Efficacy of the structured life review and the short-term life review on the spiritual well-beingof terminally ill cancer patients

doi:10.4236/health.2010.24051

Paper Menu >>

Journal Menu >>

Vol.2, No.4, 342-346 (2010) Health

doi:10.4236/health.2010.24051

Efficacy of the structured life review and the

short-term life review on the spiritual well-being

of terminally ill cancer patients

Michiyo Ando1, Tatsuya Morita2

1 Faculty of Nursing, St. Mary’s College, Kurume, Japan; andou@st-mary.ac.jp

2 Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital,

Shizuoka, Japan

Received 27 November 2009; revised 4 January 2010; accepted 20 January 2010.

ABSTRACT

GOALS: The aims of this study were to evaluate

the treatment efficacy of the structured life re-

view interviews and the Short-Term Life Review

on the spiritual well-being of terminally ill can-

cer p atient s, in order to improv e p atient s’ quality

of life. SUBJECTS and METHODS: Participants

were patients in palliative care units in Japan. In

the study 1, the structured life review interviews

were conducted with 12 patients. They com-

pleted the QOL scale of the SELT-M (Skalen zur

Erfassung von Lebens qualitat bei Tumor-

kranken–Modified Version) questionnaire before

and after the interviews. In the study 2, the

Short-Term Life Review was conducted with 30

patients. They reviewed their lives in the first

session and they confirmed the contents in the

album based on the life review in the second

session. Duration of the treatment was one

week. Measurement instruments included Func-

tional Assessment Chronic Illness Therapy-

Spiritual (FACIT-Sp). RESULTS: After the struc-

tured life review, the mean overall QOL score

and Spirituality subscale score of the SELT-M

significantly increased, from 2.57 ± 0.61 to 3.58

± 1.0 (p=0.013) and 2.57 ± 0.61 to 3.14 ± 2.25

(P=0.023), respectiv ely. After the Short-Term Life

Review, the mean FACIT-Sp scores significantly

increased from 16 ± 8.2 to 24 ± 7.1. CONCLU-

SION: Both the structured life review and the

Short-Term Life Review may be effective in im-

proving the spiritual well-being of terminally ill

cancer patients, being higher feasibility for the

Short-Term Life Review. We need to use these

therapies understanding characteristics of each

therapy.

Keywords: Psychotherapy; Life Review; Terminally

Patients; Spiritual Well-Being

1. INTRODUCTION

Meaning of life or meaning of existence is an important

for human, and it is called spirituality. World Health Or-

ganization demonstrates that spirituality is an important

factor for human’s quality of life. From the study of

Japanese terminally ill cancer patients, Murata & Morita

[1] defined spiritual well-being as meaning of life and

peaceful of mind, and psycho-existential sufferings as

loss of meaning of life or meaning of existence. Al-

though terminally ill cancer patients often experience

psycho-existential sufferings, there have been few inter-

ventions for these problems. The present study describes

an intervention to elevate spiritual well-being in termi-

nally ill cancer patients.

Butler [2] reported that the life review process is a

mean of reintegration and can give new significance and

meaning to an individual’s life. It is defined as “the pro-

gressive return to consciousness of prior experience,

which can be re-evaluated with the intentio n of resolving

and integrating past conflict, thereby giving new signifi-

cance to one’s life.” A life review is a type of reminis-

cence therapy [2]. Reminiscence itself is an act ivity of lif e

review or reminiscence therapy. Reminiscence is an in-

terpersonal or communicative psychosocial process that

can be carried out individually or in groups [3]. Previous

studies have shown the effects of life review on depres-

sion [4-6], self-esteem [4 ], and life satisfaction [7].

There are relatively few studies concerning life review

interviews for cancer patients, particularly in the form of

empirical studies, though there are some studies. To use

life review effectively in the clinical situation, we had to

know the efficacy of life review empirically. We are re-

viewing two empirical studies [8,9].

2. STUDY 1 STRUCTURED LIFE REVIEW

2.1. Purpose

In the Study 1, we evaluate the treatment efficacy of the

M. Ando et al. / Health 2 (2 010) 342-346

343

structured life review interviews on the spiritual well-

being of terminally ill cancer patients.

2.2. Methods

2.2.1. Participant s

Participants were patients with incurable cancer receiv-

ing specialized care in the palliative care unit of a gen-

eral hospital in Japan. The inclusion criteria for this

study were 1) the patient had incurable cancer, 2) the

patient was 20 years of age or older, and 3) the primary

physicians were in agreement that the patient would

benefit from the psychological interventions. Exclusion

criteria were, 1) the patients had strong physical symp-

toms, 2) the patients had cognitive impairment. During 6

month study periods, a total of 21 patients were recruited

from the primary physicians; however 9 patients were

later excluded from this study for various reasons. Thus,

12 patients (2 males, 10 females) finally participated in

the study. The patients’ ages ranged from 54 to 82, with

a mean of 63. The primary tumor sites were breast (n =

3), liver (n = 2), colon (n = 2), lun g (n = 2), thyroid (n =

1), stomach (n = 1), and gallbladder (n = 1).

2.2.2. Interv entions an d O utcome M ea surements

The interviewer was a clinical psychologist. The inter-

view procedure entailed a structured life review inter-

view [7] in which patients reviewed their own childhood,

adolescence, adult life, and current situation along Erik-

son’ development stages [10]. Some of the questions

asked were 1) Please tell me about your childhood, 2)

What do you remember to be th e most impressive ev ents

in your childhood?, and 3) How do you feel now when

you review those impressive events (Ta ble 1). Four ses-

sions were planned for each patient, addition to one ses-

sion for making relationships between a patient and the

interviewer. Interviews were conducted in the dayroom

or at the bedside. The patient reviews were recorded in

the form of notes taken during or immediately after the

session.

To evaluate the spiritual well-being, we used the

Table 1. The question items in the structured life review.

Times Examples of ques t i o n i t e ms

1 Making relati onshi ps and liste ning t o patients’ feel ing now

Theme: feeling life in the hospitals, problems, e tc .

2 Child period:

Theme: parents, home town, family members, playing,

etc.

3 Young Adult period:

Theme: study, work, human-relation in social life, etc.

4 Adult period:

Theme: marriage, born in children, role in family or

social life, etc.

5 From adult to now:

Theme: illness, medical treatment, human-relationships,

etc.

SELT-M (Skalen zur Erfassung von Lebens qualitat

bei Tumorkranken–Modified Version) [11]. The pa-

tients completed the Japanese version of the SETL-

M [12] before and after the intervention. The reli-

ability and validity of the Japanese version of the

SELT-M has been reported. The SELT-M consisted of

6 subscales, namely, Physical well-being (3 items),

Mood (6 items), Support (3 items), Orientation (3

items, e.g., “Today, I see many things in a more

positive light”), Spirituality (3 items, e.g., “It is dif-

ficult for me to see positive meaning in my illness”),

and Overall QOL (1 item). We used the overall QOL

score and Spirituality subscale score in the

post-interview results. Each subscale ranged from 1

to 5, with a higher score indicating a higher level of

patient-perceived QOL.

The institutional review board of this hospital ap-

proved this study from both ethical and scientific aspects,

and a patient gave written consent.

2.2.3. Statisti cal Analysis

In order to evaluate the treatment efficacy of life review

interviews on the patient’s spiritual well-being, a Wil-

coxon sign rank test was conducted on the sections of

the SELT-M before and after the life review interviews.

2.3. Results

As shown in Tab le 2, overall QOL and Spirituality sus-

cale scores, in addition to Mood and Orientation suscale

scores, significantly increased after the intervention.

3. STUDY 2 SHORT-TERM LIFE REVIEW

Although structured life review may be effective in

improving the spiritual well-being of terminally ill

cancer patients, the long sessions decrease the feasi-

bility, thus we need a shorter version of life review

therapy. We propose a new psychotherapy-the Short-

Term Life Review with short sessions for terminally

ill cancer patients. A Short-Term Life Review involves

only two sessions. Patients review or narrate their

lives about questions which promote the integration of

lives referring other previous studies. In the first ses-

sion, patients review their lives, and the review is then

recorded and edited. The therapist makes an album

after the first session. In the second session, the pa-

tient and therapist view the album, and confirm the

contents with appreciation.

3.1. Purpose

The primary aim of this study was to assess the efficacy

of the Short-Term Life Review on the spiritual well-

being, as well as anxiety, depression, sufferings, and

happiness, or terminally ill cancer patients.

M. Ando et al. / Health 2 (2 010) 342-346

344

Table 2. Mean scores and P value by the Wilcoxon sign rank test on scores of SELT-M.

SELT-M

Physical

well-being Mood Support Orientation Spirituality Overall QOL

Before 2.33 (SD = 0.79)3. 16 ( S D = 0 . 65 ) 3.28 (SD = 0. 65)2.93 (SD = 0.75)2.57 (SD = 0.61) 2.57 ( SD = 0.61)

After 2.80 (SD = 1.16)3.79 (SD = 0. 74) 3.61 (SD = 0. 83)3.65 (SD = 1.03)3.14 (SD = 2.25) 3.58 (SD = 1.0)

P value Z = –1.02,

P = 0.307 Z = –2.67,

P = 0.008 Z = –1.18,

P = 0.237 Z = –2.05,

P = 0.041 Z = –2.23,

P = 0.023 Z = –2.49,

P = 0.013

Table 3. Patient backgrounds.

Primary tumor site Gender

Lung

Stomach

Pancreas

Gallbladder

Uterine

Breast

Kidney

Leukemia

Rectal

Tongue

Colon

Mesothelioma

Myeloma

Lymphoma

n = 8

n = 5

n = 2

n = 1

Male (n = 8)

Female (n = 22)

Age

Mean age;74 (Total SD = 9.1)

Martial states

Married (n = 29); Widow (n = 11), Widower (n = 3)

Non-married (1)

Religion

Christian (n = 4)

Buddhism (n = 3) None(n = 22)

ECOG-PS

1 (n = 1), 2 (n = 3)

3 (n = 13), (n = 1 3)

Duration from the interview to patients’ death

Mean; 67 days

3.2. Methods

3.2.1. Participants

The participants were cancer p atients from the palliative

care unit of two general hospitals and one home-care

clinic. The inclusion criteria for this study were 1) pa-

tients with incurable cancer; 2) patients without cogni-

tive impairment; 3) patients 20 years of age or older; and

4) patients for whom the primary physicians agreed

would benefit from the psychological interventions.

During the 11-month study period, 35 patients were re-

cruited through primary physicians. Table 3 shows the

patients’ background.

3.2.2. Intervention

Ethical aspect of this study was validated by both the

board and the ethical committee of St. Mary’s Hospital

and St. Mary’s College.

The Short-Term Life Review has two parts. In the first

part, patients review their lives, and in the second, they

re-evaluate, re-construct, and appreciate their life. The

interviewer was a clinical psychologist (therapist). The

interview procedure was based on a structured life re-

view interview that was conducted individually, and the

patient was asked to re-evaluate both good and bad

memories. Question items were mainly based on the

structured life review, and some items from Chochinov

et al. [13] were added. The following questions were

asked in the revi ewi n g sessi o n ( Table 4):

1) What is the most im portant thing in your life and why?

2) W hat are the most impressive memories in your life ? 3)

In your life, what was the event that or the person who

affected you the most? 4) What is the most important

role in your life? 5) Which is the proudest moment of

your life? 6) Is ther e anyth ing abou t you th at your family

would need to know, are there things you would want

them to tell you, and, if possible, are there things you

would want them to remember? 7) What advice or word

of guidance would you wish to pass on othe important

people in your life or to the younger generation?

The patient’s narratives were recorded, and the thera

pist tried to listen to each word uttered by the patient. Af-

ter the first session, the interview was first transcribed

verbatim and the therapist made the album. To make the

album, 1) key words in the answer to each question were

selected. Words or phrases used by the patient were writ-

ten in the album as often as possible; both good and bad

things were included and feelings or re-framed thoughts-

how he feels now-were written in the album. 2) The

therapist pasted photos or drawings from various books or

magazines that were related to the patients’ words or

phrases, to make the album more beautiful and more

memory-provoking. It t ook a week for the treatm ent.

3.2.3. Outcome Measurements

To measure the effects of the Short-Term Life Review,

we used the Japanese version of FACIT-Sp [14]. The

validity and reliability of th e FACIT-Sp Japanese version

is well-established [15].

3.2.4. S ta tistical Analysis

To evaluate the efficacy of the Short-Term Life Review

in improving the patients’ spiritual well-being, the Wil-

M. Ando et al. / Health 2 (2 010) 342-346

345

Table 4. The question items in the short-term life review.

Question Items

1) Wha t is the most impor t a nt thing in your life and w hy?

2) What are the most impressive memories in your life ?

3) In your life, what was the event that or the person who affected you the most?

4) What is the most important role in your life?

5) Which is the proudest moment of your life?

6) Is there anything about you that your family would need to know, are there things you would want t hem to tell you, and, if possible, are

there things you would want them to remember?

7) What advice or word of guidance would you wish to pass on to the important people in your lif e or to the younger generation?

coxon signed rank test was conducted on all scores of

each scale before and after the Short-Term Life Review.

3.3. Results

Five of the patients were excluded from this study be-

cause of unexpected deterioratio n in health. Thus, a total

of 30 patients completed all sessions. After the Short-

Term Life Review, the mean FACIT-Sp scores signifi-

cantly increas ed from 16 ± 8.2 to 24 ± 7.1 (Z = –4.2, P =

0.001).

4. DISCUSSION

4.1. Effects of the Structured Life Review

and the Short Term-Life Review

After the structured life review, the significant increase

in the SELT-M scores, as well as the Spirituality, Orien-

tation, and Mood subscales shows the efficacy of this

therapy on spiritual well-being of terminally ill cancer

patients. As the Spirituality and Orientation subscale

quantify the levels of the patients’ meaningfulness and

positive outlook , the patients may have found a meaning

to life and had more positive thoughts. The significant

increase in the Mood subscale for terminally ill cancer

patients is accord with previous studies for elders [3-5].

After the Short-Term Life Review, the FACIT-Sp

scores significantly increased. It shows the effect of this

therapy on spiritual well-being of cancer patients. We

confirm the efficacy of this therapy even when we com-

pare it with the control group [16]. Adapting these proc-

ess with the previous theoretical model [17,18], we can

explain the effects of Short-Term Life Review. A patient

has a purpose or a goal for his life when he is healthy.

However, when he falls into serious illness, it is often

difficult for him to attain his purpose or a goal because

of unexpected serious illness, and he feels much distress.

In this situation, when he receives the Short-Term Life

Review and he can re-think and modifies his original

purpose or goals into attainable ones, he feels positive

mood. Short-Term Life Review may contribute for a

patient to reconstruct his life being congruent with can-

cer in his life.

4.2. Feasibility

It would be remarkable for Short-Term Life Review to

have high feasibility. Th e percentage of patients deterio-

rating with this therapy was only 17%, although, it was

30% for patients using the structured life review. We

describe some factors related to feasibility. 1) The

Short-Term Life Review is completed in a week, and this

short-term intervention enables terminally ill cancer pa-

tients to complete an intervention. 2) Patients with very

low functionality in ADL can participate because the

patients review th eir lives wh ile lying on b ed. If p atien ts’

ADL is high, the Problem-solving therapy for cancer

patients [19] and cognitive behavior therapy for cancer

patients [20], or meaning-centered group psychotherapy

[21] are also effective.

4.3. Characteristics of Each Life Review

There are some characteristics of each therapy. The

structured life review is suitable for patients who have

much time for interviews and require little cognitive load.

Oppositely, The Short-Term Life review is suitable for

patients who do not have much time for interviews and

require a little more cognitive load. In the Short-Term

Life review, a patient needs to think of his life pro-

foundly, resulting in requiring much cognitive load. We

use these therapies understanding patients’ physical and

mental states.

5. CONCLUSIONS

Both the structured life review and the Short-Term Life

Review have efficacy on spiritual well-being of termi-

nally ill cancer patients, being higher feasibility for the

Shot-Term Life Review. We need to use these therapies

understanding characteristics of each therapy.

REFERENCES

[1] Murata, H. and Morita, T. (2006) Conceptualization of

psycho-existential suffering by the Japanese Task Force:

The first step of a nationwide project. Pattern of Pallia-

tive Care, 4, 279-285.

M. Ando et al. / Health 2 (2 010) 342-346

346

[2] Butler, R.N. (1974) Successful aging and the role of the

life review. Journal of the American Geriatrics Society,

22, 529-535.

[3] Haight, B., Coleman, P.G., and Lord, K. (1995) The

linchpins of a successful life review: Structure, evalua-

tion, and individuality. In Haight, B.K. and Webster, J.D.

(Eds) The art and science of reminiscing: theory, research,

methods and applications. Bristol, P.A: Taylor & Francis,

179-192.

[4] Haight, B., Michel, Y., and Hendrix, S. (1998) Life re-

view: Preventing despair in newly relocated nursing

home residents: Short- and long-term effects. Interna-

tional Journal of Aging and Human Development, 47,

119-142.

[5] Haight, B., Michel, Y., and Hendrix, S. (2000) The ex-

tended effects of the life review in nursing home resi-

dents. International Journal of Aging and Human De-

velopment, 50, 151-168.

[6] Jones, E.D. and Beck-Little, R. (2002) The use of remi-

niscence therapy for the treatment of depression in ru-

ral-dwelling older adults. Issues in Mental Health Nurs-

ing, 23, 279-290.

[7] Haight, B.K. (1988) The therapeutic role of a structured

life review process in homebound elderly subjects.

Journal of Gerontology, 43, 40-44.

[8] Ando, M., Tsuda, A., and Morita, T. (2007) A preliminary

study of life review interviews on the spiritual well-being

of terminally ill ca n cer patients . Support Care Cancer, 15,

225-231.

[9] Ando, M., Morita, T., Okamoto, T., and Ninosaka, Y.

(2009) One week Short-Term Life Review interview can

improve spiritual well-being of terminally ill cancer pa-

tients. Psycho-Oncology, 17, 885-890.

[10] Erikson, E.H. (1959) Identity and the life cycle. Interna-

tional University Press, New York.

[11] Wegberg, B.V., Bacchi, M., and Heusser, P., et al. (1998)

The cognitive-spiritual dimension:-an important addition

to the assessment of quality of life: Validation of a ques-

tionnaire (SELT-M) in patients with advanced cancer.

Annals of Oncology, 9, 1091-1096

[12] Ishikawa, K. (2000) Spiritual QOL. Palliat Med, 2,

173-181 (in Japanese).

[13] Chochinov, H.M., Hack, T., Hassard, T., et al. (2005)

Dignity therapy: A novel psychotherapeutic intervention

for patients near the end of life. Journal of Clinical On-

cology, 23, 5520-5525.

[14] Peterman, A.H., Fitchett, G., Brady, M.J., et al. (2002).

Measuring spiritual well-being in people with cancer:

The Functional Assessment of Chronic Illness Ther-

apy-Spiritual Well-Being Scale (FACIT-Sp), Annals of

Behavioral Medicine, 24, 49-58.

[15] Noguchi, W., Ono, T., Morita, T., et al. (2004) An inves-

tigation of reliability and validity to Japanese version of

Functional Assessment of Chronic Illness Ther-

apy-Spiritual (FACIT-sp), Japan Journal of General

Hospital Psychiatry, 16, 42-47

[16] Ando M, Morita T, Akechi T, et al. (2009) The efficacy

of Short-Term Life Review interviews on the spiritual

well-being of terminally ill cancer patients. Journal of

Pain and Symptom Management, in press

[17] Park, C.L. and Folkman, S. (1997) Meaning in the con-

text of stress and coping. Review Genel Psycholo, 1,

115-144.

[18] Folkman, S. and Greer, S. (2000) Promoting psychologi-

cal well-being in the face of serious illness: when theory,

research and practice inform each other. Psy-

cho-Oncology, 9, 11-19.

[19] Nezu, A.M., Nezu, C.M., Friedman, S.H., et al. (2002).

Psychosocial oncology. In Nezu A.M., Nezu C.M., Geller

P.A. Eds., Health psychology, Handbook of Psychology,

Wiley, 9, 121-156.

[20] Greer, S. and Moorey, S. (1997) Adjuvant psychological

therapy for cancer patients. Palliat Med, 11, 240-244.

[21] Breitbert, W. (2002) Spirituality and meaning in suppor-

tive care: spirituality- and meaning-centered group psy-

chotherapy interventions in advanced cancer. Support

Care Cancer, 10, 272-280..