Emily A. Meier

Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue

There is little agreement about what constitutes good death or successful dying. The authors conducted a literature search for published, English-language, peer-reviewed reports of qualitative and quantitative studies that provided a definition of a good death. Stakeholders in these articles included patients, prebereaved and bereaved family members, and healthcare providers (HCPs). Definitions found were categorized into core themes and subthemes, and the frequency of each theme was determined by stakeholder (patients, family, HCPs) perspectives. Thirty-six studies met eligibility criteria, with 50% of patient perspective articles including individuals over age 60 years. We identified 11 core themes of good death: preferences for a specific dying process, pain-free status, religiosity/spirituality, emotional well-being, life completion, treatment preferences, dignity, family, quality of life, relationship with HCP, and other. The top three themes across all stakeholder groups were preferences for dying process (94% of reports), pain-free status (81%), and emotional well-being (64%). However, some discrepancies among the respondent groups were noted in the core themes: Family perspectives included life completion (80%), quality of life (70%), dignity (70%), and presence of family (70%) more frequently than did patient perspectives regarding those items (35%-55% each). In contrast, religiosity/spirituality was reported somewhat more often in patient perspectives (65%) than in family perspectives (50%). Taking into account the limitations of the literature, further research is needed on the impact of divergent perspectives on end-of-life care. Dialogues among the stakeholders for each individual must occur to ensure a good death from the most critical viewpoint-the patients.

What Did I Miss? A Qualitative Assessment of the Impact of Patient Suicide on Hospice Clinical Staff

BACKGROUND Patient suicides can affect clinicians both personally and professionally, with frequent reports of psychological and behavioral changes occurring in response to this type of patient death. Although hospice clinicians have regular exposure to dying patients, the impact of patient suicide on this group has been understudied. OBJECTIVES This study examined the personal and professional impact of patient suicides among hospice clinical staff, the coping strategies used by this group, and their recommendations for staff support after a patient suicide. DESIGN Utilizing an online survey, 186 hospice staff qualitatively described the impact of patient suicides on them as people and professionals, their resulting coping strategies, and any recommendations for supporting others. Three study investigators coded all of the staff responses at a paragraph level and summarized the most common emergent themes using grounded theory procedures. SETTING/SUBJECTS One hundred eighty-six clinical staff members who worked in an academic nonprofit hospice setting. MEASUREMENTS An open-ended, qualitative survey was used to gather data about demographics, clinical experience, exposure to known or suspected suicides, recommendations for support in the event of a patient suicide, the personal and professional impacts of suicide, and coping strategies. RESULTS The themes expressed by the hospice staff in reaction to patient suicides included: psychological responses such as feelings of guilt and self-doubt, changes in professional attitudes, and changes in clinical practice such as greater sensitivity to signs of suicide. When coping with a patient suicide, hospice staff described the use of team-based support strategies, debriefings, and personal spiritual practices. Recommendations for future support included facilitated debriefings, individual counseling, spiritual practices, leaves of absence, self-care activities, and educational interventions. CONCLUSION Data from this small study may help clinicians and administrators more fully understand the impact of patient suicides on hospice staff and may serve as a foundation for the development of effective strategies to support staff after a patient suicide.

Life satisfaction and its correlates among older cancer survivors: critical role of psychosocial factors

Dear Editor,IntroductionImprovements in early detection and treatment of cancerhave resulted in a growing number of aging cancer survi-vors. Currently, 60% of the 10 million cancer survivors inthe USA are older than 65 years [1]. Yet, research hasbeen scarce on mental health outcomes, especially satis-faction with life (SWL), in older cancer survivors (OCSs)[2]. A number of existing studies in this arena are limitedby a focus on a single cancer type such as breast cancer,small sample sizes, inclusion of people with very recentlydiagnosed cancer, and a lack of age-matched healthycomparison subjects (HCs) [1–3]. There are also prevalentassumptions that limit progress in our understanding ofpsychological well-being in this population, for example,that positive emotions are absent, dangerous, delusional,or trivial among people with life-threatening illnesses[4]. Studiessuggestthat OCSsfare muchworse physicallythan HCs as a result of adverse interactions among cancer,its treatment, aging, and comorbidity [1–3]. Findings onmental function suggest that OCSs have worse psycholog-ical functioning than HCs [1], experience age-associateddecline in health-related quality of life [5], and have loweroptimism about life expectancy than HCs [3]. Other find-ings are mixed, with some studies reporting similar de-pression scores and cognitive function between OCSsand HCs [3], whereas others report increased depressionwith age but no association between age and SWL inOCSs [2]. Conversely, OCSs have reported resilient socialwell-being, spirituality, and personal growth with aging[6]. Notably, only a few reports have employedstandardized instruments for assessing positive psychoso-cialresourcessuchas SWL,resilience,optimism,personalmastery, and spirituality [2].Thus,understandingSWLanditspsychosocialcorrelatesamong OCSs remains an important but understudied areawith high public health significance. Such research wouldbe of value in developing interventions to increase SWL.The present study compared SWL, as well as health-related physical, cognitive, and psychosocial functioninginOCSs,withthatindemographicallymatchedHCsfroma community-based sample. As several studies havereported worse physical and psychological function inOCSs than among HCs [1], we hypothesized that OCSswould perform worse in all spheres of functioningcompared with HCs. We also examined the correlates ofSWL in the two groups.Materials and methodsParticipantsCancer survivors and HCs were recruited from a largemulticohortlongitudinal,community-basedsampleofolderadults whohad beenselected using random digit dialing, inthe Successful AGing Evaluation (SAGE) study. TheSAGEdataincludestandardizedmeasuresofphysical,cog-nitive,andpsychosocialfunctioningfromatelephoneinter-view and a mail-in survey completed by 1006 participantsbetween the ages of 50 and 99 years [7]. Two hundredandnineteenSAGEparticipantsreportedhavingadiagnosisof cancer (excluding skin cancer). They were comparedwith 219 age-, gender-, and education-matched HCs fromthe same sample, who did not report a history of cancer.

Enhancing legacy in palliative care: study protocol for a randomized controlled trial of Dignity Therapy focused on positive outcomes

BackgroundDignity Therapy is a brief psychotherapy that can enhance a sense of legacy while addressing the emotional and existential needs of patients receiving hospice or palliative care. In Dignity Therapy, patients create a formalized “legacy” document that records their most cherished memories, their lessons learned in life, as well as their hopes and dreams for loved ones in the future. To date, this treatment has been studied for its impact on mitigating distress within hospice and palliative care populations and has provided mixed results. This study will instead focus on whether Dignity Therapy enhances positive outcomes in this population.Methods/DesignIn this study, 90 patients with cancer receiving hospice or palliative care will complete a mixed-methods randomized controlled trial of Dignity Therapy (n = 45) versus Supportive Attention (n = 45). The patients will be enrolled in the study for 3 weeks, receiving a total of six study visits. The primary outcomes examine whether the treatment will quantitatively increase levels of positive affect and a sense of life closure. Secondary outcomes focus on gratitude, hope, life satisfaction, meaning in life, resilience, and self-efficacy. Using a fixed, embedded dataset design, this study will additionally use qualitative interviews to explore patients’ perceptions regarding the use of positive outcome measures and whether these outcomes are appropriately matched to their experiences in therapy.DiscussionDignity Therapy has shown mixed results when evaluating its impact on distress, although no other study to date has solely focused on the potential positive aspects of this treatment. This study is novel in its use of mixed methods assessments to focus on positive outcomes, and will provide valuable information about patients’ direct experiences in this area.Trial registrationISRCTN91389194