. While specific aspects have been researched before, an overarching approach is lacking.

AIM

To understand the lived experiences of people with advanced cancer, to identify gaps along the cancer care continuum, to identify potential opportunities for meaningful interventions and to develop a theoretical framework for practitioners and researchers.

DESIGN

A qualitative study using in-depth interviews with patients, relatives, and care professionals. Interviews were transcribed verbatim and analysed using a conventional content analysis.

SETTING/PARTICIPANTS

Fifty-four interviews with 17 patients from a university oncology department and palliative care service, 15 relatives and 22 care professionals from physicians to funeral directors. All interviewees were recruited by a German university hospital.

RESULTS

We developed a novel model describing the diagnosis with advanced cancer as a highly disruptive experience that threatens to challenge the integrity of personhood in cancer patients through four areas: communication, knowledge, relationships, and confidence. We were able to identify factors leading to disintegration in these areas and factors supporting a restoration of integrity of personhood.

CONCLUSIONS

The developed model provides a more thorough understanding of patients lived experiences. It can help to develop new interventions along the cancer care continuum to support patients in the complex challenges they face. These interventions should focus on supporting the integrity of personhood.

Clinical application of mindfulness in end-of-life care from the perspective of palliative care professionals: A phenomenological study

BACKGROUND

and Purpose: With mindfulness being increasingly recognized for its potential to address psychological challenges related to advanced or terminal illnesses, palliative care professionals are incorporating mindfulness-based interventions into their practice. However, there is limited understanding of the practical applications of mindfulness in clinical settings, particularly for end-of-life patients. This study explored palliative care professionals' experiences in delivering mindfulness-based therapy to end-of-life patients, thereby aiming to inform the development of effective interventions.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 15 palliative care professionals. Participants were asked to describe their memorable experiences in applying mindfulness in a clinical setting. Data were analyzed following Moustakas's transcendental phenomenology approach.

RESULTS

The interviews produced three themes: clinicians' mindfulness experiences form the cornerstone of their clinical application of mindfulness; creating an optimal healing environment is essential for mindfulness practice; and patient-centric mindfulness guidance should be implemented.

CONCLUSION

This study underscores the critical role of mindfulness in end-of-life care, highlighting its integration into daily life by palliative care professionals. By drawing upon their own mindfulness experiences, palliative care professionals facilitated a therapeutic environment tailored to the unique needs of end-of-life patients. This patient-centered approach not only enhanced the quality of care but also fostered a healing connection rooted in compassion and empathy. The findings advocate for further education and development of mindfulness-based interventions, including group therapies, to support the holistic well-being of patients in collectivist cultures. Future research should further explore the practical applications and benefits of mindfulness in end-of-life care settings.

Collaborative advance care planning in palliative care: a randomised controlled trial

OBJECTIVE

An effective tool for establishing concordant end-of-life (EOL) care in patients with cancer is advance care planning (ACP). However, various barriers, including psychological obstacles, hamper the access to ACP. Therefore, a new conceptual model combining a psycho-oncological approach with structured ACP was developed. The effectiveness and efficiency of this new concept of collaborative ACP (col-ACP) is evaluated in the present randomised controlled trial in patients with palliative cancer.

METHODS

277 patients with palliative cancer and their relatives were randomised into three groups (1) collaborative ACP (col-ACP) consisting of a psycho-oncological approach addressing barriers to EOL conversations followed by a standardised ACP procedure, (2) supportive intervention (active control) and (3) standard medical care.

RESULTS

Patients in the col-ACP group completed advance directives (p<0.01) and healthcare proxies (p<0.01) significantly more often. Additionally, they felt better planned ahead for their future treatment (p<0.01) and were significantly more confident that their relatives were aware of their treatment wishes (p=0.03). In fact, their goals of care were known and highly fulfilled. However, patients' and caregivers' quality of life, patients' stress, depression and peace did not differ between the groups.

CONCLUSIONS

The new, well-received, concept of col-ACP improves readiness and access to ACP and results in more consistent EOL care. Further, even if no direct influence on quality of life could be proven, it supports patients in planning their treatment, making autonomous decisions and regaining self-efficacy in the face of life-limiting cancer. Therefore, a closer interlocking and information exchange between psycho-oncological and ACP services seems to be reasonable.

TRIAL REGISTRATION NUMBER

NCT03387436.

Do People Prefer Home Palliative Care? A Survey Study and Assessment of Associated Factors in China

Objectives: This study examined people's preference for the location to receive palliative care services and determined the associated factors. Methods: A questionnaire with reference to the Chinese version of the Hospice Attitude Scale and the Death Correspondence Scale was designed, piloted, revised, and distributed online and in person to collect data (N = 762). Binary logistic regression was used to analyze the effects of relevant factors. Results: The average age of the participants was 38.1, with a relatively even gender distribution. Over 90% of the participants were either single/never married (44.9%) or married with children (46.0%). 58.1% of the respondents (N = 428) indicated that they would like to receive palliative care at home, compared to 41.9% who preferred receiving such care in institutions or other places (N = 309). Each time people's attitudes toward death became one point more positive, they were 10.2% more likely to choose to receive palliative care services at home. People with a neutral attitude toward palliative care, single/never married or divorced with children, and having/had an occupation in health and social work had higher odds of preferring receiving palliative care at home. Those who had poor self-rated health or with an educational background of primary school or lower or some college had lower odds of preferring receiving palliative care at home. Conclusions: The research showed that attitudes toward death and other factors were associated with people's preferences for palliative care locations. More accessible and affordable community-based and home-based palliative care services should be further explored and provided.

Psychosocial intervention in palliative care: What do psychologists need to know

Emotional and existential suffering is prevalent in advanced diseases and psychologists have valuable skills to support people in this time of life. Yet, psychologists are rarely integrated in palliative care and relevant training is sparse. Being integrated in other areas of health, it is likely that we will be supporting these patients, whether integrated in a specialized team or not. This article is meant to serve psychologists, already skilled in the art and science of psychosocial intervention, who may find themselves supporting patients with advanced disease. Relevant history of palliative care is provided to elucidate palliative philosophy and approach. Evidence-based existential interventions will be reviewed. Integration of psychological models and both palliative theory and practice is provided to support palliative-appropriate case conceptualizations. Finally, case examples are provided throughout to help readers reconcile their existing practice in this domain of care.

The role of psychologists in supporting illness-related dying and death: A systematic mixed studies review

Psychologists remain underrepresented in end-of-life care, and there is limited understanding of their role among healthcare professionals, patients, and caregivers. This systematic mixed-studies review, prospectively registered on PROSPERO (CRD42020215775), explored the role of psychologists, and the facilitators and barriers they experience, in supporting clients with illness-related dying and death. A search of six research databases was conducted in October 2023. Fifty-one studies, mainly qualitative and from the perspectives of psychologists, met inclusion criteria. Thematic synthesis highlighted how psychologists provided expertise across various contexts. They supported clients with preparing for death, and adjusting to dying, provided professional consultancy and support, and undertook leadership in enhancing psychological end-of-life care. Results illustrated the sustaining factors and ongoing challenges working in end-of-life care, namely, the unique nature of navigating the death space, recognition and awareness of psychologists' contribution, and the support, training and development required. Given the universality of dying and death, this review is relevant to psychologists working within and beyond more traditional end-of-life care contexts, such as employee assistance programs, private practice, schools, and other psychological services. Policy, clinical and research implications are discussed, including the need for greater engagement and training of psychologists in the dying and death space.

Screening for depression and anxiety in lung cancer patients: A real-world study using GAD-7 and HADS

BACKGROUND

The psychological well-being of lung cancer patients is critical in-patient care but frequently overlooked.

METHODS

This study, employing a cross-sectional, questionnaire-based design, aimed to elucidate the prevalence of depressive and anxiety symptoms among lung cancer patients and identify associated risk factors. Participants' demographic, medical history, disease stage, and pathology were systematically collected. Psychological assessment was conducted using the general anxiety disorder-7 (GAD-7), patient health questionnaire-9 (PHQ-9), and hospital anxiety and depression scale (HADS). Statistical analyses were performed using SPSS software (version 25.0).

RESULTS

Out of 294 distributed questionnaires, 247 lung cancer patients were included in the final analysis, with an average completion time of 9.08 min. Notably, 32.4% exhibited depressive symptoms, while 30% displayed signs of anxiety. A significant correlation was found between both depressive and anxiety symptoms and a history of tobacco and alcohol consumption. Specifically, increased nicotine dependence and greater cumulative tobacco use were linked to higher rates of depressive symptoms, whereas cumulative alcohol consumption was associated with increased risks of anxiety symptoms.

CONCLUSION

The study affirms the feasibility of GAD-7, PHQ-9, and HADS as screening tools for depressive and anxiety symptoms in lung cancer patients. It further highlights tobacco and alcohol consumption as significant risk factors for poor psychological health in this population.

Palliative Care and Mental Health among Pancreatic Cancer Patients in the United States: An Examination of Service Utilization and Health Outcomes

INTRODUCTION

Palliative care (PC) utilization remains low among pancreatic cancer patients. This study explores the association of PC with mental health service and pharmacotherapy utilization among pancreatic cancer patients.

METHODS

Retrospective analysis was conducted on a sample of patients in the United States with newly diagnosed pancreatic cancer using Electronic Health Record data from Optum's Integrated Claims-Clinical data set. Subsequent diagnoses of anxiety and depression and PC consultation encounters were determined using ICD-9/10 codes. Adjusted associations of mental health treatments with PC and patient characteristics were quantified using multiple logistic regression.

RESULTS

Among newly diagnosed pancreatic cancer patients (n = 4029), those with PC consultations exhibited a higher prevalence of anxiety (33.9% vs. 22.8%) and depression (36.2% vs. 23.2%). Mental health service use and pharmacotherapy varied, with the highest utilization among patients having both anxiety and depression. Treatment pattern was also influenced by age (aOR 1.832 for age <55 vs. 65-70 years). Notably, PC consultations showed no significant effect on the likelihood of documented treatment.

DISCUSSION

Our study emphasizes underutilization of PC and MH treatment for pancreatic cancer patients. These findings imply a crucial need for further investigation into palliative care's role in addressing mental health concerns among pancreatic cancer patients.

Life beyond Loss: A Retrospective Analysis of the Impact of Meaning of Life Therapy on the Grieving Process of Cancer Patients' Family Caregivers

Oncological disease in the palliative stage is a huge challenge for patients and their family caregivers (FCs) due to the fact that it confronts them with death, as well as physical, psychological, and existential suffering. Meaning of Life Therapy (MLT) is a brief structured psycho-existential intervention aiming to help patients in a meaning-making life review process, promoting end-of-life adaptation. The Life Letter (LL) resulting from MLT is an element that facilitates communication between the patient and their caregivers. The goal of this study was to understand the impact of MLT on the grieving processes of eight FCs and to study their perceptions of the role of the LL on grief through semi-structured interviews. The results of our qualitative analysis indicate that MLT was perceived by the FCs as a positive experience despite the conspiracy of silence being identified as a drawback. The LL was interpreted as a communicational element, promoting emotional closeness with the cancer patients and serving as a valuable tool in the FCs' adaptation to loss. Our research findings show that the needs of FCs, especially after experiencing the loss of their relative, are dynamic and specific. This is why it is urgent to develop interventions that consider the idiosyncrasies of end-of-life cancer patients and their FCs in order to avoid frustrated farewells, lonely deaths, and maladaptive grieving processes. This is the direction in which MLT should evolve.

"I'm Done": A patient's wish and will to die

BACKGROUND

A desire for hastened death is commonly expressed by cancer patients. Although efforts to define and explore this issue have been undertaken, no standardized approach exists to address these desires.

CASE DESCRIPTION

Ms. J expressed a wish for accelerated death and subsequently experienced unexpected clinical decline resulting in a quick, natural death. Our team experienced a mixture of both emotional distress and awe after witnessing the pragmatic approach our patient had to her impending decline, that we felt was worthy of further exploration.

CONCLUSION

Most clinicians lack formal training in communication, potentially making cases like Ms. J's highly distressing. Clinicians should feel comfortable addressing and potentially inquiring about patients' desire to hasten death. While our initial reaction might be to correct this desire, we propose reframing this expression as an opportunity to explore more about our patients.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

SIGNIFICANCE OF RESULTS

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

Cancer-Related Symptom Frameworks Using a Biopsychosocial-Spiritual Perspective: A Scoping Review

BACKGROUND

Research to understand and manage cancer-related symptoms continues to advance, yet work that more fully adopts a biopsychosocial-spiritual view of symptoms is needed.

OBJECTIVE

The purpose of this article is to review existing frameworks that have the potential to guide research on cancer-related symptoms, to explore the characteristics of each framework, and to appraise each using a biopsychosocial-spiritual lens.

METHODS

A scoping review was conducted to identify available frameworks that could be applied to guide cancer-related symptom research and to assess their characteristics. Research questions and criteria were formulated at the outset, followed by identifying relevant publications detailing novel frameworks, charting data, and collating results. Upon identification of available frameworks, each was appraised for alignment with a standard definition of "biopsychosocial-spiritual."

RESULTS

Eleven frameworks were identified to guide cancer-related symptom research. All were developed in the United States, led by nurse scientists, including symptom experiences as well as their antecedents and outcomes, and could be applied to one or more concurrent cancer-related symptoms. While all 11 frameworks included biopsychosocial dimensions, only 4 included spirituality.

CONCLUSIONS

Four biopsychosocial-spiritual frameworks offer unique insight to support advancement of cancer-related symptom research and practice from a holistic perspective. This foundational work could lead to development and validation of new frameworks and modification of existing frameworks to more closely align with a biopsychosocial-spiritual view of cancer-related symptoms. This review offers a starting point to carefully and explicitly adopt frameworks in research and practice with increased emphasis on considering spiritual dimensions of symptoms.

Case report: Therapeutic potential of Flourishing-Life-Of-Wish Virtual Reality Therapy on Relaxation (FLOW-VRT-Relaxation)-a novel personalized relaxation in palliative care

In view of the global aging population and growing need of palliative care, innovative intervention for effective symptom management is of urgent need. Flourishing-Life-Of-Wish Virtual Reality Therapy (FLOW-VRT) is a brief, structured, manualized, and personalized psychological intervention with theoretical foundations based on stress coping theory, self-determination theory, flow theory, and attention restoration theory. With a specific focus on relaxation, FLOW-VRT-Relaxation intends to facilitate adaptive end-of-life coping through delivering personalized relaxation. This paper reports a case study of the application of FLOW-VRT-Relaxation, and discusses its therapeutic potential as a cost-effective method for reducing palliative symptoms by addressing patient's unmet needs. The case study is a 51-year-old Chinese female, diagnosed with advanced cervix cancer, and presented with unmet psychological (i.e., unfulfilled wishes) and physical needs (i.e., pain and fatigue) before FLOW-VRT-Relaxation. To address her unmet needs, FLOW-VRT-Relaxation was delivered by a registered clinical psychologist specialized in palliative care. Need assessment was first conducted, followed by a 10-min VR travel of Japan as her own choice. Relaxation was verbally coached during VR. Right after VR, consolidation with psychological components including psychoeducation, cognitive and emotional processing, and reminiscence intervention were delivered. The patient showed improvement in physical and psychological symptoms, lower sense of loneliness and engulfment, as well as enhanced peace after FLOW-VRT-Relaxation. The current findings provide encouraging initial support for the feasibility, acceptability, and therapeutic potential of using FLOW-VRT-Relaxation as a cost-effective, scalable and personalized VR relaxation for patients under palliative care. It is hoped that with its optimal use, FLOW-VRT-Relaxation can serve as an alternative therapeutic tool that effectively improves the end-on-life care.

Key aspects of psychosocial needs in palliative care - a qualitative analysis within the setting of a palliative care unit in comparison with specialised palliative home care

BACKGROUND

The number of palliative care patients with complex needs is increasing in developed countries. In addition to physical aspects and symptom control, psychosocial aspects are of great importance for palliative care patients. The aim of this study was to understand which psychosocial aspects are important to patients, relatives and health professionals within the setting of a palliative care unit in comparison with specialised palliative home-care (SPHC).

METHODS

We used a qualitative design based on semistructured interviews, which were coded via qualitative content analysis. The study took place in the state of Hesse, Germany, and data collection was conducted in 2017 (interviews from the ELSAH study, which was conducted in a SPHC) and 2018 (supplementary interviews conducted in a palliative care unit). The results from both settings were compared.

RESULTS

In the palliative care unit, 10 health professionals, 11 patients and 8 relatives were interviewed. In the outpatient setting, we interviewed 30 health professionals, 14 patients and 14 relatives. We identified four key psychosocial issues related to palliative care that were relevant in both the inpatient and outpatient settings: care planning, patient-centred care, a protected environment with feelings of safety, and psychological well-being. In addition, immediate availability of medical staff, greater relief of the relatives and better accessibility of psychological care were more important in the inpatient setting than in the specialised palliative home care setting.

CONCLUSIONS

Knowledge and application of the identified key issues may improve patient-centred palliative care. Accessibility of psychological care and immediate availability of medical staff may be important factors for enhancing psychological well-being in the inpatient palliative care setting. Consideration of the identified key issues may help to develop more collaborative transitions between the palliative care unit and the SPHC and may help to provide palliative care patients and their families with care that is appropriate and feasible for them.

TRIAL REGISTRATION

The underlying comparative study of the outpatient setting of specialised palliative home-care (ELSAH) was registered within the German Clinical Trials Register DRKS-ID: DRKS00012421, ( https://drks.de/search/de/trial/DRKS00012421 ) on 19th May 2017.

COVID-19 pandemic in the intensive care unit: Psychological implications and interventions, a systematic review

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic produced changes in intensive care units (ICUs) in patient care and health organizations. The pandemic event increased patients’ risk of developing psychological symptoms during and after hospitalisation. These consequences also affected those family members who could not access the hospital. In addition, the initial lack of knowledge about the virus and its management, the climate of fear and uncertainty, the increased workload and the risk of becoming infected and being contagious, had a strong impact on healthcare staff and organizations. This highlighted the importance of interventions aimed at providing psychological support to ICUs, involving patients, their relatives, and the staff; this might involve the reorganisation of the daily routine and rearrangement of ICU staff duties.

AIM

To conduct a systematic review of psychological issues in ICUs during the COVID-19 pandemic involving patients, their relatives, and ICU staff.

METHODS

We investigated the PubMed and the ClinicalTrials.gov databases and found 65 eligible articles, upon which we commented.

RESULTS

Our results point to increased perceived stress and psychological distress in staff, patients and their relatives and increased worry for being infected with severe acute respiratory syndrome coronavirus-2 in patients and relatives. Furthermore, promising results were obtained for some psychological programmes aiming at improving psychological measures in all ICU categories.

CONCLUSION

As the pandemic limited direct inter-individual interactions, the role of interventions using digital tools and virtual reality is becoming increasingly important. All considered, our results indicate an essential role for psychologists in ICUs.

Hope-Based Program for Portuguese Outpatients with Advanced Chronic Illness in a Community Setting: A Randomized Control Trial

Background: Hope is widely considered a subjective phenomenon able to bring beneficial consequences to human health and existence. Maintaining hope amid a life-threatening disease and during palliative care is critical. The study aims to examine the effectiveness of a psychosocial supportive Hope Promotion Program (HPP) in enhancing hope, comfort, and quality of life in Portuguese adult outpatients with advanced and progressive chronic illness. Method: Using a parallel Randomized Control Trial (RCT) with pre-post design, 56 cancer outpatients from two day hospitals. Participants were randomly assigned to either a control group (n = 28) or an intervention group (n = 28). The primary outcome measure was hope. Secondary measures included comfort and quality of life. Participants were assessed at baseline, day 15, and day 30 of follow-up. Results: Baseline characteristics were similar between the two groups. In the intervention group, there was a significant increase in the total hope scores after the HPP (day 15). Significant differences were still present after one month (p < 0.05). There was also a significant increase in comfort and quality of life scores in the intervention group one month after HPP (p = 0.018). Conclusions: The HPP may be an effective intervention to increase hope and improve comfort and quality of life among palliative patients. Future studies should increase sample size, diversify settings, and include longer and more detailed follow-ups.

The concept of holism applied in recent palliative care practice: A scoping review

BACKGROUND

Whilst there is a sense of holism existing within palliative care practice, what is not clear is the extent to which holism, as applied in recent palliative care practice, has been adequately researched. Currently, no reviews on this topic were identified through systematic and scoping review registries.

AIM

To identify and describe the available published evidence on the key features of holism and the core domains underpinning the application of holism in relation to recent palliative care practice.

DESIGN

Scoping review using the Johanna Briggs Institute design.

DATA SOURCES

MEDLINE, EMCARE, and CINAHL (Ovid), PsycINFO, SocINDEX, SCOPUS and Web of Science. (International, peer-reviewed, published papers in the English language from January 2010to December 2020).

RESULTS

Five studies met inclusion criteria. Two studies used qualitative methods, one used mixed-methods, and two were randomised controlled trials. The research investigated (1) frameworks for holistic care and (2) assessment tools applied in palliative care settings.

CONCLUSIONS

The results from the review led to identifying key features of palliative care that were presented as interconnected aspects of holistic care domains in both assessments and interventions. The literature revealed a focus on curative and biomedical approaches to disease management with holistic aspects acknowledged, but not in the forefront of core service delivery. Holism was generally conceptualised as an overarching theoretical framework to palliative care service provision and positioned as an adjunct to palliative models of care. These findings point to a gap in research that links the concept of holism to applied palliative care practices.

Advance care planning: End-of-life hopes and fears among community dwelling adults

End-of-life (EOL) medical care in the United States often does not align with patients' goals and preferences. This study explored EOL hopes and fears among 86 community-dwelling adults and examined medical and psychological predictors of death anxiety. Common EOL hopes included absence of suffering, closure, and personal fulfillment. Common EOL fears included suffering, lack of competence, and specific types of death. Fear of the dying process was greater than fear of death itself. Health predicted death anxiety; age alone, did not. Advance care planning and clinical decision making should include these psychological insights and explicitly address EOL hopes and fears.

End-of-life cancer patients' total pain: the necessity to supplement pharmacology with psycho-socio-spiritual treatments

Aim: To analyze pain considering its different bio-psycho-social-spiritual manifestations and to assess the effectiveness of the analgesic treatments in end-of-life cancer patients. Materials & methods: The study was cross-sectional. A total of 376 end-of-life cancer inpatients participated in the research. Their socio-demographic and clinical data were collected and, during the first psychological consultancy, they filled in a set of validated rating scales assessing pain, anxiety, depression and quality of life. Results: The results show that physical pain was well managed for almost all patients. Nevertheless, the majority showed clinically significant levels of psychological distress. Conclusion: Treating pain means caring for all its possible manifestations including psychological symptoms and reduced wellbeing. Thus, integrating pharmacological treatment with psycho-socio-spiritual interventions, in other words, psychological, social and spiritual support, could be effective and desirable.

Psychological Aspects of Care in Cancer Patients in the Last Weeks/Days of Life

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.

A Systematic Review and Bayesian Network Meta-Analysis Investigating the Effectiveness of Psychological Short-Term Interventions in Inpatient Palliative Care Settings

This paper reviews and summarises the evidence of short-term psychosocial interventions (up to 12 sessions delivered within less than eight weeks) on anxiety, depression, and emotional distress in palliative patients in inpatient settings. We screened publications from the following five databases, Embase, PubMed, PsycINFO, Web of Science, and CINAHL, from their inception to 10 September 2021. The eligible studies included controls receiving standard palliative care, actively treated controls, and wait-list controls. Nine studies met the eligibility criteria and reported the effects of five psychosocial interventions in a total of N = 543 patients. We followed PRISMA-guidelines for outcome reporting and the Cochrane Risk of Bias Assessment Tool for assessing study quality. This paper used the network meta-analysis to compare multiple treatments by providing greater statistical power and the cross-validation of observed treatment effects, using the R package BUGSnet. Compared to control groups, the following psychosocial interventions in inpatient settings showed to be superior: life review interventions were the best ranked treatment for improving anxiety and distress, while the top ranked treatment for reducing depression was outlook intervention. The short-term psychosocial interventions investigated in this meta-analysis, especially life review intervention, are feasible and can potentially improve anxiety, depression, and distress in palliative inpatients and should therefore be offered in inpatient settings.

Psychoneuroendocrinological effects of music therapy versus mindfulness in palliative care: results from the 'Song of Life' randomized controlled trial

PURPOSE

Although research on psychosocial interventions in palliative care provided evidence for their effectiveness regarding patient-reported outcomes, few studies have examined their psychobiological effects yet. Therefore, the purpose of the present work as part of an overarching study was to investigate differential effects of music therapy versus mindfulness on subjective distress and both neuroendocrine and autonomic stress biomarkers.

METHODS

A total of 104 patients from two palliative care units were randomly assigned to three sessions of either music therapy or mindfulness. Before and after the second session (completed by 89 patients), participants rated their momentary distress and provided three saliva samples for cortisol and α-amylase analysis. Furthermore, photoplethysmography recordings were continuously assessed to calculate mean heart rate and heart rate variability. Data were analyzed using multilevel modeling of all available data and sensitivity analysis with multiply imputed data.

RESULTS

Between 67 and 75% of the maximally available data points were included in the primary analyses of psychobiological outcomes. Results showed a significant time*treatment effect on distress (b =  - 0.83, p = .02) indicating a greater reduction in the music therapy group. No interaction effects were found in psychobiological outcomes (all p > .05), but multilevel models revealed a significant reduction in cortisol (b =  - 0.06, p = .01) and mean heart rate (b =  - 7.89, p = .05) over time following either intervention.

CONCLUSION

Findings suggest a beneficial effect music therapy on distress while no differential psychobiological treatment effects were found. Future studies should continue to investigate optimal stress biomarkers for psychosocial palliative care research.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS)-DRKS00015308 (date of registration: September 7, 2018).

Nursing, psychotherapy and advanced cancer: A scoping review

PURPOSE

Many individuals with advanced cancer have unmet psychological needs and often lack access to supportive care. Psychotherapy for adults with advanced cancer is a promising way to address some of the challenges in meeting these care needs. Nurses are the largest cohort of healthcare workers who can practice as psychotherapists and are positioned ideally to integrate these interventions as part of routine care. The purpose of this scoping review is to map the literature on psychotherapeutic interventions among adults with advanced cancer and to explore the nursing role in this body of evidence.

METHODS

We conducted a scoping review for relevant quantitative, qualitative, and mixed methods studies. The content of included studies was analyzed and grouped based on two broad categories that describe how nursing's role was mentioned, described, and utilized: 1. Nurses are not the interventionist/psychotherapist and, 2. Nurses are mentioned as the interventionist/psychotherapist.

RESULTS

Eighty-six studies were included. Overall, majority of studies did not mention a role for nursing in any capacity. Some studies mentioned a non-interventionist role for nursing in the research study. Fourteen studies mentioned nurses as interventionists/psychotherapists. These studies focused on feasibility, acceptability and patient related outcomes of brief psychotherapies. Dignity therapy was the most common psychotherapy in studies where nurses were utilized as interventionists, followed by life review and supportive expressive therapies. Very few studies discussed nursing's role in this area and nursing's capacity to deliver this form of care.

CONCLUSION

There is paucity in nursing research focused on psychotherapy for adults with advanced cancer. It is feasible and acceptable for nurses to deliver brief psychotherapies to adults with advanced cancer, and the integration of these techniques in everyday practice has great potential that must be explored. The development of this knowledge base is needed to support future education, research, and practice policy agendas.

Symptoms During Outpatient Cancer Treatment and Options for Their Management

BACKGROUND

Cancer patients account for a large segment of the German healthcare system, with a 5-year prevalence of around 1.7 million persons. Advances in oncological treatment, now frequently performed on an outpatient basis, are granting many of these individuals a longer life span. At the same time, cancer patients often suffer disease-related symptoms and adverse effects from their tumor treatment, which may strongly impair their quality of life despite the improved techniques for management of side effects.

METHODS

This review is based on a selective literature search of the PubMed and Cochrane Library databases carried out in December 2019 and January 2020. Special attention was paid to guidelines, expert opinions, and recommendations from professional societies.

RESULTS

Alongside decreased well-being, cancer patients often suffer from fatigue (70-100%), loss of appetite (6-53%), pain (30-80 %), and dyspnea (10-70%). The prevalence and severity of the symptoms varies depending on the tumor entity and the patient's sex. A meta-analysis showed that besides causal treatment, physical activity achieves moderately strong effects in tumor-associated fatigue syndrome (Cohen's d = 0.30 [0.25; 0.36]). The WHO recommends early use of opioids in tumor-associated pain. A meta-analysis of randomized trials described symptom relief by means of opioids also in dyspnea (standardized mean difference: -0.32 [-0.53; -0.10]). Increasingly, guidelines are recommending regular palliative medical symptom screening.

CONCLUSION

Regular documentation of symptoms in outpatients offers the opportunity for targeted management of symptoms during treatment with the involvement of various disciplines such as palliative medicine, exercise therapy, and psychotherapy.

"Song of Life": Results of a multicenter randomized trial on the effects of biographical music therapy in palliative care

BACKGROUND

Awareness for the importance of psychological and spiritual needs in patients with terminal diseases has increased in recent years, but randomized trials on the effects of psychosocial interventions are still rare.

AIM

To investigate the efficacy of the "Song of Life" music therapy intervention regarding the emotional and psycho-spiritual dimensions of quality of life.

DESIGN

Patients were randomly assigned to either "Song of Life" or a relaxation intervention. "Song of Life" is a novel three-session music therapy intervention working with a biographically meaningful song. Primary outcome was the improvement in psychological quality of life. Secondary outcomes included spiritual well-being, ego-integrity, momentary distress, and global quality of life and the explorative assessment of treatment satisfaction (patient and family member version). Intention-to-treat analysis was conducted including adjustment for multiple testing in secondary outcomes.

SETTING/PARTICIPANTS

Between December 2018 and August 2020, 104 patients receiving specialized palliative care were recruited from two palliative care wards.

RESULTS

No significant differences were found regarding psychological and global quality of life, but "Song of Life" participants reported significantly higher spiritual well-being (p = 0.04) and ego-integrity (p < 0.01), as well as lower distress (p = 0.05) than patients in the control group. Both patients' and family members' treatment satisfaction was higher after "Song of Life" with large between-group effect sizes on items asking for meaningfulness (d = 0.96) and importance (d = 1.00).

CONCLUSIONS

Our findings provide evidence that "Song of Life" is an effective and meaningful biographical music therapy intervention to facilitate psycho-spiritual integration in terminally ill patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS)-DRKS00015308 (date of registration: September 7th 2018).

Effects of Acceptance and Commitment Therapy on health-related outcomes for patients with advanced cancer: A systematic review

BACKGROUND

Advanced cancer is an incurable and life-threatening disease that poses a major challenge to patients' psychological and physical well-being. Acceptance and Commitment Therapy is a mindfulness-based behavioural therapy for managing health outcomes and inducing health-related behaviour changes. However, the components and modality of Acceptance and Commitment Therapy and its effectiveness on health outcomes for patients with advanced cancer remain unclear.

OBJECTIVES

This review aimed to identify the main content, delivery mode, dosage and duration of Acceptance and Commitment Therapy, and to systematically summarise evidence regarding its application in patients with advanced cancer for improving physical and psychological outcomes and health-related quality of life.

DESIGN

Systematic review.

DATA SOURCES

PubMed, British Nursing Index, Medline, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure and WANFANG Data were searched to identify eligible clinical trials.

REVIEW METHODS

Two reviewers independently assessed the eligibility of each study and extracted data. The Joanna Briggs Institute critical appraisal checklist was used to evaluate the risk of bias in the included studies. Narrative synthesis was used to present the findings of this review.

RESULTS

Six studies involving 261 participants were included in this review, including five randomised control trials and one with a pretest-posttest design. Two out of the five studies reported Acceptance and Commitment Therapy significantly reduced depressive symptoms and psychological distress post-intervention with a large effect size compared with usual care. One study indicated significant improvements in anxiety, sleep characteristics and health-related quality of life with a large effect size post-intervention. Non-significant changes in fatigue and pain were found. Intervention programmes with no more than four sessions had high adherence rates.

CONCLUSION

Acceptance and Commitment Therapy may be a beneficial way to improve depressive symptoms, anxiety, psychological distress, sleep characteristics and health-related quality of life in patients with advanced cancer. However, limited studies, small sample size and methodological heterogeneity weaken the evidence. More rigorous research using brief Acceptance and Commitment Therapy programmes should be conducted within larger samples to further confirm the effectiveness and evaluate its long-term effect on this population.

Psychological Intervention and COVID-19: What We Know So Far and What We Can Do

The coronavirus COVID-19 and the global pandemic has already had a substantial disruptive impact on society, posing major challenges to the provision of mental health services in a time of crisis, and carrying the spectre of an increased burden to mental health, both in terms of existing psychiatric disorder, and emerging psychological distress from the pandemic. In this paper we provide a framework for understanding the key challenges for psychologically informed mental health care during and beyond the pandemic. We identify three groups that can benefit from psychological approaches to mental health, and/or interventions relating to COVID-19. These are (i) healthcare workers engaged in frontline response to the pandemic and their patients; (ii) individuals who will experience the emergence of new mental health distress as a function of being diagnosed with COVID-19, or losing family and loved ones to the illness, or the psychological effects of prolonged social distancing; and (iii) individuals with existing mental health conditions who are either diagnosed with COVID-19 or whose experience of social distancing exacerbates existing vulnerabilities. Drawing on existing literature and our own experience of adapting treatments to the crisis we suggest a number of salient points to consider in identifying risks and offering support to all three groups. We also offer a number of practical and technical considerations for working psychotherapeutically with existing patients where COVID-19 restrictions have forced a move to online or technologically mediated delivery of psychological interventions.

Stress-reducing effects of a brief mindfulness intervention in palliative care: Results from a randomised, crossover study

OBJECTIVE

Mindfulness-based interventions are a widely used and highly accepted adjunct treatment in oncology. Due to a paucity of research in advanced cancer and other terminal illnesses, we aimed to evaluate the stress-reducing effects of a brief, standardised mindfulness intervention for use in palliative care.

METHODS

This study was a randomised, crossover trial where patients participated in both a single mindfulness intervention and a resting state control condition. The order of the conditions was randomised. Study outcomes encompassed self-report data on stress and well-being and measures of heart rate variability. All outcome data were measured at four times per day.

RESULTS

Forty-two patients participated in this study. We found significantly stronger reductions in self-rated stress and mean heart rate as well as an increase in heart rate variability after the mindfulness intervention. Psychophysiological effects were strongest in the immediate pre- to post-intervention comparison, while the effect on subjective stress persisted after 20 to 40 min. No significant differences were found for self-rated well-being.

CONCLUSIONS

Despite the rather small magnitude of effects, the brief mindfulness intervention showed to be effective and accepted by patients in very advanced stages of a disease and could be offered by trained healthcare professionals in palliative care.

Community health workers in palliative care provision in low-income and middle-income countries: a systematic scoping review of the literature

BACKGROUND

Community health workers (CHWs) are currently deployed in improving access to palliative care in a limited number of low-income or middle-income countries (LMICs). This review therefore aimed to document evidence from LMICs regarding (1) where and how CHWs are currently deployed in palliative care delivery, (2) the methods used to train and support CHWs in this domain, (3) the evidence surrounding the costs attached with deploying CHWs in palliative care provision and (4) challenges and barriers to this approach.

METHODS

We conducted a systematic scoping review of the literature, adhering to established guidelines. 11 major databases were searched for literature published between 1978 and 2019, as well as the grey literature.

FINDINGS

13 original studies were included, all of which were conducted in sub-Saharan African countries (n=10) or in India (n=3). Ten described a role for CHWs in adult palliative care services, while three described paediatric services. Roles for CHWs include raising awareness and identifying individuals requiring palliative care in the community, therapeutic management for pain, holistic home-based care and visitation, and provision of psychological support and spiritual guidance. Reports on training context, duration and outcomes were variable. No studies conducted a formal cost analysis. Challenges to this approach include training design and sustainability; CHW recruitment, retention and support; and stigma surrounding palliative care.

CONCLUSION

Despite relatively limited existing evidence, CHWs have important roles in the delivery of palliative care services in LMIC settings. There is a need for a greater number of studies from different geographical contexts to further explore the effectiveness of this approach.

Gespräche über das Lebensende erleichtern: Erkenntnisse aus der “Hand-in-Hand” Intervention

<b><i>Hintergrund:</i></b> Tod und Sterben sind in Psychotherapien häufig relevante Themen, besonders, wenn Menschen mit lebensbedrohlichen Erkrankungen in Behandlung kommen. Die Kommunikation über das Lebensende in der Therapie und im Alltag ist häufig mit Angst und Überforderung verknüpft. Dabei kann eine gelungene Kommunikation bedeuten, dass die Lebensqualität von Betroffenen und Angehörigen steigt, genau wie ihre Verbundenheit. Bisher existieren keine wissenschaftlich evaluierten Programme zur Anbahnung von Gesprächen über das Lebensende. Ein solches wurde im Rahmen der “Hand-in-Hand” Studie als Zugang für eine medizinische Vorausplanung entwickelt. <b><i>Fallbericht:</i></b> Zwei Krebsbetroffene, die im Rahmen einer randomisierten kontrollierten Studie an der “Hand-in-Hand” Intervention teilnahmen, werden vorgestellt. Die Interventionsbausteine aus Würde-Therapie, Wissensvermittlung und kognitiver Therapie werden beschrieben und ihre Wirkung qualitativ und quantitativ bewertet. Dabei zeigt sich eine hohe Zufriedenheit bezüglich der Intervention. Die Intervention kann die Kommunikation zwischen Betroffenen und Angehörigen verbessern, wenn auch in unterschiedlich starkem Ausmaß. <b><i>Schlussfolgerung:</i></b> Es ist wichtig, Menschen im Rahmen der psychotherapeutischen Versorgung nach lebensbedrohlichen Erkrankungen in ihrem Umfeld zu befragen. PsychotherapeutInnen besitzen dabei bereits Kompetenzen, mit denen sie Gespräche über das Lebensende fördern können. Der gezielte Einsatz dieser Kompetenzen im Rahmen der “Hand-in-Hand” Intervention hat in den beschriebenen Einzelfällen zu einer Veränderung in der Kommunikation geführt.

Emotional disclosure as a therapeutic intervention in palliative care: a scoping review protocol

INTRODUCTION

Emotional disclosure (ED) is a term used to describe the therapeutic expression of emotion. ED underlies a variety of therapies aimed at improving well-being for various populations, including people with palliative-stage disease and their family carers. Systematic reviews of ED-based psychotherapy have largely focused on expressive writing as a way of generating ED. However, heterogeneity in intervention format and outcome measures has made it difficult to analyse efficacy. There is also debate about the mechanisms proposed to explain the potential effects of ED.We present a scoping review protocol to develop a taxonomy of ED-based interventions to identify and categorise the spectrum of interventions that could be classified under the umbrella term of 'emotional disclosure' in the palliative care setting. By mapping these to associated treatment objectives, outcome measures and explanatory frameworks, the review will inform future efforts to design and evaluate ED-based therapies in this population.

METHODS AND ANALYSIS

The review will be guided by Arksey and O'Malley's five-stage scoping review framework and Levac's extension. The following electronic databases will be searched from database inception: CENTRAL, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science and MEDLINE. We will include peer-reviewed studies and reviews. We will also check grey literature, including clinical trial registers, conference proceedings and reference lists, as well as contacting researchers. Articles will be screened by at least two independent reviewers and data charted using an extraction form developed for this review. Results will be analysed thematically to create a taxonomy of interventions, outcome measures and theoretical frameworks.

ETHICS AND DISSEMINATION

This review does not require ethical approval as it is a secondary analysis of pre-existing, published data. The results will inform future research in the development of ED-based interventions and evaluation of their efficacy in the palliative care setting. We will disseminate findings through peer-reviewed journals.

Brief psychosocial interventions improve quality of life of patients receiving palliative care: A systematic review and meta-analysis

Background:

Patients with a terminal disease report a high need for psychosocial and spiritual support. Previous literature reviews on psychosocial interventions in palliative care were restricted to certain subtypes of techniques, included a wide range of patients, conditions, and settings, or required a number of sessions unrealistic to be achieved in patients nearing the end of their lives.

Aim:

The aim of this study was to review and synthesize the evidence on brief psychosocial interventions (i.e. four sessions or less and less than 21 days) for patients receiving palliative treatment.

Design:

We performed a systematic review and meta-analysis in accordance with standard guidelines and a pre-registered protocol (PROSPERO: CRD42018082713).

Data sources:

Electronic databases, journals, and references were searched for controlled clinical trials. We used the Cochrane criteria to assess the risk of bias within studies.

Results:

In total, 15 studies met the eligibility criteria and reported the effects of 17 interventions and a total of 1248 patients. The most frequently used techniques were life review techniques and music therapy. After exclusion of outliers, psychosocial interventions showed to be superior with regard to the improvement of quality of life (effect size = 0.36, confidence interval = 0.08 to 0.64), and the reduction of emotional (effect size = −0.51, confidence interval = −0.77 to −0.26) and existential distress (effect size = −0.40, confidence interval = −0.71 to −0.07) compared to the control groups.

Conclusion:

Brief psychosocial interventions can improve clinically relevant health outcomes and should therefore be made available for patients receiving palliative care.