Demoralization and spirituality in oncology: an integrative systematic review

Demoralization: A concept analysis through a scoping review methodology

Background

Demoralization is a complex construct comprising of several clinical phenomena that has gained increasing interest in clinical practice and research; however, the concept needs to be sufficiently specified and clearly described. A concept analysis of demoralization is necessary to integrate previous research findings and establish the scientific foundation for future intervention research.

Aim

To analyze the concept of demoralization in terms of its antecedents, attributes, consequences, and empirical referents in health.

Methods

A concept analysis was performed using the Joanna Briggs Institute guidelines scoping review method and mapping information through the Walker and Avant concept analysis framework. Electronic databases, including PubMed, The Cochrane Library, Embase, PsycINFO, and Web of Science, were searched until September 15, 2024. The grey literature and other minor non-indexed publications were also reviewed.

Results

A total of 106 articles were included in the review. Antecedents included medical illness, symptom burden, low social support and coping difficulties. Attributes were identified as follows: dysphoria, disheartenment, helplessness, hopelessness, loss of meaning and purpose, and sense of failure. Consequences included poor quality of life, depression, anxiety, suicidal ideation and desire to die. The concept of demoralization was illustrated through a model case, one exhibiting borderline criterion and another displaying challenge.

Conclusion

This scoping review clarifies the clinical definition of demoralization, distinguishing it from common language usage and from other emotional symptoms frequently experienced by patients.

Implications for Practice

The identified attributes of demoralization play vital roles in health assessments and should guide nurses in providing appropriate patient care early on. Interventions should address the concept's antecedents and consequences.

Physical symptoms distress and demoralization among haemodialysis patients; the mediating effect of spirituality and self-compassion. A cross-sectional questionnaire survey

Background

Long-term haemodialysis patients often experience physical symptom distress (PSD) and varying levels of demoralization. Spirituality and self-compassion can help patients to cope these challenges. However, the interrelations between these variables remain underexplored, necessitating further investigation.

Objectives

To examine the effect of PSD on demoralization among haemodialysis patients and to determine whether spirituality and self-compassion mediate these relationships.

Design

A cross-sectional correlational study.

Settings

A convenience sample was used to recruit from two haemodialysis clinics.

Methods

Self-report questionnaires were the Physical Symptom Distress Scale, Demoralization Scale, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale-12, and Self-Compassion Scale. Relationships and mediators were examined with Pearson's correlations and multiple linear regression analysis, respectively.

Results

A total of 156 participants participated. Mean age of participants was 61.3 years (SD = 11.3). Most participants were male (66 %) and had received dialysis for ≥ 5 years (61.5 %). Pearson's correlation indicated higher scores for PSD were significantly associated with lower levels of spirituality and self-compassion and higher levels of demoralization. There was a significant total and direct effect of PSD on demoralization. Mediation analysis indicated that the relationship between PSD and demoralization was partially and significantly mediated by spirituality and self-compassion. Demoralization can be explained by 46.83 % variance accounted by these predictors in the mediation model.

Conclusion

Long-term haemodialysis can cause chronic symptom distress and feelings of demoralization. The mediating effects of spirituality and self-compassion on PSD and demoralization suggest that these qualities may act as emotional regulators that enable haemodialysis patients to be more accepting of symptom distress, which results in lower levels of demoralization. Our findings imply that developing strategies to increase spirituality and self-compassion could help patients manage chronic symptom distress associated with haemodialysis, reduce demoralization, and ultimately improve their quality of life.

Experiences of participating in a preoperative comprehensive geriatric assessment and care intervention among frail older adults before colorectal cancer resection surgery

BACKGROUND

Comprehensive geriatric assessment (CGA) and care has shown benefits for frail older adults across various care settings. However, its integration into routine care within a surgical context remains limited. An ongoing randomised controlled multicentre study will evaluate the effects of a period of preoperative optimisation (up to eight weeks), involving interprofessional CGA and care, in addition to routine care before colorectal cancer resection surgery. If this approach proves favourable, it could potentially be incorporated into routine surgical care. To facilitate implementation, it is crucial to explore and understand participants' perceptions of taking part in a preoperative CGA and care intervention.

AIM

To describe how frail older adults with colorectal cancer experience participation in a preoperative CGA and care intervention.

METHODS

This qualitative, descriptive study was part of a randomised controlled multi-centre study. In total, 20 semi-structured interviews were conducted with frail older adults undergoing a CGA and care intervention before colorectal cancer surgery. The data were analysed using inductive qualitative content analysis.

RESULTS

Frail older adults with colorectal cancer experienced participation in preoperative CGA and care as an integral part of an intervention. They adopted an opportunity mindset when deciding to participate. Throughout the intervention, they observed the team working collaboratively and actively involving them in the optimisation process, enhancing their readiness for surgery by the end of the period.

CONCLUSIONS

The findings indicated that frail older adults with colorectal cancer viewed the preoperative CGA and care intervention as a meaningful opportunity for improvement and a chance to extend life. Their active involvement and the collaborative efforts of the care team during the intervention were crucial in enhancing their understanding, manageability, and readiness for surgery. They valued the opportunity to make active choices when appropriate and appreciated having the right to delegate decisions to healthcare professionals. From a frail older adult's perspective, team-based approaches in preoperative care, such as CGA and care, offer benefits in terms of involvement and satisfaction. However, the thorough evaluation of postoperative outcomes remains necessary.

TRIAL REGISTRATION

OSF registry: https://osf.io/ch49n , registered on Sep 04, 2023.

Research Synthesis Related to Oncology Family Caregiver Spirituality in Palliative Care

Background: Family caregivers are central to the delivery of serious illness care and also have needs related to their role and experience. One aspect of the family caregiver quality of life (QOL) that has received less attention is caregiver spirituality. Objectives: The research objectives for this analysis were (1) Describe spirituality in oncology family caregivers. (2) Determine the impact of palliative care interventions on spirituality and related variables in oncology family caregivers. (3) Describe findings from the research literature related to spirituality in family caregivers. The authors include two nurse researchers (BF, TB) and a physician (MK) who conducted these studies and a board-certified chaplain (PG) who contributed his expertise in chaplaincy. Design: This study synthesized data from seven earlier studies by the investigators from their research in family caregiving and also compared findings to the literature. Setting/Subjects: Subjects were family caregivers (n = 1039) of patients with cancer from studies conducted primarily in the Western United States. Measurements: The key spirituality instruments used were the Functional Assessment of Chronic Illness Therapy tool and the City of Hope QOL tool. Results: Spirituality was identified as important to family caregivers and most caregivers reported a religious affiliation. Living with uncertainty was consistently reported as the worst aspect of QOL/spirituality. Having a sense of purpose and meaning was the highest rated area. Conclusions: The authors' research synthesis and the literature support the importance of additional research and clinical focus in family caregiver spirituality in serious illness care.

[The provision of assisted death in the context of the desire to anticipate death]

The entry into force of the Organic Law on the Regulation of Euthanasia in June 2021 obliges clinicians to reconsider their professional work, in the face of a new service that expands the limits of what was considered correct until then. This new service affects the entire healthcare system, but especially primary care professionals. Beyond the procedural and moral aspects, it is necessary to rethink the assessment of the patient who expresses a wish to die. In this review, we start with the relatively recent definition of the wish to hasten death (WTHD), its causes, epidemiology and differential diagnosis. Then, we examine the different mental frameworks found in the process of dying and the concept of a «good death». Finally, we analyse the paths that can lead to the provision of aid in dying within the framework of current legislation. The WTHD is specific to requests in case of «serious and advanced illness», not in other cases contemplated by the Law. When faced with a request to activate the Aid in Dying Prestation in the context of WTHD (that is, in the proximity of death), it becomes necessary to increase the patient's sense of control and begin to work on grief. Besides, in the face of an administrative process that will necessarily be long, adapting the therapeutic efforts and sedation should be considered as possible options. We understand that it is essential not to create false expectations for patients/families and not to overload healthcare professionals with administrative tasks that will be futile. It is difficult to balance these in the face of a request for a right to which the patient should always have access.

Demoralization in cancer survivors: an updated systematic review and meta-analysis for quantitative studies

BACKGROUND

Demoralization can cause impairments across all life aspects of cancer patients. Cancer patients are also vulnerable during their survivorship. The purpose of this review is to examine the risk of demoralization and associated risk factors among cancer survivors who have completed their primary anti-cancer treatment or time since diagnosis ≥5 years without recurrence.

METHODS

We searched databases of PubMed, Cochrane, Embase, PsycINFO and ClinicalTrial.gov to identify eligible studies which reported the demoralization level among cancer survivors. A random-effect meta-analysis model was used for calculating mean demoralization level. Heterogeneity was evaluated by I2 statistics. Funnel plots and Egger's regression tests were performed for checking publication bias. We used one-study-removed method for sensitivity analysis. Subgroup analysis was also done to examine the difference of demoralization level between cancer types. Meta-regression was performed to reveal risk factors of demoralization.

RESULTS

A meta-analysis of 12 articles involving 2902 cancer survivors was conducted. The mean demoralization score among cancer survivors was 25.98 (95% CI: 23.53-28.43). Higher demoralization level was seen in participants with older age, higher female ratio, higher married/living together status ratio and higher patient health questionnaire-9 score. The literature review revealed correlations between demoralization and suicide risk, anxiety and quality of life. No consistent correlation between demoralization and post-traumatic stress symptoms could be seen.

CONCLUSIONS

High demoralization level is noticed among cancer survivors. Risks for females, elder patients or breast cancer survivors are identified. More longitudinal or interventional studies for cancer survivors' demoralization are expected in the future.