Characterizing death acceptance among patients with cancer

Reappraising personal values in cancer: Meaning-in-life adaptation, meaningfulness, and quality of life

OBJECTIVE

This study explores the reappraisal of personal values among people with cancer post-diagnosis and its connections to meaningfulness, encompassing personal meaning and sense of meaning, and various dimensions of quality of life.

METHODS

A total of 144 patients with diverse cancer types and a control group comprising 158 healthy adults with similar demographic characteristics completed the Valued Living Questionnaire-Perceived Change, the Personal Meaning Profile-Brief, the Portrait Values Questionnaire, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being.

RESULTS

Cancer patients displayed a substantial values reappraisal compared to healthy adults. They reported an increased significance of social areas and self-transcendental values, including close relationships (family, partner, and friends), spirituality, citizenship, and universalism, as well as an increased importance of self-care and self in general. Conversely, cancer patients assigned less importance to work and self-enhancement values such as stimulation, power, and achievement. Cluster analysis revealed that patients who reappraised their values exhibited higher meaningfulness and better indicators of quality of life, including spiritual and physical well-being, compared to patients who did not modify their value system.

CONCLUSIONS

These findings underscore the importance of assessing and promoting meaning-in-life adaptability among people with cancer, with potential applications in meaning-centered therapies and interventions aimed at enhancing psychological flexibility.

Developing a supportive and palliative care intervention for patients with allogeneic stem cell transplantation: protocol of a multicentre mixed-methods study (allo-PaS)

INTRODUCTION

Although allogeneic stem cell transplantation (allo-SCT) is a curative treatment for many haematological malignancies, it is often associated with a high morbidity and mortality. Yet, little is known about the needs for supportive and palliative care among allo-SCT recipients. Moreover, targeted interventions that reduce symptom burden and suffering are still lacking. The present study aims to inform a supportive-palliative care intervention for patients with allo-SCT and their informal carers by exploring their experience and assessing their needs, especially their existential concerns, regarding four research topics: symptom burden and quality of life; coexistence of a chance for cure and a relevant risk of dying; change in goals of care; dying phase.

METHODS AND ANALYSIS

This is a descriptive mixed-methods study in progress with a convergent parallel design. Data on the four research topics will be collected and analysed separately in three steps: (1) qualitative semi-structured interviews among 20 patients, 20 informal carers and 12 healthcare providers (HCPs) and focus groups among 12-24 HCPs; (2) a quantitative cross-sectional survey with validated questionnaires and self-developed questions among 100 patients, 100 informal carers and 50 HCPs; (3) a retrospective case analysis of all deceased patients who underwent an allo-SCT between 2010 and 2019, with collection of quantitative and qualitative data. The qualitative and quantitative data sets will be finally merged for comparison and interpretation. Results will serve to develop a supportive-palliative care intervention.

ETHICS AND DISSEMINATION

The Ethics Commission of the Faculty of Medicine of the University of Cologne approved this study (20-1370_2). The study results will be published in peer-review journals, be presented at congresses and will be translated into clinical practice through the development of the palliative-supportive care intervention.

TRIAL REGISTRATION NUMBER

DRKS00027290 (German Clinical Trials Register).

Loneliness, spiritual well-being, and death perception, as well as their risk factors in urological cancer patients

Cancer patients commonly suffer from loneliness, poor spiritual status, and fear of death; however, these evaluations are rarely revealed in urological cancer patients. Thus, this study aimed to assess the loneliness, spiritual well-being, and death perception, as well as their risk factors in urological cancer patients. A total of 324 urological (including renal, bladder, and prostate) cancer patients and 100 healthy controls were included. The University of California and Los Angeles loneliness scale (UCLA-LS), functional assessment of chronic illness therapy-spiritual well-being (FACIT-Sp), and death attitude profile-revised (DAP-R) scores were evaluated. The results showed that the UCLA-LS score was higher, but the FACIT-Sp score was lower in urological cancer patients than in healthy controls. According to the DAP-R score, fear of death, death avoidance, and approaching death acceptance were elevated, but neutral acceptance was lower in urological cancer patients than in healthy controls. Among urological cancer patients, the UCLA-LS score was highest but the FACIT-Sp score was lowest in bladder cancer patients; regarding the DAP-R score, fear of death and death avoidance were highest, but approaching death acceptance was lowest in bladder cancer patients. Interestingly, single/divorced/widowed status, bladder cancer diagnosis, higher pathological grade, surgery, systemic treatment, and local treatment were independent factors for higher UCLA-LS score or lower FACIT-Sp score. In conclusion, urological cancer (especially bladder cancer) patients bear increased loneliness and reduced spiritual well-being; they also carry higher fear of death, death avoidance, and approaching death acceptance but lower neutral acceptance of death.

Psychometric Properties of the Serbian Version of the Death Attitudes Profile- Revised (DAP-R) Instrument

The Death Attitude Profile-Revised (DAP-R), one of the most widely used scales for assessing death attitudes is a multidimensional questionnaire capable of measuring a wide range of attitudes towards death. The aim of our study was to assess the reliability and validity of the Serbian version of the DAP-R. The study was conducted in October 2022 and included a total of 547 students of the Faculty of Medicine University of Belgrade (FMUB). Based on Cronbach's alpha coefficient values, our data show good reliability of the DAP-RSp (Serbian version). In our study, the confirmatory factor analysis showed a good fit of the data to the original factor structure with minor discrepancy; compared to the original version (five factors), our analysis yielded one more factor (six factors in total), however, almost all items had factor loading >0.3 on the appropriate scale.

Factors associated with cancer patients' distinct death-preparedness states

BACKGROUND/OBJECTIVE

Facilitating death preparedness is important for improving cancer patients' quality of death and dying. We aimed to identify factors associated with the four death-preparedness states (no-preparedness, cognitive-only, emotional-only, and sufficient-preparedness) focusing on modifiable factors.

METHODS

In this cohort study, we identified factors associated with 314 Taiwanese cancer patients' death-preparedness states from time-invariant socio-demographics and lagged time-varying modifiable variables, including disease burden, physician prognostic disclosure, patient-family communication on end-of-life (EOL) issues, and perceived social support using hierarchical generalized linear modeling.

RESULTS

Patients who were male, older, without financial hardship to make ends meet, and suffered lower symptom distress were more likely to be in the emotional-only and sufficient-preparedness states than the no-death-preparedness-state. Younger age (adjusted odds ratio [95% confidence interval] = 0.95 [0.91, 0.99] per year increase in age) and greater functional dependency (1.05 [1.00, 1.11]) were associated with being in the cognitive-only state. Physician prognostic disclosure increased the likelihood of being in the cognitive-only (51.51 [14.01, 189.36]) and sufficient-preparedness (47.42 [10.93, 205.79]) states, whereas higher patient-family communication on EOL issues reduced likelihood for the emotional-only state (0.38 [0.21, 0.69]). Higher perceived social support reduced the likelihood of cognitive-only (0.94 [0.91, 0.98]) but increased the chance of emotional-only (1.09 [1.05, 1.14]) state membership.

CONCLUSIONS

Death-preparedness states are associated with patients' socio-demographics, disease burden, physician prognostic disclosure, patient-family communication on EOL issues, and perceived social support. Providing accurate prognostic disclosure, adequately managing symptom distress, supporting those with higher functional dependence, promoting empathetic patient-family communication on EOL issues, and enhancing perceived social support may facilitate death preparedness.

Clinical utility of demoralization: A systematic review of the literature

Demoralization is a complex clinical phenomenon which has raised a growing interest in clinical and research realms. The present systematic review of the literature aimed at (1) updating on demoralization prevalence in different populations, (2) identifying the instruments more largely used to assess demoralization, and (3) verifying whether new tools of assessment have been proposed. PubMed and Web of Science were searched from inception to April 2022. Search terms were: demoralization/demoralized/demoralizing/demoralised/demoralising. PRISMA guidelines were followed. GRADE rating system was used. A total of 188 papers were included. Demoralization appeared to be a distinctive psychological state common in medical, psychiatric, and non-clinical settings, thus not limited to life-threatening diseases. Diagnostic Criteria for Psychosomatic Research (DCPR) and Demoralization Scale (DS) are the most commonly used tools to assess it. DCPR allow to diagnose demoralization as a manifestation of dealing with chronic stress. DS captures dimensionally a psychological distress related to end of life. Demoralization is associated with clinical features encompassing allostatic overload, quality of life, wellbeing/euthymia. Implications on health outcomes and treatment are discussed. Demoralization warrants careful consideration in clinical contexts through valid assessment procedures. DCPR are recommended to diagnose it, DS can be helpful to capture clinical details.

Understanding factors influencing demoralization among cancer patients based on the bio-psycho-social model: A systematic review

OBJECTIVE

Demoralization is a prevalent psychological problem among cancer patients and reflects a sense of subjective incompetence. This systematic review aims to identify factors influencing demoralization among cancer patients.

METHODS

Eleven databases were systematically searched from database inception to 31 December 2020. Google Scholar and relevant reference lists were supplementarily searched. Studies reporting demoralization measured by Demoralization Scale and its influencing factors among cancer patients were included. A qualitative synthesis was conducted owing to the heterogeneity of the study outcome.

RESULTS

A total of 49 studies involving 10,712 participants were included in this review. The results showed substantial effect size variation, but the psychological factors showed the strongest magnitude of association. Among the biological factors, the number of physical symptoms (mean r values [rs]: 0.331) was associated with increased demoralization. Among the psychological factors, negative psychological factors include hopelessness (mean rs: 0.633), desire for death (mean rs: 0.620), dignity-related distress (mean rs: 0.595), depression (mean rs: 0.593), anxiety (mean rs: 0.589), psychological distress (mean rs: 0.465), and suicidal ideation (mean rs: 0.460) were related to increased demoralization; whereas positive psychological factors including hope (mean rs: -0.565), attachment security (mean rs: -0.530), and sense of coherence (mean rs: -0.453) were related to decreased demoralization. Among the social factors, social support (mean rs: -0.330) was negatively related to demoralization, and the demographic factors were still controversial. Quality of life was considered to be at the intersection of biopsychosocial factors and negatively associated with demoralization (mean rs: -0.599).

CONCLUSIONS

Demoralization is a consequence of the interaction of physical, psychological, and social factors among cancer patients. Factors with a significant effect should not be overlooked when designing an intervention to reduce demoralization. It is necessary to distinguish demoralization from other negative psychological states and further explore positive psychological factors influencing demoralization among cancer patients.

Spanish Version of the Death Attitude Profile-Revised. Translation and Validation Into Spanish

The Death Attitude Profile-Revised (DAP-R) was developed in English-speaking cultures with the aim of measuring attitudes towards death. This measure consists of 32 items, grouped into five factors (Fear of Death, Avoidance of Death, Neutral Acceptance, Approach Acceptance, and Escape Acceptance). The DAP-R was translated and adapted to Spanish (DAP-RSp), and the psychometric properties were analyzed accross a general sample. The face validity was evaluated by 20 experts in palliative care. N = 417 (X = 39.06 years) took part in the validation. DAP-RSp showed adequate internal consistency (Cronbach's alpha ranging from 0.67 for Neutral Acceptance to 0.95 for Escape a Acceptance, and 0.88 for the total), a multitrait scaling analysis and a confirmatory factor analysis reproduced the five dimensions of the original scale. The Spanish version of the DAP-R can be used as a valid scale to assess attitudes towards death in Spanish speaking population.

Describing Death Acceptance Among Thai Buddhists With Cancer

INTRODUCTION

Death acceptance (DA) is perceived in culturally specific ways. The purposes of this study were to describe DA among Thai Buddhists with cancer and to compare DA differences in demographic data.

METHODOLOGY

This research was a secondary data analysis. The participants were 363 Thai Buddhists with cancer, recruited using multistage sampling method. Data were collected using the Buddhist Death Acceptance Scale, reliability coefficient. .82. Data were analyzed using T-Tests and Two-Way ANOVA.

RESULTS

The participants had high levels of DA. Age and stage of cancer had main effects on DA.

DISCUSSION

This study highlighted the significant demographic differences with regard to DA levels among Thai Buddhists with cancer. Interventions include determining the patient's DA level, or offering patients and their families advance care plans. Nurses can then explore DA with patients, particularly those with life-limiting illnesses to ease their patients' lives and foster a good death.

Existential Insights in Cancer: Meaning in Life Adaptability

Previous research demonstrated that the cancer diagnosis and treatment evoke existential concerns, especially ones related to meaning in life and meaning-making processes. The cancer experience is a vital challenge that often entails changes in what is personally important in life. Firstly, this paper collects evidence supporting that meaning adaptability, the way people adapt their meaning in life to the cancer experience, is a central element in the mental health of cancer patients. Various theories that could account for this meaning adaptability are introduced. Secondly, the paper provides a compilation of studies showing how people change what is significant in their lives within the course of cancer. Finally, the paper presents the available psychological therapies directed to facilitate meaning adaptability in this population. Meaning-centered interventions have been demonstrated to be effective in alleviating the suffering related to the cancer experience and promoting personal growth.

Death Acceptance Process in Thai Buddhist Patients With Life-Limiting Cancer: A Grounded Theory

Cancer patients with life-limiting illnesses have varied levels of death acceptance pervarious scales. Nevertheless, the process of developing death acceptance in patients with life-limiting cancer remains unclear. This study explores the death acceptance process among patients with life-limiting cancer. We used grounded theory methodology. Data were collected through in-depth interviews of 13 patients with cancer in a palliative care setting, and researchers completed field notes. Data were analyzed using constant and comparative methods. Thai Buddhist patients with cancer in palliative care process death acceptance through three dynamic phases: engaging suffering, being open-minded about death, and adhering to Buddhist practices for increasing death consciousness. The death acceptance process described in this study could serve as a guideline to support death acceptance in Thai Buddhist patients with cancer, and other patients with cancer in palliative care, to improve peaceful life and attain good death.

Matters of Life and Death: An Experimental Study Investigating Psychological Interventions to Encourage the Readiness for End-of-Life Conversations

INTRODUCTION

Talking about death and dying is evoking discomfort in many persons, resulting in avoidance of this topic. However, end-of-life discussions can alleviate distress and uncertainties in both old and young adults, but only a minority uses this option in palliative care. Even in healthy populations, talking about death is often seen as alleviative and worthwhile, but rarely initiated.

OBJECTIVE

To investigate different psychological interventions (a) encouraging the readiness for end-of-life discussions and (b) changing death attitudes in healthy adults of different ages.

METHODS

168 participants were randomized to four different interventions (IG1: value-based intervention with end-of-life perspective, IG2: motivation-based intervention with end-of-life perspective, IG3: combination of IG1 and IG2, CG: control group). Primary outcome was the readiness to engage in end-of-life topics. Secondary outcomes were fear of death, fear of dying and death acceptance. Assessments took place before, directly after the intervention and at 2 weeks of follow up.

RESULTS

IG2 and IG3 reported significantly more changes in the readiness to engage in end-of-life discussions than the CG (F[5.61, 307] = 4.83, p < 0.001, ηp2 = 0.081) directly after the intervention. The effect of IG3 remained stable at the follow-up. There were no significant effects of the interventions on end-of-life fears or death acceptance. Acceptability of the interventions was very high.

CONCLUSIONS

Short interventions can be useful to encourage end-of-life discussions and could be integrated in health care programs. The efficacy and effectiveness of these short interventions in palliative patients are currently examined.

Pathways to Acceptance in Participants of Advanced Cancer Online Support Groups

Background and Objectives: Individuals with cancer, especially advanced cancer, are faced with numerous difficulties associated with the disease, including an earlier death than expected. Those who are able to confront and accept the hardships associated with the disease in a way that aligns with their beliefs benefit from more positive psychological outcomes compared to those who are aware of their diagnosis but are unable to accept it. To date, there is limited research exploring factors contributing to illness and death acceptance in the context of advanced cancer in group therapy settings. Materials and Methods: The current study used a Directed Content Analysis approach on transcripts of online advanced cancer support groups to investigate if and how Yalom’s existential factors played a role in the emergence of acceptance. Results: The online support group platform, combined with the help of facilitators, offered supportive environments for individuals seeking help with cancer-related distress by helping patients move towards acceptance. Some participants had already begun the process of accepting their diagnosis before joining the group, others developed acceptance during the group process, while a few continued to be distressed. Our analysis revealed the emergence of four themes related to illness acceptance: (1) Facilitator-Initiated Discussion, including sub-themes of Mindfulness, Relaxation and Imagery, Changing Ways of Thinking, and Spirituality; (2) Personal attitudes, including sub-themes of Optimism and Letting Go of Control; (3) Supportive Environment, including the sub-themes of Providing Support to Others and Receiving Support from Others; and (4) Existential Experience, which included sub-themes of Living with the Diagnosis for an Extended Amount of Time, Legacy and Death Preparations, and Appreciating life. Conclusions: With a paradigm shift to online delivery of psychological services, recognizing factors that contribute to acceptance when dealing with advanced cancer may help inform clinical practices. Future studies should explore patient acceptance longitudinally to inform whether it emerges progressively, which has been suggested by Kübler-Ross.

Paediatric oncology ward nurses' experiences of patients' deaths in China: A qualitative study

BACKGROUND

Considering cancer death is second only to accidental death in the number of lives claimed each year,nurses in paediatric oncology wards often experience helplessness, sadness, frustration and such other adverse emotions when they witness children's death due to cancer.However,there is a lack of qualitative studies on nurses who witness the death of children in paediatric oncology wards in China.

METHOD

A qualitative study was conducted using a semi-structured interview guide with 22 paediatric oncology ward nurses. Interviews were recorded and simultaneously translated and transcribed. Thematic analysis was used to analyse the data.

RESULTS

The analysis resulted in the identification of three main thematic categories: Different emotional expression, Different copingstrategies, A weak support system. Nursing managers should pay attention to problems faced by nurses in paediatric oncology wards, and take targeted measures in terms of continuing training courses, improving the psychological adaptability of oncology professional nurses, and providing them substantive support.

CONCLUSION

Nurses in paediatric oncology wards have strong stress responses to facing the death of children. They reported experiencing complex psychological feelings and have different coping attitudes. Healthcare authorities should recognise and understand the needs of paediatric oncology ward nurses, who often witness the death of children. Appropriate and effective support measures should be planned and implemented for these nurses to maintain their mental health, thus enabling them to better serve patients.

Caregiver bereavement outcomes in advanced cancer: associations with quality of death and patient age

Purpose

We investigated relationships between domains of quality of dying and death in patients with advanced cancer and their caregivers’ bereavement outcomes and the moderating effect of patient age at death.

Methods

Bereaved caregivers of deceased patients with advanced cancer who had participated in an early palliative care trial completed measures of grief (Texas Revised Inventory of Grief [TRIG]), complicated grief (Prolonged Grief Inventory [PG-13]), and depression (Center for Epidemiologic Studies-Depression [CESD-10]). They also completed the Quality of Dying and Death measure (QODD), which assesses patients’ symptom control, preparation for death, connectedness with loved ones, and sense of peace with death.

Results

A total of 157 bereaved caregivers completed the study. When patient age × QODD subscale interactions were included, greater death preparation was related to less grief at patient death (past TRIG: β =  − .25, p = .04), less current grief (present TRIG: β =  − .26, p = .03), less complicated grief (PG-13: β =  − .37, p = .001), and less depression (CESD-10: β =  − .35, p = .005). Greater symptom control was related to less current grief (present TRIG: β =  − .27, p = .02), less complicated grief (PG-13: β =  − .24, p = .03), and less depression (CESD-10: β =  − .29, p = .01). Significant patient age × connectedness interaction effects for current grief (present TRIG: β = .30, p = .02) and complicated grief (PG-13: β = .29, p = .007) indicated that, with less connectedness, younger patient age at death was associated with greater caregiver grief.

Conclusion

Better end-of-life death preparation and symptom control for patients with cancer may attenuate later caregiver grief and depression. Less connectedness between younger patients and their families may adversely affect caregiver grief.

Exploring the needs and experiences of palliative home care from the perspectives of patients with advanced cancer in China: a qualitative study

PURPOSE

The needs and experiences of palliative home care for patients with advanced cancer have received little research attention. We aimed to explore the needs and experiences of palliative home care among patients with advanced cancer in China.

METHODS

This qualitative study was conducted using semi-structured interviews with patients with advanced cancer. Participants (n = 15) were recruited from an oncology palliative care unit and a hospice outpatient unit, and were selected using purposive sampling from October 2019 to March 2020. Interviews were audio-recorded, transcribed verbatim, and subjected to thematic analysis. Two researchers coded the interviews independently in NVivo 12 and developed major themes and subthemes by inductive and constant comparison.

RESULTS

Five themes were identified: (1) physical need; (2) psychological experience; (3) spiritual need; (4) social need; and (5) information need. Patients need to manage their symptoms (especially cancer pain), prolong life as long as possible, reconstruct their attitudes to adapt to their roles, be socially supported, be respected, maintain spiritual peace, and obtain more information about illness and home care.

CONCLUSIONS

The current palliative home care services are imperfect, and patients face substantial challenges, including physical symptoms, psychological/spiritual distress, and inadequate social support and information. Our findings may provide evidence and a reference for the development of palliative home care in China.

Psychosocial stress of dermatology inpatients and their relatives - Comparison of patients with and without cancer

BACKGROUND

In the clinical treatment pathways of certified oncological centers, psychotherapeutic services are mandatory. Although patients with somatic, non-oncological illnesses show an equally high prevalence of psychosocial stress, these guidelines do not exist for the general hospital sector. Are these patients really less burdened and is psychological support only needed in individual cases? The example of dermatological patients will be used to show whether the need for psychosocial care and the desire for support vary between individuals with and without malignant disease.

PATIENTS AND METHODS

Using the Hornheider screening instrument and distress thermometer, 216 dermatological inpatients assessed their psychosocial stress and that of a close relative. In addition, they were asked about their desire for support and preferred support provider.

RESULTS

i) Patients without skin cancer were more frequently and more severely distressed than cancer patients. ii) Patients of both groups assessed their relatives to be approximately equally distressed. Compared with their own distress, cancer patients assessed their relatives as more frequently and on average more severely distressed. More than 50 % of all patients regarded their own disease as the cause of their relatives' distress. iii) The desire for support in both groups was about 18 %. iv) Doctors and psychologists were usually named as potential contact persons.

CONCLUSIONS

The expansion of psychosocial support services for non-tumor patients and their relatives seems necessary. The establishment of appropriate screening methods should be considered. Further studies in other clinical areas are required.

Expression of resilience, coping and quality of life in people with cancer

Considering the importance of coping strategies and resilience in adapting to the stress caused by cancer, the objective of this research is to explore which coping strategies are the most used, in order to know whether different groups of levels of resilience and an appropriate coping style are related to a higher quality of life and better adaptation to the disease. There were 74 participants with cancer in this study (79.7% of them were women) ranging in age from 29 to 85 years (M = 50.9). Different instruments were used to measure the resilience construct (ER-20 items Resilience Scale), coping strategies (Cognitive Emotion Regulation Questionnaire-Short) and quality of life (General Health Questionnaire). People with higher resilience showed higher scores in the use of adaptive strategies, being acceptance and positive revaluation the most frequent ones. Regarding perception of quality of life, people with lower resilience showed statistically significant differences in the dimensions of pain and general health, which were likewise the most common ones for people with lower resilience. A significant association has been demonstrated between resilience and an adaptive coping, which at the same time are positively linked to quality of life of people with cancer. This study provides information about how different groups of resilience levels are related with coping and quality of life in people with cancer. It could be useful information for psychologists in the oncological area who have to take decisions in the clinical context. A practical consequence would involve trying to modify the type of coping, as well as increasing the level of resilience in people with cancer, in order to achieve a better adjustment to the disease.