Engaging Mortality: Effective Implementation of Dignity Therapy.

Abstract

<b><i>Background:</i></b> Patients consider the life review intervention, Dignity Therapy (DT), beneficial to themselves and their families. However, DT has inconsistent effects on symptoms and lacks evidence of effects on spiritual/existential outcomes. <b><i>Objective:</i></b> To compare usual outpatient palliative care and chaplain-led or nurse-led DT for effects on a quality-of-life outcome, dignity impact. <b><i>Design/Setting/Subjects:</i></b> In a stepped-wedge trial, six sites in the United States transitioned from usual care to either chaplain-led or nurse-led DT in a random order. Of 638 eligible cancer patients (age ≥55 years), 579 (59% female, mean age 66.4 ± 7.4 years, 78% White, 61% stage 4 cancer) provided data for analysis. <b><i>Methods:</i></b> Over six weeks, patients completed pretest/posttest measures, including the Dignity Impact Scale (DIS, ranges 7-35, low-high impact) and engaged in DT+usual care or usual care. They completed procedures in person (steps 1-3) or via Zoom (step 4 during pandemic). We used multiple imputation and regression analysis adjusting for pretest DIS, study site, and step. <b><i>Results:</i></b> At pretest, mean DIS scores were 24.3 ± 4.3 and 25.9 ± 4.3 for the DT (<i>n</i> = 317) and usual care (<i>n</i> = 262) groups, respectively. Adjusting for pretest DIS scores, site, and step, the chaplain-led (<i>β</i> = 1.7, <i>p</i> = 0.02) and nurse-led (<i>β</i> = 2.1, <i>p</i> = 0.005) groups reported significantly higher posttest DIS scores than usual care. Adjusting for age, sex, race, education, and income, the effect on DIS scores remained significant for both DT groups. <b><i>Conclusion:</i></b> Whether led by chaplains or nurses, DT improved dignity for outpatient palliative care patients with cancer. This rigorous trial of DT is a milestone in palliative care and spiritual health services research. clinicaltrials.gov: NCT03209440.