Dignity Therapy for Older Cancer Patients: Identifying Mechanisms and Moderators

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-posttherapy. 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).