Harnessing Complex Emergent Metaphors for Effective Communication in Palliative Care

Art Therapy in Advanced Cancer. A Mapping Review of the Evidence

PURPOSE OF REVIEW

The benefits of arts in improving well-being in end-of-life patients have been stated by the WHO. To inspire clinical practice and future research, we performed a mapping review of the current evidence on the effectiveness of art therapy interventions in stage III and IV cancer patients and their relatives.

RECENT FINDINGS

We identified 14 studies. Benefits reported by the authors were grouped as improved emotional and spiritual condition, symptom relief, perception of well-being, satisfaction, and helpfulness. As a body of evidence, notable limitations were observed: Only 1 study was a randomized controlled trial (RCT), and there was heterogeneity in the interventions and outcome measures. This mapping review highlights the evidence available on the effectiveness of art therapy in advanced cancer, which remains limited and presents specific challenges. It also provides a visual representation of the reported benefits, encouraging further and more rigorous investigation.

Fear, Pain, Denial, and Spiritual Experiences in Dying Processes

Purpose:

Approaching death seems to be associated with physiological/spiritual changes. Trajectories including the physical–psychological–social–spiritual dimension have indicated a terminal drop. Existential suffering or deathbed visions describe complex phenomena. However, interrelationships between different constituent factors (e.g., fear and pain, spiritual experiences and altered consciousness) are largely unknown. We lack deeper understanding of patients’ inner processes to which care should respond. In this study, we hypothesized that fear/pain/denial would happen simultaneously and be associated with a transformation of perception from ego-based (pre-transition) to ego-distant perception/consciousness (post-transition) and that spiritual (transcendental) experiences would primarily occur in periods of calmness and post-transition. Parameters for observing transformation of perception (pre-transition, transition itself, and post-transition) were patients’ altered awareness of time/space/body and patients’ altered social connectedness.

Method:

Two interdisciplinary teams observed 80 dying patients with cancer in palliative units at 2 Swiss cantonal hospitals. We applied participant observation based on semistructured observation protocols, supplemented by the list of analgesic and psychotropic medication. Descriptive statistical analysis and Interpretative Phenomenological Analysis (IPA) were combined. International interdisciplinary experts supported the analysis.

Results:

Most patients showed at least fear and pain once. Many seemed to have spiritual experiences and to undergo a transformation of perception only partly depending on medication. Line graphs representatively illustrate associations between fear/pain/denial/spiritual experiences and a transformation of perception. No trajectory displayed uninterrupted distress. Many patients seemed to die in peace. Previous near-death or spiritual/mystical experiences may facilitate the dying process.

Conclusion:

Approaching death seems not only characterized by periods of distress but even more by states beyond fear/pain/denial.

Employing imaginative rationality: using metaphor when discussing death

The prevalence of metaphors in medicine is widely acknowledged. In a qualitative study exploring expectations of longevity, we observed repeated recourse to the imaginative rationality provided by metaphors to express perspectives on longevity and death. Bafflement, acceptance, uncertainty and distress were conveyed through metaphors, providing valuable insight into the internal healthcare frameworks of participants. Skilful use of imaginative rationality in the healthcare setting may illuminate the elusive and often eschewed topic of death in a way that fosters clarity and new understandings, and pave the way towards a better life, and death for patients. By becoming aware of the nuances contained within patients'-as well as their own-metaphors, clinicians may enhance patients' overall healthcare experience and avert unintended miscommunication.

A Thematic Literature Review

The purpose of this review was to investigate within the literature the link between transcendent phenomena and peaceful death. The objectives were firstly to acknowledge the importance of such experiences and secondly to provide supportive spiritual care to dying patients. Information surrounding the aforementioned concepts is underreported in the literature. The following 4 key themes emerged: spiritual comfort; peaceful, calm death; spiritual transformation; and unfinished business. The review established the importance of transcendence phenomena being accepted as spiritual experiences by health care professionals. Nevertheless, health care professionals were found to struggle with providing spiritual care to patients who have experienced them. Such phenomena are not uncommon and frequently result in peaceful death. Additionally, transcendence experiences of dying patients often provide comfort to the bereaved, assisting them in the grieving process.