BACKGROUND: Patient suicides can affect clinicians both personally and professionally, with frequent reports of psychological and behavioral changes occurring in response to this type of patient death. Although hospice clinicians have regular exposure to dying patients, the impact of patient suicide on this group has been understudied. OBJECTIVES: This study examined the personal and professional impact of patient suicides among hospice clinical staff, the coping strategies used by this group, and their recommendations for staff support after a patient suicide. DESIGN: Utilizing an online survey, 186 hospice staff qualitatively described the impact of patient suicides on them as people and professionals, their resulting coping strategies, and any recommendations for supporting others. Three study investigators coded all of the staff responses at a paragraph level and summarized the most common emergent themes using grounded theory procedures. SETTING/SUBJECTS: One hundred eighty-six clinical staff members who worked in an academic nonprofit hospice setting. MEASUREMENTS: An open-ended, qualitative survey was used to gather data about demographics, clinical experience, exposure to known or suspected suicides, recommendations for support in the event of a patient suicide, the personal and professional impacts of suicide, and coping strategies. RESULTS: The themes expressed by the hospice staff in reaction to patient suicides included: psychological responses such as feelings of guilt and self-doubt, changes in professional attitudes, and changes in clinical practice such as greater sensitivity to signs of suicide. When coping with a patient suicide, hospice staff described the use of team-based support strategies, debriefings, and personal spiritual practices. Recommendations for future support included facilitated debriefings, individual counseling, spiritual practices, leaves of absence, self-care activities, and educational interventions. CONCLUSION: Data from this small study may help clinicians and administrators more fully understand the impact of patient suicides on hospice staff and may serve as a foundation for the development of effective strategies to support staff after a patient suicide.

ABSTRACTObjective:Wisdom is a complex trait, and previous research has identified several components of wisdom. This study explored the possible impact of a diagnosis of a terminal illness on the conceptualization and evolution of wisdom while facing the end of life. DESIGN AND PARTICIPANTS:Semi-structured qualitative interviews were conducted with 21 hospice patients aged 58-97 years who were in the last six months of their life. METHODS:Hospice patients were asked to describe the core characteristics of wisdom, as well as how their terminal illness might have impacted their understanding of this concept. The interviews were audiotaped, transcribed, and coded by the research team using a grounded theory analytic approach based on coding consensus, co-occurrence, and comparison. RESULTS:Broad concepts of wisdom described by the hospice patients align with the extant literature, thereby supporting those general conceptualizations. In addition, hospice patients described how their life perspectives shifted after being diagnosed with a terminal illness. Post-illness wisdom can be characterized as a dynamic balance of actively accepting the situation while simultaneously striving for galvanized growth. This delicate tension motivated the patients to live each day fully, yet consciously plan for their final legacy. CONCLUSION:The end of life offers a unique perspective on wisdom by highlighting the modulation between actively accepting the current situation while continuing the desire to grow and change at this critical time. This paradox, when embraced, may lead to even greater wisdom while facing one's own mortality.

There is little agreement about what constitutes good death or successful dying. The authors conducted a literature search for published, English-language, peer-reviewed reports of qualitative and quantitative studies that provided a definition of a good death. Stakeholders in these articles included patients, prebereaved and bereaved family members, and healthcare providers (HCPs). Definitions found were categorized into core themes and subthemes, and the frequency of each theme was determined by stakeholder (patients, family, HCPs) perspectives. Thirty-six studies met eligibility criteria, with 50% of patient perspective articles including individuals over age 60 years. We identified 11 core themes of good death: preferences for a specific dying process, pain-free status, religiosity/spirituality, emotional well-being, life completion, treatment preferences, dignity, family, quality of life, relationship with HCP, and other. The top three themes across all stakeholder groups were preferences for dying process (94% of reports), pain-free status (81%), and emotional well-being (64%). However, some discrepancies among the respondent groups were noted in the core themes: Family perspectives included life completion (80%), quality of life (70%), dignity (70%), and presence of family (70%) more frequently than did patient perspectives regarding those items (35%-55% each). In contrast, religiosity/spirituality was reported somewhat more often in patient perspectives (65%) than in family perspectives (50%). Taking into account the limitations of the literature, further research is needed on the impact of divergent perspectives on end-of-life care. Dialogues among the stakeholders for each individual must occur to ensure a good death from the most critical viewpoint-the patient's.

Background

Dignity Therapy is a brief psychotherapy that can enhance a sense of legacy while addressing the emotional and existential needs of patients receiving hospice or palliative care. In Dignity Therapy, patients create a formalized "legacy" document that records their most cherished memories, their lessons learned in life, as well as their hopes and dreams for loved ones in the future. To date, this treatment has been studied for its impact on mitigating distress within hospice and palliative care populations and has provided mixed results. This study will instead focus on whether Dignity Therapy enhances positive outcomes in this population.

Methods/design

In this study, 90 patients with cancer receiving hospice or palliative care will complete a mixed-methods randomized controlled trial of Dignity Therapy (n = 45) versus Supportive Attention (n = 45). The patients will be enrolled in the study for 3 weeks, receiving a total of six study visits. The primary outcomes examine whether the treatment will quantitatively increase levels of positive affect and a sense of life closure. Secondary outcomes focus on gratitude, hope, life satisfaction, meaning in life, resilience, and self-efficacy. Using a fixed, embedded dataset design, this study will additionally use qualitative interviews to explore patients' perceptions regarding the use of positive outcome measures and whether these outcomes are appropriately matched to their experiences in therapy.

Discussion

Dignity Therapy has shown mixed results when evaluating its impact on distress, although no other study to date has solely focused on the potential positive aspects of this treatment. This study is novel in its use of mixed methods assessments to focus on positive outcomes, and will provide valuable information about patients' direct experiences in this area.

Trial registration

ISRCTN91389194.