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Dignity Therapy: Advancing the Science of Spiritual Care in Terminal Illness

Department of Nursing Research, City of Hope National Medical Center, Duarte, CA

In this issue of the Journal of Clinical Oncology, Chochinov et al¹ make a major contribution to advancing care for the terminally ill through their study "Dignity Therapy: A Novel Psychotherapeutic Intervention for Patients Near the End of Life." This international study, testing a novel intervention to address dignity and meaning in the final days of life, was conducted in Canada and Australia; however, it has significance for other countries attempting to address this highly neglected aspect of health care.

The investigators have advanced an area of palliative care that has been cited in recent years by groups such as the WHO, Institute of Medicine, National Cancer Institute, and others as being in serious need of improvement. Many clinicians and institutions have struggled to advance the most basic aspects of care in advanced disease, such as improvements in the treatment of pain and symptoms or treatment of common psychological problems such as anxiety and depression. These investigators, however, have advanced an aspect of terminal care that is perhaps far more challenging than titrating doses of opioids.

"Dignity therapy," which addresses psychosocial and existential distress, is of great importance and shows promise as a novel intervention to diminished suffering and distress in end-of-life care. Several characteristics of this intervention are noteworthy.

SIMPLICITY OF DIGNITY THERAPY

First, it is commendable that the investigators built on extensive previous work, as cited in the article, to move the field beyond descriptions of suffering or a lack of meaning to create an effective intervention. The investigators' approach to the problem of dignity in end-of-life care is commendable in asserting that the end of life is a natural phase of life and that the lack of meaning or dignity is not a psychiatric disorder but rather a natural life occurrence.

Many psychiatric interventions discussed in the literature or applied in clinical settings are complex and of a longitudinal nature, which limits their application to those persons with advanced disease or who are facing the end of life. The dignity-therapy intervention is commendable in its simplicity, in recognizing that individuals have a need for life closure and enhanced communication with those whom they love. It is especially encouraging that most patients in the study were able to complete the process of the interview with one recorded session. This research could be a model for other palliative care researchers in constructing theoretically based detailed interventions that recognize the burden to these vulnerable subjects.

UNANSWERED QUESTIONS

Reading this report sparked my wish to be physically present during one of these sessions to appreciate the skills of the psycho-oncology professionals that must be evident in implementing this intervention. Observing the communication skills of the professionals and the personal awareness of death by the patients would be insightful. It would also be interesting to know how the investigators dealt with troublesome patients. For example, although most individual patients described in their article seemed able to resolve difficulties and have meaningful interactions with their family, it would be interesting to know how the therapists dealt with patients who had intense regrets about their lives or had conflicts surface from life-long conflicts that needed resolution. Future work by these authors should include presentation of case studies and sharing of their experiences with the most complex and difficult cases and relationships. It also would be valuable to have a videotape library of these sessions available for viewing in professional education programs.

The authors report that 19.6% of patients refused to take part in this study. It would be of interest to know more about these individuals. More detailed qualitative analysis of actual transcripts might also provide insight into individual characteristics, end-of-life concerns, or conflicts that kept the patients or families from accepting this kind of intervention.

REAL EVIDENCE

Bereavement research has been challenged to identify not only benefits to patients but ultimately the outcomes of family caregivers. The authors focused on the impact of this intervention on patients but did not provide evidence of the ultimate outcomes of dignity therapy through interviews of family members after the patient died. It would be of great interest to know if the therapeutic work of the interview affected the bereavement experience of family survivors.

Finally, and likely of most importance, there has been significant documentation of the lack of psychosocial support services in many cancer care settings. It is of great importance that the authors suggested that dignity therapy is a feasible and effective approach and that this intervention could be disseminated through other professionals with expertise in psychosocial oncology. The dissemination of dignity therapy to nurses, social workers, chaplains, physicians, and others, accompanied by the availability of psychologists or psychiatrists for support, is an exciting possibility.

As Chochinov et al remind us, all professionals have the opportunity to promote dignity in those whose lives are ending. Their research will provide us with more precise interventions to ultimately improve the quality of care provided to patients and their families.

Author's Disclosures of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.

REFERENCE

1. Chochinov HM, Hack T, Hassard T, et al: Dignity therapy: A novel psychotherapeutic intervention for patients near the end of life. J Clin Oncol 23:5520-5525, 2005[Abstract/Free Full Text]

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• Dignity Therapy: A Novel Psychotherapeutic Intervention for Patients Near the End of Life
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