Elsevier

The Lancet Oncology

Volume 12, Issue 8, August 2011, Pages 753-762
The Lancet Oncology

Articles
Effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial

https://doi.org/10.1016/S1470-2045(11)70153-XGet rights and content

Summary

Background

Dignity therapy is a unique, individualised, short-term psychotherapy that was developed for patients (and their families) living with life-threatening or life-limiting illness. We investigated whether dignity therapy could mitigate distress or bolster the experience in patients nearing the end of their lives.

Methods

Patients (aged ≥18 years) with a terminal prognosis (life expectancy ≤6 months) who were receiving palliative care in a hospital or community setting (hospice or home) in Canada, USA, and Australia were randomly assigned to dignity therapy, client-centred care, or standard palliative care in a 1:1:1 ratio. Randomisation was by use of a computer-generated table of random numbers in blocks of 30. Allocation concealment was by use of opaque sealed envelopes. The primary outcomes—reductions in various dimensions of distress before and after completion of the study—were measured with the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale, Patient Dignity Inventory, Hospital Anxiety and Depression Scale, items from the Structured Interview for Symptoms and Concerns, Quality of Life Scale, and modified Edmonton Symptom Assessment Scale. Secondary outcomes of self-reported end-of-life experiences were assessed in a survey that was undertaken after the completion of the study. Outcomes were assessed by research staff with whom the participant had no previous contact to avoid any possible response bias or contamination. Analyses were done on all patients with available data at baseline and at the end of the study intervention. This study is registered with ClinicalTrials.gov, number NCT00133965.

Findings

165 of 441 patients were assigned to dignity therapy, 140 standard palliative care, and 136 client-centred care. 108, 111, and 107 patients, respectively, were analysed. No significant differences were noted in the distress levels before and after completion of the study in the three groups. For the secondary outcomes, patients reported that dignity therapy was significantly more likely than the other two interventions to have been helpful (χ2=35·50, df=2; p<0·0001), improve quality of life (χ2=14·52; p=0·001), increase sense of dignity (χ2=12·66; p=0·002), change how their family saw and appreciated them (χ2=33·81; p<0·0001), and be helpful to their family (χ2=33·86; p<0·0001). Dignity therapy was significantly better than client-centred care in improving spiritual wellbeing (χ2=10·35; p=0·006), and was significantly better than standard palliative care in terms of lessening sadness or depression (χ2=9·38; p=0·009); significantly more patients who had received dignity therapy reported that the study group had been satisfactory, compared with those who received standard palliative care (χ2=29·58; p<0·0001).

Interpretation

Although the ability of dignity therapy to mitigate outright distress, such as depression, desire for death or suicidality, has yet to be proven, its benefits in terms of self-reported end-of-life experiences support its clinical application for patients nearing death.

Funding

National Cancer Institute, National Institutes of Health.

Introduction

Research into methods to understand and support patients who are nearing the end of their lives is increasing.1, 2, 3 Dignity therapy, a unique, individualised, brief psychotherapy, was developed for the purpose of relieving distress and enhancing the end-of-life experiences of terminally ill patients. It provides these patients with an opportunity to reflect on things that matter most to them or that they would most want remembered. The therapeutic process begins with a framework of questions (panel 1) that are based on an empirical model of dignity in the terminally ill patient.4, 5 These conversations, guided by a trained therapist, are flexible to accommodate the patients' needs and choices about what they specifically wish to address. Dignity therapy is audiorecorded and transcribed, with an edited version of the transcript given to patients to share or bequeath to individuals of their choice.

In a phase 1 trial with 100 terminally ill patients, 91% were satisfied with dignity therapy, and 76% reported a heightened sense of dignity, 68% an increased sense of purpose, 67% a heightened sense of meaning, 47% an increased will to live, and 81% that it had been or would be of help to their family.6 Post-intervention assessments of suffering and depressive symptoms showed small, but significant improvements.6 78% of patients' family members reported that the therapy enhanced the patient's dignity, and 72% that it heightened the meaning of life for the patient; 78% said the document from the therapy session was a comfort to them in their time of grief, and 95% that they would recommend dignity therapy to other patients and their families.7 We therefore investigated whether this novel psychotherapeutic approach would be better than standard palliative care and client-centred care (which focused on non-generativity—ie, here and now issues) in terms of reducing psychological, existential, and spiritual distress in patients who are terminally ill.

Section snippets

Participants

Individuals were eligible for participation in the study if they had a terminal prognosis with a life expectancy of 6 months or less, according to their treating physician; were receiving palliative care in a hospital or community setting (hospice or home) through an affiliated recruitment site in Canada, USA, and Australia; were aged 18 years or older; were willing to commit to three or four contacts over about 7–10 days; and were able and willing to provide written informed consent. Patients

Results

The figure shows the trial profile. 1513 patients were assessed for eligibility by use of a consecutive sampling approach between April, 2005, and October, 2008. After randomisation, 28 patients died, 85 withdrew because of declining health, and two failed Blessed Orientation Memory Concentration screening. These individuals were excluded from the analysis because we had either no or only incomplete data for them. Therefore, 326 participants—108 (33%) assigned to dignity therapy, 111 (34%) to

Discussion

Although floor effects precluded our ability to show significant differences between the study groups in terms of the primary outcomes, our secondary outcomes showed substantive benefits of dignity therapy, a novel psychotherapeutic approach, over standard palliative care and client-centred care. Patients in this group, when surveyed after the study, were significantly more likely to report benefits in terms of finding the treatment helpful, improving their quality of life, their sense of

Glossary

Generativity
or the ability to guide the next generation, encompasses how patients might find strength or comfort in knowing that they will leave behind something lasting and transcendent after death

References (33)

  • AH Peterman et al.

    Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy—spiritual well-being scale (FACIT-sp)

    Ann Behav Med

    (2002)
  • S Moorey et al.

    The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer

    Br J Psychiatry

    (1991)
  • KG Wilson et al.

    Structured interview assessment of symptoms and concerns in palliative care

    Can J Psychiatry

    (2004)
  • KY Graham et al.

    Quality of life in persons with melanoma: preliminary model testing

    Cancer Nursing

    (1987)
  • E Bruera et al.

    The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients

    J Palliat Care

    (1991)
  • J Cohen

    Statistical power analysis for the behavioral sciences (revised edition)

    (1977)
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