Dignity therapy: Preliminary cross-cultural findings regarding implementation among Japanese advanced cancer patients

Dignity therapy is a novel, brief, and individualized psychotherapeutic intervention developed in Western countries1,2 and appears to be a feasible and effective approach for addressing the existential distress experienced by advanced cancer patients.3 4 We investigated the feasibility of providing dignity therapy for terminally ill cancer patients in Japan. This study consisted of a hospice/palliative care inpatient setting (Study 1) and an inpatient setting in a regional cancer center and/or general hospital (Study 2). The subjects were adult advanced cancer patients whose estimated prognosis was of less than six months. In Study 1, potentially eligible subjects were consecutively enrolled for the study in hospice/palliative care units. In Study 2, trained psychiatrists sampled potentially eligible participants who were expected to benefit from dignity therapy. The current study was approved by the Institutional Review Board and Ethics Committee of each research institution; the trial was registered as UMIN000001140. Written consent was obtained from each patient. The study procedure was almost the same as that used in the original study.1 The participation rate of the eligible patients and the completion rate of the participants were evaluated as indicators of the feasibility. The patient’s experience undergoing dignity therapy was evaluated using the Dignity Therapy Feedback Questionnaire (DTFQ), which is a self-reported questionnaire developed by Chochinov (personal communication) to evaluate a patient’s perception regarding the usefulness of and his or her satisfaction with dignity therapy. Regarding feasibility, among 22 eligible patients (14%) who had been consecutively admitted to two palliative care units, three subjects participated while 19 patients (86%) refused. Because the refusal rate was much higher than expected and the reason for refusal as described by the subjects suggested a potentially negative influence of introducing dignity therapy to some patients, the research committee decided to stop the consecutive sampling in Study 1. The reasons for refusal were as follows: ‘It just makes me think about death’; and ‘Why would you recommend such a thing to me when I am dying? ’ Because there were eight participants in Study 2 (no problems with the enrollment of these subjects were encountered), a total of 11 patients participated and completed the intervention. Regarding the DTFQ, the following findings were obtained (percentages indicate the proportion of positive responses): usefulness for improving dignity (67%), benefits (56%), improvement of meaning of current situation (56%), improvement of purpose of life (44%), usefulness for ameliorating suffering (44%), helpfulness for family (78%), usefulness for sense of well-being (56%), burden to physical condition (0%), and recommendation for other patients (33%). Our findings suggest the potential influence of unexpected underlying cultural differences and may have several potential interpretations. First, underlying differences regarding the general attitude toward a ‘good death’ between Western and Japanese populations may have influenced the lower participation rate. A previous Japanese study demonstrated that ‘unawareness of death’ is a relevant concept of good death in Japan.5 Terminally ill cancer patients who wish that they were unaware of their impending death may be less likely to participate in dignity therapy, even though they are receiving specialized palliative inpatient care. Their aversion to participating in the study may not have been due to the dignity therapy per se, but rather, their having been confronted with information that they did not wish to hear. Second, the higher refusal rate in Japan, compared with Western countries (such as a recent randomized trial with a participation rate of 50%),2 suggests that terminally ill cancer patients in Japan may try to cope with their terminal condition by denying their impending death. While some previous studies have indicated that denial is a commonly observed psychological defense mechanism among cancer patients, 6 Japanese cancer patients may be more likely to cope with their distressing medical condition using denial than Western cancer populations, as suggested by a previous study.7 Lastly, Japan still has many unique cultural characteristics. For example, because the preferred communication style is generally nonverbal, indirect, and serene, tacit understanding or heart-to-heart communication (‘ishin denshin’) operates as a powerful traditional value that is possible in a close community.8 In addition, a previous Japanese study 437214 PMJ26510.1177/02692163124372142012Akechi et al.Palliative Medicine