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In health care, spirituality is defined as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose, and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” ( 10).
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Spiritual distress can be a component of existential suffering and may or may not be associated with religiosity ( 8, 9). Distress related to life’s meaning and purpose and lack of control in the face of loss and imminent death often result in spiritual distress. There is surprisingly little research on anticipatory grief among patients receiving palliative care ( 6), and when identified, this grief is often treated suboptimally ( 7). The threatened and experienced losses faced by patients at the end of life are also associated with anticipatory grief and fear of death ( 5). Undertreated depression and anxiety can reduce treatment adherence, increase physical symptoms, and hamper the developmental tasks of dying (e.g., pursuit of meaning and connection and saying goodbye) ( 1). Helping clinicians recognize and treat depression at the end of life has significant implications for patients’ and families’ quality of life. Reasons for lack of diagnosis and treatment include limited clinician ability to differentiate a normal emotional response from clinically significant symptoms, difficulty distinguishing physical symptoms from those secondary to depression, and uncertainty in applying psychotropic medications and psychotherapy for this medically complex population ( 2, 4). Approximately 14% of patients receiving palliative care meet criteria for an anxiety disorder, with many more experiencing decreased quality of life or deteriorating emotional well-being caused by anxiety about death ( 3). Yet such depression remains “misunderstood, underdiagnosed, and undertreated” ( 1, 2). Psychological Issues Among Patients With Terminal Illnessĭepression is one of the most common mental health problems faced by individuals with terminal illness, affecting approximately 20% of patients. Increasing research on empirically supported psychotherapies that target this patient population can help psychologists, psychiatrists, and other mental health clinicians to provide enhanced care for these patients. Awareness of these sources of distress and understanding of how personal dignity can be maintained or compromised in approaching death can help health care providers offer services in a sensitive and ever-narrowing time frame.
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Patients approaching death experience physical symptoms along with psychological, spiritual, and existential distress for which appropriate psychotherapeutic intervention can have significant impact. Quality palliative care at the end of life encompasses care of the whole person, focusing on multiple domains of human suffering. Several evidence-based treatments, including dignity therapy, meaning-centered psychotherapy, acceptance and commitment therapy, and cognitive-behavioral therapy, address psychological, social, spiritual, and existential issues at the end of life. Psychological issues at the end of life include depression, anxiety, anticipatory grief, pain management, and dignity-related concerns.Īdaptations to therapy, including therapist flexibility in regard to scheduling and goals of care, inclusion of family or health care team members, and shortened or unpredictable duration of therapy, are all important considerations in treating this population. Future research is needed to directly compare the efficacy and feasibility of these interventions to determine optimal care delivery. Thus, the choice of psychotherapy for patients at the end of life will reflect patient characteristics, therapist orientation and expertise with various approaches, and feasibility within the care context. Each of these therapies has an emerging evidence base, but they have not been compared to each other in trials. The authors reviewed several evidence-based treatments for enhancing end-of-life experience and mitigating suffering, including a primary focus on dignity therapy and an additional review of meaning-centered psychotherapy, acceptance and commitment therapy, and cognitive-behavioral therapy. This article reviews psychological, spiritual, existential, and physical issues facing patients at the end of life as well as practical considerations in providing therapy for this population. Dignity has gained increasing attention as a vital component of quality of life and quality of end-of-life care.