Mariona Guerrero, PhD student from our research group, presents her thesis
A PhD student from our research group, Mariona Guerrero, presented her thesis Meaning in life and the wish to hasten death in patients with advanced illness.This thesis was supervised by Dr Cristina Monforte Royo and Dr Albert Balaguer. The thesis committee was made up of Dr. Joaquim Limonero García (Universitat Autònoma de Barcelona), Dra. Montserra Edo Gual (Escoles Universitàries Gimbernat) and Dra. María Fernández Capo (Universitat Internacional de Catalunya)
INTRODUCTION: It is not uncommon for patients with advanced disease to present different symptoms; not only those related to physical and functional deterioration, but also those related to other factors such as psycho-emotional and spiritual-existential aspects. Recently, clinicians and researchers have shown an increasing interest in meaning in life (MiL) in these patients, as well as the wish to hasten death (WTHD) that may appear in patients at the end of life. The WTHD emerges in this population as a reactive phenomenon in a situation of extreme suffering.
AIMS: To analyse the role of MiL in the development of the WTHD in a sample of advanced cancer patients and propose a model of functional relationships between the WTHD, functional status, depression and MiL. In addition, to examine the potential clinical benefits of MiL interventions and to analyse the mechanisms behind those interventions.
METHOD: This thesis is composed of two studies. In the first cross-sectional study, 101 in-patients from a palliative care unit in Barcelona were included. In the context of a clinical interview we evaluated several outcomes such as functional status, depression, MiL and the WTHD. A structural equation modeling was then used to analyse the functional relationships between the WTHD, functional status, depression and MiL.
The second study consists of a systematic review and realistic synthesis of MiL interventions implemented in a sample of patients with advanced disease. The selection of articles was performed according to the PRISMA guide. The realistic synthesis was carried out applying the RAMESES project criteria for complex interventions. This project suggests an in-depth analysis of the context, mechanisms and outcomes of each of the interventions.
RESULTS: A structural relationship model was defined between the following outcomes: functional status, the WTHD, MiL and depression. The resulting structural equation model showed that MiL and depression are the mediators between functional status and the WTHD. MiL was the variable responsible for this mediation in 76.5%. Likewise, WTHD correlated significantly with MiL, functional status and depression.
Twelve articles, both quantitative and qualitative, were included in the review. In the end, nine different MiL interventions were identified. The clinical benefits that stood out were quality of life, spiritual well-being, optimism, decreased anxiety, hopelessness, depression, etc. The analysis of the context, mechanisms and outcomes showed a common pattern or mechanism of action that lies in the interpersonal encounter between patient-therapist; that is key to reestablishing the connection with oneself and others, due to the reflexive process that is promoted.
CONCLUSION: A functional relationship model between functional status, MiL, depression and the WTHD has been established and it explains the WTHD that may emerge in advanced cancer patients. MiL is responsible, to a great extent, for the mediation between functional status and the WTHD.
All MiL interventions identified showed clinical benefits that lie in the improvement of the emotional/psychological dimension and the spiritual/existential well-being. We also have an explanatory model of the key mechanism of action for MiL interventions. These interventions could be the appropriate way to deal with or treat spiritual/existential suffering at the end of life.