Academic Scientific JournalsThinking clearly about dignity: relationships between cognitive processes underlying perceived dignity as determinants of psychological adjustment
Keywords:
dignity, cognitions, uncertainty, anxiety, depressionAbstract
Background:
Public and professional views strongly equate dignity among the dying with their abilities to make decisions about medical and personal treatment and care. To make these decisions requires cognitive processes that inform our understanding of circumstances by integrating thoughts, experiences, and perceptions with prior knowledge. But patients with terminal illnesses, especially cancer, often experience problems stemming from cognitive changes and the cognitive state of uncer-tainty that can interfere with knowing what options for care are essential to targeting their sense of dignity. This paper aims to propose and test a model that defines targets for dignity-conserving care from underlying cognitive changes as antecedents to uncertainty that impact psychological adjustment of patients with advanced cancer.
Participants and procedure:
This is a cross-sectional observational study using participant data from 257 patients with advanced cancer. The Patient Dignity Inventory and the Hospital Anxiety and Depression Scale were administered to patients and analyzed according to model hypotheses.
Results:
Analyses used structural equational modeling to confirm model pathways. In the context of perceived dignity in advanced cancer, there was a direct pathway from patient reported problems with cognitive changes to uncertainty, that in turn had both direct and indirect effects on depression.
Conclusions:
The results suggest that cognitive changes challenge perceptions of dignity and can independently be targeted as modifia-ble processes to provide dignity-conserving care.
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References
Ahles, T. A., Root, J. C., & Ryan, E. L. (2012). Cancerand cancer treatment-associated cognitive change: an update on the state of the science. Journal of Clinical Oncology, 30, 3675–3686. https://doi. org/10.1200/JCO.2012.43.0116.
Anderson, E. C., Carleton, R. N., Diefenbach, M., & Han, P. K. J. (2019). The relationship between uncertainty and affect. Frontiers in Psychology, 10, 2504. https://doi.org/10.3389/fpsyg.2019.02504.
Bellido-Pérez, M., Crespo, I., Wilson, K. G., PortaSales, J., Balaguer, A., & Monforte-Royo, C. (2018). Assessment of the wish to hasten death in patients with advanced cancer: a comparison of 2 different approaches. Psycho-Oncology, 27, 1538–1544. https://doi.org/10.1002/pon.468.9.
Broadbent, E. (2019). Health and illness cognitions. In C. Llewellyn, S. Ayers, C. McManus, S. Newman, K. Petrie, & Revenson, T. A. (Eds.), Cambridge handbook of psychology, health and medicine (3rd ed., pp. 188–192). Cambridge University Press.
Chochinov, H. M. (2007). Dignity and the essence of medicine: The A, B, C, and D of dignity conserving care. British Medical Journal, 335, 184–187. https:// doi.org/10.1136/sbmj.0709328.
Chochinov, H. M., Hack, T., McClement, S., Kristjanson, L., & Harlos, M. (2002). Dignity in the terminally ill: a developing empirical model. Social Science & Medicine, 54, 433–443. https://doi.org/10.1016/ S0277-9536(01)00084-3.
Chochinov, H. M., Hassard, T., McClement, S., Hack, T., Kristjanson, L. J., Harlos, M., Sinclair, S., & Murray, A. (2008). The Patient Dignity Inventory: a novel way of measuring dignity-related distress in palliative care. Journal of Pain and Symptom Management, 36, 559–571. https://doi.org/10.1016/j. jpainsymman.2007.12.018.
Chochinov, H. M., Tataryn, D. J., Wilson, K. G., Enns, M., & Lander, S. (2000). Prognostic awareness and the terminally ill. Psychosomatics, 41, 500–504. https://doi.org/10.1176/appi.psy.41.6.500.
Crespo, I., Rodríguez-Prat, A., Monforte-Royo, C., Wilson, K. G., Porta-Sales, J., & Balaguer, A. (2020). Health-related quality of life in patients with advanced cancer who express a wish to hasten death: a comparative study. Palliative Medicine, 34, 630– 638. https://doi.org/10.1177/0269216320904607.
Etkind, S. N., Bristowe, K., Bailey, K., Selman, L. E., & Murtagh, F. E. (2017). How does uncertainty shape patient experience in advanced illness? A secondary analysis of qualitative data. Palliative Medicine, 31, 171–180. https://doi.org/10.1177/0269 216316647610.
Etkind, S. N., & Koffman, J. (2016). Approaches to managing uncertainty in people with life-limiting conditions: Role of communication and palliative care. Postgraduate Medical Journal, 92, 412–417. https://doi.org/10.1136/postgradmedj-2015-133371.
Gramling, R., Stanek, S., Han, P. K. J., Duberstein, P., Quill, T. E., Temel, J. S., Alexander, S. C., Anderson, W. G., Ladwig, S., & Norton, S. A. (2018). Distress due to prognostic uncertainty in palliative care: Frequency, distribution, and outcomes among hospitalized patients with advanced cancer. Journal of Palliative Medicine, 21, 315–321. https://doi.org/10.1089/jpm.2017.0285.
Guerrero-Torrelles, M., Monforte-Royo, C., TomásSábado, J., Marimon, F., Porta-Sales, J., & Balaguer, A. (2017). Meaning in life as a mediator between physical impairment and the wish to hasten death in patients with advanced cancer. Journal of Pain and Symptom Management, 54, 826–834. https://doi.org/10.1016/j.jpainsymman.2017.04.018.
Hagger, M. S., Koch, S., Chatzisarantis, N. L. D., & Orbell, S. (2017). The common sense model of self-regulation: Meta-analysis and test of a process model. Psychological Bulletin, 143, 1117–1154. https://doi.org/10.1037/bul0000118.
Herrero, M. J., Blanch, J., Peri, J. M., De Pablo, J., Pintor, L., & Bulbena, A. (2003). A validation study of the Hospital Anxiety and Depression Scale (HADS) in a Spanish population. General Hospital Psychiatry, 25, 277–283. https://doi.org/10.1016/ S0163-8343(03)00043-4.
Hosie, A., Davidson, P. M., Agar, M., Sanderson, C. R., & Phillips, J. (2013). Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: a systematic review. Palliative Medicine, 27, 486–498. https://doi. org/10.1177/0269216312457214.
Houska, A., & Loučka, M. (2019). Patients’ autonomy at the end of life: a critical review. Journal of Pain and Symptom Management, 57, 835–845. https:// doi.org/10.1016/j.jpainsymman.2018.12.339.
Jabloo, V. G., Alibhai, S. M. H., Fitch, M., Tourangeau, A. E., Ayala, A. P., & Puts, M. T. E. (2017). Antecedents and outcomes of uncertainty in older adults with cancer: a scoping review of the literature. Oncology Nursing Forum, 44, E152–E167. https://doi.org/10.1188/17.ONF.E152-E167.
Janelsins, M. C., Heckler, C. E., Peppone, L. J., Kamen, C., Mustian, K. M., Mohile, S. G., Magnuson, A., Kleckner, I. R., Guido, J. J., Young, K. L., Conlin, A. K., Weiselberg, L. R., Mitchell, J. W., Ambrosone, C. A., Ahles, T. A., & Morrow, G. R. (2017). Cognitive complaints in survivors of breast cancer after chemotherapy compared with agematched controls: an analysis from a nationwide, multicenter, prospective longitudinal study. Journal of Clinical Oncology, 35, 506–514. https://doi. org/10.1200/JCO.2016.68.5826.
Janelsins, M. C., Kesler, S. R., Ahles, T. A., & Morrow, G. R. (2014). Prevalence, mechanisms, and management of cancer-related cognitive impairment. International Review of Psychiatry, 26, 102– 113. https://doi.org/10.3109/09540261.2013.864260.
Johnson, P. R. S. (1998). An analysis of “dignity”. Theoretical Medicine and Bioethics, 19, 337–352. https://doi.org/10.1023/A:1009951813110.
Klepsch, M., Schmitz, F., & Seufert, T. (2017). Development and validation of two instruments measuring intrinsic, extraneous, and germane cognitive load. Frontiers in Psychology, 8, 1997. https://doi. org/10.3389/fpsyg.2017.01997.
Konrath, S., Meier, B. P., & Bushman, B. J. (2018). Development and validation of the Single Item Trait Empathy Scale (SITES). Journal of Research in Personality, 73, 111–122. https://doi.org/10.1016/j. jrp.2017.11.009.
Kurita, K., Garon, E. B., Stanton, A. L., & Meyerowitz, B. E. (2013). Uncertainty and psychological adjustment in patients with lung cancer. Psycho-Oncology, 22, 1396–1401. https://doi.org/10.1002/pon.3155.
Lucas, R. E., & Donnellan, M. B. (2012). Estimating the reliability of single-item life satisfaction measures: Results from four national panel studies. Social Indicators Research, 105, 323–331. https://doi. org/10.1007/s11205-011-9783-z.
Mairis, E. D. (1994). Concept clarification in professional practice – dignity. Journal of Advanced Nursing, 19, 947–953. https://doi.org/10.1111/j.1365- 2648.1994tb01173.x.
Massie, M. J. (2004). Prevalence of depression in patients with cancer. JNCI Monographs, 10021, 57–71. https://doi.org/10.1093/jncimonographs/lgh014.
McCormick, K. M. (2002). A concept analysis of uncertainty in illness. Journal of Nursing Scholarship, 34, 127–131. https://doi.org/10.1111/j.1547- 5069.2002.00127.x.
Mishel, M. H. (1990). Reconceptualization of the uncertainty in illness theory. Image: The Journal of Nursing Scholarship, 22, 256–262. https://doi.org/ 10.1111/j.1547-5069.1990.tb00225.x.
Mishel, M. H., & Braden, C. J. (1988). Finding meaning: Antecedents of uncertainty in illness. Nursing Research, 37, 98–103. https://doi.org/10.1097/ 00006199-198803000-00009.
Mitchell, A. J. (2008). Is it time to separate subjective cognitive complaints from the diagnosis of mild cognitive impairment? Age and Ageing, 37, 497–499. https://doi.org/10.1093/ageing/afn147.
Monforte-Royo, C., Crespo, I., Rodríguez-Prat, A., Marimon, F., Porta-Sales, J., & Balaguer, A. (2018). The role of perceived dignity and control in the wish to hasten death among advanced cancer patients: a mediation model. Psycho-Oncology, 27, 2840–2846. https://doi.org/10.1002/pon.4900.
Oh, Y. S. (2017). Communications with health professionals and psychological distress in family caregivers to cancer patients: a model based on stresscoping theory. Applied Nursing Research, 33, 5–9. https://doi.org/10.1016/j.apnr.2016.09.008.
Östlund, U., Brown, H., & Johnston, B. (2012). Dignity conserving care at end-of-life: a narrative review. European Journal of Oncology Nursing, 16, 353–367. https://doi.org/10.1016/j.ejon.2011.07.010.
Pergolizzi, D., & Crespo, I. (2020). Recognition of cognitive complaints for patients with advanced cancer. Supportive Care in Cancer, 28, 5055–5057. https://doi.org/10.1007/s00520-020-05678-5.
Pergolizzi, D., Monforte-Royo, C., Balaguer, A., PortaSales, J., Rodriguez-Prat, A., & Crespo, I. (2021). Older age: a protective factor against perceived dignity-related distress in patients with advanced cancer? Journal of Pain and Symptom Management, 61, 928–939. https://doi.org/10.1016/j.jpainsymman.2020.09.041.
Reysen, S., Katzarska-Miller, I., Nesbit, S. M., & Pierce, L. (2013). Further validation of a singleitem measure of social identification. European Journal of Social Psychology, 43, 463–470. https:// doi.org/10.1002/ejsp.1973.
Robinson, S., Kissane, D. W., Brooker, J., Hempton, C., & Burney, S. (2017). The relationship between poor quality of life and desire to hasten death: a multiple mediation model examining the contributions of depression, demoralization, loss of control, and low self-worth. Journal of Pain and Symptom Management, 53, 243–249. https://doi.org/10.1016/ j.jpainsymman.2016.08.013.
Rullán, M., Carvajal, A., Núñez-Córdoba, J. M., Martínez, M., Carrasco, J. M., García, I., Arantzamendi, M., Belar, A., & Centeno, C. (2015). Spanish version of the Patient Dignity Inventory: Translation and validation in patients with advanced cancer. Journal of Pain and Symptom Management, 50, 874–881.e1. https://doi.org/10.1016/j.jpainsymman.2015.07.016.
Salvo, N., Zeng, L., Zhang, L., Leung, M., Khan, L., Presutti, R., Nguyen, J., Holden, L., Culleton, S., & Chow, E. (2012). Frequency of reporting and predictive factors for anxiety and depression in patients with advanced cancer. Clinical Oncology, 24, 139–148. https://doi.org/10.1016/j.clon.2011.05.003.
Vardy, J. L., & Dhillon, H. M. (2018). “Mind the gaps”: Cognition and cancer. Psycho-Oncology, 27, 10–12. https://doi.org/10.1002/pon.4582.
Wefel, J. S., Kesler, S. R., Noll, K. R., & Schagen, S. B. (2015). Clinical characteristics, pathophysiology, and management of noncentral nervous system cancer-related cognitive impairment in adults. CA: A Cancer Journal for Clinicians, 65, 123–138. https://doi.org/10.3322/caac.21258.
Westland, J. C. (2015). An introduction to structural equation models. Studies in Systems, Decision and Control, 22, 1–8. https://doi.org/10.1007/978-3-319- 16507-3_1.
