Spiritual Distress Research Articles

An Agenda of Psychedelic-Assisted Therapy Research in Seriously Ill Patients: Highlights from the Harvard Radcliffe Institute Exploratory Seminar (FR405)

•Describe psychedelic-assisted therapies content and delivery in seriously ill patients.•Identify and examine research priorities and agenda for psychedelic-assisted therapies in seriously ill patients, as collectively defined by experts from different fields of serious illness care.•Evaluate and discuss the implications of developing a psychedelic-assisted therapies research field integrated into the psychosocial and palliative care landscape. Seriously ill patients commonly experience burdensome physical and psychological symptoms and express existential and spiritual distress. In advanced cancer populations, major depression affects 13% to 26% of patients, and increases morbidity, hastened-death requests, and healthcare use (Breitbart et al., 2000; Wilson et al., 2007). More than 50% of cancer patients receive daily anxiolytics (Masman et al., 2015). In one study, 44% of patients reported spiritual pain during admission to a palliative care unit (n= 282), which correlated with higher physical and psychological distress (Delgado-Guay et al., 2016). Despite significant advancements in psychosocial and palliative care, the efficacy of pharmacological, psychotherapeutic, and spiritual care interventions remains limited in addressing this suffering. Recently, clinical research assessing the effects of psychedelic-assisted therapies has resumed, spurring interest among psychosocial and palliative care providers (Back, 2018; Byock, 2018). Recent phase 2 studies demonstrate safety and efficacy of psychedelic-assisted therapies for the treatment of anxiety, depression, and existential distress in seriously ill patients (Griffiths et al., 2016; Grob et al., 2011; Ross et al., 2016). Future studies should confirm these findings and build on extant evidence and best practices in seriously ill patients' care. We received a grant to convene researchers with expertise in palliative care, psychosocial oncology, spiritual care, oncology, and psychedelic-assisted therapies for a 2-day seminar at the Harvard Radcliffe Institute. Our goal is to collectively define priorities and an agenda for future psychedelic-assisted therapies research in seriously ill patients. This seminar will further the findings of a qualitative study presented in a concurrent session at AAHPM-HPNA 2019. In this session, we will present specific features of psychedelic-assisted therapies content and delivery, expose highlights from the Harvard Radcliffe seminar, and facilitate an open discussion between attendees and a multidisciplinary panel constituted by experts who participated to the Radcliffe seminar.

CE: Assessing and Managing Spiritual Distress in Cancer Survivorship.

More than 67% of people diagnosed with cancer in the United States are alive five years after receiving the diagnosis; but even if they are cancer free, the effects of the disease and its treatment will remain with them for the rest of their lives. Distress, which can be of a psychological, social, physical, or spiritual nature, is common among cancer survivors. Spiritual distress is a broad concept that is not necessarily associated with any specific religious beliefs, practices, or affiliations. Both religious and nonreligious people may have a strong sense of spirituality and may experience spiritual distress at various points throughout cancer survivorship. But clinicians often neglect to explore the spiritual components of distress, and despite the well-established association between spiritual well-being and quality of life, few of the instruments designed to assess the care needs of cancer survivors address spiritual needs. Through a composite clinical case, this article illustrates how nurses can incorporate into practice evidence-based recommendations for assessing and managing spiritual distress in cancer survivors.

Out of the Foxhole: Spiritual Support for Veteran Nursing Students.

As more veterans apply to nursing programs, nurse educators must acknowledge that many veterans are disadvantaged by moral injury and spiritual distress resulting from their military service. University faculty, in collaboration with Veterans Administration healthcare services, have found that referring students with unresolved spiritual distress to the Building Spiritual Strength intervention is a beneficial faith-based means for students to learn to manage their struggles and continue their education.

Palliative Care Interventions from a Social Work Perspective and the Challenges Faced by Patients and Caregivers during COVID-19.

Aim:The aim of this article is to describe the range of challenges faced by both patients and caregivers during the lockdown due to the COVID-19 pandemic. It also seeks to describe the nature of interventions provided by the social work team to address these challenges. In addition, it aims to highlight the lessons that can be learnt in supporting families on palliative care in such unique disaster situations.Methods:This exploratory study uses a qualitative approach and analyses the perceptions of patients, their caregivers, and the staff in providing care. Out of 30 patients worked with during the lockdown period, a total of nine families were selected that had received services during this time. The challenges faced and the interventions provided were analyzed using Framework analysis. We then used this framework to develop the themes that have been presented in the article.Results:The analysis indicates that the range of challenges faced by patients included physical distress due lack of availability of medicines and nursing care; emotional distress due to the interruption of cancer treatment; financial and social distress about loss of incomes, isolation; and spiritual distress due to the uncertainty of last rites as well as fulfilment of last wishes. The concerns outlined by caregivers included: living with guilt due to the inability to ease their relative's distress; the stress of constant care giving; lack of information about available services and confidence to ask for help from others as well as the dealing with the grief of a dying relative. These families were supported through telephone calls and home visits for critical patients with the social work team providing active listening, reassurance, empathy, and networking to assist patients and families at this time.Conclusion:Palliative care is an essential component, especially in a disaster-related situation such as the COVID pandemic as patients and caregivers are left more vulnerable at this time. Telephonic and video calls play an important role in supporting patients and caregivers and in the most critical cases. However, it is also important to find the ways to provide direct home-based support to patients and families at this time so that they feel less alone, cope better, and experience meaningful support to build their resilience.

1.5 CE Test Hours: Assessing and Managing Spiritual Distress in Cancer Survivorship.

AJN, American Journal of Nursing 120(1):p 48, January 2020. | DOI: 10.1097/01.NAJ.0000652036.59404.30

Health Care Professionals' Reflections on Their Learning as Spiritual Generalists and Integration Into Practice.

Meeting spiritual needs of patients is an important aspect of quality health care, but continuing professional development and training to provide spiritual care remains inadequate. The purpose was to identify participants' learning from simulation-based spiritual generalist workshops and application to practice. Interdisciplinary participants completed self-report demographic questionnaires before the workshops and questionnaires after workshops that listed open-ended take-home learning. Responses were analyzed using qualitative content analysis. A subgroup was surveyed 3 to 9 months after training to examine whether and how participants had incorporated workshop learning into clinical work. Workshop participants 181/211 (85.8%) reported learning in four categories: core values and skills of spiritual generalists, understanding spirituality/religion and its role in health care, interfacing with chaplaincy, and interprofessional teamwork. Of the subsample, 73.5% (25/34) completed surveys 3 to 9 months after training. Of those, 25/25 (100%) reported drawing on what they learned in workshops, and 24/25 (96%) reported making clinical practice changes. One-day spiritual generalist simulation-based workshops can improve continuing professional development learning experiences to provide generalist level of spiritual care. Workshops offered valuable learning and resulted in applicable clinical skills across professional roles. At 3 to 9 months after training, participants reported improved spiritual screening, recognition of spiritual distress, and referral to chaplaincy.

Social and Psychological Factors Associated With Health Care Transition for Young Adults Living With Sickle Cell Disease.

Introduction: Due to advances in disease management, mortality rates in children with sickle cell disease (SCD) have decreased. However, mortality rates for young adults (YA) increased, and understanding of social and psychological factors is critical. The aim of this study was to explore factors associated with health care transition experiences for YA with SCD. Method: This was a qualitative descriptive study. A 45-minute semistructured interview was conducted with 13 YA (M = 21.5 years, SD = 1.73). Results: Results suggest that social and psychological factors and self-management experiences influence health care transition. Eight themes emerged: "need for accessible support"; "early assistance with goal setting"; "incongruence among expectations, experiences, and preparation"; "spiritual distress"; "stigma"; "need for collaboration"; "appreciation for caring providers"; and "feeling isolated." Discussion: Consideration of cultural contexts will guide nurses in supporting health care transition. Designing culturally relevant interventions that address unique needs for YA living with SCD is warranted.

Interprofessional Spiritual Care Education Curriculum: A Milestone toward the Provision of Spiritual Care.

Background: Spiritual care is a key domain of quality palliative care. Spiritual distress is highly prevalent in patients and their families facing serious illness. Guidelines support the ethical obligation of health care providers to attend to spiritual distress as part of total distress. All clinicians require education and support to provide this care to patients and their families facing serious illness. Objective: This project focused on the development of a curriculum for education of health care professionals in spiritual care. It was based on a consensus-derived generalist-specialist model of spiritual care, with all clinicians providing generalist-spiritual care and trained chaplains providing specialist spiritual care. Design: The curriculum was designed for classroom and online learning. Setting: The curriculum is appropriate for all clinical settings in the United States and internationally. Measurements: Needs assessment surveys and course evaluation data have provided a basis on which to develop and refine the curriculum. This curriculum is built on a pilot Interprofessional Spiritual Care Education Curriculum (ISPEC) course held at the Veterans Administration, DC. Results: Needs assessment and course evaluation data support the ISPEC course content. Conclusions: The ISPEC curricula serve as a much-needed training resource to improve spiritual care for all people with serious illness.

Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain.

Nonmedical opioid use (NMOU) in patients with cancer is a term covering a spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. The objectives of this study were to (A) evaluate current literature regarding management of NMOU in patients with cancer-related pain; (B) provide best practice recommendations based on evidence; and (C) integrate practices derived from the management of noncancer pain, where clinically appropriate or when the oncology literature is limited. This study is a narrative review. Although harm from NMOU was thought to be rare among oncology patients, about one in five patients with cancer is at risk of adverse outcomes including prolonged opioid use, high opioid doses, and increased health care utilization. The management of NMOU can be challenging because pain is a multidimensional experience encompassing physical, psychological, and spiritual domains. An interdisciplinary team approach is most effective, and management strategies may include (A) education of patients and families; (B) harm reduction, including opioid switching, decreasing the overall daily dose, avoiding concurrent sedative use, and using adjuvant medications for their opioid-sparing potential; (C) managing psychological and spiritual distress with an interdisciplinary team and techniques such as brief motivational interviewing; and (D) risk mitigation by pill counts, frequent clinic visits, and accessing statewide prescription drug monitoring plans. Although many of the management strategies for NMOU in patients with cancer-related pain are modeled on those for chronic non-cancer-related pain, there is emerging evidence that education and harm-reduction initiatives specifically for cancer-related pain are effective. Nonmedical opioid use (NMOU) in patients with cancer is a term covering a broad spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. This review evaluates the evidence for best practices in oncology and addresses limitations in the literature with supplemental evidence from noncancer chronic pain. Management recommendations for NMOU are provided, based on a combination of literature-based evidence and best clinical practice. Effective management of NMOU in oncology has the potential to improve quality of life, decrease health utilization, and improve survival.

Spiritual Distress Manifested in a Teenager After a Stem Cell Transplant

A mother and nurse 20 years after her son's tragic death, after a high-risk stem cell transplant, learns that his major behavioral changes while in strict isolation came under the term of spiritual distress. Through her personal experience, the writer describes how her son's thoughts and feelings were expressed in behaviors, atypical for his usual demeanor.This article highlights the importance and value of healthcare providers listening to a parent's perceptions of their child's state of mind. Atypical behavior could be a manifestation of spiritual distress and requires further assessment from the health care team.

Life Experience of Seventh-Day Adventist Church Members in Caring for Their Parents Who Suffer from Alzheimer’s Dementia

Introduction: Previous phenomenological studies explain that family member faced many consequences in caring for family members with Alzheimer’s Dementia at home. The consequences are in the form of the impact of financial, social and psychological pressure. Considering such consequences, families especially in Eastern cultures will continue to care for their elderly at home for reasons of compassion or retribution toward parents even though they feel frustrated and burdened. The purpose of this study is to describe the life experience of Seventh-day Adventist church members in caring for their parent who suffer from Alzheimer’s Dementia. Method: This qualitative study is using phenomenological design. There are 3 participants are selected who are fit with the inclusion criterions: immediate family member, seventh-day Adventist church member, live together with their Alzheimer’s Dementia parent who suffer at least 2 years of dementia, and agree to sign inform consent after the full explanation of the study. Data are gathered using semi structured face to face interview in participant’s home setting. Data than transcribed in to world document and analyzed using Cresswel step by step content analysis. Result: There are five negative categories of family member experiences in taking care of their Alzheimer’s Dementia parent: 1) physical abuse, 2) psychological abuse, 3) social limitation, 4) spiritual distress, and 5) knowledge deficit. It also found that there are several coping mechanism or adaptation made by family member in caring their Alzheimer Dementia parent: 1) family members are motivated to learn more about Alzheimer Dementia, 2) spiritual growth that they pray more often and surrendered to God, 3) increase understanding toward elderly. Discussion: Based on the result of the study, all the informants experienced pressures in all holistic aspects of life. If they are not able to cope with the pressure, illness may be arrived and made the family situation become worse. Therefore, professional health care must provide support to the family who take care of their Alzheimer Dementia parent.

Palliative care advanced practice nursing in Israel: bridging creation and implementation.

To describe Israel's development of the palliative care advanced practice registered nurse as a foundation for the development of the advanced practice registered nurse role in other specialties. Palliative care centres on alleviating physical, emotional, social and spiritual distress associated with life-limiting illness. In 2009, Israel introduced the palliative care advanced practice nurse role, that is, registered nurses with specialized training in palliative care, to address increasing palliative care needs. While there has been investment in its development, full implementation of the advanced practice nurse has not yet been achieved. In this qualitative descriptive study, we conducted a document analysis (n=11) and key informant interviews (n=11), extracted themes using qualitative content analysis and triangulated data sets. Documents reflected growing palliative care needs and uniform requirements for advanced practice nurse training. Interviews uncovered a perceived lack of awareness of palliative care, the need for increased role definition and practice authority for advanced practice nurses, and barriers to entry and training for this role. Findings highlight ongoing needs in palliative care and advanced practice nursing and a trajectory of growth. The challenges Israel faces in implementation of the palliative care advanced practice nurse role inform development of other advanced practice nursing roles in Israel and other countries. Streamlining training pathways and resolving scope of practice issues will assist in implementation of advanced practice nursing roles. Our data offer targets for policymakers advocating the advanced practice nurse role, including training requirements and scope of practice.

Religious/spiritual coping and spiritual distress in people with cancer.

To investigate the relation between the presence of spiritual distress and use of RSC and sociodemographic, clinical and religious/spiritual variables in people with cancer. Cross-sectional study conducted in an association for support to people with cancer. The data obtained with the tools were analyzed using the Spearman's correlation coefficient and the Mann-Whitney Test. 129 volunteers participated in the study, of which 57% showed moderate spiritual distress, 96% used medium and high positive religious/spiritual coping. Spiritual distress showed positive correlation with negative religious/spiritual coping (P<0.001) and inverse correlation with age (p 0.002). The use of positive religious coping was statistically significant in people who have religious practices (p 0.001). Spiritual distress is a phenomenon that is present in the lives of people with cancer and has significant relation with the use, in a negative manner, of religion/spirituality as a way of coping with the disease.

Critical Care Nurses as Frontline Warriors During COVID-19 in Pakistan

BackgroundThe COVID-19 pandemic resulted in several short-term and long-term impacts on the physical, social, and psychological health of every individual globally, especially among frontline workers including nurses working in the critical care settings. In Pakistan, 85,264 confirmed cases have been identified and 1,770 deaths are reported so far. The death rate is 2.0% as compared to Europe (14.6%) and the United States (5.7%) per 100,000 population. Frontline workers are the most vulnerable population during this pandemic. Nearly 440 frontline staff including nurses, doctors, and other health workers have been infected with COVID-19 with 8 confirmed deaths reported in different provinces of Pakistan. These numbers are continuously increasing posing a serious threat for the health and well-being of the healthcare professionals especially nurses working in the critical care settings.ObjectiveThe paper outlines the challenges and experiences of critical care nurses working in acute hospital settings of a low resourced country Pakistan during a pandemic.MethodsLiterature search using CINAHL, MEDLINE, PubMed databases, local and international news papers, magazines, websites, international nursing colleagues and personal experiences/insights are included in the paper.ResultsFindings include common challenges such as lack of staff, lack of personal protective equipment (PPE), limited knowledge regarding standard infection control practices, isolation protocols, lack of administrative support, transportation, accommodation, childcare facility, and so forth. As a result, most nurses are reporting symptoms of fear, anxiety, depression, post-traumatic symptoms, spiritual, and moral distress. Nurses often become targets of violence and harassment by the general public in the Pakistani healthcare system, due to lack of awareness, cultural beliefs, low status/image of nurses, low literacy levels, and poverty.ConclusionTargeted interventions and policies are needed to maintain safety and protect physical, social, psychological, and spiritual health and well-being of nurses. Health authorities in Pakistan should take the responsibility in creating awareness, providing adequate guidance, and support to enhance nurses' well-being and quality of life during the pandemic.

Relationship of spiritual constructs to mental health PROs in adolescents with cancer.

136 Background: Global beliefs and goals form a meaning system, which plays a role in adjusting to stressors like cancer. Spirituality (search for the sacred) is a meaning system that can play a role in adolescent coping, and psychosocial adjustment to chronic disease. When malignancies occur during adolescence, there are long-term consequences to adjustment, functioning, and disease self-management. Methods: Data were obtained from 126 adolescents diagnosed with cancer at various stages and 4 sites in a longitudinal pediatric advance care planning intervention trial. Scales used: demographic; 2 spiritual scales (Brief-MMRS and FACIT-Sp v4); and 2 emotional PROMIS items (anxiety and depression). Bivariate relationships were analyzed. Structural equation modeling examined the relationship between spiritual and PROMIS items. Bootstrap with 1000 resamples was applied to due to sample size. Results: Mean age was 16.9 years (range: 14-20), with a mean time since diagnosis of 77 months (range: 1-232); 21% were on active treatment. The majority were female (57%) and white (79%). Most identified as spiritual (89%) and religious (83%). When asked if they believed they will be spiritually healed from cancer by a miracle, 49% reported “yes.” Adolescents viewing cancer as God’s punishment were more likely to have high depression (p = 0.03). Very or moderately spiritual teens were more likely to have high anxiety and high depression (p = 0.02). Meaning/peace (FACIT-Sp subscale) mediated feeling God’s presence on anxiety (β = -3.5; 95% CI: -9.2, -0.48) and depression (β = -4.6; 95%CI: -10.7, -1.1); and mediated religious identification on anxiety (β = -3.1; 95%CI:-6.9, -0.6) and depression (β = -4.1; 95%CI:-9.3,-0.24). Conclusions: Our findings are consistent with adult literature and a single longitudinal study of teens with cancer: spiritual distress (cancer is God’s punishment) is associated with poorer mental health outcomes, and meaning with positive outcomes. Adolescent anxiety and depression were inversely related to feeling God’s presence, and to identifying as religious; this effect was mediated by their sense of meaning/peace. Meaning-making is a modifiable process, opening a novel focus for intervention development. Clinical trial information: NCT02693665.

Validation of the Spiritual Distress Scale in Portuguese Cancer Patients Undergoing Chemotherapy: A Methodological Study

Spiritual distress may ascend from unmet spiritual needs. The use of instruments to measure spiritual distress seems to facilitate the approach to spirituality, such as the Spiritual Distress Scale (SDS) that has been used worldwide. No instrument to assess spiritual distress in cancer patients is currently available in Portugal. This study aims to conduct the translation, adaptation and validation of the SDS in Portuguese cancer patients undergoing chemotherapy. Methodological study based on Sousa and Rojjanasrirat (2011), a seven-step approach, started with the linguistic translation to the psychometric tests. The main participants (55.4%) were older than 60 years; about 64.7% were females, married (68.0%), and 86.7% were Catholic. Moderate spiritual distress was experienced by 49.3% of the participants. Linguistic and conceptual equivalences were obtained. The SDS European Portuguese version has an overall Cronbach’s alpha of 0.91, and the subscales were as follows: “relationship with self” (0.92), “relationship with others” (0.63), “relationship with God” (0.64) and “facing death” (0.85). Four factors emerged after Varimax rotation. Overall, these results indicate that the SDS European Portuguese version has good psychometric characteristics and can used in assessing spiritual distress in cancer patients.

The national comprehensive cancer network distress thermometer as a screening tool for the evaluation of quality of life in uveal melanoma patients.

To assess quality of life (QoL) status via the National Comprehensive Cancer Network (NCCN) distress thermometer as a psychooncological screening tool in uveal melanoma patients. One hundred and six consecutive patients suffering from uveal melanoma completed the distress thermometer between 04/2018 and 12/2018. Practical, emotional, family concerned, spiritual, physical and overall distress levels, distribution of distress and subgroup analyses defining groups of potential high distress levels in need of intervention were assessed. Descriptive statistics, cross-tabulations, chi-square and Fisher's exact test as well as correlation coefficients (Spearman's rho) and receiver operating characteristic (ROC) were used for analysis. Patients with higher T-category had significantly more emotional problems and spiritual concerns (p=0.046 and p=0.023, respectively). Female patients accounted for higher rates of physical issues (p=0.034). Lower best corrected visual acuity (BCVA) was correlated with higher distress levels (p=0.037). Patients resulting in loss of BCVA of ≥3 lines reported higher distress levels (p=0.029). A distress threshold of 5 on the basis of ROC analysis showed a corresponding sensitivity of 100% and specificity of 76%. The NCCN distress thermometer could be integrated well into our clinical routine and proved to be a rapid, yet sensible screening tool for emotional and physical distress in patients with uveal melanoma. Special attention should be paid to patients with higher T-category and patients resulting in lower levels of BCVA. As in patients with different tumour entities, the established distress threshold of ≥5 proposing intervention proved to be adequate for uveal melanoma patients.

Nursing Modality Therapy (Spiritual Deep Breathing) Resolve Student Distress

The condition of nursing faculty students has many academic tasks such as attending classes, taking exams, socializing, adjusting to fellow students with different characteristics and backgrounds, developing talents and interests through non-academic activities. This condition causes students to not be able to manage time well so that they experience distress. Quasy experiment research used two groups pre-post-test design. The sample included 15 control groups and 15 treatment groups. The sampling technique uses simple random sampling. Research variables include spiritual deep breathing therapy and distress rate. The instrument uses depression anxiety stress scale-42 (DASS-42) in the form of a Likert scale. This type of unfavorable questionnaire contains 42 questions. The spiritual instrument deep breathing therapy is about 20 minutes a day for seven days. Statistical test using Wilcoxon signed rank test against both groups. There was a significant effect on the treatment group (p-value 0.001). In the control group there was no effect (p-value 0.263). Distress conditions in a person can be overcome with one therapy such as spiritual deep breathing therapy. Spiritual deep breathing therapy as a therapy for nursing modalities can optimize oxygen demand for cells that are distressed, blood flow to the muscles decreases otherwise blood flows to the brain and skin increases so as to provide a sense of warmth, comfort and calm.

Spiritual Well being of Breast Cancer Patients Undergoing Chemotherapy through Mindfulness Based Spiritual

Breast cancer patients newly diagnosed and undergoing chemotherapy experience physical and emotional changes. Patients experience stress due to side effects of chemotherapy drugs, financial changes, self-perceptions and beliefs so that the risk of experiencing spiritual distress. Adaptive coping is needed to improve the spiritual well being so that patients more adaptive and have a good quality of life. The purpose of this study was to determine the effect of mindfulness based spiritual to spiritual well being on breast cancer patients undergoing chemotherapy. The study used pilot study with pre and post-test design, with purposive sampling techniques. Total sample 12 breast cancer moslem patients undergoing chemotherapy &lt;3 months. Measurement of spiritual well-being using Spiritual Well Being Scale (SWBS). Data analysis used Paired T-Test. The results showed there was significant efect of mindfulness based spiritual to improve spiritual well being (p-value 0,001). Mindfulness based spiritual can improve the spiritual well being of breast cancer patients undergoing chemotherapy. The recommendation of this pilot study needs to be carried out research with a larger number of samples and analyzed the factors that can improve the spiritual well being of breast cancer patients.

A Brief Psychodynamic and Person-Centered Approach to Address Anticipatory Loss in Acute Care Settings

Palliative care addresses the biopsychosocial and spiritual distress of people with critical and chronic illness. Depending on the trajectory of an illness, a social worker in an acute care setting may have a limited number of opportunities to engage in meaningful interaction with an emotionally distressed patient. The social worker is often faced with providing care to a patient who is having the dual experience of maintaining hope for medical improvement and anticipating loss. This article offers therapeutic practice skills needed by social workers to address the experience of anticipatory loss in an acute care setting. Brief psychodynamic and person-centered therapy, provided in combination, are highlighted as one method to explore a patient’s feelings and wishes in the face of critical illness. Case-based vignettes illustrate how five open-ended questions help mitigate suffering and heighten a patient’s sense of autonomy and self-worth.