Dignity Therapy for Older Cancer Patients: Identifying Mechanisms and Moderators

项目摘要 每年有近60万美国老年人死于癌症。维护人的尊严是 严重疾病患者的生活质量。我们的长期目标是培养最佳的人文模式， 以患者为中心的临床沟通。我们专注于尊严疗法（DT）的拟议研究， 旨在维护癌症患者的尊严，尽管他们的健康下降。理论上是基于 老年学生活回顾研究，DT涉及治疗师指导患者产生自己独特的， 结构化的生活叙事患者报告了DT的益处，但迄今为止DT的机制尚未得到证实。 经验调查。随着这种疗法在国际上的推广，迫切需要 描绘出精确的机制。这项研究首次可靠地分析了老年癌症的内容。 患者在DT疗程中与治疗师的互动（N=280名接受DT的老年人）。我们的设计 允许调查理论上对通过DT改善患者尊严至关重要的两种机制。这些 提出的机制，DT期间的移情提供者-患者沟通和患者生活的丰富性 DT期间产生的叙述，将作为治疗前后尊严变化的预测因素进行分析 冲击我们提出的研究使用创新的方法工具：它将采用插入和叙述 基于患者自身经验的分析，以建立治疗影响的机制 病人的尊严过去的研究由于对接受DT的概念性远端结果的评估而受到影响。 作为回应，建议的结局已被选为DT密切指导的近端结构 概念基础。我们感兴趣的主要结果是患者尊严感的程度 从测试前到测试后增加（即，尊严的影响）。拟议研究的另一个方面是调查 患者最有能力进行DT。这将通过评估 DT后的尊严影响受患者症状严重程度的调节。共同界定机制， 确定患者参与DT的最佳时机将在实施DT方面取得实质性进展， 为老年癌症患者提供心理社会护理。我们的跨学科团队确保研究结果将 以改进DT培训和交付。这包括我们的创新传播计划， 与全国意见领袖举行护理科学峰会。我们的具体目标如下：SA 1： 移情沟通与患者尊严影响（主要结局）之间的关系 疗法SA 2：调查患者被引导产生的生活叙述的丰富性与 在DT期间，和尊严的影响（主要结果）治疗前到治疗后。SA 3：确定最佳拟合模型， 患者-提供者共情沟通与治疗后对患者尊严影响的关系，附叙述 丰富度作为中介和患者的症状严重性作为调节（即，调解分析）。

PROJECT SUMMARY Nearly 600,000 older Americans die a cancer-related death each year. Maintaining human dignity is central to quality of life for patients with serious illness. Our long-term goal is to foster optimal humanistic modes of patient-centered clinical communication. We focus in the proposed study on Dignity Therapy (DT) which was designed to preserve cancer patients’ dignity despite declines in their health. Theoretically grounded in gerontological life review research, DT involves a therapist guiding a patient to generate their own unique, structured life narrative. Patients report benefits of DT but to date the mechanisms of DT have not been empirically investigated. As the use of this therapy spreads internationally, there is thus a pressing need to delineate precise mechanisms. The proposed study is the first to reliably analyze the content of older cancer patients’ interactions with the therapist in DT sessions (N=280 older adults who received DT). Our design allows for investigation of two mechanisms theoretically central to improving patient dignity through DT. These proposed mechanisms, empathic provider-patient communication during DT and richness of the patient’s life narrative produced during DT, will be used analytically as predictors of pre-to-post-therapy change in dignity impact. Our proposed study uses innovative methodological tools: it will employ both interactional and narrative analysis, grounded in the patient’s own experience, to establish mechanisms through which the therapy affects patient dignity. Past research has suffered due to assessment of conceptually distal outcomes of receiving DT. In response, the proposed outcomes have been chosen as proximal constructs closely guided by DT’s conceptual underpinnings. Our primary outcome of interest is the extent to which the patients sense of dignity increases from pre-to-posttest (i.e., Dignity Impact). Another aspect of the proposed study is to investigate when patients are most able to engage in DT. This will be accomplished through assessing whether extent of dignity impact after DT is moderated by patients’ symptom severity. Together, delineating mechanisms and identifying best timing for patient engagement in DT will provide substantial progress in implementing DT as a form of psychosocial care for older cancer patients. Our interdisciplinary team ensures that study findings will be implemented to improve DT training and delivery. This includes our innovative dissemination plan of hosting a Science of Care Summit with national opinion leaders. Our specific aims are as follows: SA1: Delineate the relation between empathic communication and higher patient dignity impact (primary outcome) pre-to-post- therapy. SA2: Investigate the relation between richness of the life narrative the patient is guided to produce during DT, and dignity impact (primary outcome) pre-to-post therapy.SA3: Identify the best-fitting model of relation of patient-provider empathic communication to post-therapy impact on patients’ dignity, with narrative richness as a mediator and patients’ symptom severity as a moderator (i.e., moderated-mediation analyses).