“Dignity therapy” at the end of life

Most readers of this blog will never have heard of “dignity therapy.” It isn’t even listed on Wikipedia — although perhaps it will be shortly.

Dignity therapy is a form of personalized psychotherapeutic intervention that was developed about a decade ago to address the “psychosocial and existential distress” felt by many terminally ill patients. For terminal patients who are still able to communicate effectively with a trained therapist, it offers “an opportunity to reflect on things that matter most to them or that they would most want remembered.”

The process uses a series of questions and subsequent conversations under the guidance of a trained therapist. The discussions are designed to be flexible and to meet the needs of individual patients and what is important to them. Dignity therapy is audio-recorded and transcribed, and an edited version of the transcript is given to patients to share or bequeath to individuals of their choice.

A recent clinical trial randomized over 400 Australian, American, and Canadian patients with terminal clinical conditions (i.e., a life expectancy of < 6 months) to one of three types of therapy:

  • Dignity therapy
  • Client-centred care
  • Standard palliative care

The vast majority of these patients had a terminal form of cancer and were being managed in a hospital, a hospice, or at home.

The findings of this study, as reported by Chochinov et al., have now been published in The Lancet Oncology:

  • 441 patients were enrolled in the study.
  • 165/441 patients (37.4 percent) were assigned to dignity therapy; data from 108/165 of these patients were evaluable.
  • 136/441 patients (30.8 percent) were assigned to client-centered care; data from 111/136 of these patients were evaluable.
  • 140/441 patients (31.7 percent) were assigned to standard palliative care; data from 107/140 of these patients were evaluable.
  • No significant differences in the distress levels of evaluable patients before and after completion of the study were evident between the three groups.
  • Patients reported that dignity therapy was significantly more likely than the other two interventions to have been helpful, to have improved their quality of life, to have increased their sense of dignity, to have changed how their family saw and appreciated them, and to have been helpful to their families.
  • Dignity therapy was significantly better than client-centered care in improving spiritual well-being.
  • Dignity therapy was also significantly better than standard palliative care in terms of lessening sadness or depression.
  • Significantly more patients who had received dignity therapy reported that the study group had been satisfactory, compared with those who received standard palliative care.

The primary endpoint of the study was the ability of dignity therapy to mitigate outright distress, such as depression, desire for death or suicidality, as compared to client-centered or standard palliative care. This was outcome was not demonstrated in the current trial. However, it does seem evident from some of the secondary endpoints that dignity therapy offers beneficial results for some patients that might support its widespread clinical application among the terminally ill.

An article by Nelson on the Medscape Oncology web site gives additional and helpful information about dignity therapy in general and the results of this study in particular.

An editorial by Nekolaichuk appearing in the same issue of The Lancet Oncology notes the “rigor in the development of this psychotherapeutic intervention and in the design of the study” but is careful to point out some problems, in particular the following:

  • Recruitment appears to have been restricted (inevitably) to patients who were articulate and not cognitively impaired.
  • The random assignment of patients to different groups did not necessarily ensure equivalence of the groups.
  • The standardization of psychosocial interventions — especially across multiple sites — is a “significant challenge.”

Perhaps the take-away at this point in time is that dignity therapy appears to have potential as one of several ways to help the terminally ill and their families (including those with prostate cancer) cope with the impending loss in ways that allow the patient to leave behind a set of records that can be shared with future generations. This form of care — as with other forms of psychotherapeutic intervention — can help the patient to accept the inevitable while feeling that he (or she) has been “heard” as he takes the inevitable step into the unknown.

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