Top Ten Tips Palliative Care Clinicians Should Know About Attending to the Existential Experience.

Identifying and attending to the existential needs of persons with serious illness and their care partners are integral to whole-person palliative care (PC). Yet, many PC clinicians, due to individual factors and wider systemic barriers, are ill-prepared and under-resourced to navigate the existential dimension. In this article, written from clinical, research, and lived experiences, we offer tips to empower PC clinicians to understand, recognize, and respond to patients' and care partners' existential experiences by leveraging their existing skills, collaborating closely with colleagues, exploring their own existential experience, and implementing evidence-based interventions. We propose that by prioritizing existential care within PC, we can shift the culture of health care to better affirm the humanity of both patients and clinicians.

Examining Moderation of Dignity Therapy Effects by Symptom Burden or Religious/Spiritual Struggles.

CONTEXT: Dignity therapy (DT) is a well-researched psychotherapeutic intervention but it remains unclear whether symptom burden or religious/spiritual (R/S) struggles moderate DT outcomes. OBJECTIVE: To explore the effects of symptom burden and R/S struggles on DT outcomes. METHODS: This analysis was the secondary aim of a randomized controlled trial that employed a stepped-wedge design and included 579 participants with cancer, recruited from six sites across the United States. Participants were ages 55 years and older, 59% female, 22% race other than White, and receiving outpatient specialty palliative care. Outcome measures included the seven-item dignity impact scale (DIS), and QUAL-E subscales (preparation for death; life completion); distress measures were the Edmonton Symptom Assessment Scale (ESAS-r) (symptom burden), and the Religious Spiritual Struggle Scale (RSS-14; R/S). RESULTS: DT effects on DIS were significant for patients with both low (P = 0.03) and moderate/high symptom burden (P = 0.001). They were significant for patients with low (P = 0.004) but not high R/S struggle (P = 0.10). Moderation effects of symptom burden (P = 0.054) and R/S struggle (P = 0.52) on DIS were not significant. DT effects on preparation and completion were not significant, neither were the moderation effects of the two distress measures. CONCLUSION: Neither baseline symptom burden nor R/S struggle significantly moderated the effect of DT on DIS in this sample. Further study is warranted including exploration of other moderation models and development of measures sensitive to effects of DT and other end-of-life psychotherapeutic interventions.

Engaging Mortality: Effective Implementation of Dignity Therapy.

Background: Patients consider the life review intervention, Dignity Therapy (DT), beneficial to themselves and their families. However, DT has inconsistent effects on symptoms and lacks evidence of effects on spiritual/existential outcomes. Objective: To compare usual outpatient palliative care and chaplain-led or nurse-led DT for effects on a quality-of-life outcome, dignity impact. Design/Setting/Subjects: In a stepped-wedge trial, six sites in the United States transitioned from usual care to either chaplain-led or nurse-led DT in a random order. Of 638 eligible cancer patients (age ≥55 years), 579 (59% female, mean age 66.4 ± 7.4 years, 78% White, 61% stage 4 cancer) provided data for analysis. Methods: Over six weeks, patients completed pretest/posttest measures, including the Dignity Impact Scale (DIS, ranges 7-35, low-high impact) and engaged in DT+usual care or usual care. They completed procedures in person (steps 1-3) or via Zoom (step 4 during pandemic). We used multiple imputation and regression analysis adjusting for pretest DIS, study site, and step. Results: At pretest, mean DIS scores were 24.3 ± 4.3 and 25.9 ± 4.3 for the DT (n = 317) and usual care (n = 262) groups, respectively. Adjusting for pretest DIS scores, site, and step, the chaplain-led (ß = 1.7, p = 0.02) and nurse-led (ß = 2.1, p = 0.005) groups reported significantly higher posttest DIS scores than usual care. Adjusting for age, sex, race, education, and income, the effect on DIS scores remained significant for both DT groups. Conclusion: Whether led by chaplains or nurses, DT improved dignity for outpatient palliative care patients with cancer. This rigorous trial of DT is a milestone in palliative care and spiritual health services research. clinicaltrials.gov: NCT03209440.

Does Psychological Flourishing Have the Potential to Mitigate Self-Injurious Thoughts and Behaviors? A Preliminary Analysis of the Protective Influence of Flourishing.

AIM: The purpose of this article was to examine whether psychological flourishing, a multi-dimensional construct of well-being, has the potential to play a preventative role in suicidal and nonsuicidal thoughts and actions. METHODS: This two-part study utilized cross-sectional survey data from college students across the United States, assessing levels of psychological distress, loneliness, and psychological flourishing. Frequencies of suicidal ideation, intent, previous suicidal attempts, and nonsuicidal self-injury (NSSI) were also assessed. Data collected in 2019 were used for Study 1 (n = 38,679) and data collected in 2020 were used for Study 2 (n = 50,307). RESULTS: Psychological flourishing is significantly inversely related to suicide and NSSI risk when controlling for loneliness and psychological distress. There were two-way interactions between flourishing and distress, whereby under conditions of high distress, the inverse effect of flourishing on suicidal ideation, intent, and attempts and NSSI was more pronounced. These results were consistent across both studies. Subgroup analyses revealed similar results regardless of participants' race, sexual orientation, and gender identity. CONCLUSION: Inverse associations between flourishing and self-injurious thoughts and behaviors suggest that flourishing may buffer risk of suicide and NSSI, and these findings may have important implications for developing evidence-based therapeutic interventions. Additional research, including longitudinal and clinical work, is warranted.

Death Anxiety and Correlates in Cancer Patients Receiving Palliative Care.

Background: Death anxiety is powerful, potentially contributes to suffering, and yet has to date not been extensively studied in the context of palliative care. Availability of a validated Death Anxiety and Distress Scale (DADDS) opens the opportunity to better assess and redress death anxiety in serious illness. Objective: We explored death anxiety/distress for associations with physical and psychosocial factors. Design: Ancillary to a randomized clinical trial (RCT) of Dignity Therapy (DT), we enrolled a convenience sample of 167 older adults in the United States with cancer and receiving outpatient palliative care (mean age 65.9 [7.3] years, 62% female, 84% White, 62% stage 4 cancer). They completed the DADDS and several measures for the stepped-wedged RCT, including demographic factors, religious struggle, dignity-related distress, existential quality of life (QoL), and terminal illness awareness (TIA). Results: DADDS scores were generally unrelated to demographic factors (including religious affiliation, intrinsic religiousness, and frequency of prayer). DADDS scores were positively correlated with religious struggle (p < 0.001) and dignity-related distress (p < 0.001) and negatively correlated with existential QoL (p < 0.001). TIA was significantly nonlinearly associated with both the total DADDS (p = 0.007) and its Finitude subscale (p ≤ 0.001) scores. There was a statistically significant decrease in Finitude subscale scores for a subset of participants who completed a post-DT DADDS (p = 0.04). Conclusions: Findings, if replicable, suggest that further research on death anxiety and prognostic awareness in the context of palliative medicine is in order. Findings also raise questions about the optimal nature and timing of spiritual and psychosocial interventions, something that might entail evaluation or screening for death anxiety and prognostic awareness for maximizing the effectiveness of care.

Journalistic Denial of Death during the Very First Traumatic Period of the Italian COVID-19 Pandemic.

Exactly one year ago, between February and March 2020, the COVID-19 infection went from an epidemic confined to China to a worldwide pandemic that was particularly lethal in Italy. This study examined the media accounts during that period by analysing the representation of death-related constructs in Corriere della Sera, the most widely read newspaper in Italy. A textual and thematic analysis of articles published between period A (epidemic: 23 January-22 February 2020) and period B (pandemic: 23 February-31 March 2020) was conducted using Nvivo-11. A total of 141 articles comprising 48,524 words were collected. The most utilised words and meanings linked to COVID-19 were computed. In the rank distribution, 'China' and 'virus' were the terms most frequently used in both periods. The terms 'death' and 'dead' were completely absent in period A and appeared in the 535th position in period B. The term 'dead' was used primarily to indicate the number of deceased. From a Terror Management Theory perspective, it is possible that the minimal reference to death-related issues was a reflection of death denial and a manifestation of efforts to deny death to manage terror. These findings highlight the ambiguities and ambivalence surrounding any issue pertaining to death; on the one side, undue alarmism may provoke exaggerated reactions, such as moral panic, while on the other denial-based messages that minimise references to mortality may reduce safe behaviour during a pandemic.

Fostering Existential Maturity to Manage Terror in a Pandemic.

Background: The COVID-19 pandemic has created an environment in which existence is more fragile and existential fears or terror rises in people. Objective: Managing existential terror calls for being mature about mortality, something with which palliative care providers are familiar and in need of greater understanding. Methods: Using a case to illustrate, we describe existential terror, terror management, and existential maturity and go on to outline how existential maturity is important for not only the dying and the grieving but for also those facing risk of acquiring COVID-19. Results: Next, we describe how essential components in attaining existential maturity come together. (1) Because people experience absent attachment to important people as very similar to dying, attending to those experiences of relationship is essential. (2) That entails an internal working through of important relationships, knowing their incompleteness, until able to "hold them inside," and invest in these and other connections. (3) And what allows that is making a meaningful connection with someone around the experience of absence or death. (4) We also describe the crucial nature of a holding environment in which all of these can wobble into place. Discussion: Finally, we consider how fostering existential maturity would help populations face up to the diverse challenges that the pandemic brings up for people everywhere.

Terror Management Theory and the COVID-19 Pandemic.

Terror management theory is focused on the role that awareness of death plays in diverse aspects of life. Here, we discuss the theory's implications for understanding the widely varying ways in which people have responded to the COVID-19 pandemic. We argue that regardless of whether one consciously believes that the virus is a major threat to life or only a minor inconvenience, fear of death plays an important role in driving one's attitudes and behavior related to the virus. We focus on the terror management theory distinction between proximal defenses, which are activated when thoughts of death are in current focal attention and are logically related to the threat at hand, and distal defenses, which are activated when thoughts of death are on the fringes of one's consciousness and entail the pursuit of meaning, personal value, and close relationships. We use this framework to discuss the many ways in which COVID-19 undermines psychological equanimity, the diverse ways people have responded to this threat, and the role of ineffective terror management in psychological distress and disorder that may emerge in response to the virus.

Searching for God: Illness-Related Mortality Threats and Religious Search Volume in Google in 16 Nations.

We tested predictions about religiosity and terror management processes in 16 nations. Specifically, we examined weekly variation in Google search volume in each nation for 12 years (all weeks for which data were available). In all 16 nations, higher than usual weekly Google search volume for life-threatening illnesses (cancer, diabetes, and hypertension) predicted increases in search volume for religious content (e.g., God, Jesus, prayer) in the following week. This effect held up after controlling for (a) recent past and annual variation in religious search volume, (b) increases in search volume associated with religious holidays, and (c) variation in searches for a non-life-threatening illness ("sore throat"). Terror management threat reduction processes appear to occur across the globe. Furthermore, they may occur over much longer periods than those studied in the laboratory. Managing fears of death via religious belief regulation appears to be culturally pervasive.

Mortality salience effects on the life expectancy estimates of older adults as a function of neuroticism.

Research has shown that reminders of mortality lead people to engage in defenses to minimize the anxiety such thoughts could arouse. In accord with this notion, younger adults reminded of mortality engage in behaviors aimed at denying vulnerability to death. However, little is known about the effects of mortality reminders on older adults. The present study examined the effect of reminders of death on older adults' subjective life expectancy. Mortality reminders did not significantly impact the life expectancy estimates of old-old adults. Reminders of death did however lead to shorter life expectancy estimates among young-old participants low in neuroticism but longer life expectancy estimates among young-old participants high in neuroticism, suggesting that this group was most defensive in response to reminders of death.

Going for broke: mortality salience increases risky decision making on the Iowa gambling task.

Research on gambling, and risk taking in general, has focused primarily on approach-related motivations. The current study examined the avoidance of existential anxiety as a possible source of risky decision making and behaviour. The authors hypothesized that participants reminded of their own mortality would consequently make riskier decisions (and therefore perform more poorly) on the Iowa gambling task. Results confirmed this prediction. Implications of the finding that existential concerns undermine efficient decision making are considered.

A terror management analysis of the psychological functions of religion.

From a terror management theory (TMT) perspective, religion serves to manage the potential terror engendered by the uniquely human awareness of death by affording a sense of psychological security and hope of immortality. Although secular beliefs can also serve a terror management function, religious beliefs are particularly well suited to mitigate death anxiety because they are all encompassing, rely on concepts that are not easily disconfirmed, and promise literal immortality. Research is reviewed demonstrating that mortality salience produces increased belief in afterlife, supernatural agency, human ascension from nature, and spiritual distinctions between mind and body. The social costs and benefits of religious beliefs are considered and compared to those of secular worldviews. The terror management functions of, and benefits and costs associated with, different types of religious orientation, such as intrinsic religiosity, quest, and religious fundamentalism, are then examined. Finally, the TMT analysis is compared to other accounts of religion.

Interpersonal politics: the role of terror management and attachment processes in shaping political preferences.

Research on terror management theory (TMT) indicates that reminders of death affect political attitudes, but political orientation only sometimes moderates these effects. We propose that secure relationships are associated with values of tolerance and compassion, thus orienting people toward liberalism; insecure attachments are associated with more rigid and absolutist values that orient people toward conservatism. Given that attachment relationships become especially active when security needs are heightened, we predicted that mortality salience would be an important factor in understanding the relationship between attachment processes and political orientation. Supporting these ideas, Study 1 showed that after a mortality-salience manipulation, securely attached participants increased their support for a liberal presidential candidate, and less securely attached participants increased their support for a conservative presidential candidate. In Study 2, a secure-relationship prime following a mortality-salience manipulation engendered a less violent approach to the problem of terrorism than did a neutral-relationship prime. We discuss the interaction of TMT processes and individual differences in attachment in shaping political preferences.

Terror management and adults' attachment to their parents: the safe haven remains.

Six studies examined the role of young adults' parental attachment in terror management. Studies 1-3 revealed that activating thoughts of one's parent in response to mortality salience (MS) reduced death-thought accessibility and worldview defense and increased feelings of self-worth. Studies 4-5 demonstrated that MS led to greater ease of recalling positive maternal interactions and greater difficulty recalling negative interactions, and increased attraction to a stranger who was described as being similar to one's parent. If reliance on parents for terror management purposes reflects the operation of attachment mechanisms, then such effects should vary on the basis of an individual's attachment style. Study 6 demonstrated that, after MS, insecure individuals were more likely to rely on relationships with their parents, whereas secure individuals were more likely to rely on relationships with romantic partners.

Age-related differences in responses to thoughts of one's own death: mortality salience and judgments of moral transgressions.

Two experiments explored age differences in response to reminders of death. Terror management research has shown that death reminders lead to increased adherence to and defense of one's cultural worldview. In Study 1, the effect of mortality salience (MS) on evaluations of moral transgressions made by younger and older adults was compared. Whereas younger adults showed the typical pattern of harsher judgments in response to MS, older adults did not. Study 2 compared younger and older adults' responses to both the typical MS induction and a more subtle death reminder. Whereas younger adults responded to both MS inductions with harsher evaluations, older adults made significantly less harsh evaluations after the subtle MS induction. Explanations for this developmental shift in responses to reminders of death are discussed.

Terror mismanagement: evidence that mortality salience exacerbates phobic and compulsive behaviors.

Terror management theory (TMT) posits that cultural worldviews and self-esteem function to buffer humans from mortality-related anxiety. TMT research has shown that important behaviors are influenced by mortality salience (MS) even when they have no obvious connection to death. However, there has been no attempt to investigate TMT processes in anxious responding. The present research examines that question. In Study 1, compared to a control condition, MS increased anxious responding to spider-related stimuli, but only for participants who met criteria for specific phobia. In Study 2, compared to an aversive control condition, MS increased time spent washing hands, but only for those scoring high on a measure of compulsive hand washing (CHW). In Study 3, compared to a different aversive control condition, MS increased avoidance of a social interaction, but only for those scoring high on a measure of social interaction anxiety. The relevance of TMT in anxious responding is discussed.

Windows into nothingness: terror management, meaninglessness, and negative reactions to modern art.

Why do people dislike art that they find meaningless? According to terror management theory, maintaining a basic meaningful view of reality is a key prerequisite for managing concerns about mortality. Therefore, mortality salience should decrease liking for apparently meaningless art, particularly among those predisposed to unambiguous knowledge. Accordingly, mortality salience diminished affection for modern art in Study 1, and this effect was shown in Study 2 to be specific to individuals with a high personal need for structure (PNS). In Studies 3 and 4, mortality salient high-PNS participants disliked modern art unless it was imbued with meaning, either by means of a title or a personal frame of reference induction. Discussion focused on the roles of meaninglessness, PNS, and art in terror management.

Mortality salience, martyrdom, and military might: the great satan versus the axis of evil.

Study 1 investigated the effect of mortality salience on support for martyrdom attacks among Iranian college students. Participants were randomly assigned to answer questions about either their own death or an aversive topic unrelated to death and then evaluated materials from fellow students who either supported or opposed martyrdom attacks against the United States. Whereas control participants preferred the student who opposed martyrdom, participants reminded of death preferred the student who supported martyrdom and indicated they were more likely to consider such activities themselves. Study 2 investigated the effect of mortality salience on American college students' support for extreme military interventions by American forces that could kill thousands of civilians. Mortality salience increased support for such measures among politically conservative but not politically liberal students. The roles of existential fear, cultural worldviews, and construing one's nation as pursing a heroic battle against evil in advocacy of violence were discussed.