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Dignity therapy is a unique, individualised, short-term psychotherapy that was developed for patients (and their families) living with life-threatening or life-limiting illness. We investigated whether dignity therapy could mitigate distress or bolster the experience in patients nearing the end of their lives. Patients (aged ≥18 years) with a terminal prognosis (life expectancy ≤6 months) who were receiving palliative care in a hospital or community setting (hospice or home) in Canada, USA, and Australia were randomly assigned to dignity therapy, client-centred care, or standard palliative care in a 1:1:1 ratio. Randomisation was by use of a computer-generated table of random numbers in blocks of 30. Allocation concealment was by use of opaque sealed envelopes. The primary outcomes—reductions in various dimensions of distress before and after completion of the study—were measured with the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale, Patient Dignity Inventory, Hospital Anxiety and Depression Scale, items from the Structured Interview for Symptoms and Concerns, Quality of Life Scale, and modified Edmonton Symptom Assessment Scale. Secondary outcomes of self-reported end-of-life experiences were assessed in a survey that was undertaken after the completion of the study. Outcomes were assessed by research staff with whom the participant had no previous contact to avoid any possible response bias or contamination. Analyses were done on all patients with available data at baseline and at the end of the study intervention. This study is registered with ClinicalTrials.gov, number NCT00133965. 165 of 441 patients were assigned to dignity therapy, 140 standard palliative care, and 136 client-centred care. 108, 111, and 107 patients, respectively, were analysed. No significant differences were noted in the distress levels before and after completion of the study in the three groups. For the secondary outcomes, patients reported that dignity therapy was significantly more likely than the other two interventions to have been helpful (χ 2=35·50, df=2; p<0·0001), improve quality of life (χ 2=14·52; p=0·001), increase sense of dignity (χ 2=12·66; p=0·002), change how their family saw and appreciated them (χ 2=33·81; p<0·0001), and be helpful to their family (χ 2=33·86; p<0·0001). Dignity therapy was significantly better than client-centred care in improving spiritual wellbeing (χ 2=10·35; p=0·006), and was significantly better than standard palliative care in terms of lessening sadness or depression (χ 2=9·38; p=0·009); significantly more patients who had received dignity therapy reported that the study group had been satisfactory, compared with those who received standard palliative care (χ 2=29·58; p<0·0001). Although the ability of dignity therapy to mitigate outright distress, such as depression, desire for death or suicidality, has yet to be proven, its benefits in terms of self-reported end-of-life experiences support its clinical application for patients nearing death. National Cancer Institute, National Institutes of Health.

أظهرت دراسات متعددة أن المصابين بأمراض مهددة للحياة معرضون أكثر من غيرهم للإصابة بعدد من الاضطرابات النفسية الجسيمة، ولهذا فقد دعت منظمة الصحة العالمية إلى توسيع مفهوم الرعاية التلطيفية لتشمل تقديم الرعاية التكاملية النفسية، والاجتماعية، والروحية، بالإضافة إلى الرعاية الجسدية، وذلك أثناء جميع مراحل المرض المهدد للحياة كلها، بدءا من مرحلة التشخيص وحتى ما بعد موت المريض. يعد هذا الكتاب إضافة مهمة للمكتبة العربية؛ نظرا لغناه بالمادة العلمية المستندة للبراهين، والمفيدة لكل من له دور في تقديم الرعاية التلطيفية للمرضى وعوائلهم.

The aim of this study was to compare the efficacy and side-effect profile of the typical antipsychotic haloperidol with that of the atypical antipsychotics risperidone, olanzapine, and aripiprazole in the management of delirium. The Memorial Delirium Assessment Scale (MDAS), the Karnofsky Performance Status (KPS) scale, and a side-effect rating were recorded at baseline (T1), after 2-3 days (T2), and after 4-7 days (T3). Some 21 cases were case-matched by age, preexisting dementia, and baseline MDAS scores, and subsequently analyzed. The baseline characteristics of the medication groups were not different: The mean age of the patients ranged from 64.0 to 69.6 years, dementia was present in between 23.8 and 28.6%, and baseline MDAS scores were 19.9 (haloperidol), 18.6 (risperidone), 19.4 (olanzapine), and 18.0 (aripiprazole). The doses of medication at T3 were 5.5 mg haloperidol, 1.3 mg risperidone, 7.1 mg olanzapine, and 18.3 mg aripiprazole. Over one week, the decline in MDAS scores between medications was equal, and no differences between individual MDAS scores existed at T2 or T3. After one week, the MDAS scores were 6.8 (haloperidol), 7.1 (risperidone), 11.7 (olanzapine), and 8.3 (aripiprazole). At T2, delirium resolution occurred in 42.9-52.4% of cases and at T3 in 61.9-85.7%; no differences in assessments between medications existed. Recorded side effects were extrapyramidal symptoms (EPSs) in haloperidol- and risperidone-managed patients (19 and 4.8%, respectively) and sedation with olanzapine (28.6%). Haloperidol, risperidone, aripiprazole, and olanzapine were equally effective in the management of delirium; however, they differed in terms of their side-effect profile. Extrapyramidal symptoms were most frequently recorded with haloperidol, and sedation occurred most frequently with olanzapine.

Background This mixed methods study identified needed refinements to a telehealth-delivered cultural and linguistic adaptation of Meaning-Centered Psychotherapy for Chinese patients with advanced cancer (MCP-Ch) to enhance acceptability, comprehensibility, and implementation of the intervention in usual care settings, guided by the Ecological Validity Model (EVM) and the Practical, Robust Implementation and Sustainability Model (PRISM). Methods Fifteen purposively sampled mental health professionals who work with Chinese cancer patients completed surveys providing Likert-scale ratings on acceptability and comprehensibility of MCP-Ch content (guided by the EVM) and pre-implementation factors (guided by PRISM), followed by semi-structured interviews. Survey data were descriptively summarized and linked to qualitative interview data. Three analysts independently coded the transcripts according to EVM and PRISM domains; discrepancies were resolved through discussion and consensus. Results Quantitative findings showed high appropriateness and relevance of MCP-Ch across five EVM domains of Language, Metaphors/Stories, Goals, Content, and Concepts. Qualitative analysis yielded 23 inductive codes under the seven EVM domains: (1) Language (3 subcodes), (2) Persons (2 subcodes), (3) Metaphors/Stories (2 subcodes), (4) Methods (8 subcodes), (5) Content (2 subcodes), (6) Goals (4 subcodes), and (7) Concepts (2 subcodes). Themes based on PRISM included (1) Intervention characteristics (organizational perspective, 7 subcodes; and patient perspective, 6 subcodes) (2) External environment (2 subcodes), (3) Implementation and sustainability infrastructure (4 subcodes), and (4) Recipients (organizational characteristics, 5 subcodes; and patient characteristics, 4 subcodes). Conclusion Recommendations for next steps include increasing the MCP-Ch protocol’s flexibility and adaptability to allow interventionists to flexibly tailor MCP-Ch material to meet patients’ individual needs, simplifying content to improve comprehension and acceptability, providing additional training to Chinese-serving providers to increase adoption and sustainability, and considering interpreter-assisted delivery to increase access. Findings yielded important information to maximize cultural relevance as well as the implementation and sustainability potential of MCP-Ch in real-world settings.

The role of neuroleptics for terminal agitated delirium is controversial. We assessed the effect of three neuroleptic strategies on refractory agitation in patients with cancer with terminal delirium. In this single-centre, double-blind, parallel-group, randomised trial, patients with advanced cancer, aged at least 18 years, admitted to the palliative and supportive care unit at the University of Texas MD Anderson Cancer Center (Houston, TX, USA), with refractory agitation, despite low-dose haloperidol, were randomly assigned to receive intravenous haloperidol dose escalation at 2 mg every 4 h, neuroleptic rotation with chlorpromazine at 25 mg every 4 h, or combined haloperidol at 1 mg and chlorpromazine at 12·5 mg every 4 h, until death or discharge. Rescue doses identical to the scheduled doses were administered at inception, and then hourly as needed. Permuted block randomisation (block size six; 1:1:1) was done, stratified by baseline Richmond Agitation Sedation Scale (RASS) scores. Research staff, clinicians, patients, and caregivers were masked to group assignment. The primary outcome was change in RASS score from time 0 to 24 h. Comparisons among group were done by modified intention-to-treat analysis. This completed study is registered with ClinicalTrials.gov, NCT03021486. Between July 5, 2017, and July 1, 2019, 998 patients were screened for eligibility, with 68 being enrolled and randomly assigned to treatment; 45 received the masked study interventions (escalation n=15, rotation n=16, combination n=14). RASS score decreased significantly within 30 min and remained low at 24 h in the escalation group (n=10, mean RASS score change between 0 h and 24 h −3·6 [95% CI −5·0 to −2·2]), rotation group (n=11, −3·3 [–4·4 to −2·2]), and combination group (n=10, −3·0 [–4·6 to −1·4]), with no difference among groups (p=0·71). The most common serious toxicity was hypotension (escalation n=6 [40%], rotation n=5 [31%], combination n=3 [21%]); there were no treatment-related deaths. Our data provide preliminary evidence that the three strategies of neuroleptics might reduce agitation in patients with terminal agitation. These findings are in the context of the single-centre design, small sample size, and lack of a placebo-only group. National Institute of Nursing Research.

BackgroundDepression and vitamin D deficiency are common in patients with lung cancer and have prognostic implications in cancer settings. However, their relationship and concomitant survival implications have not been evaluated in patients with metastatic lung cancer specifically. We hypothesised that vitamin D deficiency would be associated with depression and inferior cancer-related survival in patients receiving therapies for stage IV lung cancer.MethodsThis was a cross-sectional analysis of vitamin D, depression and lung cancer characteristics. Vitamin D levels were stratified by level (no deficiency ≥30 units, mild deficiency 20 to 29 units and moderate-to-severe <20 units). Depression was measured by the Hospital Anxiety and Depression Scale-Depression (HADS-D). Survival estimations were made using Cox proportional hazard model and Kaplan-Meier analyses.ResultsVitamin D deficiency was evident in almost half of the sample (n=98) and was associated with significant depression (HADS-D ≥8) (χ2=4.35, p<0.001) even when controlling for age, sex and inflammation (β=-0.21, p=0.03). Vitamin D deficiency and depression were associated with worse survival and showed evidence of an interaction effect (HR 1.5, p=0.04).ConclusionVitamin D deficiency is associated with depression in patients with metastatic lung cancer. Depression modulates the survival implications of vitamin D deficiency in this population. The role of vitamin D deficiency in cancer-related depression warrants further investigation since both are amenable to treatment. Psychological and nutritional prognostic considerations may help inform treatment paradigms that enhance quality of life and survival.

Chimeric antigen receptor T cells are used in the treatment of B-cell leukemias. Common chimeric antigen receptor T-cell toxicities can range from mild flu-like symptoms, such as fever and myalgia, to a more striking neuropsychiatric toxicity that can present as discrete neurological symptoms and delirium. We report here two cases of chimeric antigen receptor T-cell neuropsychiatric toxicity, one who presented as a mild delirium and aphasia that resolved without intervention, and one who presented with delirium, seizures, and respiratory insufficiency requiring intensive treatment. The current literature on the treatment and proposed mechanisms of this clinically challenging chimeric antigen receptor T-cell complication is also presented.

Caregivers of patients with advanced cancer shoulder immense responsibilities as they care for patients, including symptom and medication management, providing emotional support, and navigating healthcare treatment and decision-making. Due to the heavy toll of these responsibilities, caregivers are at high risk for profound mental health challenges, including anxiety, depression, and posttraumatic stress disorder. A key driver of this heightened risk for psychopathology in caregivers is existential distress, manifesting as a loss of meaning and purpose, decreased spiritual well-being, and hopelessness. Historically, psychosocial interventions targeting distress in cancer caregivers have neglected to address existential distress. Meaning-Centered Psychotherapy for Cancer Caregivers, a seven-session structured intervention, was developed to address this gap. In a pilot randomized controlled trial, the approach led to enhancements in personal meaning, benefit finding, and spiritual well-being. Here, we present a large, multi-site trial that aims to definitively examine the efficacy of Meaning-Centered Psychotherapy for Cancer Caregivers in an adequately powered study. This randomized controlled trial will evaluate the efficacy of Meaning-Centered Psychotherapy for Cancer Caregivers versus Supportive Psychotherapy for Cancer Caregivers on primary (personal meaning and spiritual well-being) and secondary (anxiety, depression, sense of meaning in caregiving, benefit finding, caregiver burden, social support) outcomes at baseline, posttreatment, and at 6- and 12- months follow-up. It will also evaluate the role of sense of meaning in life as a mediator of secondary outcomes, as well as the impact of Meaning-Centered Psychotherapy for Cancer Caregivers on pre- and post-loss bereavement outcomes. Caregivers (N = 200) of patients with advanced (stage III/IV) solid tumor cancers from Memorial Sloan Kettering Cancer Center, Sylvester Comprehensive Cancer Center, and the community will be enrolled. Meaning-Centered Psychotherapy for Cancer Caregivers has the potential to help alleviate existential suffering in caregivers as they manage the multifaceted demands of caring for patients with advanced cancer. This trial seeks to evaluate the efficacy of this intervention in a more robust and representative trial of cancer caregivers and extends prior research to explore mediators of improvement and the impact of the intervention on pre- and post-loss bereavement outcomes. ClinicalTrials.gov NCT06307535. Registered on 03/05/2024.