Dignity therapy has substantial benefits over standard palliative care and client-centred care, significantly improving quality of life and enhancing the dignity of patients at the end of life while helping their families. The findings of the first randomised trial of this new psychotherapy, published Online First in The Lancet Oncology, suggest that dignity therapy should be made widely available to all individuals nearing the end of their lives.
Despite much progress in improving physical comfort for dying patients, few interventions have been developed to address the emotional, social, and spiritual needs of patients and their families, and this remains an ongoing challenge. Dignity therapy (a unique, individualised, psychotherapy) was designed to relieve distress and improve the end-of-life experience by allowing patients to discuss and document things that they would most want known or remembered. A previous phase 1 trial suggested that dignity therapy is helpful to nearly all patients.
In this study, an international team led by Harvey Max Chochinov from the University of Manitoba, Winnipeg, Canada examined whether dignity therapy could reduce distress and enrich the end-of-life experience in 326 terminally ill patients aged 18 years or older enrolled from hospitals and community settings across Canada, USA, and Australia. Patients were randomly assigned to dignity therapy (108 patients), client-centred care (107), or palliative care (111). Scores on scales measuring spiritual wellbeing, dignity, depression, and quality of life were completed at the start and end of the study. Patients' end-of-life experiences were also assessed using a self-reported survey after the study ended.
Patients receiving dignity therapy were significantly more likely to report that the approach was helpful, improved their quality of life, enhanced their sense of dignity, changed how their family saw and appreciated them, and provided benefits to their relatives compared with those given conventional care.
Dignity therapy was also significantly better than client-centred care at improving spiritual wellbeing, and significantly better than palliative care at reducing sadness and depression. However, no significant differences were noted in distress levels between the groups.
The authors say: "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."
In a Comment, Cheryl Nekolaichuk from Grey Nuns Community Hospital, Edmonton, Canada discusses the difficulties of assessing psychosocial interventions in this vulnerable population.
She says: "Psychotherapeutic interventions, such as dignity therapy, offer timely opportunities for patients and families to address important existential issues. Randomised controlled trials provide one level of evidence. However, we also need to consider other questions and approaches for demonstrating the effectiveness of an intervention. For instance, how can we measure the effect of dignity therapy on a patient's expression of existential pain? How might the creation of a dignity therapy generativity document* assist with reconciliation between a patient and estranged family members? How do we measure the long-term effect of a generativity document on the grief and further development of a 3-year-old daughter whose mother dies from cancer? We need to find ways to measure these equally important questions to show that we are making a difference."
Professor Harvey Max Chochinov, University of Manitoba, Winnipeg, Canada. T) +1 204 787 4933 E) Harvey.Chochinov@cancercare.mb.ca
Dr Cheryl Nekolaichuk, Grey Nuns Community Hospital, Edmonton, Canada. T) +1 780 735 9675 E) Cheryl.nekolaichuk@covenanthealth.ca
Notes to Editors: *Conversations during dignity therapy are recorded and transcribed, with an edited version of the transcript given to patients to share or leave to individuals of their choice.
Journal
The Lancet Oncology