Article of the Month

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

Chochinov HM, Kristjanson LJ, Breitbart W, McClement  S, Hack TF, Hassard T, Harlos M.
Lancet Oncology 2011; 12:753-62.

In 2005, Chochinov et al. (JCO) published a phase 1 trial on a novel psychotherapeutic intervention for patients nearing death called “Dignity Therapy”. The results of the study showed that about 91% of the patients were satisfied with dignity therapy and 81% considered it of some utility for their family.

Dignity therapy is “a unique individualized brief psychotherapy developed, by Harvey Chochinov, for the purpose of relieving distress and enhancing the end-of-life experiences of terminally ill patients.  It provides these patients (and their families) with an opportunity to reflect on things that matter most to them or that they would most want remembered”.

Dignity therapy is based on an initial conversation on a series of questions about dignity with a psychologist, psychiatrist or experienced palliative-care nurse who completed a 3-day workshop led by Prof. Chochinov and then followed by continuous supervision every 6-8 weeks.

The framework of questions for dignity therapy and the role of this therapy are explained to the patients who then decide what they want to consider during the session(s). All the therapy sessions are audio taped and the record transcribed verbatim, edited, returned to the patients and read to them to be sure that there are no errors or omissions.

A recent randomized controlled trial was carried out in patients with life expectancy ≤ 6 months who received hospice or home palliative care in Canada and Australia. The patients were randomized to dignity therapy (165 of 441), client-centred care (136 of 441), or standard palliative care (140 of 441) (ratio 1:1:1) and asked to complete a baseline psychosocial questionnaire.

Client-centred care is a supportive psychotherapeutic approach in which the research nurse therapist guides the patient through discussions that focus on their symptoms and their need to address the distress. The therapist maintains the discussion on these topics.
Patients assigned to standard palliative care had access to specialist palliative care physicians and nurses, experts in pain and symptom management, social workers, chaplains, psychologists or psychiatrists. But, in this group of patients, there is no program similar to dignity therapy.

The primary outcomes were the mean changes between baseline and the end of the intervention of the psychosocial, spiritual and existential distress assessed using the following tools: Performance Status,  Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale (FACIT-Sp), Patient Dignity Inventory (PDI), Hospital Anxiety and Depression Scale, items from the structured interview for Symptoms and Concerns, Quality of Life Scale (QoL), and the modified Edmonton Symptom Assessment Scale (ESAS).

Secondary outcomes were determined as the extent to which the interventions affected the participants’ end-of-life experiences.

No significant differences were found in the distress levels before or after the end of the study in all groups of patients.

Dignity Therapy was significantly more likely to have been helpful compared to the two other interventions (p<0.0001) in the following ways:

• It improved QoL (p=0.001),
• It increased the sense of dignity (p=0.002),
• It changed how their families appreciated them (p<0.0001) and
• It helped the families (p<0.0001).

With respect to client-centered care, dignity therapy improved spiritual well-being (p=0.006) whereas when compared to standard palliative care, dignity therapy was better in lessening depression or sadness (p=0.009).

Why I chose this article

Dignity therapy is a novel, individualized, short term psychotherapy that reduces the distress in patients at the end of their lives.

It is important to know more about this therapy, to understand how to use it in the routine clinical palliative care setting and how and where is it possible to be trained.

This paper was reviewed by Dr. Carla Ripamonti (Italy) who is a member of the IAHPC Board of directors. Her biography may be found at http://www.hospicecare.com/Bio/c_ripamonti.htm