Empirical Foundations of Dignity Therapy: Comparing Dignity Therapy with Life Review for Palliative Care Patients

Abstract

Approaching end of life is a time of significant change. The physical impacts of an advancing illness can be overwhelming, and this can be closely followed by psychological, social, existential, and spiritual contributors to distress and suffering. Palliative care patients also typically need to navigate complex healthcare systems, and face difficult decisions relating to medical, personal, family, and financial matters. Not surprisingly, sense of demoralisation and expressions of desire to die are particularly prevalent in this patient population. In order to meet these complex biopsychosocial needs, palliative care relies on active cooperation and coordination of a variety of health professionals, volunteers, and community representatives. Its key guiding principle is to help patients maintain sense of dignity throughout the dying process. However, there is evidence that palliative care clinicians may not have sufficient skills and confidence in optimally assessing and treating psychosocial, existential, and spiritual domains of distress. Furthermore, there is a need to better understand the acceptability, feasibility, and effectiveness of psychotherapeutic interventions that are specifically tailored to palliative care patients. Dignity Therapy is one such promising intervention, as it is based on an empirical model of dignity in this patient population. It aims to address dignity-related distress by facilitating a creation of a lasting legacy document that is then typically shared with family or friends, and archived for future generations. Systematic reviews to date have found that Dignity Therapy has very high acceptability and satisfaction rates, variable feasibility, and generally uncertain effectiveness. Similar interventions such as Life Review also have the potential to demonstrate clinically meaningful patient outcomes but the relative lack of empirical evidence is a key barrier to their inclusion into standard palliative care practice. The overarching aim of this project was to conduct research that examined the efficacy of Dignity Therapy for palliative care patients by comparing this intervention to Life Review and a Waitlist Control Group. In order to achieve this aim, the first study involved developing a brief measure of Erik Erikson’s concepts of generativity and egointegrity that is suitable for use in palliative care settings. The second study was a Randomised Controlled trial that compared the efficacy of Dignity Therapy vs Life Review vs Waitlist Control Group on a range of outcome measures, including the newly-developed generativity and ego-integrity measure from the first study. The third study utilised qualitative research methods to further explore and better understand similarities and differences between Dignity Therapy and Life Review. The first study (N=143) demonstrated that the newly-developed measure of Erikson’s concepts generativity and ego-integrity is suitable for use with middle-aged and older adults. In the second study, Dignity Therapy was able to positively impact a sense of generativity and ego-integrity in a sample of 56 palliative care patients, when compared to Life Review and Waitlist Control groups. Creating a tangible legacy document seemed to bolster the sense of productivity, purpose, meaning, and acceptance. These outcomes were not replicated in recipients of Dignity Therapy after the waitlist period, though this group also had higher functional well-being and lower physical and psychological distress at baseline, and more frequently engaged in other memory/legacy activities. Dignity Therapy also had consistently positive therapeutic outcomes, as rated by patients and their families. This included improvements in the sense of dignity, meaning, and purpose; assistance with unfinished business; and helpfulness to family. Life Review had similarly high patient satisfaction ratings. The study did not demonstrate any meaningful changes in dignity-related distress; or physical, social, emotional, or functional well-being; following either intervention. Further qualitative analyses in the third study (N=56 palliative care patients who also participated in Study 2) showed that both Dignity Therapy and Life Review facilitated the reflection and affirmation of a variety of meaningful and important aspects of participants’ lives. Legacy documents were particularly facilitative of exploration of themes involving hope, resilience, and legacy. Themes involving interpersonal regrets, unfinished business, and aftermath concerns were less prevalent in Dignity Therapy compared to Life Review sessions, despite controlling for interview questions, session length, and therapist influences. Overall, this project introduced a new measure of generativity and ego-integrity and provided preliminary evidence of its suitability for use with patients receiving palliative care. Whilst previous studies have had challenges in demonstrating change on standardised outcome measures following Dignity Therapy, the newly developed generativity and ego-integrity measure showed differential improvement in patients receiving Dignity Therapy compared to Life Review. Qualitative analyses provided further insight into how each patient’s individual needs, vulnerabilities, preferences, and family circumstances may help to determine whether Dignity Therapy and/or Life Review might be appropriate and beneficial to them. Expanding the evidence base for such systematically developed psychotherapeutic interventions is essential in meeting complex psychosocial and emotional needs of palliative care patients.