Ask an answerable question (PICO)：
Demoralization is a common form of psychological distress among terminally ill patients, which potentially leads to a loss of meaning in life, desire for death, and even suicidal thoughts. Dignity Therapy (DT) can help such patients regain a sense of dignity and meaning in life. Through brief narrative conversations, the patients are guided to report their life stories, roles, and achievements, helping them maintain their dignity during their final journey. Recently, several studies have explored the effectiveness of DT in addressing demoralization in terminally ill patients. Therefore, this study conducted a systematic review and meta-analysis to investigate the overall effectiveness of DT on improving demoralization in terminally ill patients and to provide a basis for its clinical application.
The Method and Analysis of Literature Review：
This study follows the first three steps of the evidence-based 5As (ask, acquire, and appraise) and proposes a PICO question: "Can DT improve demoralization in terminally ill patients?" We used medical subject headings (MeSH) and synonyms, both in English and Chinese, for "terminally ill patients" and "dignity therapy." Advanced searches were conducted using truncation and Boolean logic. Systematic searches were performed in six databases—CINAHL, Cochrane Library, Embase, PubMed, Index of the Taiwan Periodic Literature System, and Airiti Library—up to July 1, 2024. The inclusion criteria were as follows: P (population), terminally ill patients; I (intervention), DT combined with standard palliative care; C (comparison), standard palliative care alone; O (outcome), outcomes related to demoralization; and S (study design), systematic reviews or randomized controlled trials (RCTs). In total, 200 studies were identified. After excluding duplicate articles and those that did not explore the effect of demoralization, we included three RCTs. The meta-analysis was conducted using RevMan 5.4 software.
Critical Appraisal：
In our review, we used the 2024 CASP RCT checklist as the tool for critical appraisal. The three RCTs included a total of 182 participants. A critical appraisal of the quality assessment revealed a high risk of selection bias (2 RCTs, 66.67%), performance bias (3 RCTs, 100%), attrition bias (2 RCTs, 66.67%), and detection bias (2 RCTs, 66.67%), and no risk of reporting bias. All 3 studies are level 2 evidence in Oxford’s Centre for Evidence-Based Medicine (2011).
Results, Conclusions and Recommendations：
The meta-analysis results showed that DT combined with palliative care significantly reduced the incidence of demoralization in terminally ill patients compared to palliative care alone (1 RCT, RR= 0.22, 95% CI [0.08, 0.56], p= .002) and alleviated existential distress (3 RCTs, MD= -0.82, p= .003), psychological distress (3 RCTs, MD= -2.12, p= .02), and physical distress in the dignity inventory (3 RCTs, MD= -0.99, p= .0006). It also enhanced the Peace of Spiritual Well-Being Scale (2 RCTs, MD= 3.17, p< .00001). However, there were no statistically significant differences between meaning and purpose (2 RCTs, MD= -1.36, p= .11) and distress and coping ability on the Demoralization Scale (2 RCTs, MD= 0.24, p= .73), and meaning (2 RCTs, MD= 1.10, p= .15) and faith in the Spiritual Well-being Scale (2 RCTs, MD= 0.80, p= .27), or the incidence of desire for death (1 RCT, RR= 0.11, p= .13). Based on these three RCTs, DT can significantly reduce the incidence of demoralization and improve dignity-related physical, psychological, existential distress, and peace of spiritual well-being in terminally ill patients. Thus, in addition to standard palliative care, DT should be considered to help terminally ill patients face their final stages of life with dignity and calmness. However, the current evidence is based on only three RCTs, indicating relatively weak evidence. Therefore, it is recommended that the clinical application of DT be continuously monitored to examine its effectiveness and develop tailor-made programs based on individuals’ needs.
郭嘉琪*
