Compassionate Presence in Seriously Ill Cancer Patients.

Background: Compassion is a relational response to patients' suffering. Palliative care focuses not only on skills but also on compassion. Nevertheless, incorporated patient perspectives are largely missing from existing research. Aim: Our mixed-method exploratory study in a major Swiss cancer center sought to better understand compassionate presence, its benefits and challenges for patients and providers (ie, close relatives, close friends, and professionals-all referred to here as providers). It also investigated providers' motivation. Method: Twelve multidisciplinary, specially trained professionals interviewed 50 patients who had received compassionate presence. All patients had advanced cancer with risk of death. Providers were also interviewed. Data on the positive and burdensome effects of compassionate presence on patients and providers were gathered using a specific protocol. This also served to record patients' characteristics and providers' motivations to give compassion and whether providers felt sustained (eg, by nature). Results: The study suggests a high impact of compassionate presence with benefits on patients (50/50) and on providers (49/50). Enhanced connectedness was evident not only in the patient-provider relationship (38/50) but also, for instance, in an increased ability to love (8/50) or in an intensified solidarity (29/50). A considerable number of patients and providers experienced mental-spiritual change but also burdensome effects (eg, ambivalences). Providers showed a range of motivations. Conclusion: Compassion is not only necessary in existential crises and near death, but also happens and takes considerable effects precisely in such situations.

Forgiveness and Reconciliation Processes in Dying Patients With Cancer.

This article studies forgiveness and reconciliation (F/R) in patients with cancer. It focuses on the end of life, when family conflicts resurface and unfinished business challenges patients and causes spiritual distress. Forgiveness and reconciliation may intensify patient-family relationships and facilitate peace of mind and peaceful death. Existing forgiveness models and interventions focus on coping in life, yet no study has examined F/R processes until death. Our mixed-method exploratory study hypothesized that F/R processes occur in phases, repeatedly, and are spurred by approaching death. Three interdisciplinary units at a major Swiss hospital observed 50 dying patients with cancer experiencing severe conflicts with relatives, themselves, and/or with fate/God. Participant observation was combined with interpretative phenomenological analysis and descriptive statistical analysis. A semi-structured observation protocol was developed based on a 5-phase model. The protocol included space for notes (emotions, interventions, effects on dying processes). It was assessed by 20 professionals for 1 year. Analysis was supported by international interdisciplinary experts. We found that conflicts were complex and involved relational, biographical, and spiritual layers. In 62% of patients, F/R processes occurred repeatedly. Many patients died after finding F/R (22 within 48 hours). Patients indicated that imminent death, a mediating third party, acceptance, and experiences of hope motivated them to seek F/R. Although deep relationships may support F/R processes, our limited data on near-death experience/spiritual experiences restrict interpretation. Forgiveness and reconciliation processes oscillate between 5 phases: denial, crisis, experience of hope, decision, and finding F/R. Understanding F/R processes, empathy, hope, and a neutral third party may support patients in seeking forgiveness.

Fear, Pain, Denial, and Spiritual Experiences in Dying Processes.

PURPOSE: Approaching death seems to be associated with physiological/spiritual changes. Trajectories including the physical-psychological-social-spiritual dimension have indicated a terminal drop. Existential suffering or deathbed visions describe complex phenomena. However, interrelationships between different constituent factors (e.g., fear and pain, spiritual experiences and altered consciousness) are largely unknown. We lack deeper understanding of patients' inner processes to which care should respond. In this study, we hypothesized that fear/pain/denial would happen simultaneously and be associated with a transformation of perception from ego-based (pre-transition) to ego-distant perception/consciousness (post-transition) and that spiritual (transcendental) experiences would primarily occur in periods of calmness and post-transition. Parameters for observing transformation of perception (pre-transition, transition itself, and post-transition) were patients' altered awareness of time/space/body and patients' altered social connectedness. METHOD: Two interdisciplinary teams observed 80 dying patients with cancer in palliative units at 2 Swiss cantonal hospitals. We applied participant observation based on semistructured observation protocols, supplemented by the list of analgesic and psychotropic medication. Descriptive statistical analysis and Interpretative Phenomenological Analysis (IPA) were combined. International interdisciplinary experts supported the analysis. RESULTS: Most patients showed at least fear and pain once. Many seemed to have spiritual experiences and to undergo a transformation of perception only partly depending on medication. Line graphs representatively illustrate associations between fear/pain/denial/spiritual experiences and a transformation of perception. No trajectory displayed uninterrupted distress. Many patients seemed to die in peace. Previous near-death or spiritual/mystical experiences may facilitate the dying process. CONCLUSION: Approaching death seems not only characterized by periods of distress but even more by states beyond fear/pain/denial.

Spiritual experiences of transcendence in patients with advanced cancer.

PURPOSE: Spirituality encompasses a wide range of meanings between holistic wellbeing and mysticism. We explored advanced cancer patients' spiritual experiences of transcendence. METHODS: A total of 251 patients with advanced cancer were included and observed (participant observation) over 12 months by a psycho-oncologist/music-therapist. She recorded and documented patients' spontaneously expressed spiritual experiences during hospitalisation. Interpretative Phenomenological Analysis was applied. RESULTS: 135 patients communicated a spiritual experience, as expressed by altered body-awareness, less pain, less anxiety, higher acceptance of illness/death, new spiritual identity. Spiritual experiences were communicated by patients across different religious affiliations/attitudes. We identified types of spiritual experiences. CONCLUSION: The occurrence of spiritual experiences seems to be frequent and associated with profound, powerful reactions. Our results indicate that experienced-based spiritual care may complement current needs-based approaches.

Safety, tolerability and pharmacokinetics of intravenous ghrelin for cancer-related anorexia/cachexia: a randomised, placebo-controlled, double-blind, double-crossover study.

Twenty-one adult patients were randomised to receive ghrelin on days 1 and 8 and placebo on days 4 and 11 or vice versa, given intravenously over a 60-min period before lunch: 10 received 2 microg kg(-1) (lower-dose) ghrelin; 11 received 8 microg kg(-1) (upper-dose) ghrelin. Active and total ghrelin, growth hormone (GH), and insulin-like growth factor 1 levels were monitored at baseline (4-5 days before day 1), during treatment days, and at end of study (day 17/18). Drug-related adverse events (assessed by NCI-CTC-toxicity criteria and cardiac examination) did not differ between ghrelin and placebo. No grade 3/4 toxicity or stimulation of tumour growth was observed. The peak increase of GH, a biological marker of ghrelin action, was 25 ng ml(-1) with lower-dose and 42 ng ml(-1) with upper-dose ghrelin. Morning fasting total ghrelin levels were higher (P<0.05) for upper-dose patients at end of study (3580 pg ml(-1)) than at baseline (990 pg ml(-1)). Insulin-like growth factor 1 levels did not change. At day 8, 81% of patients preferred ghrelin to placebo as against 63% at the end of study. Nutritional intake and eating-related symptoms, measured to explore preliminary efficacy, did not differ between ghrelin and placebo. Ghrelin is well tolerated and safe in patients with advanced cancer. For safety, tolerance, and patients' preference for treatment, no difference was observed between the lower- and upper-dose group.

The influence of dietary levels of vitamin A and fat on colon cancer.

Rats fed diets high (24%) or low (5%) in fat were given dietary levels of vitamin A (retinyl acetate) ranging from 0.3 to 30 micrograms/g food. The lowest tumor incidence was in the group fed diets high in vitamin A and low in fat. When the diet was high in fat and low in vitamin A, tumor incidence and frequency were significantly increased over that in rats fed the high-fat diet with normal levels of vitamin A (10 micrograms/g feed). However, even with a high level of fat in the diet, raising the level of vitamin A above 10 micrograms/g feed had no further beneficial effect. Thus, although there was a significant interaction between vitamin A and fat, it is the latter that appears to require the most attention, once the vitamin A intake is adequate. These data support the view that we should set as a goal an adequate, diversified diet that is low in fat but that an excessive intake of vitamins such as vitamin A that are toxic should be avoided.

The influence of pre- and postnatal caloric intake on colon carcinogenesis.

Mother rats were allowed to litter under conventional conditions. They were fed a complete, semipurified diet during gestation, and at time of littering the numbers of pups were reduced to either eight per litter or four per litter in two additional groups. At weaning, all rats were continued on the same diet that their mothers had consumed. One group of those reduced to four per litter at birth was allowed to continue to eat ad libitum while the other group, reduced to four per litter, was pair fed to the ad libitum eight per litter group. The group reduced to four per litter at birth and allowed to eat ad libitum during postnatal life gained the most weight and were heaviest at the termination of the study. This group also had the greater incidence and frequency of colon tumors when exposed to dimethylhydrazine (DMH). The group pair fed to rats fed conventional diets, eight rats per litter, had an incidence and frequency of tumors between the other two groups. These data demonstrate that early exposure to excess calories increased risk for cancer and that early and late excess caloric intake further increased risk. Thus, pre- and perinatal caloric intake may have a significant influence on susceptibility to cancer later in life. Mechanisms are only speculative but may include differences in metabolism and modulation of hormonal balance.

Effect of vitamin A nutriture on experimental esophageal carcinogenesis.

The effect of mild vitamin A deficiency or vitamin A supplementation on methylbenzylnitrosamine (MBN; CAS: 937-40-6)-induced esophageal carcinogenesis was examined in Sprague-Dawley rats. The animals were fed semipurified diets containing levels of retinyl acetate, which were adequate (2.2 mg/kg diet), deficient (0.30 mg/kg diet), or supplemented (29.9 mg/kg diet) with respect to vitamin A content. Carcinogen-treated rats received 2.5 mg MBN/kg (body wt) twice a week for 5 weeks; they were then sacrificed for evaluation of esophageal tumorigenesis 15 weeks later. Liver levels of retinol reflected vitamin A nutriture, but there were no clinical signs of deficiency or toxicity. There were no significant differences in the frequency or incidence of esophageal tumors (either carcinomas or papillomas) among the dietary groups. There was also no indication that either vitamin A deficiency or vitamin A supplementation influenced the formation of preneoplastic lesions. Although the time was short for the neoplastic development, tumors were observed. These data suggest that vitamin A is selective in tissues it may protect from cancer induction and that the esophagus is less involved than other tissues.

Effect of beef fat on DMH-induced colon tumorigenesis: influence of rat strain and nutrient composition.

The modulating effect of high levels of dietary fat on chemically induced colon tumorigenesis has been studied in animal models, with conflicting results. The present study was designed to examine the influence of rat strain, stage of tumor development and micronutrient composition of the diet on 1,2-dimethylhydrazine (DMH)-induced intestinal tumorigenesis. Two strains of rats [Sprague-Dawley (SD) and Fischer-344 (F-344)] were fed one of three experimental diets. The diets contained 5 or 20% dietary fat but differed in nutrient composition and nutrient-energy ratio. After receiving the experimental diets for 4 wk, animals were treated with DMH X 2HCl (10 mg/kg body wt) once a week for 20 wk and killed 10 wk after receiving the last dose of carcinogen. Long-term administration of DMH was more toxic to F-344 rats than to SD animals, and the toxicity was potentiated by reductions in the micronutrient composition of the diet. High levels of dietary fat (20%) resulted in a barely significantly higher incidence in colon tumor (but not frequency or size) in SD rats that received the diet promoting optimal growth than did low levels of dietary fat. No effect of 20% beef fat was seen in SD animals fed a diet that produced a slower growth rate or in F-344 animals.

Effect of dietary selenium levels on methylbenzylnitrosamine-induced esophageal cancer in rats.

Male Sprague-Dawley rats fed selenium deficient diets received either 0 ppm, 0.15 ppm or 4.0 ppm selenium in the drinking water. Animals were treated with methylbenzylnitrosamine (MBN). Dietary selenium deficiency had no effect on MBN-induced esophageal carcinogenesis. Animals treated with 4 ppm selenium in the drinking water during the initiation and post-initiation period had the same number of tumors as the group which received 0.15 ppm selenium for the entire experimental period. The incidence and frequency of carcinomas was lowest in the group which was supplemented with extra selenium (4.0 ppm) during the period of carcinogen administration and highest in the group which received 4.0 ppm selenium during the post-initiation period.