Physical impairment, meaning in life
and the wish to hasten death in
advanced cancer patients
Cristina Monforte Royo
Stephanie Lichtenfeld
Christian Villavicencio
Joaquín Tomás-Sábado
Josep Porta Sales
Markus Maier
Albert Balaguer
Introduction: 1
WTHD in patients with advanced illness:
is a complex phenomenon with multi-factor aetiology1,2
is reactive to the presence of physical, psychological,
emotional and existential suffering3
is a response to emotional distress in these patients3
1. Kelly B, Burnett P, Pelusi D, Badger S, Varghese F, Robertson M. Terminally ill cancer patients’ wish to hasten death. Palliat Med. 2002;
16:339-45
2. Morita T, Sakaguchi Y, Hirai K, Tsuneto S, Shima Y. Desire for death and request to hasten death of Japanese terminally ill cancer patients
receiving specialized inpatient palliative care. J Pain Symptom Manage. 2004;27:44-52
3. Monforte-Royo C, Villavicencio-Chávez C, Tomás-Sábado J, Balaguer A. What lies behind the wish to hasten death? A systematic review
and meta-ethnography from the perspective of the patients. PLoS one. 2012; 7(5):e37117
Introduction: 2
WTHD in patients with advanced illness:
is triggered by exacerbation of physical or psychological
symptoms, leading to a situation of emotional distress
and hopelessness3
emerges as a response to Fears and…
Loss of Self:
Loss of Function
Loss of Control
Perception of “loss of dignity”
Loss of Meaning
Loss of Hope
3. Monforte-Royo C, Villavicencio-Chávez C, Tomás-Sábado J, Balaguer A. What lies behind the wish to hasten
death? A systematic review and meta-ethnography from the perspective of the patients. PLoS one. 2012;
7(5):e37117
Introduction: & 3.
Meaning in life (MiL):
a
key
element
interventions4, 5
of
certain
psychotherapeutic
is associated with hopelessness and WTHD4
Patients who, despite their illness, continue to feel that life
is meaningful, are able to regard their life as worth
living3
3. Monforte-Royo C, Villavicencio-Chávez C, Tomás-Sábado J, Balaguer A. What lies behind the wish to hasten death? A systematic review and
meta-ethnography from the perspective of the patients. PLoS one. 2012; 7(5):e37117
4. Breitbart W. Reframing hope: meaning-centered care for patients near the end of life. J Palliat Med. 2003; 6:977-88.
5. Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, et al. Understanding the will to live in patients nearing death.
Psychosomatics. 2005; 46:7-10
Main Objective
To assess the relationship between
WTHD and MiL in palliative care patients
in an oncological hospital
Methods
Subjects: n=101 cancer patients admitted to a palliative
care unit
Inclusion criteria:
Pfeiffer SPMSQ <5
Ability to communicate. Knowledge of diagnosis and
prognosis
Interview would not be a cause of additional emotional
distress for the patient
Participation was voluntary
Signed the informed consent
Exclusion criteria:
Diagnosed psychiatric disorder
Physical or psychological deterioration
Methods
Instruments:
SAHD (Schedule of Attitudes toward Hastened Death) by Rosenfeld
et al.
SMiLE (Schedule for Meaning in Life Evaluation) by Fegg et al.
POS (Palliative Outcomes Scale) by Hearn et al. (Quality of life in
Palliative Care)
HADS: Hospital Anxiety and Depression Scale
Barthel Index: functional status
ECOG-PS: Eastern Cooperative Oncology Group-Performance status scale
Karnofsky Index: performance status scale
Demographic Variables: age, sex, city, country, marital status, studies…
Methods
WTHD assessed with SAHD6
MiL assessed with SMiLE7,8
Item 7 of POS9,10
6. Rosenfeld B, Breitbart W, Galietta M, Kaim M, Funesti-Esch J, Pessin H, Nelson CJ, Brescia R. The schedule of attitudes toward hastened
death. Measuring desire for death in terminally ill cancer patients. Cancer. 2000; 88:2868-75.
7. Fegg M, Kramer M, L’Hoste S, Borasio GD. The schedule for Meaning in Life evaluation (SMiLE): Validation of a new instrument for a
Meaning in Life Research. J Pain Symptom Manage. 2008; 35:356-64.
8. Monforte-Royo C, Villavicencio-Chávez C, Tomás-Sábado J, Balaguer A. Psychometric properties of the Spanish form of the schedule
for meaning in life evaluation (SMILE). Qual Life Res. 2011; 20:759-62
9. Hearn J, Higginson I. Development and validation of a core outcome measure for a palliative care: the palliative care outcome scale.
Qual Health Care. 1999; 8:219-27.
10. Serra-Prat M, Nabal M, Santacruz V, Picaza JM, Trelis J et al. Traducción, adaptación y validación de la Palliative Care Outcome Scale al
español. Med Clin (Barc). 2004; 123: 406-12
Results
Psychological Factors and WTHD
Psychological Factors
MiL (POS 7)
Well-Being
Total POS
HADS-A
HADS-D
TotalHADS
0.601**
0.483**
0.436**
0.148
0.397**
0.332**
SAHD
**p<0.01
Spearman’s rho coefficients among the SAHD and the measures of
MiL, Well-Being, Total POS, HADS-A, HADS-D and Total-HADS
Results
Physical Factors and WTHD
Physical Factors
SAHD
Barthel Index
Karnofsky Index
ECOG-PS
-0.324**
-0.356**
0.276**
**p<0.01
Spearman’s rho coefficients among the SAHD and the measures of
Barthel Index (BI), Karkofsky Index (KI) and the ECOG-PS
Results
Structural Equation Modeling
Karnofsky
Index
Schedule of
Attitudes to
Hastened Death
-.40
.20
.00
.00
Meaning
in Life
.00
Well-being
Results
Structural Equation Modeling
Karnofsky
Index
Schedule of
Attitudes to
Hastened Death
n.s.
n.s.
.72
-.49
Meaning
in Life
.37
Well-being
Results
Estimate
S.E.
p-value
-.403
.026
< .001
SAHD  Well-being
-.198
.007
.043
Karnofsky  MiL
-.495
.005
< .001
Karnofsky  SAHD
-.046
.022
.550
MiL  SAHD
.723
.356
< .001
SAHD  Well-being
-.076
.010
.592
MiL  Well-being
.369
.048
.010
Direct Paths Karnofsky  SAHD
Mediation
Model
Limitations
Cross-sectional observational design
The sample was comprised of advanced cancer
patients in an acute palliative care unit who were
selected by means of convenience sampling
MiL Scale
…
Conclusions
There is a direct relationship between functional
status and WTHD in advanced cancer patients
The functional status predicts the WTHD in these
patients
MiL acts as a full mediator variable in this
relationship
Thank you!