Thomas Hassard

Dignity Therapy: A Novel Psychotherapeutic Intervention for Patients Near the End of Life

PURPOSE This study examined a novel intervention, dignity therapy, designed to address psychosocial and existential distress among terminally ill patients. Dignity therapy invites patients to discuss issues that matter most or that they would most want remembered. Sessions are transcribed and edited, with a returned final version that they can bequeath to a friend or family member. The objective of this study was to establish the feasibility of dignity therapy and determine its impact on various measures of psychosocial and existential distress. PATIENTS AND METHODS Terminally ill inpatients and those receiving home-based palliative care services in Winnipeg, Canada, and Perth, Australia, were asked to complete pre- and post-intervention measures of sense of dignity, depression, suffering, and hopelessness; sense of purpose, sense of meaning, desire for death, will to live, and suicidality; and a post-intervention satisfaction survey. RESULTS Ninety-one percent of participants reported being satisfied with dignity therapy; 76% reported a heightened sense of dignity; 68% reported an increased sense of purpose; 67% reported a heightened sense of meaning; 47% reported an increased will to live; and 81% reported that it had been or would be of help to their family. Post-intervention measures of suffering showed significant improvement (P = .023) and reduced depressive symptoms (P = .05). Finding dignity therapy helpful to their family correlated with life feeling more meaningful (r = 0.480; P = .000) and having a sense of purpose (r = 0.562; P = .000), accompanied by a lessened sense of suffering (r = 0.327; P = .001) and increased will to live (r = 0.387; P = .000). CONCLUSION Dignity therapy shows promise as a novel therapeutic intervention for suffering and distress at the end of life.

Dignity in the terminally ill: a cross-sectional, cohort study

BACKGROUND Considerations of dignity are often raised in reference to the care of dying patients. However, little research that addresses this issue has been done. Our aim was to identify the extent to which dying patients perceive they are able to maintain a sense of dignity, and to ascertain how demographic and disease-specific variables relate to the issue of dignity in these individuals. METHODS We did a cross-sectional study of a cohort of terminally ill patients with cancer, who had a life expectancy of less than 6 months. We enrolled 213 patients from two palliative care units in Winnipeg, Canada, and asked them to rate their sense of dignity. Our main outcome measures included: a 7-point sense of dignity item; the symptom distress scale; the McGill pain questionnaire; the index of independence in activities of daily living (IADL); a quality of life scale; a brief battery of self-report measures, including screening for desire for death, anxiety, hopelessness, and will to live; burden to others; and requirement for social support. FINDINGS 16 of 213 patients (7.5%; 95% CI 4-11) indicated that loss of dignity was a great concern. These patients were far more than likely than the rest of the cohort to report psychological distress and symptom distress, heightened dependency needs, and loss of will to live. INTERPRETATION Loss of dignity is closely associated with certain types of distress often seen among the terminally ill. Preservation of dignity should be an overall aim of treatment and care in patients who are nearing death.

The Patient Dignity Inventory: A Novel Way of Measuring Dignity-Related Distress in Palliative Care

Quality palliative care depends on a deep understanding of distress facing patients nearing death. Yet, many aspects of psychosocial, existential and spiritual distress are often overlooked. The aim of this study was to test a novel psychometric--the Patient Dignity Inventory (PDI)--designed to measure various sources of dignity-related distress among patients nearing the end of life. Using standard instrument development techniques, this study examined the face validity, internal consistency, test-retest reliability, factor structure and concurrent validity of the PDI. The 25-items of the PDI derive from a model of dignity in the terminally ill. To establish its basic psychometric properties, the PDI was administered to 253 patients receiving palliative care, along with other measures addressing issues identified within the Dignity Model in the Terminally Ill. Cronbachs coefficient alpha for the PDI was 0.93; the test-retest reliability was r = 0.85. Factor analysis resulted in a five-factor solution; factor labels include Symptom Distress, Existential Distress, Dependency, Peace of Mind, and Social Support, accounting for 58% of the overall variance. Evidence for concurrent validity was reported by way of significant associations between PDI factors and concurrent measures of distress. The PDI is a valid and reliable new instrument, which could assist clinicians to routinely detect end-of-life dignity-related distress. Identifying these sources of distress is a critical step toward understanding human suffering and should help clinicians deliver quality, dignity-conserving end-of-life care.

Information and patient participation in screening for prostate cancer

The purpose of this study was to determine if providing men with information about screening for prostate cancer would enable them to assume a more active role in decision making with their family physician, and lower levels of anxiety and decisional conflict. Men were recruited from one family medical clinic in Winnipeg, Manitoba. One hundred men scheduled for a periodic health examination (PHE) were randomly assigned to receive verbal and written information either prior to the PHE, or following the second interview. Men completed measures of preferred decisional role and anxiety prior to the PHE; and assumed decisional role, decisional conflict, and anxiety post PHE. Results demonstrated that men who received the information prior to the PHE assumed a significantly more active role in making a screening decision, and had lower levels of decisional conflict post PHE. The two groups did not differ with regard to levels of state anxiety. Providing men with information enables them to make informed screening decisions with their family physicians.

Learning from dying patients during their final days: life reflections gleaned from dignity therapy

Dignity therapy is a novel therapeutic approach designed to decrease suffering, enhance quality of life and bolster a sense of dignity for patients approaching death. The benefits of dignity therapy were previously documented in a sample of 100 terminally ill patients. One of the products of dignity therapy is a transcript of the edited therapy session(s). In this qualitative study, 50 of the 100 (17 from Winnipeg, Manitoba, Canada, and 33 from Perth, Australia) dignity therapy transcripts were randomly drawn, and independently coded and analysed by three investigators using a grounded theory approach. The transcripts revealed that dignity therapy serves to provide a safe, therapeutic environment for patients to review the most meaningful aspects of their lives in such a manner that their core values become apparent. The most common values expressed by the patients included ‘Family’, ‘Pleasure’, ‘Caring’, ‘A Sense of Accomplishment’, ‘True Friendship’, and ‘Rich Experience’. Exemplars of each of these values illustrate the pervasive, defining role of values in our lives. The findings are discussed in terms of values theory, the role of dignity therapy, and consideration of values clarification in clinicians’ efforts to enhance the dignity of terminally ill patients.

A comparison of thyroxine- and polyamine-mediated enhancement of rat facial nerve regeneration

Thyroid hormones and spermidine, a motor neuron trophic polyamine (PA), have been shown to enhance peripheral motor nerve regeneration; however, the mechanism by which these treatment modalities exert their effect is unknown. Similarities in treatment outcome suggest that these molecules may be working via a common mechanism. Such an explanation is plausible since thyroid hormone is a potent inducer of ornithine decarboxylase (ODC), which is the rate-limiting enzyme involved in polyamine synthesis. This study was designed to morphologically evaluate the effects of exogenous thyroxine and spermidine on the regeneration of the rat facial nerve. Myelinated fiber density, axonal size, and degree of myelination were assayed by light and electron microscopy 21 days following facial nerve crush. Strikingly, the two treatment modalities had identical effects on all parameters tested. Each significantly enhanced the density of myelinated axons in regenerating nerves relative to the vehicle control. In addition, relative to the control treatment, both thyroxine and spermidine significantly increased the cross-sectional area of regenerating axons (P < 0.05). Interestingly, neither of the drug treatments had any effect on remyelination at the position where this parameter was analyzed. The concurrent administration of both thyroxine and spermidine did not synergistically enhance motor neuron regeneration. These data support the hypothesis that thyroxine and spermidine enhance neural regeneration by a common mechanism.

The fibromyalgia bladder index

The aim of this study was to determine whether an existing outcome measure, the Interstitial Cystitis Symptom and Problem Index (ICSI/ICPI), is a valid, reliable, and clinically relevant instrument to assess the sensory urinary symptoms in women with fibromyalgia syndrome (FM). Ninety women with American College of Rheumatology 90 FM and who had at least two sensory bladder symptoms participated in the study. All underwent urological screening to exclude lower urinary tract pathology. All participants completed the following: ICSI/ICPI, Fibromyalgia Impact Questionnaire (FIQ), Medical Outcome Study Short Form 36, King’s Health Questionnaire (KHQ), and Vulval Symptom Assessment Scale. Assessment was made for internal consistency reliability, test–retest reliability, and concurrent validity. Factor analysis was used to assess the internal structure of the scale. Factor analysis displayed two separate components of symptom and problem combinations as distinct from the original ICSI/ICPI developed for the interstitial cystitis population. The eight items of the index configured differently and formed two subscales of a newly developed Fibromyalgia Bladder Index. The two subscales of this index include the Bladder Urgency and Pain Subscale and the Bladder Frequency and Nocturia Subscale. This index has high internal consistency reliability (Cronbach’s α coefficient of 0.81), test–retest reliability showing intraclass correlation of 0.85, and high concurrent validity through correlations between the Fibromyalgia Bladder Index and the KHQ (0.735, p = 0.000) and the FIQ (0.433, p = 0.000). This more specific configuration of the ICSI/ICPI better reflects FM bladder symptomatology. The Fibromyalgia Bladder Index is a validated FM-specific instrument that captures information about the sensory bladder symptoms and their impact in this fibromyalgia population. This instrument should allow for better understanding and management of this important fibromyalgia-associated problem.

Clinical Modalities for the Diagnosis, Characterization and Detection of Bone Metastases

Breast cancer is a leading cause of death in women, occurring in one of eight during their lifetime. A comparable cancer in men, prostate cancer, claims the lives of just under 30,000 men in the United States each year with a prevalence of one in six (1). These tumors, along with carcinomas of the lung, thyroid, and kidney have a high propensity to metastasize to bone, which constitutes one of their most serious complications, creates a great challenge for treatment, and often carries a poor prognosis. Metastases are the most frequent bone tumors and cause significant morbidity due to pain, osteolysis, pathological fractures, hypercalcemia, and anemia (2). Established bone metastases are resistant to treatment and current therapeutic approaches such as endocrine therapy, radiation therapy, and chemotherapy are often ineffective (3). This chapter has been written on the premise that a better understanding of the pathophysiology of bone metastasis may provide insight into the design of diagnostic techniques that would help to identify bone metastasis formation at its earliest stages. This may provide an opportunity for early treatment and alleviate the necessity to treat them at a late stage.