Developing and Evaluating a Psychological Intervention for use in Palliative Care

As a GWR research project joint funded by Hospiscare, the main objective of this research was to examine the nature of psychological distress in palliative care, with the specific purpose of developing and evaluating accessible psychological interventions suitable for Hospiscare staff to use with clients. There is evidence that palliative care patients and their caregivers experience psychological difficulties including (a) studies of depression and anxiety in palliative care; (b) the concerns expressed by palliative care patients and their caregivers. However, the studies are generally qualitative in nature based on interviews of small samples of participants. Therefore, Study 1 and Study 2 adopted a cross-sectional design to examine psychological distress and rumination in samples of palliative care patients, their caregivers and an age-matched control group. The results from Study 1 and Study 2 indicated that psychological distress and rumination on existential concerns were elevated in palliative care patients and their caregivers. Furthermore, findings suggested an association between psychological distress and abstract rumination. Study 3 reported a case series piloting an intervention developed from concreteness training (CT) designed to address abstract rumination in palliative care. The case series indicated that with some modification to the identification and screening of patients, the treatment could be acceptable and feasible for palliative care patients. Study 4 examined the effectiveness of the CT guided self-help intervention in a randomized controlled trial. Findings indicated that the intervention could be effective for reducing anxiety, but not depression in palliative care patients. Moreover, Study 5’s findings also raised the possibility that abstractness was a partial mediator of the effects of the intervention on self-reported symptoms of anxiety in palliative care patients. Study 5 utilised a cluster randomized controlled design to evaluate a training programme designed to teach hospice staff how to deliver the CT guided self-help intervention. Results indicated that there was a more positive impact of routine care on patient distress for nurses attending training, when compared to nurses not attending the training. However, the training did not impact on nurses’ self-reported confidence or behaviour in addressing patients’ distress. TABLE OF CONTENTS ABSTRACT 2 ACKNOWLEDGEMENTS 4 STATEMENT OF THE CANDIDATE’S CONTRIBUTION TO CO-AUTHORED PAPERS 5 STATEMENT OF THE SUPERVISORS’ CONTRIBUTION TO CO-AUTHORED PAPERS 7 CHAPTER 1: INTRODUCTION 19 1.1 Definition of palliative care 19 1.2 Levels of psychological distress in palliative care patients 21 1.3 Practical drivers for research 26 Psychological issues in palliative care 28 2.1 Psychological distress in palliative care 29 2.1.1 Definition of depression 29 2.1.2 Definition of anxiety 32 2.1.3 Methods of assessing prevalence of depression and anxiety in palliative care patients 35 2.1. 4 Rates of diagnosis of depression and anxiety in palliative care patients 37 2.1. 5 Prevalence of depression and anxiety in carers of palliative care patients 40 2.1. 6 Concerns expressed by palliative care patients 41 2.1. 7 Concerns expressed by carers of palliative care patients 45 2.1. 8 Limitations of studies identifying concerns in palliative care 46 Conclusion for Section 2.1. 47 2.2 Implications of psychological distress in palliative care 48 2.2.1 Impact of psychological distress on physical symptoms 48 2.2.2 Relationship between psychological distress and emotional wellbeing 49 2.2.3 Impact of psychological distress on quality of life 50 2.2.4 Impact of psychological distress on desire for hastened death 50 2.2. 5 Impact of psychological distress for carers of palliative care patients 52 Conclusion for Section 2.2. 53 2.3 Issues in assessment and treatment of psychological distress in palliative care 53 2.3. 1 Assessment of psychological distress in palliative care 54 2.3. 2 Psychological interventions for palliative care patients 55 2.3. 3 Psychological interventions for carers of palliative care patients 66 2.3. 4 Pharmaceutical interventions in palliative care 68 2.3. 5 Accessibility and availability of psychological interventions in palliative care 70 Conclusion for Section 2.3. 71 2.4 Rumination and distress in palliative care 72 2.4. 1 Rumination 72 Prospective longitudinal studies 74 Experimental studies 75 2.4. 2 Theoretical rationales for rumination in palliative care 77 2.4. 3 Empirical evidence of rumination in palliative care 79