Abstract
Reflective Listening
A
Management Pitfalls
Clinicians of seriously ill patients should avoid focusing their clinical assessment solely on physical symptoms. As existential suffering, spiritual suffering, physical symptoms, and psychiatric symptoms may all exacerbate the other, it is important to ensure patients are receiving excellent management of their physical, spiritual, and psychiatric domains. Failure to do so can result in inappropriate dose escalations of analgesics, anxiolytics, or antidepressants. Palliative sedation has been used for refractory existential suffering; however, its use is controversial and in many cases avoidable with the proper engagement of an interdisciplinary team that includes social workers, chaplains, psychologists, and grief counselors.
Psychotherapeutic Modalities
A variety of psychotherapeutic modalities may alleviate the multifaceted aspects of existential suffering.1–5 Many of these interventions such as dignity therapy do not require a referral to a trained psychotherapist, as members of the interdisciplinary team (traditionally social workers, nurses, and chaplains) can be trained with relative ease. 6
Meaning -centered group psychotherapy and individual meaning -centered psychotherapy
Founded on Viktor Frankl's teaching regarding the human need for meaning, meaning-centered group psychotherapy (MCGP)/ individual meaning-centered psychotherapy (IMCP) is a form of group or individual psychotherapy initially designed for patients with advanced cancer. MCGP/IMCP strives to help patients find meaning in their experiences with illness while exploring philosophical questions of life. The goal is to have patients refocus on living rather than dying, and has been shown to have psychological benefit in patients with advanced cancer.1,2
Dignity therapy
This is a brief form of individual psychotherapy that involves a guided interview to allow patients to reflect on past experiences that mattered most to them and how they want to be remembered (legacy). Sessions are often audio-recorded, transcribed, and then provided to the patient to share or pass on to individuals of their choosing.3,4 A recent systematic review demonstrated benefits for both patients and families that sustained after the patient's death. 5
Supportive expressive group therapy
This form of group therapy has its foundation in the benefits of social support and the use of coping skills to help decrease the trauma of a terminal illness often through normalization (initially established for metastatic breast cancer patients). The aim is to create a supportive environment for patients where they can adjust to the demands of their illness while learning to live life fully and authentically and improve their quality of life.4,6 Sustained responses have been demonstrated particularly in patients with breast cancer. 7
Communication Pearls
For those patients who are too ill to participate in formal psychotherapy, a thoughtful, empathetic presence may relieve, to a degree, the existential suffering many patients experience. Examples of common clinical questions that utilize the tenets of psychotherapeutic modalities to help patients explore their existential distress and seek meaning in their illness include:
• It sounds like you have a lot on your mind. What in particular is causing you the most concern? • Tell me a little about your life, particularly those parts you remember most or think are most important. • What are the most important roles you have played in life (family roles, vocational roles, community-service roles, etc)? Why were they so important to you? What did you accomplish in those roles? • Are there particular things that you feel you still need to say to your loved ones or say once again? • How do you want to be remembered by your loved ones?