Cancer-related communication during sessions of family therapy at the end of life.

OBJECTIVES: A goal of family-focused therapies in oncology is to help families communicate effectively about illness and its management. Yet there has been no examination of whether and how conjoint sessions are conducive to this process. In this study, we (a) described the extent of cancer-specific communication during family sessions at the end of life; (b) identified characteristics associated with SC; and (c) determined the association between SC and longer-term family bereavement outcomes. METHODS: Data were collected as part of a randomized controlled trial of Family Focused Grief Therapy (FFGT) for advanced cancer patients and their families. Demographics, depressive symptoms, and family functioning were assessed at baseline. Cancer-specific communication, perceived responsiveness to communication, and therapeutic alliances were reported after each session. At 13-month bereavement, surviving families were assessed for symptoms of depression and prolonged grief disorder (PGD). RESULTS: Participants were 257 advanced cancer patients and family members receiving FFGT at the end of life. On average, participants perceived significantly more cancer-related communication in session (SC) than at baseline. Both therapist-family and within-family alliances were associated with SC, especially for those with more severe depressive symptoms at baseline. Long-term outcomes were moderated by perceived responsiveness to in-session communication: for those who perceived high responsiveness, SC was associated with fewer depressive and PGD symptoms in bereavement. CONCLUSIONS: Conjoint family sessions can effectively increase communication about cancer at the end of life. Clinicians should consider key contextual factors in their effort to facilitate this process: perceived responsiveness, family role, alliances with therapist, and within-family.

An open trial of meaning-centered grief therapy: Rationale and preliminary evaluation.

OBJECTIVE: To determine the preliminary feasibility, acceptability, and effects of Meaning-Centered Grief Therapy (MCGT) for parents who lost a child to cancer. METHOD: Parents who lost a child to cancer and who were between six months and six years after loss and reporting elevated levels of prolonged grief were enrolled in open trials of MCGT, a manualized, one-on-one cognitive-behavioral-existential intervention that used psychoeducation, experiential exercises, and structured discussion to explore themes related to meaning, identity, purpose, and legacy. Parents completed 16 weekly sessions, 60-90 minutes in length, either in person or through videoconferencing. Parents were administered measures of prolonged grief disorder symptoms, meaning in life, and other assessments of psychological adjustment preintervention, mid-intervention, postintervention, and at three months postintervention. Descriptive data from both the in-person and videoconferencing open trial were pooled.ResultEight of 11 (72%) enrolled parents started the MCGT intervention, and six of eight (75%) participants completed all 16 sessions. Participants provided positive feedback about MCGT. Results showed postintervention longitudinal improvements in prolonged grief (d = 1.70), sense of meaning (d = 2.11), depression (d = 0.84), hopelessness (d = 1.01), continuing bonds with their child (d = 1.26), posttraumatic growth (ds = 0.29-1.33), positive affect (d = 0.99), and various health-related quality of life domains (d = 0.46-0.71). Most treatment gains were either maintained or increased at the three-month follow-up assessment.Significance of resultsOverall, preliminary data suggest that this 16-session, manualized cognitive-behavioral-existential intervention is feasible, acceptable, and associated with transdiagnostic improvements in psychological functioning among parents who have lost a child to cancer. Future research should examine MCGT with a larger sample in a randomized controlled trial.

Decrease in Intercourse Satisfaction in Men Who Recover Erections After Radical Prostatectomy.

INTRODUCTION: Recovery of erections after radical prostatectomy (RP) is assumed to lead to recovery in sexual satisfaction. Although data suggest a relationship between sexual function and sexual satisfaction, it is unclear whether presurgical levels of sexual satisfaction are attained for men who "recover" erections post-RP. AIM: The goal of this analysis is to determine whether the recovery of erectile function restores presurgical levels of sexual satisfaction. METHODS: We assessed 229 men pre-RP and 24-months post-RP. At both time points, participants completed the Erectile Function Domain (EFD) and the Intercourse Satisfaction Domain (ISD) of the International Index of Erectile Function (IIEF). Erectile function recovery at 24 months was defined as (1) (EFD≥24) or (2) EFD back to baseline (BTB). One hundred sixty-six men with penetration hardness erections (PHEs) at baseline (EFD >24) were included in the analyses. Repeated measure t-tests were used to compare changes in ISD scores and effect size (Cohen's d) was calculated to determine the clinical significance of these changes. Multivariable analyses (MVA) were used to test the relationship between EFD and ISD. RESULTS: The mean age of men was 58 (SD = 7) years. The mean EFD score at baseline was 29 (SD = 2), which declined significantly to 20 (SD = 10) at 24 months. ISD also decreased significantly between baseline and 24 months (12 to 8.3, P < .001, d = 0.87), even among men with PHEs at 24 months (12.3 to 11.3, P < .001, d = 0.50) and men who achieved BTB erections at 24 months (12.4 to 11.7, P = .02, d = 0.35). For men with PHEs at 24 months, MVAs identified baseline ISD (beta = 0.46) and 24-month EFD (beta = 0.23) as the only significant predictors of 24-month ISD. However, among men who achieved BTB erections at 24 months, baseline ISD (beta = 0.49) was the only significant predictor of 24-month ISD. CLINICAL IMPLICATIONS: These findings underscore the importance of the integration of psychological support and medical care to best meet the needs of patients. Furthermore, these results can be used to facilitate pre-RP communication and counseling with patients to improve understanding and manage post-RP expectations. STRENGTHS & LIMITATIONS: The study methodology, specifically the use of BTB as a means of defining erectile function and the longitudinal, prospective study design are relative strengths. Despite the longitudinal design, the study did not include a control group of healthy, age-matched men. CONCLUSION: Results highlight the enduring impact of sexual dysfunction, namely erectile dysfunction, on intercourse satisfaction following RP and suggest that restoration of function in and of itself does not ensure the restoration of satisfaction. Terrier JE, Masterson M, Mulhall JP, et al. Decrease in intercourse satisfaction in men who recover erections after radical prostatectomy. J Sex Med 2018;15:1133-1139.

Beyond the bucket list: Unfinished and business among advanced cancer patients.

OBJECTIVE: The study aims to examine the prevalence and common themes of unfinished business (UB) and its associations with distress among advanced cancer patients. METHODS: A total of 223 patients from a larger randomized controlled trial of Individual Meaning-Centered Psychotherapy (IMCP) completed self-report questionnaires that assessed UB and UB-related distress, hopelessness, desire for hastened death, anxiety and depression, quality of life, spiritual well-being, and purpose/meaning. Unfinished business themes were identified by qualitative analysis of open-ended data. RESULTS: A total of 161 (72%) patients reported the presence of UB. The mean UB-related distress score was 7.01 (SD = 2.1) out of 10. Results of independent t tests showed that patients with UB reported significantly higher levels of anxiety and lower levels of existential transcendence than patients without UB. Linear regression equations indicated that UB-related distress significantly predicted hopelessness (F1,154  = 9.54, P < 0.05, R2  = 0.058), anxiety (F1,154  = 4.31, P < 0.05, R2  = 0.027), personal meaning (F1,136  = 6.18, P < 0.05, R2  = 0.043), and existential transcendence (F1,119  = 6.7, P < 0.05, R2  = 0.053). Ten UB themes emerged from open-ended responses; UB themes were not associated with UB-related distress or psychological adjustment. CONCLUSIONS: Unfinished business was both prevalent and distressing in our sample. Findings underscore the need to develop and implement interventions designed to help patients resolve or find solace with UB.

Don't Shoot the Messenger: Experiences of Delivering Prognostic Information in the Context of Advanced Cancer.

The study of prognostic understanding is imperative as the trend toward individualized medicine continues. However, without guidelines for discussing prognosis, palliative care clinicians face challenges presenting prognostic information in a way that optimizes patient understanding, psychological adjustment, and decision-making. The present study draws on the experiences of experts in the field of palliative care in order to examine the communication of prognostic information. Fifteen oncology, psycho-oncology, and palliative care professionals with expertise in doctor-patient communication participated in semi-structured interviews that focused on identifying the breadth of factors underlying prognostic understanding, as well as methods to identify and quantify this understanding. Three independent raters utilized a thematic content analysis framework to identify core themes that reflected unique aspects of prognostic understanding. Interviews yielded 2 types of information. Participants described the multifaceted nature of prognostic understanding and identified 5 distinct elements of prognostic understanding: understanding of current state of disease, life expectancy, curability, decline trajectory, and available treatment options. Participants also offered "best practice" techniques, including methods for determining a patient's preferences for and understanding of prognostic information, assessing patient fears and concerns, and communicating medical uncertainties. Results emphasize the need for clinicians to join with patients to ensure that prognostic information is well understood. These results highlight the salience of health information preferences and strategies to provide comprehensive prognostic information, compassionately and with respect for each individual patient.

Individual meaning-centered psychotherapy for the treatment of psychological and existential distress: A randomized controlled trial in patients with advanced cancer.

BACKGROUND: Patients with advanced cancer have high rates of psychological distress, including depression, anxiety, and spiritual despair. This study examined the effectiveness of individual meaning-centered psychotherapy (IMCP) in comparison with supportive psychotherapy (SP) and enhanced usual care (EUC) in improving spiritual well-being and quality of life and reducing psychological distress in patients with advanced cancer. METHODS: Patients (n = 321) were randomly assigned to IMCP (n = 109), SP (n = 108), or EUC (n = 104). Assessments were conducted at 4 time points: before intervention, midtreatment (4 weeks), 8 weeks after treatment, and 16 weeks after treatment. RESULTS: Significant treatment effects (small to medium in magnitude) were observed for IMCP, in comparison with EUC, for 5 of 7 outcome variables (quality of life, sense of meaning, spiritual well-being, anxiety, and desire for hastened death), with Cohen's d ranging from 0.1 to 0.34; no significant improvement was observed for patients receiving SP (d < 0.15 and P > .05 for all variables). The effect of IMCP was significantly greater than the effect of SP for quality of life and sense of meaning (d = 0.19) but not for the remaining study variables. CONCLUSIONS: This study provides further support for the efficacy of IMCP as a treatment for psychological and existential/spiritual distress in patients with advanced cancer. Significant treatment effects (small to moderate effect sizes) were observed in comparison with usual care, and somewhat more modest differences in improvement (small effect sizes) were observed in comparison with SP. Thus, the benefits of meaning-centered psychotherapy appear to be unique to the intervention and highlight the importance of addressing existential issues with patients approaching the end of life. Cancer 2018. © 2018 American Cancer Society.

Perceived Family Functioning Predicts Baseline Psychosocial Characteristics in U.S. Participants of a Family Focused Grief Therapy Trial.

CONTEXT AND OBJECTIVES: Screening and baseline data on 170 American families (620 individuals), selected by screening from a palliative care population for inclusion in a randomized controlled trial of family-focused grief therapy, were examined to determine whether family dysfunction conferred higher levels of psychosocial morbidity. We hypothesized that greater family dysfunction would, indeed, be associated with poorer psychosocial outcomes among palliative care patients and their family members. METHODS: Screened families were classified according to their functioning on the Family Relationships Index (FRI) and consented families completed baseline assessments. Mixed-effects modeling with post hoc tests compared individuals' baseline psychosocial outcomes (psychological distress, social functioning, and family functioning on a different measure) according to the classification of their family on the FRI. Covariates were included in all models as appropriate. RESULTS: For those who completed baseline measures, 191 (30.0%) individuals were in low-communicating families, 313 (50.5%) in uninvolved families, and 116 (18.7%) in conflictual families. Family class was significantly associated (at ps ≤ 0.05) with increased psychological distress (Beck Depression Inventory and Brief Symptom Inventory) and poorer social adjustment (Social Adjustment Scale) for individual family members. The family assessment device supported the concurrent accuracy of the FRI. CONCLUSION: As predicted, significantly greater levels of individual psychosocial morbidity were present in American families whose functioning as a group was poorer. Support was generated for a clinical approach that screens families to identify those at high risk. Overall, these baseline data point to the importance of a family-centered model of care.

Adapting Meaning-Centered Psychotherapy for the palliative care setting: Results of a pilot study.

AIMS: To establish preliminary evidence for the feasibility, acceptability, and utility of an abbreviated version of Meaning-Centered Psychotherapy tailored to the needs of palliative care patients in the final weeks or months of life. BACKGROUND: Surprisingly, few mental health interventions have specifically targeted the psychological needs of palliative care patients, when physical comfort seems to take precedence over mental health and emotional needs. Yet the need for mental health services targeting these patients is clear, as one in three palliative care patients experience clinically significant depression and an equal proportion experience clinically significant anxiety. DESIGN: This pilot study used an open-label design to assess the feasibility, acceptability, and perceived utility of Meaning-Centered Psychotherapy-palliative care, a brief intervention that focuses on enhancing meaning at the end of life. SETTING/PARTICIPANTS: A total of 12 patients admitted to a palliative care hospital for supportive care consented to participate in the study. RESULTS: Of the 11 patients that began treatment (one patient died before the first session), 8 completed the three-session intervention. Patients expressed positive feedback about the structure, focus, and length of the intervention, but varied in precisely which elements they found most helpful. CONCLUSION: An abbreviated version of Meaning-Centered Psychotherapy tailored to the needs of palliative care patients (Meaning-Centered Psychotherapy-palliative care) appears to be feasible, acceptable, and has the potential to help patients better cope with the challenges inherent in confronting death and dying. Further research, with larger and more representative samples, is needed in order to clarify the strengths and weaknesses of this approach.

Psychosocial Health Outcomes for Family Caregivers Following the First Year of Bereavement.

The authors examined psychosocial outcomes following the first year of bereavement, for 51 family caregivers, including both spouses and offspring. Researchers assessed caregivers during palliative care and again during the second year of bereavement, for social functioning, depression, and distress. For all family caregivers, only depression scores declined significantly between T1 and T2 (p < 0.05). Caregiver relationship and gender did not make a difference in recovery. Results demonstrate that poor psychosocial health outcomes exist beyond the first year of bereavement. Early identification of these caregivers is necessary to provide mental health professionals the opportunity to intervene proactively.

Toward a model of continuous care: A necessity for caregiving partners.

OBJECTIVE: Caregiving partners constitute a unique group, who provide both physical and emotional care for patients. There has been extensive research conducted on caregivers during either the caregiving or bereavement phase; however, these phases are often treated as separate entities rather than as part of a continuum. METHOD: In this paper, utilizing relevant literature and clinical observations, we map the emotional journey and lived experience of caregivers moving from disease progression, to the end of life, to the dying process itself, and then through life after the death of a partner. Along this journey, we identify the links between pre-death caregiving and bereavement. RESULTS: Our illustration raises awareness regarding the unmet needs experienced by caregiving partners across the continuum and provides an alternative framework through which clinicians can view this course. SIGNIFICANCE: of Results We bolster arguments for improved palliative care services and early interventions with distressed caregiving partners by emphasizing continuity of care both before and after a patient's death.

Typology of perceived family functioning in an American sample of patients with advanced cancer.

CONTEXT: Poor family functioning affects psychosocial adjustment and the occurrence of morbidity following bereavement in the context of a family's coping with advanced cancer. Family functioning typologies assist with targeted family-centered assessment and intervention to offset these complications in the palliative care setting. OBJECTIVES: Our objective was to identify the number and nature of potential types in an American palliative care patient sample. METHODS: Data from patients with advanced cancer (N = 1809) screened for eligibility for a larger randomized clinical trial were used. Cluster analyses determined whether patients could be classified into clinically meaningful and coherent groups, based on similarities in their perceptions of family functioning across the cohesiveness, expressiveness, and conflict resolution subscales of the Family Relations Index. RESULTS: Patients' reports of perceived family functioning yielded a model containing five meaningful family types. CONCLUSION: Cohesiveness, expressiveness, and conflict resolution appear to be useful dimensions by which to classify patient perceptions of family functioning. "At risk" American families may include those we have called hostile, low-communicating, and less-involved. Such families may benefit from adjuvant family-centered psychosocial services, such as family therapy.

Family focused grief therapy: a versatile intervention in palliative care and bereavement.

A diagnosis of advanced stage cancer is a difficult life event for the entire family. Previous studies have demonstrated the negative psychosocial outcomes associated with the burden of caregiving in conjunction with dysfunctional family relations. Family Focused Grief Therapy (FFGT) is a time-limited intervention that has been shown to be effective in aiding dysfunctional families through the promotion of family functioning, communication, cohesiveness, and conflict management. This paper outlines the content of FFGT therapy and highlights its unique aspects as well as the challenges of providing therapy to different types of families in the context of palliative care. FFGT shows promise as an effective intervention applicable across multiple settings in the future.