Letter to the Editor Received: April 13, 2014 Accepted after revision: July 24, 2014 Published online: December 24, 2014
Psychother Psychosom 2015;84:57–58 DOI: 10.1159/000366207
Dignity Therapy and Its Effect on the Survival of Terminally Ill Portuguese Patients Miguel Juliãoa–c, f, Baltazar Nunesd, António Barbosaa, e a Center of Bioethics, and b Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, c Centro Clínico Champalimaud, Champalimaud Centre for the Unknown, d Department of Epidemiology, Instituto Dr. Ricardo Jorge, and e Department of Psychiatry, Hospital de Santa Maria, Lisbon, and f Department of Palliative Medicine, IIHSCJ, Casa de Saúde da Idanha, Belas, Portugal
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 MiniMental 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
Survival estimates
1.00
Intervention (DT)
0.75 0.50
Control group (SPC)
0.25 0
Fig. 1. Survival estimates by intervention group obtained with the Kaplan-Meier method.
© 2014 S. Karger AG, Basel 0033–3190/14/0841–0057$39.50/0 E-Mail [email protected] www.karger.com/pps
10
Time (days)
20
30
Miguel Julião Centro Clínico Champalimaud, Champalimaud Centre for the Unknown Avenida Brasília, s/n PT–1400-038 Lisbon (Portugal) E-Mail miguel.juliao @ fundacaochampalimaud.pt
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/25/2015 12:40:32 AM
0
Control group (n = 41)
DT group (n = 39)
Gender, n (%) Male 18 (43.9) 19 (48.7) Female 23 (56.1) 20 (51.3) Mean age ± SD, years 66.1 ± 12.9 (28 – 90) Age, n (%) ≤65 years 21 (51.2) 20 (51.3) >65 years 20 (48.8) 19 (48.7) Race/ethnicity, n (%) Caucasian 39 (95.1) 37 (94.8) African 2 (5.0) 2 (5.1) Diagnosis, n (%) 37 (90.2) 37 (94.9) Cancera Non-cancerb 4 (9.8) 2 (5.1) Time since diagnosisc, n (%)
Psychother Psychosom 2015;84:57–58 DOI: 10.1159/000366207
Dignity Therapy and Its Effect on the Survival of Terminally Ill Portuguese Patients Miguel Juliãoa–c, f, Baltazar Nunesd, António Barbosaa, e a Center of Bioethics, and b Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, c Centro Clínico Champalimaud, Champalimaud Centre for the Unknown, d Department of Epidemiology, Instituto Dr. Ricardo Jorge, and e Department of Psychiatry, Hospital de Santa Maria, Lisbon, and f Department of Palliative Medicine, IIHSCJ, Casa de Saúde da Idanha, Belas, Portugal
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 MiniMental 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
Survival estimates
1.00
Intervention (DT)
0.75 0.50
Control group (SPC)
0.25 0
Fig. 1. Survival estimates by intervention group obtained with the Kaplan-Meier method.
© 2014 S. Karger AG, Basel 0033–3190/14/0841–0057$39.50/0 E-Mail [email protected] www.karger.com/pps
10
Time (days)
20
30
Miguel Julião Centro Clínico Champalimaud, Champalimaud Centre for the Unknown Avenida Brasília, s/n PT–1400-038 Lisbon (Portugal) E-Mail miguel.juliao @ fundacaochampalimaud.pt
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/25/2015 12:40:32 AM
0
Control group (n = 41)
DT group (n = 39)
Gender, n (%) Male 18 (43.9) 19 (48.7) Female 23 (56.1) 20 (51.3) Mean age ± SD, years 66.1 ± 12.9 (28 – 90) Age, n (%) ≤65 years 21 (51.2) 20 (51.3) >65 years 20 (48.8) 19 (48.7) Race/ethnicity, n (%) Caucasian 39 (95.1) 37 (94.8) African 2 (5.0) 2 (5.1) Diagnosis, n (%) 37 (90.2) 37 (94.9) Cancera Non-cancerb 4 (9.8) 2 (5.1) Time since diagnosisc, n (%)
