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Demoralization and spirituality in oncology: an integrative systematic review

Supportive Care in Cancer volume 31, Article number: 259 (2023) Cite this article

Abstract

Objective

To synthesize the scientific findings on demoralization and spirituality in the oncology context.

Methods

This is an integrative systematic review, in line with the PRISMA 2020 guidelines, as proposed by Whittemore and Knalf (2005). The MEDLINE via PubMed, Scopus, Web of Science, APA PsycNet, CINAHL, Cochrane Library, EMBASE, and LILACS databases were searched without limitations regarding language or year of publication. The studies were screened for inclusion according to the predefined eligibility criteria. Data extraction and evidence quality assessment were performed.

Results

Out of the 1587 articles evaluated, 10 studies were included in this review. In general, it was found that demoralization tends to increase with the proximity of death and seems to be inversely related to spirituality, with spiritual well-being being a protective factor against demoralization, while the non-fulfillment of spiritual needs is related to increased demoralization in people with cancer. Furthermore, even among caregivers of people with advanced cancer, demoralization seems to be associated, among other factors, with spiritual suffering. These results should be analyzed with caution, considering that the studies included in this review are all observational studies, which prevents establishing cause and effect relationships.

Conclusions

Demoralization tends to increase with growing frailty and the proximity of death in people with cancer, and it seems to be inversely related to spirituality, both in these patients and in their caregivers.

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References

  1. Kissane DW, Clarke DM, Street AF (2001) Demoralization syndrome--a relevant psychiatric diagnosis for palliative care. J Palliat Care 17:12–21

    Article  CAS  PubMed  Google Scholar 

  2. Clarke DM, Kissane DW (2002) Demoralization: its phenomenology and importance. Aust N Z J Psychiatry 36:733–742. https://doi.org/10.1046/j.1440-1614.2002.01086.x

    Article  PubMed  Google Scholar 

  3. Kissane DW (2014) Demoralization: a life-preserving diagnosis to make for the severely medically ill. J Palliat Care 30:255–258

    Article  PubMed  Google Scholar 

  4. Gan LL, Gong S, Kissane DW (2022) Mental state of demoralisation across diverse clinical settings: a systematic review, meta-analysis and proposal for its use as a 'specifier' in mental illness. Aust N Z J Psychiatry 56:1104–1129. https://doi.org/10.1177/00048674211060746

    Article  PubMed  Google Scholar 

  5. Eggen AC, Reyners AK, Shen G et al (2020) Death anxiety in patients with metastatic non-small cell lung cancer with and without brain metastases. J Pain Symptom Manage 60:422–429. https://doi.org/10.1016/j.jpainsymman.2020.02.023

    Article  PubMed  Google Scholar 

  6. Bovero A, Sedghi NA, Opezzo M et al (2018) Dignity-related existential distress in end-of-life cancer patients: prevalence, underlying factors, and associated coping strategies. Psycho-Oncol 27:2631–2637. https://doi.org/10.1002/pon.4884

    Article  Google Scholar 

  7. Peng H, Hsueh H, Chang Y, Li R (2021) The mediation and suppression effect of demoralization in breast cancer patients after primary therapy: a structural equation model. J Nurs Res 29:e144. https://doi.org/10.1097/JNR.0000000000000421

    Article  PubMed  Google Scholar 

  8. Nikoy Kouhpas E, Karimi Z, Rahmani B et al (2020) The relationship between existential anxiety and demoralization syndrome in predicting psychological well-being of patient with cancer. Clin Psychol 8:175–182. https://doi.org/10.32598/jpcp.8.3.515.1

    Article  Google Scholar 

  9. Lin F, Hong Y, Lin X et al (2022) Demoralization profiles and their association with depression and quality of life in Chinese patients with cancer: a latent class analysis. Support Care Cancer. 30(12):10019–10030. https://doi.org/10.1007/s00520-022-07412-9

    Article  PubMed  Google Scholar 

  10. Chang TG, Huang PC, Hsu CY et al (2022a) Demoralization in oral cancer inpatients and its association with spiritual needs, quality of life, and suicidal ideation: a cross-sectional study. Health Qual Life Outcomes 20:60. https://doi.org/10.1186/s12955-022-01962-6

    Article  PubMed  PubMed Central  Google Scholar 

  11. Ghiggia A, Pierotti V, Tesio V et al (2021) Personality matters: relationship between personality characteristics, spirituality, demoralization, and perceived quality of life in a sample of end-of-life cancer patients. Support Care Cancer 29:7775–7783. https://doi.org/10.1007/s00520-021-06363-x

    Article  PubMed  PubMed Central  Google Scholar 

  12. Boston P, Bruce A, Schreiber R (2011) Existential suffering in the palliative care setting: an integrated literature review. J Pain Symptom Manage 41(3):604–618. https://doi.org/10.1016/j.jpainsymman.2010.05.010

    Article  PubMed  Google Scholar 

  13. Rodin G, Lo C, Rydall A et al (2018) Managing cancer and living meaningfully (CALM): a randomized controlled trial of a psychological intervention for patients with advanced cancer. J Clin Oncol 36(23):2422–2432. https://doi.org/10.1200/JCO.2017.77.1097

    Article  PubMed  PubMed Central  Google Scholar 

  14. Ross S, Bossis A, Guss J et al (2016) Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: a randomized controlled trial. J Psychopharmacol 30(12):1165–1180. https://doi.org/10.1177/0269881116675512

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Liu ML, Hsiao YC (2019) The impact of demoralization on spiritual well-being in terminally ill patients. Hu Li Za Zhi 66:48–59. https://doi.org/10.6224/JN.201902_66(1).07

    Article  PubMed  Google Scholar 

  16. Bovero A, Opezzo M, Tesio V (2023) Relationship between demoralization and quality of life in end-of-life cancer patients. Psycho-oncology 32(3):429–437. https://doi.org/10.1002/pon.6095

    Article  PubMed  Google Scholar 

  17. Puchalski CM, Vitillo R, Hull SK et al (2014) Improving the spiritual dimension of whole person care: reaching national and international consensus. J Palliat Med 17:642–656. https://doi.org/10.1089/jpm.2014.9427

    Article  PubMed  PubMed Central  Google Scholar 

  18. Balboni TA, VanderWeele TJ, Doan-Soares SD, Long KNG, Ferrell BR, Fitchett G, Koenig HG, Bain PA, Puchalski C, Steinhauser KE, Sulmasy DP, Koh HK (2022) Spirituality in serious illness and health. JAMA 328(2):184–197. https://doi.org/10.1001/jama.2022.11086

    Article  PubMed  Google Scholar 

  19. Cannon AJ, Dokucu ME, Loberiza FR Jr (2022) Interplay between spirituality and religiosity on the physical and mental well-being of cancer survivors. Support Care Cancer 30(2):1407–1417. https://doi.org/10.1007/s00520-021-06534-w

    Article  PubMed  Google Scholar 

  20. Wang Y, Sun H, Ji Q, Wu Q, Wei J, Zhu P (2023) Prevalence, associated factors and adverse outcomes of demoralization in cancer patients: a decade of systematic review. Am J Hosp Palliat Care 31:10499091231154887. https://doi.org/10.1177/10499091231154887

    Article  Google Scholar 

  21. Whittemore R, Knafl K (2005) The integrative review: updated methodology. J Adv Nurs 52:546–553. https://doi.org/10.1111/j.1365-2648.2005.03621.x

    Article  PubMed  Google Scholar 

  22. Torraco RJ (2016) Writing integrative literature reviews: using the past and present to explore the future. Hum Resour Dev Rev 15:404–428. https://doi.org/10.1177/1534484316671606

    Article  Google Scholar 

  23. Page MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71

    Article  PubMed  PubMed Central  Google Scholar 

  24. Jadad AR, Moher D, Klassen TP (1998) Guides for reading and interpreting systematic reviews: II. How did the authors find the studies and assess their quality? Arch Pediatr Adolesc Med 152:812–817. https://doi.org/10.1001/archpedi.152.8.812

    Article  CAS  PubMed  Google Scholar 

  25. Ouzzani M, Hammady H, Fedorowicz Z et al (2016) Rayyan—a web and mobile app for systematic reviews. Syst Rev 5:210. https://doi.org/10.1186/s13643-016-0384-4

    Article  PubMed  PubMed Central  Google Scholar 

  26. Miles MB, Huberman AM (1994) Qualitative data analysis. Sage Publications, Thousand Oaks

    Google Scholar 

  27. Dang D, Dearholt S (2017) Johns Hopkins nursing evidence-based practice: model and guidelines, 2nd edn. Sigma Theta Tau International

    Google Scholar 

  28. Jacobsen J, Vanderwerker L, Block S et al (2006) Depression and demoralization as distinct syndromes: preliminary data from a cohort of advanced cancer patients. Indian J Palliat Care 12(1)

  29. Bovero A, Botto R, Adriano B, Opezzo M, Tesio V, Torta R (2019) Exploring demoralization in end-of-life cancer patients: prevalence, latent dimensions, and associations with other psychosocial variables. Palliat Support Care 17:596–603. https://doi.org/10.1017/S1478951519000191

    Article  PubMed  Google Scholar 

  30. Bovero A, Opezzo M, Botto R, Gottardo F, Torta R (2021) Hope in end-of-life cancer patients: a cross-sectional analysis. Palliat Support Care 19(5):563–569. https://doi.org/10.1017/S1478951520001388

    Article  PubMed  Google Scholar 

  31. Chang T-G, Hung C-C, Huang P-C, Hsu C-Y, Yen T-T (2022) Demoralization and its association with quality of life, sleep quality, spiritual interests, and suicide risk in breast cancer inpatients: a cross-sectional study. Int. J. Environ 19:12815. https://doi.org/10.3390/ijerph191912815

    Article  Google Scholar 

  32. Bovero A, Vitiello LP, Botto R, Gottardo F, Cito A, Geminiani GC (2022) Demoralization in end-of-life cancer patients’ family caregivers: a cross-sectional study. Am J Hosp Palliat Care 39:332–339. https://doi.org/10.1177/10499091211023482

    Article  PubMed  Google Scholar 

  33. Zimmermann C, Mathews J (2022) Palliative care is the umbrella, not the rain-a metaphor to guide conversations in advanced cancer. JAMA Oncol 8:681–682. https://doi.org/10.1001/jamaoncol.2021.8210

    Article  PubMed  Google Scholar 

  34. Varelius J (2019) Suffering at the end of life. Bioethics 33:195–200. https://doi.org/10.1111/bioe.12513

    Article  PubMed  Google Scholar 

  35. Wilson KG, Chochinov HM, McPherson CJ et al (2007) Suffering with advanced cancer. J Clin Oncol 25:1691–1697. https://doi.org/10.1200/JCO.2006.08.6801

    Article  PubMed  Google Scholar 

  36. An E, Lo C, Hales S et al (2018) Demoralization and death anxiety in advanced cancer. Psychooncology 27:2566–2572. https://doi.org/10.1002/pon.4843

    Article  PubMed  Google Scholar 

  37. Maxfield M, Pyszczynski T, Solomon S (2013) Finding meaning in death: terror management among the terminally ill. In: Straker N (ed) Facing cancer and the fear of death: a psychoanalytic perspective on treatment. Rowman & Littlefield, Plymouth, pp 41–60

    Google Scholar 

  38. Folkman S (1997) Positive psychological states and coping with severe stress. Social Science & Medicine 45:1207–1221. https://doi.org/10.1016/s0277-9536(97)00040-3

    Article  CAS  Google Scholar 

  39. Puchalski CM (2012) Spirituality in the cancer trajectory. Ann Oncol 23:49–55. https://doi.org/10.1093/annonc/mds088

    Article  PubMed  Google Scholar 

  40. Delgado-Guay MO (2014) Spirituality and religiosity in supportive and palliative care. Curr Opin Support Palliat Care 8:308–313. https://doi.org/10.1097/SPC.0000000000000079

    Article  PubMed  Google Scholar 

  41. Garssen B, Visser A, de Jager ME (2016) Examining whether spirituality predicts subjective well-being: how to avoid tautology. Psychol Relig Spiritual 8:141–148

    Article  Google Scholar 

  42. Kissane DW, Wein S, Love A et al (2004) The Demoralization Scale: a report of its development and preliminary validation. J Palliat Care 20:269–276

    Article  PubMed  Google Scholar 

  43. Robinson S, Kissane DW, Brooker J, Burney S (2015) A systematic review of the demoralization syndrome in individuals with progressive disease and cancer: a decade of research. J Pain Symptom Manage 49:595–610. https://doi.org/10.1016/j.jpainsymman.2014.07.008

    Article  PubMed  Google Scholar 

  44. Peterman AH, Fitchett G, Brady MJ et al (2002) Measuring spiritual well-being in people with cancer: the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp). Ann Behav Med 24:49–58

    Article  PubMed  Google Scholar 

  45. Noguchi W, Ohno T, Morita S et al (2004) Reliability and validity of the Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT- Sp) for Japanese patients with cancer. Support Care Cancer 12:240–245

    Article  PubMed  Google Scholar 

  46. Aktürk Ü, Erci B, Araz M (2017) Functional evaluation of treatment of chronic disease: validity and reliability of the Turkish version of the Spiritual Well-Being Scale. Palliat Support Care 15:684–692

    Article  PubMed  Google Scholar 

  47. Pereira F, Santos C (2011) Adaptação cultural da Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp): estudo de validação em doentes oncológicos na fase final de vida. Cad Saúde 4:37–45

    Google Scholar 

  48. Damen A, Visser A, Laarhoven HWM et al (2021) Validation of the FACIT-Sp-12 in a Dutch cohort of patients with advanced cancer. Psycho-Oncology 30:1930–1938. https://doi.org/10.1002/pon.5765

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Interdisciplinary Center for Studies in Palliative Care, School of Nursing, Federal University of Alfenas (UNIFAL-MG), Gabriel Monteiro da Silva Street, 700, Centro, Alfenas, MG, 37130-001, Brazil

    Ana Cláudia Mesquita Garcia, Milena Schneiders, Kárita Santos da Mota & Vander Monteiro da Conceição

  2. University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, Brazil

    Kárita Santos da Mota

  3. Department of Nursing, Federal University of Fronteira Sul, Chapecó, Brazil

    Vander Monteiro da Conceição

  4. University of Notre Dame, Sydney, Australia

    David W. Kissane

  5. Cunningham Centre, St Vincent’s Hospital, Sydney, Australia

    David W. Kissane

  6. Szalmuk Family Psycho Oncology Research Unit, Cabrini Health and Monash Partner’s Comprehensive Cancer Centre, Melbourne, Australia

    David W. Kissane

Authors
  1. Ana Cláudia Mesquita Garcia
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  2. Milena Schneiders
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  3. Kárita Santos da Mota
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  4. Vander Monteiro da Conceição
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  5. David W. Kissane
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Contributions

Ana Cláudia Mesquita Garcia: conceptualization, methodology, formal analysis, interpretation, writing the original draft, writing, reviewing, editing, and supervision. Milena Schneiders and Karita Santos da Mota: methodology, database searching, and reviewing. Vander Monteiro da Conceição: methodology and reviewing. David W. Kissane: interpretation, reviewing, and editing.

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Correspondence to Ana Cláudia Mesquita Garcia.

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Garcia, A.C.M., Schneiders, M., da Mota, K.S. et al. Demoralization and spirituality in oncology: an integrative systematic review. Support Care Cancer 31, 259 (2023). https://doi.org/10.1007/s00520-023-07722-6

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