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