Dignity Therapy: Setting theFoundation for this Novel Palliative
Care Psychotherapeutic Approach

Harvey Max Chochinov OC OM MD PhD FRSCDistinguished Professor, Department of Psychiatry, Family Medicine & Community
Health Sciences University of Manitoba
Senior Scientist, Research Institute on Oncology and Hematology (Patient Experience),
CancerCare ManitobaStability of Will to Live with Pain in an 80 Year-old
Patient with Colorectal Cancer
60-- Will to LiveWill to Live & ESAS Score

50403020

100050100

150200Observation Number (two per day)

250300Lancet. 1999;354:816-9.

Stability of Will to Live with Pain in an 80 Year-old
Patient with Colorectal Cancer
60

Will to Live & ESAS Score50

Will to Live---- Pain

403020100050100

150200Observation Number (two per day)

250

300

Lancet. 1999;354:816-9.

Reasons - According to Physicians Patients Requested Euthanasia/PAS• Loss of Dignity• Pain• Unworthy Dying• Being Dependent• Tiredness of Life
• Pain Alone

- 57%

- 49%
- 49%
- 33%
- 23%
- 5%
Van der Maas Lancet 1991

Distribution of Sense of Dignity Responses
Responses

Prevalence

0 No sense of lost dignity

114 (53%)

1 Minimal sense of lost dignity

64 (30%)2 Mild; sense of lost dignity occasionally;
regarded as minor problem
3 Moderate sense of lost dignity; regards
as significant problem
4 Strong; feels clear sense of lost dignity
most of time
5 Severe; clear sense of lost dignity almost
always present
6 Extreme; sense of lost dignity virtuallyconstant

19 (9%)
11 (5%)
5 (2%)
0 (0%)
0 (0%)

Chochinov et al. Lancet. 1999;354:816-9

• Desire for death (p < 0.0014)• Loss of will to live (p < 0.013)• Depression (p < 0.0084)• Hopelessness (p < 0.020)• Anxiety (p < 0.003)

Chochinov et al. Lancet. 1999;354:816-9

• Pain (p < 0.048)• Difficulty
withbowel functioning (p< 0.026)• Physical appearance(p < 0.002)

Chochinov et al. Lancet. 1999;354:816-9

• Bathing (OR = 8.45 [1.50 to47.70]; p < 0.016)• Dressing (OR = 2.79 [0.95 8.15]; p < 0.061)• Incontinence (OR = 3.47
[1.27 - 9.51]; p < 0.016)

Chochinov et al. Lancet. 1999;354:816-9

Chochinov et al. Social Science and Medicine 2002

Social Support

Care Tenor

Generativity

Dignity Therapy

Aftermath Concerns

Continuity of Self

Maintenanceof Pride

Maintaining Hope
Role Preservation

Chochinov HM. Dignity-conserving care-a new model for palliative care. JAMA.2002

Dignity Therapy: Step by Step
1. Identify eligible patient;
2. Provide full explanation of Dignity Therapy;
3. Share Dignity Therapy Question Framework;
4. Obtain ‘framing’ history for Dignity Therapy;
5. Arrange Dignity Therapy session;
6. Conduct Dignity Therapy session;
7. Follow editing protocol to create generativity document;
8. At follow-up session, read document to patient; address
any final editing issues;
9. Provide patient final generativity document.

Dignity Therapy Question Framework•••••••••“Tell me a little about your life history, particularly the parts that you either

remember most, or think are the most important. When did you feel most alive?”“Are there specific things that you would want your family to know about you, andare there particular things you would want them to remember?”“What are the most important roles you have played in life (family roles, vocationalroles, community service roles, etc.)? Why were they so important to you, and what
do you think you accomplished in those roles?”“What are your most important accomplishments, and what do you feel most proudof?”“Are there particular things that you feel still need to be said to your loved ones, orthings that you would want to take the time to say once again?”“What are your hopes and dreams for your loved ones?”“What have you learned about life that you would want to pass along to others? Whatadvice or words of guidance would you wish to pass along to your (son, daughter,husband, wife, parents, others)?”“Are there words or perhaps even instructions you would like to offer your family tohelp prepare them for the future?”“In creating this permanent record, are there other things that you would likeincluded?”Dignity Therapy Study: Phase I Trial(n=100)Satisfied or highly satisfied

91%

Helpful or very helpful

86%

Increased Sense of Dignity

76%

Increased sense of purpose

68%

Heightened sense of meaning

67%

Increased will to live

47%

Believed it had or would help their family 81%

Finding the Dignity Intervention
Helpful to ones Family*Finding life more meaningful(r =.489; p<.000)*Having a heightened sense ofpurpose (r =.562; p<.000)*A lessened sense of suffering(r =.327; p=.001)*An increased will to live(r =.389; p<.000)

Family Dignity Follow-up Data (n=60)
Question
Helped patient

Percentage
95%

Gave patient heightened sense of purpose
Heightened patient's sense of dignity
Helped patient prepare for deathWas as important as any other aspect ofpatient’s care

71.7%
78.3%
65%
64.6%

Reduced patient’s suffering

43.3%

Helped surviving family during time of grief

78%

Will continue to comfort family
Recommend it to other patients and families

76.7%
95%

Dignity Therapy RCTPatient Data
Post Study Survey Questions
The study arm has…

χ2StandardCare (SC)ClientCenteredCare(CCC)

Dignity
Therapy(DT)…been as helpful as any other aspect of myhealth care

3.27

3.12

3.63

6.386 0.041…given me a sense of looking after
unfinished business

2.86

2.93

3.35

6.874 0.032…made me feel like I am still me

3.59

3.40

3.81

5.906 0.052…made me feel that I am still able to carryout importanttasks or fill an important role

3.48

3.02

3.62

8.963 0.011…made me feel that life was moremeaningful

3.19

3.31

3.55

6.731 0.035…given me a heightened sense of purpose

3.20

3.15

3.49

6.858 0.032

In general, I am satisfied with mypsychosocial care

4.14

3.99

4.25

5.969 0.051

2 dfpvalueDignity Therapy RCTPatient Data
Post Study Survey Questions

StandardCare (SC)ClientCenteredCare(CCC)

Dignity
Therapy
(DT)

χ2

3.00
2.57

2.56
2.65

3.27
3.11

10.354
9.379

pArms DTvalue SignificantlyOutperfor
med
CCC
0.006
SC
0.009

3.80
3.50
2.96
3.09
3.20
2.85

4.17
3.72
2.84
3.11
3.29
2.85

4.26
4.23
3.54
3.52
3.93
3.58

29.58335.501
14.52012.65533.86433.811

0.000
0.000
0.001
0.002
0.000
0.000

The study arm has…
…improved my spiritual well being…lessened my sense of sadness anddepression…been satisfactory…been helpful to me…improved my quality of life
…increased my sense of dignity…or will be of help to my family…or could change way my family seesof appreciates meSC
CCC, SC
CCC, SC
CCC, SC
CCC, SCCCC, SC

Dignity Therapy Data Overview• Establish high satisfaction; high acceptability• Benefits for themselves and their families• Increased sense of meaning and purpose.
• Studies with higher base rates of distressindicate lower depression, anxiety; andincreased hopefulness• Multiple adaptations i.e. different populations
and settings

Dignity Therapy Knowledge Translation•••••••••TRIALS
SwedenDenmark
Spain
Portugal
Italy
ScotlandEngland
Australia
Canada (Hamilton, Ottawa,Quebec City)

•••••
•••

TRAINING
USA
Australia
China
Portugal
Switzerland
IsraelGermany
Winnipeg