Dignity Therapy and Its Effect on the Survival of Terminally Ill Portuguese Patients
Authors: Miguel Julião, Baltazar Nunes, António Barbosa
Journal: Psychotherapy and Psychosomatics (2014)

The empirical literature regarding the effect of psychotherapy on the survival of cancer patients is highly contested [1,2]. Dignity therapy (DT) is a brief, individualized intervention, which gives terminally ill patients the opportunity to convey memories and important disclosures and to prepare a legacy document [3]. We conducted a 36-month phase II, nonblinded randomized controlled trial (RCT), comprised of two study arms: (1) DT and standard palliative care (SPC) and (2) SPC alone. Results demonstrating the significant benefits of DT on depressive and anxiety symptoms have been previously reported [4]. The aim of this study was to determine whether those patients randomized to DT along with SPC had a survival advantage over those randomized to SPC alone. Ninety-two patients were assessed for eligibility, 80 of whom were randomized (39 to DT and 41 to SPC). All participants were ≥18 years old, had a prognosis ≤6 months, showed no evidence of dementia or delirium, had a Mini-Mental State score ≥20, were able to read and speak Portuguese and provided written informed consent.There were no differences between the two groups regarding baseline characteristics (table 1). The estimated median survival time (measured as the time from first contact to death) was 23.2 days (95% CI 20.9-25.6) for the total sample (80 participants), 26.1 days (95% CI 23.2-20.0) for the DT group (39 participants) and 20.8 days (95% CI 17.4-24.2) for the control group (41 participants; p = 0.025). After adjustment by Cox regression for sex, age, educational level, occupation, tumor type, metastasis, performance status, previous treatment and follow-up in palliative care, group allocation remained a significant predictor of survival [hazard ratio of death for the DT group was 0.35 (95% CI 0.13-0.92)] (fig. 1).This is the first RCT studying the effect of DT on the survival of terminally ill patients. The increased survival of patients allocated to the DT, although modest, begs some explanation. Being engaged in a psychotherapeutic intervention may enhance a sense of meaning and purpose. Our RCT previously demonstrated the efficacy of DT compared to SPC on several psychosocial variables, including quality of life [4,5]. The relationship between these variables and survival is unclear, but could be affiliated with the improvement in disposition, the will to live and physical suffering, along with nutritional and endocrine parameters. It is difficult to establish causality, given the poorly understood relationship between psychological well-being and survival [6]. Given this RCT was not designed with survival as a primary outcome, there may be other nonspecific factors accounting for group differences.It must be remembered that our sample primarily included older patients. As such, the relationship between DT and survival within younger cohorts remains unknown. Furthermore, all participants were imminently dying; as such, we do not know if survival advantages would have been observed in earlier stages of the illness trajectory. While a survival advantage may have been psychologically mediated, future blinded studies are needed to ensure that this was not an attentional effect. These findings suggest that future studies, examining the mechanisms underlying this important and complex phenomenon, are warranted.We would like to express our gratitudeto Prof. H. Chochinov for his unwavering guidance and wisdom.