Existential distress in patients with advanced cancer and their caregivers: study protocol of a longitudinal cohort study

End-Of-Life Cancer Patients' Dignity Perception Before and During COVID-19 Pandemic

Background: The safety and restriction regulations implemented to contain the COVID-19 pandemic significantly impacted people's quality of life compromising the perception of dignity. Preserving dignity for end-of-life patients remains a paramount objective in palliative care. This study aimed to compare dignity levels in terminal cancer patients between pre- and during-pandemic periods. Methods: Dignity was assessed by the Italian version of the Patient Dignity Inventory (PDI-IT) in both pre- and during-pandemic groups of terminal cancer inpatients (hospitalized or admitted in hospice). The 2 groups were compared using non-parametric tests and a multivariate logistic regression analysis to estimate the association of the different dimensions of dignity with COVID-19 period, adjusting for other confounders. The study involved 2 groups of end-of-life cancer patients with a Karnofsky Performance Status (KPS) index less than 50. The first group included 506 patients before COVID-19, and the second group consisted of 156 patients enrolled during pandemic. Results: Existential Distress, Loss of Purpose and Meaning, Physical Symptoms and Dependency, Social Support PDI subscales and PDI Total score were higher in the during-pandemic group. The multivariate regression model partially supported the previous results as Loss of Purpose and Meaning, Social Support, and Existential Distress PDI subscales were associated with during-pandemic period, whereas PDI Physical Symptoms and Dependency and PDI Psychological Distress were not. Conclusion: Social isolation and other restrictions put in place to contain the COVID-19 pandemic may have had a negative impact on the perception of dignity in cancer patients at the end of life.

Palliative and Supportive Care in the Philippines: Systems, Barriers, and Steps Forward

Although integral to alleviating serious health-related suffering, global palliative care remains systemically and culturally inaccessible to many patients living in low- and middle-income countries. In the Philippines, a lower-middle income country in Southeast Asia of over 110 million people, up to 75% of patients with cancer suffer from inadequate pain relief. We reviewed factors that preclude access to basic palliative care services in the Philippines. PubMed and Google Scholar were searched thoroughly; search terms included but were not limited to "palliative care," "supportive care," "end-of-life care," and "Philippines." We found that a limited palliative care workforce, high out-of-pocket healthcare costs, and low opioid availability all hinder access to palliative care in the archipelago. Religious fatalism, strong family-orientedness, and physician reluctance to refer to palliative care providers represent contributory sociocultural factors. Efforts to improve palliative care accessibility in the country must address health systems barriers while encouraging clinicians to discuss end-of-life options in a timely manner that integrates patients' unique individual, familial, and spiritual values. Research is needed to elucidate how Filipinos-and other global populations-view end-of-life, and how palliative care strategies can be individualised accordingly.

A 6-Week Program to Strengthen Resiliency Among Women With Metastatic Cancer: A Randomized Clinical Trial

PURPOSE

The objective of this study was to evaluate the effect of an intervention (Growing Resilience And CouragE; GRACE) on spiritual well-being, quality of life, and general well-being in women with metastatic cancers reporting existential or spiritual distress.

PATIENTS AND METHODS

Prospective, randomized, wait-list control clinical trial. Women with metastatic cancer experiencing existential or spiritual concerns were randomized to GRACE or waitlist control. Survey data were collected at baseline, end of program, and 1-month follow-up. Participants included English-speaking women, 18 or older, with metastatic cancer, existential or spiritual concerns, and reasonable medical stability. Eighty-one women were assessed for eligibility; 10 were excluded (not meeting exclusion criteria, refusal to participate, and death). The primary outcome was spiritual well-being measured pre- and post-program. Secondary measures assessed quality of life, anxiety, depression, hopelessness, and loneliness.

RESULTS

Seventy-one women (aged 47-72) were enrolled (GRACE n = 37, waitlist control n = 34). GRACE participants demonstrated significant improvements in spiritual well-being compared to control at end of program (parameter estimate (PE), 16.67, 95% CI, 13.17, 20.16) and 1-month follow-up (PE, 10.31, 95% CI, 6.73, 13.89). Additionally, significant improvements were demonstrated in quality of life at the end of program (PE, 8.51, 95% CI, 4.26, 12.76) and 1-month follow-up (PE, 6.17, 95% CI, 1.75, 10.58). GRACE participants also demonstrated improved depression and hopelessness at follow-up, as well as improved anxiety.

CONCLUSIONS

Findings suggest the value of evidence-based psychoeducational and experiential interventions for improving the well-being and quality of life of women with advanced cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02707510.

Coping in caregivers of patients with hematologic malignancies undergoing hematopoietic stem cell transplantation

Caregivers of patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) must cope with substantial caregiving burden, high rates of psychological distress, and diminished quality of life (QOL). However, data describing coping strategies before HSCT and the association between coping, QOL, and psychological outcomes in this population are lacking. We conducted a secondary analysis of data collected during a multisite randomized clinical trial of a supportive care intervention in HSCT recipients and their caregivers. Caregivers completed the Brief COPE, Hospital Anxiety and Depression Scale, and the Caregiver Oncology Quality of Life Questionnaire to measure coping strategies, psychological distress, and QOL, respectively. We grouped coping into 2 higher-order domains: approach-oriented (ie, emotional support and active coping) and avoidant (ie, self-blame and denial). We used the median split method to describe the distribution of coping and multivariate linear regression models to assess the relationship between coping and caregiver outcomes. We enrolled 170 caregivers, with a median (range) age of 53 (47-64) years. Most were White (87%), non-Hispanic (96%), and female (77%). Approach-oriented coping was associated with less anxiety (β = -0.210, P = .003), depression symptoms (β = -0.160, P = .009), and better QOL (β = 0.526, P = .002). In contrast, avoidant coping was associated with more anxiety (β = 0.687, P<.001), depression symptoms (β = 0.579, P < .001), and worse QOL (β = -1.631, P < .001). Our findings suggest that coping is related to distress and QOL among caregivers of HSCT recipients even before transplant. Hence, caregivers of patients with hematologic malignancies undergoing HSCT may benefit from resources that facilitate adaptive coping with the demands of caregiving.

Benefits of integrating palliative care: a qualitative exploration of the perspectives of palliative care providers in a tertiary health facility in Ghana

Background

Integration of palliative care (PC) services entails combining administrative, organisational, clinical and service elements to ensure continuity of care between all parties participating in the care network of patients. There is a need to understand the benefits of integrating PC to inform policy making and advance advocacy, especially in resource-constrained settings such as Ghana where PC is sub-optimally implemented. Yet, existing research in Ghana is sparse on what benefits are likely to be experienced as a result of integrating PC.

Objective

The study explored service providers' perspectives on the benefits of integrating PC in Ghana.

Design

The design was an exploratory descriptive qualitative research design.

Methods

A total of seven in-depth interviews were conducted using semi-structured interview guides. The data were managed using NVivo-12. Inductive thematic analysis was carried out following Haase's modification of Colaizzi's approach to qualitative research analysis. The study follows the COREQ guidelines and the ICMJE recommendations.

Result

Two main themes emerged: patient-related outcomes, and system/institution-related outcomes. For the patient-related outcomes, the following sub-themes emerged: restored hope, appreciated care and better preparation for the end of life (EoL). The emerging sub-themes under the system/institution-related outcomes include the following: early initiation of care, enhanced communication between primary healthcare providers and the PC team and strengthening staff capacity to provide PC services.

Conclusion

In conclusion, there are substantial benefits to be experienced from integrating PC. For the patients, it would restore shattered hopes, result in appreciated care and better preparation for the EoL. For the healthcare system, it would promote early initiation of care, enhance communication between primary healthcare providers and the PC team and strengthen service providers' capacity to provide PC services. This study, thus, furthers the case for a more integrated PC service in Ghana.

Demoralization: Where it stands-and where we can take it: A bibliometric analysis

Objectives

The purpose is to analyze existing studies related to the field of demoralization through bibliometrics.

Methodology

Relevant literature on demoralization was searched from PubMed, Web of Science, the Cochrane Library, and CINAHL Complete. Bibliometric analysis was performed using GraphPad Prisma 8.2.1, VOSviewer 1.6.18 and R software. Research publication trends, author-country collaboration, research hotspots and future trends were explored by generating network relationship maps.

Results

A total of 1,035 publications related to the field of demoralization were identified. The earliest relevant studies have been published since 1974, and the studies have grown faster since 2000. Psyche-oncology and Psychother Psychosom had the highest number of publications (n = 25). The United States, Italy and Australia have made outstanding contributions to the field and there was an active collaboration among leading scholars. Major research hotspots include the multiple ways of assessing demoralization, the specificity of various demographics and psychological disorders in different disease contexts, and the association and distinction of diverse clinical psychological abnormalities. The impact of COVID-19 on demoralization and subsequent interventions and psychological care may become a future research direction.

Conclusion

There has been a significant increase in research in the field of demoralization after 2000. The United States provided the most publications. There is overall active collaboration between authors, countries, and institutions. In future research, more attention will be paid to the effects of COVID-19 on demoralization and intervention care for this psychology.

[DNVF Memorandum: Health Services Research in the Last Year of Life]

This memorandum outlines current issues concerning health services research on seriously ill and dying people in the last year of their lives as well as support available for their relatives. Patients in the last phase of life can belong to different disease groups, they may have special characteristics (e. g., people with cognitive and complex impairments, economic disadvantage or migration background) and be in certain phases of life (e. g., parents of minor children, (old) age). The need for a designated memorandum on health services research in the last year of life results from the special situation of those affected and from the special features of health services in this phase of life. With reference to these special features, this memorandum describes methodological and ethical specifics as well as current issues in health services research and how these can be adequately addressed using quantitative, qualitative and mixed methods. It has been developed by the palliative medicine section of the German Network for Health Services Research (DNVF) according to the guidelines for DNVF memoranda.

Predicting unplanned hospital readmission in palliative outpatients (PRePP) – study protocol of a longitudinal, prospective study to identify informal caregiver-related and structural predictors

Background

Although the majority of German patients in a palliative state prefer to die at home, the actual place of death is most often a hospital. Unplanned hospital readmissions (UHA) not only contradict most patients’ preferences but also increase the probability of an aggressive end-of-life treatment. As limited knowledge is available which factors contribute to an UHA, the PRePP-project aims to explore predictors related to informal caregivers (IC) as well as medical and structural factors.

Methods

This prospective, observational, mono-centric study will assess structural and medical factors as well as ICs’ psychological burden throughout seven study visits. Starting in April 2021 it will consecutively include 240 patients and their respective IC if available. Standardized measures concerning ICs’ Quality of Life (WHOQOL-BREF), psychological distress (NCCN-Distress Thermometer), anxiety (GAD-7) and depressiveness (PHQ-9) will be assessed. If participants prefer, assessment via phone, browser-based or paper-based will be conducted. Medical records will provide routinely assessed information concerning patient-related characteristics such as gender, age, duration of hospital stay and medical condition. Nurse-reported data will give information on whether hospitalization and death occurred unexpectedly. Data will be progressed pseudonymized. Multivariable regression models will help to identify predictors of the primary endpoint “unplanned hospital admissions”.

Discussion

The PRePP-project is an important prerequisite for a clinical risk assessment of UHAs. Nevertheless, it faces several methodological challenges: as it is a single center study, representativity of results is limited while social desirability might be increased as the study is partly conducted by the treatment team. Furthermore, we anticipated an underrepresentation of highly burdened participants as they might refrain from participation.

Trial registration

This study was retrospectively registered 19 October 2021 at clinicaltrials.gov (NCT05082389). https://clinicaltrials.gov/ct2/show/NCT05082389

Psychometric Testing of the Spanish Modified Version of the Mini-Suffering State Examination

Background: The mini-suffering state examination is a valid and reliable measure that have been used to assess suffering in patients with advanced cancer. The aim of this study was to carry out a psychometric analysis of the Spanish version of the mini-suffering state examination. Method: A validation study was conducted. Seventy-two informal caregivers of deceased patients in palliative care were included in this study. A psychometric testing of content validity, internal consistency, and convergent validity with the Spanish version of the quality of dying and death questionnaire was performed. Results: The original instrument was modified to be used by informal caregivers. The content validity was acceptable (0.96), and the internal consistency was moderate (α = 0.67). Convergent validity was demonstrated (r = −0.64). Conclusion: The Spanish modified version of the MSSE showed satisfactory measurement properties. The Spanish modified version of MSSE can be useful to facilitate screening, monitor progress, and guide treatment decisions in end-of-life cancer patients.