Creating communicative opportunity: The supportive benefits of legacy building for families of advanced cancer patients

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Background: Being diagnosed with advanced cancer is a painful reality that impacts entire families. Families face the challenge of great loss and can regret conversations left unspoken. Dignity therapy (DT) is an empirically supported intervention that gives families communicative opportunity. During DT, terminally ill patients engage in legacy building and create a written project containing their meaningful memories and values. This project is given to the family, succeeding the person in death and providing continuity to those who are left behind. We developed a narrative intervention based on DT that used a novel web portal for project dissemination. This study qualitatively explores the family’s reactions to legacy building to learn about its potential for future bereavement support. Methods: Semi-structured phone interviews (20-30 minutes) with family members (n=7) of terminally ill cancer patients were completed approximately one week after receiving the legacy project. Recipients were spouses (n=4), siblings (n=2), or an adult child (n=1). Interviews were coded using conventional content analysis and an open-coding strategy. Themes were recorded as they emerged. Results: Three communication themes emerged from the data. Legacy building: (1) facilitates conversation; (2) creates new knowledge and understanding; and (3) leaves lasting communication for future generations. The family members felt overall communication improved before the patient died, and they were able to discuss the terminal nature of their loved one’s illness. New knowledge was communicated in the project, which sometimes led to further understanding of personal life events. Also, the project was viewed as a family heirloom to be bequeathed to future generations. All family members stated they would recommend legacy building to others. Conclusions: This study adds the unique impact of communication to the literature on the supportive benefit of DT for families of advanced cancer patients. Future research should investigate and quantitatively assess bereavement outcomes for families over time, as well as the direct impact these outcomes have on family members’ quality of life.

Impact of mindfulness training on avoidant coping and advance care planning

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Background: Timely end-of-life (EOL) discussions and advance care planning (ACP) are crucial to quality cancer care; however, patients, family caregivers (CGs), and oncologists often avoid these tender conversations. When EOL discussions are avoided, patients are more likely to receive non-beneficial treatment near death and CGs are more likely to experience psychiatric disturbance. Mindfulness meditation facilitates emotional regulation and may enhance adaptive coping necessary for EOL discussions and ACP. Methods: Mindfully Optimizing Delivery of End-of-Life (MODEL) Care is a within-group pilot study developed to train patients with advanced-stage solid malignancies and their CGs (n=13 dyads) in present-moment awareness and non-reactive coping through a variety of mindfulness practices. Eligible patients met a threshold for avoidant coping and had not completed a Physician Orders for Scope of Treatment (POST) form documenting care preferences. Cognitive avoidance and quality of life (QoL) for patients and CGs were assessed from baseline (T1) to post-intervention (T2) and 1-month follow-up (T3) with standardized response mean (SRM) effect sizes. ACP from T1 to T3 was assessed descriptively. Results: Moderate decreases in cancer-related avoidance were found for patients (SRM=-0.47) and CGs (SRM=-0.59) T1 to T2, while T1 to T3 effects were small for patients (SRM=-0.31) and large for CGs (SRM=-1.12). At T1, no patient had completed a POST form; by T3, 50% reported completing one and 40% were preparing to do so soon. At T1, 23% of patients reported having had a ‘goals of care’ discussion with their oncologist, with 82% doing so by T3. At T1, 46% of patients reported having discussed ‘goals of care’ with their CGs, with 100% doing so by T3. Large improvements in QoL were found at both time points for patients and CGs (SRMs ranging from 0.85 to 1.21). Conclusions: Mindfulness was associated with mostly moderate reductions in avoidant coping and large improvements in QoL for patients and caregivers, with notable ACP progress for patients.

Feasibility and acceptability of a novel web portal to enhance legacy building for adults with advanced cancer

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Background: Being diagnosed with advanced cancer is a painful reality encompassing physical, psychosocial, and spiritual challenges as death draws near. Some patients cope resiliently, while others struggle. Dignity therapy (DT) is an empirically supported intervention where patients reflect on meaningful memories and values during interviews. These interviews are transcribed into a legacy project (LP) that can be edited and shared with loved ones. DT has been shown to benefit patients and LP recipients; however, it requires resources to implement and is not widely available in community settings. We developed a narrative intervention based on DT using a novel web portal (ZarpZ) to disseminate the LPs. This pilot assesses the feasibility, acceptability, and efficacy of our intervention to determine if it could be an affordable, user-friendly, and accessible alternative to traditional DT. Methods: Adults (n=16) with advanced-stage solid malignancies participated in a therapist-led intervention including (1) a modified DT session; (2) orientation to ZarpZ; and (3) brief weekly phone calls to aid self-led online LP building. We collected baseline and post-intervention data on primary (acceptability) and secondary (existential well-being, dignity, demoralization, peaceful acceptance of illness, and family communication) outcomes. Results: 69% of participants completed a LP. Participants reported high satisfaction with the LP created (100%) and with the intervention, particularly the home visit with the interventionist (81%). Participants were less satisfied with ZarpZ—only 45% used it. Among ZarpZ users, 40% reported it as somewhat difficult to use. Our sample was not distressed at baseline; thus, post-intervention secondary outcomes did not significantly differ from baseline. Conclusions: Participants found value in the intervention and in the LPs created, but were generally dissatisfied with ZarpZ. Future research should aim to improve usability. Since our sample size was small and participants were not distressed at baseline, we were not able to show significant improvement in secondary outcomes. Future research should examine these outcomes in a larger and more distressed sample.

Measuring dispositional cancer worry in China and Belgium: a cross-cultural validation

Dispositional cancer worry (DCW) is the uncontrollable tendency to dwell on cancer independent of relevant stimuli (e.g., diagnosis of the disease). Past research has suggested that DCW has two underlying dimensions: severity and frequency. Available measures of DCW severity and frequency were translated and validated in two countries: China and Belgium. Participants (N = 623) completed translated scales, as well as measures of general dispositional worry, cancer fear, and perceived risk. In both locations, DCW measures were reliable (Cronbach's alphas ranged from .78 - .93) and demonstrated strong convergent, divergent, and concurrent validity. Severity and frequency factors loaded as expected in exploratory factor analysis. Future research should pursue longitudinal tests of DCW's predictive validity and explore DCW in theoretical models predicting the relationship between worry and cancer prevention and early detection behaviors.