Fast Fact #319 explored the definition and risk factors of existential suffering.  This Fast Fact will offer clinical guidance on how to respond to patients exhibiting signs of existential suffering.

Reflective Listening   While existential questions at the end of life are a natural and common occurrence, for some patients these existential concerns can be associated with overt suffering stemming from a loss of meaning or value in life.  When palliative care clinicians encounter a patient with existential distress, they may feel a clinical need to “fix” the existential distress or manage it with clinical therapies.  Instead, words communicating empathy and validation of the existential distress may be more comforting. “I can only imagine how scary this must feel for you.  I sometimes wonder how anyone can make sense of this” is an example of reflective listening phrase which may normalize the patient’s existential distress.

Management Pitfalls   Clinicians of seriously ill patients should avoid focusing their clinical assessment solely on physical symptoms.  Since existential suffering, spiritual suffering, physical symptoms and psychiatric symptoms may all exacerbate the other, it is important to ensure patients are receiving excellent management of their physical, spiritual, and psychiatric domains.  Failure to do so can result in inappropriate dose escalations of analgesics, anxiolytics, or antidepressants. Palliative sedation has been used for refractory existential suffering; however, its use is controversial and in many cases avoidable with the proper engagement of an interdisciplinary team that includes social workers, chaplains, psychologists, and grief counselors.

Psychotherapeutic Modalities   A variety of psychotherapeutic modalities may alleviate the multifaceted aspects of existential suffering (1-5). Many of these interventions such as dignity therapy do not require a referral to a trained psychotherapist, as members of the interdisciplinary team (traditionally social workers, nurses and chaplains) can be trained with relative ease (6).​

Meaning Centered Group Psychotherapy (MCGP) and Individual Meaning Centered Psychotherapy (IMCP): Founded on Viktor Frankl’s teaching regarding the human need for meaning, MCGP/IMCP is a form of group or individual psychotherapy initially designed for patients with advanced cancer.   MCGP/IMCP strives to help patients find meaning in their experiences with illness while exploring philosophical questions of life.  The goal is to have patients refocus on living rather than dying, and has been shown to have psychological benefit in patients with advanced cancer (1,2).

Dignity Therapy: This is a brief form of individual psychotherapy which involves a guided interview to allow patients to reflect on past experiences that mattered most to them and how they want to be remembered (legacy).  Sessions are often audio-recorded, transcribed, and then provided to the patient to share or pass on to individuals of their choosing (3,4). A recent systematic review demonstrated benefits for both patients and families that sustained after the patient’s death (5).

Supportive Expressive Group Therapy (SEGT): This form of group therapy has its foundation in the benefits of social support and the use of coping skills to help decrease the trauma of a terminal illness often via normalization (initially established for metastatic breast cancer patients).  The aim is to create a supportive environment for patients where they can adjust to the demands of their illness while learning to live life fully and authentically and improve their quality of life (4,6).Sustained responses have been demonstrated particular in patients with breast cancer (7).

Communication Pearls   For those patients who are too ill to participate in formal psychotherapy, a thoughtful, empathetic presence may relieve, to a degree, the existential suffering many patients experience. Examples of common clinical questions which utilize the tenets of psychotherapeutic modalities to help patients explore their existential distress and seek meaning in their illness include:

• It sounds like you have a lot on your mind. What in particular is causing you the most concern?
• Tell me a little about your life, particularly those parts you remember most or think are most important.
• What are the most important roles you have played in life (family roles, vocational roles, community-service roles, etc)? Why were they so important to you? What did you accomplished in those roles?
• Are there particular things that you feel you still need to be say to your loved ones or say once again?
• How do you want to be remembered by your loved ones?

REFERENCES

1. Breitbart W, Rosenfield B, Pessin H, et al: Meaning-centered group psychotherapy: An effective intervention for improving psychological well-being in patients with advanced cancer. Journal of Clinical Oncology. 2015 Mar;33(7):749-54.
2. Breitbart W, Rosenfield B, Vickers A, et al. Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer. Journal of Clinical Oncology. 2012 April;30(12):1304-1309.
3. Chochinov HM, Kristjanson LJ, Breitbart W, et al: The effect of dignity therapy on distress and end-of-life experience in terminally ill patients: A randomized controlled trial. Lancet Oncology. 2011 Aug;12(8):753-62.
4. LeMay K, Wilson KG: Treatment of existential distress in life threatening illness: A review of manualized interventions. Clinical Psychology Review. 2008;28:472-93.
5. Fitchett G, Emanuel L, Handzo G et al: Care of the human spirit and the role of dignity therapy: A systematic review of dignity therapy research. BMC Palliative Care. 2015 May 14(8): 1-12.
6. Kissane DW, Grabsch B, Clarke DM, et al: Supportive-expressive group therapy: The transformation of existential ambivalence into creative living while enhancing adherence to anti-cancer therapies. Psycho-Oncology. 2004 Mar;13:755-768.
7. Reuter K, Scholl I, Sillem M, Hasenburg A, Harter M: Implementation and benefits of psychooncological group interventions in german breast centers: A study on supportive-expressive group therapy for women with primary breast cancer. Breast Care. 2010:5(2): 91-96

Conflicts of Interest: None

Authors Affiliation: University of Michigan Health System, Ann Arbor MI

Version History: Originally edited by Sean Marks MD and Drew Rosielle MD; first electronically published August 2016.