Life Review in Palliative Care

Craig Goldie Palliative Rounds April 22, 2016

Objective

– Overview of therapeutic life review techniques (reminiscence therapy / legacy creation) – Look at evidence supporting these interventions – Discuss (as a group) how we are doing in Kingston in these areas and whether we need to improve

Conflict of Interest

– None to declare

Palliative Care definition

– Palliative care aims to provide whole-person care by relieving pain and other distressing symptoms, integrating psychological and spiritual aspects of patient care, enhancing quality of life and death while neither hastening nor postponing death and, where possible, positively influencing the course of an illness.

Are we good at whole-person care? – Many have unmet psychological/emotional needs – Patient consultation (oncologist) – less than 1% of time focused on psychological/spiritual concerns – Physician/HCP inadequacy in those domains – Lack of time and skill – Perceived need to prioritized unresolved physical symptoms

Therapeutic Life Review

– Evaluative activity – Examination – Addressing – Resolving or rectifying conflict (if able)

– Different from reminiscence – Pleasurable re-telling or re-living of older memories – More of a passive activity; less critical assessment

Therapeutic Life Review In Non-Palliative Care – Therapeutic Life Review shown to be effective in: – Reducing depression in elderly, CVA patients – Improving self-esteem/life satisfaction in veterans – Improving QOL in people living with AIDS – Preventing/reducing despair in new LTC patients

In Palliative Care

– TLR is gaining support in terminally ill – Several studies support use – No large systematic review until 2015 JPSM

Inclusion Criteria

1.

They quantitatively evaluated the implementation of a “manualized” therapeutic life review with palliative care patients or patients identified with life-limiting illnesses with a prognosis of six months or less

2.

Patients were adults (18 years+)

3.

Publication was reported in English

4.

Publication was published in a peer-reviewed journal.

Inclusion Criteria cont’d

– Interventions needed to be manualized, either in a published or unpublished form and available to the public for replication, or an adequate description of the intervention needed to be given so that the reader could implement the intervention.

Systematic Review Studies

– N = 14 studies, – US 5, Japan 3, Canada 2, Australia 1, H.Kong 1 – Canada + Australia +/- US (2)

– In 9, intervention by SW, psychologist or psychiatrist alone – In 3, above + RN, In 2, RN alone – In inpatient (2), outpatient (3), home (1), anywhere (8)

– N = 10 interventions – In 8, TLR was whole intervention – In 2, TLR was a component

Systematic Review Studies

– All done face-to-face (alone mostly, group) – Interventions varied – number of sessions, duration of sessions – Patient population functional status ranged from independent to bed-bound – Survival 28 – 110 days

Interventions

1.

Legacy Activities

2.

Life Review Intervention

3.

One-Week Short-Term Life Review

4.

Meaning-Centered Group Psychotherapy

5.

Individual Meaning-Centered Psychotherapy

6.

Dignity Therapy

7.

Forgiveness Therapy

8.

Meaning-Making Intervention

9.

Adaptation to Meaning-Making Intervention

10.

Meaning of Life Intervention

11.

Outlook Intervention

1. Legacy Activities

– Patient and carer dyad, led by interventionist – Goal to create legacy activities to be enjoyed both before and after death – Scrapbook – Cookbook – Audio/videotape of family stories

– 3 sessions – Plan activity, coach activity, share project – Legacy Participant Notebook

1. Legacy Activities

– Single RCT (31 patients) – Improvements in: – Caregiver stress – Talkativeness/social interaction (patient + caregiver reports) – Breathlessness

– No improvement for pain or global wellbeing

2. Life Review Intervention

– Patients asked to describe important events in their lives – 4 sessions, chronological: – Childhood – Adolescence – Adulthood – Present situation

– Take notes, no “product”

2. Life Review Intervention

– Single-armed pilot study (N=12) – Improvements in: – Mood – Orientation – Spirituality – Overall QOL

– Noted more improvements in patients who could evaluate their lives and integrate the bad memories with the good.

3. One-Week Short-Term Life Review – Condensed version of Life Review Intervention – 2 sessions: – 1st: Review life (good and bad memories) in structured fashion – Interventionist selects key words from first session, creates album with pictures from books/magazines – 2nd: Review the album, patient given time to re-evaluate, reconstruct, appreciate their lives

3. One-Week Short-Term Life Review – Single arm (N=30)  RCT (N=68) – Improvements: – Spiritual well-being – Hope – ‘Life completion’ – Suffering

– No effect on physical symptoms

4. Meaning-Centered Group Psychotherapy – Eight group sessions (weekly themes) – Concepts/sources of meaning – Cancer and meaning – Historical sources of meaning (past) – Historical sources of meaning (present/future) – Attitudinal sources of meaning / life limitations

– Creative sources of meaning-creativity – Experiential sources of meaning-nature, art, humor – Termination – goodbyes, hopes for future

4. Meaning-Centered Group Psychotherapy – RCT (vs Supportive Group Therapy) (N=90) – Improvements: – Spiritual well-being – Meaning / peace

– Non-significant improvement for hopelessness, desire for death, anxiety

5. Individual MeaningCentered Psychotherapy – Adapted from meaning-centered group psychotherapy – Didactic and experiential exercises and psychotherapeutic techniques (reflection, clarification, exploration) – 7 one-hour sessions, themes similar to group – Patients receive readings/complete activities on their own time

5. Individual MeaningCentered Psychotherapy – RCT (vs Therapeutic Massage) (N=120) – Improvements: – Spiritual well-being – Meaning / peace – Faith – QOL – Number of symptoms – Symptom distress

– No change to hopelessness/anxiety/depression

6. Dignity Therapy

– 2 sessions: – 1st, dignity therapy questions – “Tell me about your life?” – “What are the important roles you have played?” – “What are your hopes and dreams for your loved ones?”

– Interview recorded/transcribed

– 2nd, review transcription and edit to their “generativity document” – Can be bounded/bequeathed.

6. Dignity Therapy

– Single-arm (N=100)  RCT (N=441) – Improvements: – No significant improvements of validated measures – Distress-specific Patient Dignity Inventory

– Felt to be secondary to low levels of preintervention distress – Patient evaluation showed improvements: – Likeliness of helpfulness – Ability to increase QOL – Increasing sense of dignity

7. Forgiveness Therapy

– Four sessions (usually 10wks – 14mos) – Review an issue from their life that needs resolution – Concepts of positive, negative anger

– Expand on the situation from perspective of offending person – Identifying compassion/cognitive reframing

– To let go of the associated painful memory

– Identify outcomes of forgiveness and a new way of relating to the offender

7. Forgiveness Therapy

– ‘Yoked pair’ design (N=20) – Improvements: – Forgiveness – Anger – Hope – QOL

8. Meaning-Making Intervention – One to four sessions – Acknowledge present – Contemplate past

– Commit to the present for the future

– Achieved using “life timeline” – Tell story starting from diagnosis – Add in their life “turning points” – Review how they dealt with those critical events

– Plan for future with short + long-term goals “using their previously recalled strengths”

8. Meaning-Making Intervention – RCT (N=74) – Improvements: – Self-esteem – Optimism – Self-efficacy

– Noted participation resulted in increased psychological support (3x intervention group, 2x control group) – Did intervention increase vulnerability or proactivity?

9. Adaptation to MeaningMaking Intervention – One to four sessions (mostly 3) with therapist – Support self-exploration of 3 tasks: – Review the impact cancer has made on their lives – Recall other life events and successful coping mechanisms they used – Review their life goals now that they have a cancer diagnosis

9. Adaptation to MeaningMaking Intervention – RCT (N=28) – Improvements: – Spiritual well-being – Spiritual support – Existential well-being (at 3 months)

– Also showed increase in external counseling in both arms (too small to draw significance)

10. Meaning of Life Intervention – Two sessions (over 2-3 days): – Session 1 – recorded semistructured interview re: search for personal meaning: – “What do you think about your life?” – “How have you faced adversity in your life?” – “What do you do to love yourself and others?” – “What brings you joy?” – “What do you appreciate in your life?”

10. Meaning of Life Intervention – In-between sessions, facilitator listens to recording and extracts information into 3 themes: – “The taste of life” – “The power of love” – “The meaning of life”

– Session 2 – reviews the summary of the interview with the patient

10. Meaning of Life Intervention – RCT (N=84) – Improvements: – Quality of life – Existential distress – “Overall quality of life”

11. Outlook Intervention

– Three sessions: – Ask several questions in following themes: – Life story – Forgiveness – Legacy and heritage

– Given prompt cards to encourage personal reflection

– Given handout encouraging own legacy activity – I.e. scrapbook, photo album, letter writing

11. Outlook Intervention

– Single-arm (N=11), RCT (N=82) – (Non-significant) improvements: – Functional status – Anxiety – Depression – End-of-life preparation

Systematic Review Results

– A few robust RCTs showed improvements – Diversity of interventions/measures – hard to promote one intervention as “the most effective way”. – Each team can choose one that suits patient population and team abilities/make-up

– Weakness of several studies was inadequate power

Systematic Review Results

– Weakness of several studies was inadequate power (mostly due to attrition) – Very common issue in palliative care research

– Shorter interventions fared better – Individual meaning-centered psychotherapy – One-week short-term life review

– Did not screen for distress prior to participation – Low pre-intervention distress left little room for improvement (i.e. dignity therapy) – Forgiveness therapy showed more (as inclusion required “sense of being treated unjustly and hurt deeply by another”

Systematic Review Conclusion – “…Therapeutic life interventions are showing promise as a viable option in helping palliative care patients to address their existential/spiritual domains, an area often undertreated.”

Discussion