TUGAS UTS

CRITICAL APPRAISAL
THE EFFECTIVENESS OF DIGNITY THERAPY AS APPLIED TO END-OF-
LIFE PATIENTS WITH CANCER IN TAIWAN: A QUASI-EXPERIMENTAL
STUDY

MATA KULIAH RISET KEPERAWATAN

Dosen Pengampu: Dr. Fitria, S.Kep.,M.Si.Med (ME)

Disusun Oleh:
Lalu Amri Yasir
NIM 22020121410030

MAGISTER KEPERAWATAN
FAKULTAS KEDOKTERAN
UNIVERSITAS DIPONEGORO
TAHUN 2021
 Daftar Isi

Halaman Judul
Daftar Isi..............................................................................................................................2
Kata Pengantar.....................................................................................................................3
BA B I Masalah Klinis........................................................................................................4
BAB II Critical Apprasial....................................................................................................5
Daftar Pustaka......................................................................................................................9
Lampiran Journal.................................................................................................................10
Nilai SJR Journal.................................................................................................................18

2
 KATA PENGANTAR

Dengan menyebut nama Allah SWT yang Maha Pengasih dan Maha Penyayang,
kami panjatkan puji syukur kehadirat-Nya yang telah melimpahkan rahmat, hidayah,
serta inayah-Nya kepada kami sehingga kami bisa menyelesaikan Laporan Critical
Appraisal.
Laporan ini dibuat sebagai latihan dalam menerapkan materi Critical Appraisal
guna menunjang pemilihan artikel Riset Keperawatan yang tepat untuk digunakan
sebagai tugas ujian tengah semster. Laporan ini disusun secara individu sekaligus untuk
memenuhi tugas Mata Riset Keperawatan.
Penulis menyadari bahwa tanpa bimbingan dari bapak/ibu dosen, penulis tidak
mampu menyelesaikan laporan ini. Untuk itu kami menyampaikan terimakasih kepada
Dosen Pegampu Mata Kuliah Riset Keperawatan dan semua pihak yang telah
berkontribusi dalam pembuatan tugas ini. Penulis menyadari bahwa masih banyak
kekurangan dalam tugas ini, kritik dan saran diharapkan demi kemajuan dan perbaikan
di masa mendatang. Semoga tugas Critical Apprasial ini bermanfaat bagi para
pembaca.

Mataram, Oktober 2021

Saya

3
 BAB I
GAMBARAN PERMASALAHAN KLINIS

Penderita kanker sering mengalami rasa sakit dan ketidaknyamanan fisik serta
ketidakmampuan dalam memenuhi peran dan tanggung jawabnya. Penderita kanker
selalu merasakan tekanan psikologis, seperti merasa menjadi beban orang lain,
memiliki martabat yang lebih rendah, makna hidup yang lebih rendah, kualitas
hidup yang lebih buruk, dan rasa putus asa, kecemasan, depresi, dan keinginan
untuk mati (Chochinov HM, Hack T, dkk. 2009). Pada tahun 2014 dan 2016, studi
di Amerika Serikat menunjukkan bahwa 63,0% hingga 77,0% dari pasien dengan
kanker menderita tekanan psikologis, masing-masing (Griffiths RR, Johnson MW,
dkk 2016).
Pengembangan perawatan paliatif hospice pada tahun 1990 memiliki tujuan
untuk melindungi martabat pasien akhir hayat dan mengurangi tekanan
psikologis( WHO,2015). Namun, mengambil Taiwan sebagai contoh, hanya 60,9%
dari pasien kanker yang menggunakan perawatan paliatif rumah sakit sebelum
mereka meninggal dalam waktu satu tahun (Promkes RS Taiwan, 2018). Dengan
40,0% pasien akhir hayat dengan kanker yang tidak menggunakan perawatan
paliatif hospice di Taiwan, mengetahui bagaimana membantu mereka menerima
perawatan yang bermartabat, mengurangi tekanan psikologis mereka, dan membuat
mereka merasa hidup mereka masih memiliki makna dan nilai adalah masalah
penting untuk penyedia layanan kesehatan. Penyedia layanan kesehatan sangat
perlu memberikan perhatian dan bantuan terhadap tekanan psikologis pasien ini.
Studi sebelumnya telah menunjukkan bahwa terapi martabat dapat meningkatkan
tekanan psikologis pada pasien akhir kehidupan (Houmann LJ, Chochinov HM,
2014); oleh karena itu, penelitian ini bertujuan untuk mengeksplorasi keefektifan
terapi martabat pada pasien akhir hayat dengan kanker.
 BAB II
CRITICAL APPRAISAL

A. Merumuskan Pertanyaan Dengan Konsep PICO

1. Masalah aktual
Pada artikel penelitian ini yang berjudul The Effectiveness of Dignity Therapy
as Applied to End-of-Life Patients with Cancer in Taiwan: A Quasi-Experimental
Study dapat diindentifikasi yang menjadi masalah aktual adalah pasien terminal
dengan diagnosis medis kanker.

2. Urgensi penanganan masalah

Pasien dengan kanker sering menderita sakit fisik dan ketidaknyamanan
serta kecacatan dalam kemampuan mereka memenuhi peran dan tanggung jawab.
Penderita kanker selalu merasa psychological distress, seperti perasaan menjadi
beban orang lain, memiliki martabat yang lebih rendah, makna hidup yang lebih
rendah, kualitas hidup yang lebih buruk, dan rasa putus asa, kecemasan, depresi,
dan keinginan untuk kematian.
Pasien dengan penyakit terminal, biasanya semakin tidak bisa menunjukkan
dirinya secara ekspresif. Mereka menjadi sulit untuk mempertahankan kontrol
biologis dan fungsi sosialnya. Ancama terhada konsep diri yang terjad karena
menurunnya fungsi mental dan fisik pasien dapat juga mengancam interaksi sosoal
pasien. Interaksi sosial pada pasien terminal dengan diagnosa medis kanker dan
sejenisnya dapat membuat pasien mearik diri dari kehidupan sosialnya yang
berakibat pada kondisi depresi, cemas, keputusasaan dan cenderung ingin
mengakhiri hidupnya sendiri(Darmayanti Dwi A., Fitriah, 2008)
3. Relevansi praktik yang sudah ada terkait masalah
Terapi martabat adalah semacam terapi spiritual yang diusulkan pada tahun
2005 oleh Chochinov, seorang peneliti Kanada; itu bisa membantu pasien
mengurangi tekanan psikologis mereka yang diekspresikan melalui keputusasaan,
ketidakberdayaan, depresi, martabat yang lebih rendah, kehilangan keinginan untuk
hidup, atau keinginan untuk mati. Terapi martabat menggunakan metode melihat,
merekam, dan mencatat hal-hal penting di pasien kehidupan untuk membuat
dokumen generativitas, yang diteruskan ke paada keluarga atau kerabat pasien.
Selama perawatan, pasien sendiri makna hidup diperkaya dan martabat
ditingkatkan, dengan tekanan psikologis juga berkurang ( Houmann LJ, Chochinov
 HM, Kristjanson LJ, 2014)
Pada tahun 2014, sebuah studi di Denmark menunjukkan 73,0% hingga
89,0% pasien mengalami martabat terapi menemukan itu membantu, dan pada
tahun 2014, sebuah studi di Amerika Serikat menunjukkan 67,0% hingga 78,0%
pasien telah meningkatkan keinginan mereka untuk hidup, rasa tujuan, dan
martabat. Pada tahun 2014 dan 2017, Portugal studi tebakan menunjukkan terapi
martabat dapat menurunkan depresi ( p < .001), kecemasan ( p < .001) demoralisasi
( p < .001), dan keinginan untuk mati ( p .054) pada pasien akhir-hidup dengan
kanker. Di dalam pendek, terapi martabat adalah unik, personal, dan jangka pendek
psikoterapi dan efektif dalam meningkatkan rasa tujuan dan makna hidup,
mengurangi stres psikologis, dan meningkatkan keinginan untuk hidup pada pasien
akhir hayat ( Juli- ao M, Oliveira F, dkk. 2014)
1. Meningkatnya keinginan untuk hidup pada pasien akhir kehidupan
Komponen PICO

Population Pasien terminal dengan diagnosa medis kanker

Intervention Terapi martabat selama 4 bulan dari bulan Oktober 2016 s.d Januari
2017
Comparison Kelomok eksperimen yang diberikan intervensi terapi maratabat dan
kelompok kontrol
Outcome Intervensi terpi martabat mencerminkan terjadinya peningkatan
martabat diri pasien, mengurangi keemasan dan depresi secara
signifikan.

B. Critical Appraisal

1. Bukti Ilmiah/Referensi

Bukti ilmiah yang di dapatkan adalah penelitian kuasi eksperimen tentang

efektifitas terapi martabat untuk pasien terminal dengan diagnosa medis kanker .
Artikel penelitian yang digunakan berjudul The Effectiveness of Dignity Therapy
as Applied to End-of-Life Patients with Cancer in Taiwan: A Quasi-Experimental
Study.
2. Menilai Bukti dengan Critical Appraisal Tools
Alat ukur yang digunakan dalam critical appraisal ini adalah JBI untuk
Quasy experiment study. Analisisnya adalah sebagai berikut:
a. Apakah jelas dalam penelitian apa 'penyebab' dan apa 'akibat' (yaitu tidak
ada kebingungan tentang variabel mana yang lebih dulu)?
Analisis: Pada artikel penerlitian ini yang berjudul “The Effectiveness of Dignity
Therapy as Applied to End-of-Life Patients with Cancer in Taiwan: A Quasi-
Experimental Study”. Pada artikel ini Dignity Therapy/Terapi Martabat dapat
diidentifikasi sebagai variabel independen/bebas yang mempengaruhi variabel
dependen dan Pasien Terminal dengan diagnosa medis kanker merupakan
sebagai variabel dependen/terikat yang dipengaruhi oleh variabel independen.
b. Apakah peserta termasuk dalam perbandingan yang serupa?
Analisis: Semua peserta atau partisipan dalam penelitian ini adalah pasien
dengan diagnosa medi kanker dengan harapan hidup kurang dari enam
bulan/pasien terminal. Dalam penelitian ini peserta/partisipan yang menjadi
sample ditentukan dengan menggunakan metode perhitungan G-Power 3.1.10
berdasarkan pada ukuran efek 0,30, tingkat signifikan 0,05, pagkat 0,80 dan
korelasi 0,50. Peserta/partisipan kemudian dibagi menjadi dua kelompok yaitu
kelompk intervensi atau yang mendapatkan perlakuan dan kelompok kontrol.
c. Apakah peserta termasuk dalam perbandingan yang menerima
perlakuan/perawatan serupa, selain paparan atau intervensi yang
diinginkan?
Analisis: Pada artikel penelitian ini hanya kelompok intervensi yang menerima
perlakukan/intervensi terapi martabat, intervensi terapi maratabat diberikan
selama empat bulan. Sebelum pemberian terapi martabat pada kelompok
intervensi maupun pada kelompok kontrol dilakukan pre tes dengan
menggunakan intrument kuesioner. Kemudian dilakukan post tes 1 pada hari ke-
7 dan postest ke 2 pada hari ke 17 setelah intervensi. Kelompok kontrol
penelitian hanya menerima kunjungan umum dalam waktu tujuh hari setelah
kuesioner pra test selesai, dengan kunjungan berfukus pada pemeriksaan kondisi
kesehatan dan tingkat kenyamanan peserta dan setiap kunjungan hanya
berlangsung 30 menit.
d. Apakah ada kelompok kontrol?
Analisis: Artikel penelitian ini menggunakan desain penelitian quasi eksperimen.
Menurut Creswell (2009: 158), quasi-experiment melibatkan 2
grup, experimental group dan control group namun tidak memasukkan
partisipan secara acak ke dalam dua grup tersebut karena sudah ada grup utuh
yang sudah terbentuk dan tidak bisa di otak-atik lagi oleh si peneliti, sehingga
peneliti hanya bisa mengambil individu-individu secara utuh dalam suatu grup.
Pada artikel ini peneliti membagi peserta/patisipan menjadi dua kelompok, yaitu
kelompok dengan perlakukan/intervensi terapi martabat dan kelompok yang
tidak diberikan perlakuan/intervensi terapi martabat yang kemudian disebut
menjadi kelompok kontrol (Creswell, 2009).
e. Apakah ada beberapa pengukuran hasil baik sebelum dan sesudah
intervensi/paparan?
Analisis: Dari banyak desain eksperimental sebenarnya, pretest dan posttest
desain-metode yang banyak dipakai oleh para peneliti untuk membandingkan
kelompok peserta dan mengukur tingkat perubahan yang terjadi sebagai hasil
dari perlakuan. Artikel peneliti ini menjelaskan tentang perbadingan data
demografi antara kelompok intervensi dan kelompok kontrol hasilnya tidak ada
perbedaan. Pada bagian ini dapat dijelasakan bahwa studi ini melakukan
pengukuran untuk mengeveluasi 57 peserta dari bulan Oktober 2016 hingga
Januari 2017, didapatkan hasil bahwa 27 (47,4%) menolak untuk berpartisipasi
dalam penelitian (ketidaknyamanan berbicara 12 orang, tabu untuk berbicara 15
orang) dan 30 orang (52,6%) setuju untuk berpartisipasi, yang kemudian 16
(53,35%) di jadikan kelompok ekspereimen, dan 14 (46,7%) dijadikan kelompok
kontrol. Sebelum dilakukan perlakuan pada kelompok eksperimen dan kelompok
kontrol partisipan pada kedua kelompok diberikan kuesioner pre tes. Setelah
dilakukan pengukuran hasil studi para peserta menunjukkan peningkatan
martabat dan penguranga demoralisasi dan depresi setelah terapi martabat.
Perbedaan yang signifikan secara statistik masih terlihat pada hari ke-7 (post test
1) dan hari ke-14 (post test 2) setelah terapi martabat dengan hasil penurunan
pada aspek Dignity sebesar 44,94% pada hari ke-7 dan 40,54% pada hari ke-14,
penurunan dari aspek Demoralization sebesar 29, 25% pada hari ke-7 dan
22,15% pada hari ke-14, penurunan dari aspek depression sebesar 6,00% pada
hari ke-7 dan 4,00% pada hari ke-14
f. Apakah tindak lanjut lengkap dan jika tidak, apakah perbedaan antar
kelompok dalam hal tindak lanjut dijelaskan dan dianalisis secara
memadai?
Analisis: Peneliti melakukan intervensi terapi martabat pada kelompok
eksperimen/perlakuan selama empat bulan dan intervensi mempertahankan
kebiasaan rutin pada kelompok kontrol. Penelitian ini menganalisis karakteristik
demografi dan penyakit dengan statistik deskriptif. Analisis homogenitas kedua
kelompok dilakukan dengan menggunakan C2 tes dan mandiri T tes. Efektifitas
intervensi di kelompok eksperimen dan kelompok kontrol diuji dengan
mengunakan persamaan estimasi umum dengan P nilai yang ditetapkan menjadi
<0,05. Anaisis data dilakukan dengan menggunakan SPSS AMOS 19.0 (IBM,
Corp.,Armonk, NY,USA)
g. Apakah hasil peserta dimasukkan dalam perbandingan yang diukur dengan
cara yang sama?
Analisis: Hasil peserta yang menjadi sampel penelitian dari kelompok intervensi
dan kelompok kontrol dimasukkan ke dalam software statistik SPPS IBM.
Satistik deskriptif digunakan utuk menggambarkan karakteristik demografi
peserta. Identifikasi perbedaan dan persamaan antara rata-rata 2 kelompok
menggunakan Uji- C2 tes dan mandiri T tes sampel independen. Uji- C2 tes
digunakan untuk mengidentifikasi homogenitas antar kelompok untuk variabel
kategori. Uji-t sampel berpasangan digunakan dalam perbandingan dalam
kelompok sebelum dan sesudah evaluasi. Dari hasil analisis dan kelompok
kontrol keduanya menunjukkan perbedaan yang signifikan secara statistik.
Mengenai efek waktu perlakuan/pemeberin intervensi terapi martavat ,
dibandingkan dengan kelompok kontrol pada masing-masing post tes 1 dan 2
semuanya menunjukkan perbedaan yang signifikan secara statistik. homogenitas
pendugaan umum, dalam membandingkan kelompok eksperimen
h. Apakah hasil diukur dengan cara yang dapat diandalkan?
Analisis: Peserta dalam penelitian ini memliki kesamaan kelompok antara
kelompok intervensi dan kelompok kontrol. Penelitian ini menggunakan analisis
DS-MV ¼ Skala Demoralisasi Versi Mandarin; PDI-MV¼ Inventarisasi
Martabat Pasien Versi Mandarin; PHQ-9¼ Kuesioner Kesehatan Pasien-9; SD¼
standar deviasi; C2 ¼ uji chi-kuadrat; tahun¼, untuk menggambarkan data
demografi peserta menggunakan statistik deskriptif, untuk mengidentifikasi
 perbedaan antar perbedaan antara rata-rata 2 kelompok menggunakan Uji-t
sampel independen. Untuk mengidentifikasi perbedaan antar kelompok untuk
variabel kategori peneliti menggunakan Uji- C2 tes dan mandiri T tes sampel
independen. Penelitian ini sudah menggunakan alat analisis yang lengkap dan
dapat di pertanggung jawabkan.
i. Apakah analisis statistik yang tepat digunakan?
Analisis: Saat ini SPSS sudah sangat jauh berkembang, terutama setelah tahun
2009 IBM mengakusisi Product SPSS ini. SPSS sudah berkembang dan
bertransformasi menjadi lebih banyak varian. Dalam artikel penelitian ini peneliti
sudah menggunakan uji/analisa statistik yang tepat, yaitu denga menggunakan
varian statistik SPSS IBM.
C. Tindakan yang dapat diambil dari temuan dan terapannya
Penelitian ini menjadi penelitian pertama yang meneliti tentang
pengaruh/efektifitas terapi martabat pada pasien terminal dengan diagnosis medis
kanker. Implikasi yang dapat diterapkan secara praktikal untuk mengurangi
demoralisasi dan depresi pada populasi pasien akhir hayat dengan kanker. Pada
penelitian ini, terapi martabat yang diterapkan pada penelitian ini mengungkapkan
bahwa terapi martabat memiliki efek yang signifikan dalam meningkatkan martabat
dan mengurangi demoralisasi dan depresi pada pasien akhir hayat dengan kanker di
Taiwan. Dalam beberapa tahun terakhir, telah terjadi peningkatan penggunaan terapi
martabat untuk mengurangi tekanan psikologis pada pasien akhir hidup dengan kanker
oleh para sarjana dan penyedia layanan kesehatan, yang juga telah secara aktif terlibat
dalam penelitian yang relevan ( Hong JS, Tain J. 2014).
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Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, Harlos M, et al. The
landscape of distress in the terminally ill. J Pain Symptom Manag.
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Darmayanti Dwi A., Fitriah, dkk. 2008.Penanganan Masalah Sosial dan Psikologis
Pasien Kanker Stadium Lanjut dalam Perawatan Paliatif. Indonesian Journal Of
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penanganan-masalah-sosial-dan-psikologis.pdf. Diakses pada tanggal 6 Oktober
2021.Pukul 19.30 WITA

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of life of palliative cancer patients and their caring relatives during home care.
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Griffiths RR, Johnson MW, Carducci MA, Umbricht A, Richards WA, Richards BD, et
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care [Internet]. Taipei, Taiwan; Health Promotion Administration, Ministry of
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Chochinov HM, Kristjanson LJ, Petersen MA, Groenvold M. A prospective
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Yu-Chi Li, Yin-Hsun Feng, Hui-Ying Chiang, Shu-Ching Ma, Hsiu-Hung Wang. 2019
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Asian Nursing
Research
14
(2020)
189e195
Contents lists available at ScienceDirect

Asian Nursing Research

jo ur nal h o m ep a g e : w ww .a s i a n - n u r s i n g re se a r c h .c om
Research Article

The Effectiveness of Dignity Therapy as Applied to End-of-

Life Patients with Cancer in Taiwan: A Quasi-
Experimental Study
Yu-Chi Li,1 Yin-Hsun Feng,2 Hui-Ying Chiang,3, 4 Shu-Ching Ma,3, 4 Hsiu-Hung Wang1,
*

1
College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
2
Department of Hematology-Oncology, Chi-Mei Medical Center, Tainan, Taiwan
3
Department of Nursing, Chi-Mei Medical Center, Tainan, Taiwan
4
College of Humanities and Social Sciences, Southern Taiwan University of Science and Technology, Tainan, Taiwan

A R T I C A B S T R A C T
L E I
Purpose: The aim of the study was to determine the effectiveness of dignity
N F O therapy for end-of-life patients with cancer.
Methods: This study used a quasi-experimental study design with a
Article history: nonrandomized controlled trial. Dignity therapy was used as an intervention in
Received 21 the experimental group, and general visit was used in the control group. Thirty
August 2019
end-of-life patients with cancer were recruited, with 16 in the experimental group
Received in
and 14 in the control group. Outcome variables were the participants' dignity,
revised form 9
April 2020 demoralization, and depression. Measurements were taken at the following time
Accepted 13 April 2020 points: pre-test (before intervention), post- test 1 (the 7th day), and post-test 2
(the 14th day). The effectiveness of the intervention in the two groups was
K analyzed using the generalized estimating equation, with the p value set to be less
ey than .05. Results: After dignity therapy, the end-of-life patients with cancer
w reflected increased dignity signifi-
or cantly [b ¼ —37.08, standard error (SE) ¼ 7.43, Wald c2 ¼ 24.94, p < .001],
ds whereas demoralization
: (b ¼ —39.55, SE ¼ 6.42, Wald c2 ¼ 37.95, p < .001) and depression (b ¼ —12.01, SE ¼
ca
2.17, Wald c2 ¼ 30.71,
nc
p < .001) were both reduced significantly.
er
de
Conclusion: Clinical nurses could be adopting dignity therapy to relieve
pr psychological distress and improve spiritual need in end-of-life patients with
es cancer. Future studies might be expanded to looking at patients vis-a`-vis
si end-of-life patients without cancer to improve their psychological
o distress. These results provide reference data for the care of end-of-life patients
n with cancer for nursing professionals.
ne © 2020 Korean Society of Nursing Science. Published by Elsevier BV. This is an
o
open access article under the CC BY-NC-ND license
pl
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
as
m
s
psychologica
l distress
terminal
care

Introduction distress, such as feeling of being a burden on others,

Patients with cancer often suffer from physical
pain and discomfort as well as disability in their
capability of fulfilling their roles and responsibilities.
Patients with cancer always feel psy- chological
having lower dignity, lower meaning of life, poorer
quality of life,
Yu-Chi Li: https://orcid.org/0000-0002-1467-5290; Yin-Hsun Feng:
https://orcid. org/0000-0002-8660-0685; Hui-Ying Chiang:
https://orcid.org/0000-0001-8148- 6708; Shu-Ching Ma: and a sense of hopelessness, anxiety, depression, and
https://orcid.org/0000-0003-2128-173X; Hsiu-Hung Wang: desire for death [1,2]. In 2014 and 2016, studies in
https://orcid.org/0000-0001-6055-5401 the United States of America showed that 63.0% [3]
* Correspondence to: Hsiu-Hung Wang, RN, Ph.D, FAAN, College of
to 77.0% [4] of patients with cancer suffered from
Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st
Road, San-Ming District, Kaohsiung, 80708, Taiwan. psychological distress, respectively.
E-mail address: hhwang@kmu.edu.tw The development of hospice palliative care in
1990 had the goal of protecting the dignity of end-of-
life patients and mitigating psychological distress [5].
However, taking Taiwan as an example, only 60.9%
of such patients with cancer used hospice palliative
care before they passed away within one year [6]. With
40.0% end-of-life patients with cancer not using
hospice palliative care in Taiwan, knowing how to
help them receive dignified care, reduce their
psychological distress, and lead them to feel their life
has still held meaning and value is an important
issue for health-care providers [5,6]. Health-care
providers urgently need to provide attention and
assistance toward these patients' psychological
distress. Previous studies have indicated that
dignity therapy could improve

https://doi.org/10.1016/j.anr.2020.04.003
p1976-1317 e2093-7482/© 2020 Korean Society of Nursing Science. Published by Elsevier BV. This is an open access article under
the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
190 Y.-C. Li et al. / Asian Nursing Research 14 (2020) 189e195

psychological distress in end-of-life patients [7]; therefore, the therapy found it helpful [20], and in 2014, a study in the United
present study aimed at exploring the effectiveness of dignity
therapy in end-of-life patients with cancer.

Dignity, demoralization, and depression

The National Comprehensive Cancer Network [8] has pointed

out that psychological distress is an unpleasant feeling resulting
from a psychological, social, or spiritual nature, such as lower
dignity, anxiety, depression, demoralization, and phobia, all of
which fall within the scope of psychological distress, and can result
in negative impact on self, family, disease recovery, mortality, and
other modalities.
The concept of dignity is often used to indicate the inherent
value of human beings and the right to be respected by others [9].
Dignity is a universal value in human beings that is the product of
the interaction between individuals, communities, cultures, and
tradition. When providing health care, one of the most important
ethical considerations is protecting the patient's dignity. For
health- care providers, this key mission is a moral obligation and
ethical norm [9,10]. In particular, assisting patients to die with
dignity is a major principle that must be upheld when caring for
end-of-life patients [11]. In 2014, a study in Germany showed that
end-of-life patients with cancer had lower dignity when they were
suffering from pain, tiredness, shortness of breath, anxiety,
sadness, and ir- ritability [12].
Demoralization is a nonspecific state of suffering and relates to
suffering from incompetence or impotence in facing certain stress,
often occurring in hospice patients, patients with cancer, and in
those who are critically ill [13]. Previous studies from 2014 to
2017 have shown that the proportion of patients with cancer with
high demoralization varied from 21.0% in Germany [14], 23.7% in
Italy [15], 42.0% in northern Taiwan [16], to 49.4% in southern
Taiwan [17]. Such patients suffering from severe depression and
demoral- ization are at risk of suicide [14,16] and deserving of
attention from health-care providers.
Depression is a mood disorder, causing negative thoughts and
emotions that can affect cognition, motivation, and behavior [18].
It affects more than 300 million people worldwide and is the major
consequence in disability [18]. Receiving a cancer diagnosis and
then treatment is a life-changing experience and is a source of
considerable psychological distress [2,3], previous studies have
shown the most common psychological distress of patients with
cancer is depression [4], with incidence varying from 26.0% in
Scotland in 2014 [19], 66.7% in China in 2014 [20], to 69.0% in
the
United States in 2016 [4].

Dignity therapy

Dignity therapy is a kind of spiritual therapy proposed in 2005

by Chochinov, a Canadian researcher; it could help end-of-life pa-
tients mitigate their psychological distress expressed through
hopelessness, helplessness, depression, lower dignity, loss of will
to live, or desire to die [7]. Dignity therapy uses methods of inter-
viewing, recording, and logging important matters in the patient's
life to create a generativity document, which is passed to the pa-
tient's family or relatives. During treatment, the patient's own
meaning of life is enriched and dignity is enhanced, with psycho-
logical distress being alleviated as well [21].
In recent years, there has been an increase in the use of dignity
therapy for mitigating psychological distress in end-of-life patients
with cancer by scholars and health-care providers, who have also
been actively involved in relevant research. In 2014, a study in
Denmark showed 73.0% to 89.0% of patients experiencing dignity
States indicated 67.0% to 78.0% patients had increased their met the inclusion criteria were screened and contacted to confirm
will to live, sense of purpose, and dignity [22]. In 2014 and that
2017, Portu- guese studies showed dignity therapy could
decrease depression (p < .001), anxiety (p < .001) [23],
demoralization (p < .001), and desire to die (p .054) [24] in
end-of-life patients with cancer. In short, dignity therapy is a ¼
unique, personalized, and short-term psychotherapy and is
effective in enhancing the sense of purpose and meaning of life
[20], reducing psychological stress, and increasing will to live
in end-of-life patients [23,24].

Methods

Study design

The study was conducted using a quasi-experimental study

design with a nonrandomized controlled trial. Dignity therapy
was used in the experimental group, and general visits were
conducted in the control group. The group was assigned
according to the wishes of the participants.

Participants

Participants included patients diagnosed with cancer with a

life expectancy of less than six months according to a medical
diag- nosis. The inclusion criteria were as follows: (1) aged
at least 20 years; (2) having been diagnosed with terminal
cancer; and (3) able to communicate verbally in Mandarin or
Taiwanese Hokkien. The exclusion criteria were as follows: (1)
those diagnosed with dementia, delirium, or other organic
brain disorders; (2) those who were unconscious and
incapacitated; and (3) those currently receiving hospice care.

Sample size

The sample size was calcuated using G-power 3.1.10 [25]

based on a effect size of .30 [26], a significance level of .05, a
power of .80, and a correlation coefficient of .50. The
participants were divided into experimental or control groups.
The number of participants was calculated to be 20 individuals
for repeated measurements of within-between interactions.
The turnover rate was estimated to be 20.0%, with the total
number of participants expected to be 24, with at least 12
individuals in each group.

Study process

The study took place in an oncology ward of a medical

center in Southern Taiwan and was performed from October
2016 to January 2017. The research team comprised one
dignity therapist, one questionnaire investigator, and one
transcriptionist. The dignity therapist was the interviewer for
both the experimental and con- trol groups, with nursing
experience of 23 years, and had taken part in a three-day
dignity therapy training workshop in Canada in May 2016. The
questionnaire investigator and the verbatim transcrip- tionist
both had nursing experience of more than 10 years. They held
master's degrees in nursing and were able to communicate in
both Mandarin and Taiwanese languages. The verbatim
transcrip- tionist was a qualitative researcher who had 4 years
of verbatim transcription experience. Before this study, the
dignity therapist had reached a consensus with the
questionnaire investigator and the verbatim transcriptionist to
confirm that their cognition was correct.
Before dignity therapy, the attending physician in the oncology
ward provided daily sessions for newly hospitalized end-of-life
patients with cancer with the dignity therapist. Patients who
 Y.-C. Li et al. / Asian Nursing Research 14 (2020) 189e195 191
at the next visit to
Table 1 Dignity Therapy Question Protocol.

1. Tell me a little about your life history; particularly the parts that you either
remember most or think are the most important? When did you feel most alive?
2. Are there specific things that you would want your family to know about you, and
are there particular things you would want them to remember?
3. What are the most important roles you have played in life (family roles,
vocational roles, community-service roles, etc.)? Why were they so impor- tant
to you, and what do you. think you accomplished in those roles?
4. What are your most important accomplishments, and what do you feel most
proud of?
5. Are there particular things that you feel still need to be said to your loved
ones or things that you would want to take the time to say once again?
6. What are your hopes and dreams for your loved ones?
7. What have you learned about life that you would want to pass along to
others? What advice or words of guidance would you wish to pass along
to your (son, daughter, husband, wife, parents, others)?
8. Are there words or perhaps even instructions that you would like to offer
your family to help prepare them for the future?
9. In creating this permanent record, are there other things that you would like
included?

they were aware of their diagnosis. Then, the dignity therapist

explained the purpose and procedure of the study to the study
participants, who were assigned to the experimental group or the
control group according to their wishes, and then, their informed
consent in writing was obtained. Outcome variable collection was
performed by the questionnaire investigator before the
intervention and on the 7th day (post-test 1) and 14th day (post-
test 2) after the intervention. The questionnaire investigator was
blinded as to who was in the experimental group or the control
group.

Intervention

In the study, dignity therapy was used in the experimental

group, and general visits were conducted in the control group. The
dignity therapist used interviews and audio recording to help the
participants create a generativity document that was then passed
on to the participant's families, relatives, or friends [21]. Before
starting dignity therapy, the dignity therapist provided the partic-
ipant with a dignity therapy question protocol (Table 1) [1]. The
dignity therapy question protocol offers guidelines for participants
to talk about issues that mattered the most to them, to share mo-
ments that they felt were the most important and meaningful, to
speak about things that they would like to be remembered by, or
to offer advice to their families, relatives, or friends [1]. If the
partic- ipant could not read, the dignity therapist read out the
contents of the protocol one at a time. That allowed the
participants to prepare in advance what they wished to respond
to. The dignity therapy was accomplished in an independent
oncology ward. All dignity therapy session participants were
offered some drinks, and facial tissues were also provided. Dignity
therapy was conducted on the same day or the next day based on
the physical condition of the participant, and the participant could
choose to accept dignity therapy in the company of family
members or alone. Each dignity therapy session was
approximately 30 to 60 minutes in length, and 1 to 3 questions
were addressed each time.
After the dignity therapy session, the dignity therapist took the
recorded material to the transcriptionist, who transcribed the
audio files into word documents within 24 hours. Subsequently,
the dignity therapist edited the word file within 24 hours. The
editing steps included converting dialog formats into text formats,
deleting colloquial words, correcting the sequence of events,
eliminating irrelevant information not related to the dignity
therapy question, and letting the participant read the edited file
ensure the contents were correct. All transcriptions, manuscript
editing, and modifications made after the participants' reading
were completed within 3 days. Once all modifications were
made, the dignity therapist provided the participant with a
generativity document. Considering the uncontrollable state of
the lives of end- of-life patients and according to suggestions
from previous studies, the dignity therapy was to be completed
within a week [1,21].
The control group of the study received general visits. The
dig- nity therapist conducted three visits within seven days after
the pre-test questionnaire was completed, with visits focusing on
the medical condition and comfort level of the participants; each
visit lasting approximately 30 minutes. The study flowchart is
shown in Figure 1.

Measurements

Basic information

The patients' basic information including demographic (i.e.,

gender, age, children, marital status, education, occupation,
cohabitation status, and religion) and disease characteristics (i.e.,
cancer site, disease status, and treatment type) was collected.

Patient Dignity Inventory Mandarin Version

Patient Dignity Inventory Mandarin Version (PDI-MV) was

used to test the degree of life distress and psychological distress
faced by

Figure 1. The study flowchart.

Note. DS-MV ¼ Demoralization Scale Mandarin Version; PDI-MV ¼ Patient Dignity
Inventory Mandarin Version; PHQ-9 ¼ Patient Health Questionnaire-9.
192 Y.-C. Li et al. / Asian Nursing Research 14 (2020) 189e195

end-of-life patients in their last few days. PDI-MV consists of 25

Results
questions in four factors (existential distress, loss of support and
sense of meaning, symptom distress, and loss of autonomy), with
Participant characteristics
each question rated on a scale from 1 to 5: 1 (not a problem), 2 (a
slight problem), 3 (a problem), 4 (a major problem), and 5 (an
The study evaluated 57 participants from October 2016 to
overwhelming problem). Higher scores expressed lower dignity. In
January 2017; of whom, 27 (47.4%) refused to participate in the
terms of reliability, Cronbach coefficient a of PDI-MV and four
study (discomfort: 12; taboo to talk: 15) and 30 (52.6%) agreed to
factors were .95, .95, .84, .83, and .89, respectively. The concurrent
participate; of the latter, 16 (53.3%) were assigned to the experi-
validity showed PDI-MV was significantly correlated with Rosen-
berg Self-Esteem Scale (r ¼ —0.30, p < .010), Demoralization Scale mental group, and 14 (46.7%), to the control group (Figure 1). The
Mandarin Version (DS-MV) (r ¼ 0.58, p < .010), and Patient Health study participants consisted of an equal number of men and
Questionnaire-9 (PHQ-9) (r ¼ 0.54, p < .010) [27]. In our study, women, with a mean age of 66.03 years [standard deviation
(SD) ¼10.05]. No significant differences in the demographic and
Cronbach coefficient a of PDI-MV and four factors were .97, .96, .93,
disease characteristics existed between the two groups (Table 2).
.92, and .94, respectively. The concurrent validity showed PDI-MV
was significantly correlated with DS-MV (r ¼ 0.91, p < .001) and
PHQ-9 (r ¼ 0.80, p < .001).
Table 2 The Homogeneity Analysis (N ¼ 30).

Demoralization Scale Mandarin Version

Variable Experimental group Control group c2 or t p
(n ¼ 16) (n ¼ 14)
DS-MV is used to assess the quantified feelings of demoraliza-
n (%) or mean ± SD n (%) or mean ± SD
tion over the past two weeks. DS-MV consists of 24 questions in
five factors (loss of meaning, dysphoria, disheartenment, Gender 0.01 .642
Men 8 (50.0) 7 (50.0)
helplessness, and sense of failure), with each question rated on a Women 8 (50.0) 7 (50.0)
scale of 0 to 4: 0 (strongly disagree), 1 (disagree), 2 (uncertain), 3 Age (yrs) 65 ± 10.51 67.21 ± 11.71 0.54a .589
(agree), and 4 (strongly agree). Scores higher than 30 indicated Children 3.13 ± 1.36 2.43 ± 1.79 —1.19a .236
high demoral- Marital status 3.21 .200
Single 0 (0.0) 2 (14.3)
ization. Cronbach coefficient a of DS-MV and five factors were .92, Married 15 (93.7) 10 (71.4)
.84, .69, .88, .72, and .63, respectively. In terms of validity, DS-MV Widowed 1 (6.3) 2 (14.3)
was significantly correlated with the Beck Hopelessness Scale Education 4.09 .394
(r ¼ 0.703, p < .001) and the McGill Quality of Life Scale-Taiwan No 4 (25.0) 5 (35.7)

(r ¼ 0.680, p < .001) [28]. In our study, Cronbach coefficient a of

Elementary 5 (31.2) 6 (43.0)
Junior 5 (31.3) 1 (7.1)
— and five factors were .97, .90, .89, .96, .92, and .77, respec-
DS-MV Senior 2 (12.5) 1 (7.1)
tively. The concurrent validity showed DS-MV was significantly College 0 (0.0) 1 (7.1)
correlated with PDI-MV (r ¼ 0.91, p < .001) and PHQ-9 (r ¼ 0.78, Occupation 4.04 .066
p < .001). No 12 (75.0) 14 (100.0)
Yes 4 (25.0) 0 (0.0)
Patient Health Questionnaire-9 Cohabitation 0.01 .724
status
PHQ-9 consisted of nine questions to assess the degree of Alone 1 (6.3) 1 (7.1)
Live with 15 (93.7) 13 (92.9)
depression during the past two weeks, with each question rated on
family
a scale of 0 to 3: 0 (not at all), 1 (a few days), 2 (more than half), and Religion 2.68 .126
3 (almost every day). The Cronbach coefficient a of PHQ-9 was .77, No 1 (6.3) 4 (28.6)
and the test-retest reliability was .79. In terms of validity, PHQ-9 Yes 15 (93.7) 10 (71.4)
Cancer site 8.48 .582
was significantly correlated with the 17-item Hamilton Depression
Rating Scale (r ¼ 0.66, p < .001) and Quality of Life Enjoyment and Colon 5 (31.2) 2 (14.4)
Liver 5 (31.3) 2 (14.4)
Satisfaction Questionnaire (r ¼ —0.53, p < .001) [29]. In our study, Oral 1 (6.2) 2 (14.3)
the Cronbach coefficient a of PHQ-9 was .92. The concurrent val- Pancreatic 2 (12.5) 1 (7.1)
idity showed PHQ-9 was significantly correlated with PDI-MV Lung 1 (6.2) 2 (14.3)

(r ¼ 0.80, p < .001) and DS-MV (r ¼ 0.78, p < .001). Breast 1 (6.3) 1 (7.1)
Gastric 0 (0.0) 1 (7.1)
Leukemia 1 (6.3) 0 (0.0)
Statistical analysis Bladder 0 (0.0) 1 (7.1)
Prostate 0 (0.0) 1 (7.1)
This study analyzed demographic and disease characteristics Esophageal 0 (0.0) 1 (7.1)
Disease status 4.74 .057
with descriptive statistics. The homogeneity analysis of the two
Initial 3 (18.8) 8 (57.1)
groups was conducted using the c2 test and the independent t test. diagnosis
The effectiveness of the interventions among the two groups was Recurrence 13 (81.2) 6 (42.9)
tested using the generalized estimating equation with the p value Treatment type 4.81 .091
Radiotherapy 1 (6.2) 5 (35.7)
set to be less than .05. Data analysis was carried out using SPSS
Chemotherapy 9 (59.3) 7 (50.0)
AMOS 19.0 (IBM. Corp., Armonk, NY, USA). Symptomatic 6 (32.5) 2 (14.3)
Questionnaire
Ethical consideration

The study protocol was approved by an institutional review forms.

board of the Chi-Mei medical center (Approval no.10508-007).
Data were collected after the participants signed informed consent
 PDI-MV 65.62 ± 26.63 86.43 ± 20.88 2.36a .026
DS-MV 52.44 ± 24.26 66.93 ± 14.78 1.94a .063
PHQ-9 13.00 ± 6.85 14.86 ± 6.40 0.76a .451

Note. DS-MV ¼ Demoralization Scale Mandarin Version; PDI-MV ¼ Patient

Dignity Inventory Mandarin Version; PHQ-9 ¼ Patient Health
Questionnaire-9; SD ¼ standard deviation; c2 ¼ Chi-square test; yrs ¼ years.
a
Independent samples t test.
 Y.-C. Li et al. / Asian Nursing Research 14 (2020) 189e195
The experimental group had a mean PDI-MV score of 65.63
(SD ¼ 26.63), while the control group had a mean score of 86.43
(SD ¼ 20.88), and the difference was statistically signi ficant
(t ¼ ¼
2.36, p .026). The experimental and control groups had mean
DS-MV scores of 52.44 (SD ¼ 24.26) and 66.93 (SD ¼ 14.78),
respectively; there was no statistically significant difference be-
tween the two groups (t¼ 1.94, p ¼.063). The experimental and
control groups had mean PHQ-9 scores of 13.00 (SD ¼ 6.85) and
14.86 (SD¼6.40), respectively; there was no statistically significant
difference between the two groups (t¼ 0.76, p ¼.451) (Table 2). At
the three measured time points, the means of PDI-MV, DS-MV, and
PHQ-9 decreased gradually in the experimental group, indicating
dignity in this group was increased gradually, while
demoralization and depression were decreased gradually. The
control group showed an opposite result. The changes of
measurements between the three time points for the two groups
are shown in Figure 2.
Effectiveness of dignity therapy
Table 3 shows the effectiveness of dignity therapy on dignity,
demoralization, and depression in end-of-life patients with cancer.
193
In the results of generalized estimating equation analysis, in
comparing the experimental and control groups, the participants'
dignity (b 20.08, p .013) and demoralization (b 14.63,
p .037) both ¼ —illustrated¼ statistically significant difference.
¼ — Con-
¼
cerning time effects, in comparison with the pre-test, the partici-
pants' dignity at post-test 1 and 2 (b ¼ 8.93, p ¼ .002; b ¼
12.58,
p ¼ .027, respectively), demoralization at post-test 1 and 2
(b ¼ 6.36, p ¼ .025; b ¼ 9.35, p < .032, respectively), and depression
at post-test 2 (b ¼ 9.35, p < .032) all showed change effect over time
significantly. Concerning group and time interaction effect, in
comparison with the control group, the study found the experi-
mental group's dignity (b ¼ - 32.18, p < .001; b ¼ - 37.08, p < .
001,
respectively), demoralization (b ¼ —29.55, p < .001; b ¼ —39.55,
p < .001, respectively), and depression (b ¼ —8.07, p < .001;
b ¼ 12.01, p < .001, respectively) at post-test 1 and 2 all showed
—
statistically significant difference.
The study results showed the participants showed increase in
dignity and reduction in demoralization and depression after dig-
nity therapy. Furthermore, as time progressed, statistically signifi-
cant differences were still noted on the 7th day (post-test 1) and
the 14th day (post-test 2) after dignity therapy.
Figure 2. The results of repeat measures.
194 Y.-C. Li et al. / Asian Nursing Research 14 (2020) 189e195

Table 3 The GEE Analysis on Dignity Therapy.

Variable PDI-MV DS-MV PHQ-9

b SE Wald c 2 p b SE Wald c 2 p b SE Wald c2 p

Intercept 86.43 5.38 258.25 <.001 67.07 3.85 303.94 <.001 14.86 1.65 81.37 <.001
Groupa (experimental group vs control) —20.80 8.39 6.14 .013 —14.63 7.02 4.35 .037 —1.86 2.34 0.63 .427
Timeb
Control group (post-test 1 vs pre-test) 8.93 2.94 9.21 .002 6.36 2.84 5.00 .025 1.07 1.06 1.02 .313
Control group (post-test 2 vs pre-test) 12.58 5.67 4.92 .027 9.35 4.35 4.62 .032 3.30 1.64 4.05 .044
Interactionc
Experimental group × post-test 1d —32.18 5.49 34.30 <.001 —29.55 5.59 27.89 <.001 —8.07 1.74 21.42 <.001
Experimental group × post-test 2e —37.08 7.43 24.94 <.001 —39.55 6.42 37.95 <.001 —12.01 2.17 30.71 <.001

Note. DS-MV ¼ Demoralization Scale Mandarin Version; GEE ¼ generalized estimating equation; PDI-MV ¼ Patient Dignity Inventory Mandarin Version; PHQ-9 ¼ Patient
Health Questionnaire-9; SE ¼ standard error.
a
Reference: control group.
b
Reference: pre-test.
c
Reference: control group × pre-test.
d
Experimental group (post-test 1 e pre-test) e control group (post-test 1 e pre-test).
e
Experimental group (post-test 2 e pre-test) e control group (post-test 2 e pre-test).

Discussion
rewrite the texts themselves. Generative documents should main-
tain the patient's usual tone of speech so that it feels genuine when
The results of this study revealed that dignity therapy had sig-
read by family members and as if it came from the patient.
nificant effects in increasing dignity and reducing demoralization
In our research, it was observed that complete dignity therapy
and depression in end-of-life patients with cancer in Taiwan. Since
success required repeated interviews with patients, transcriptions,
the development of dignity therapy by a Canadian researcher in
and editing of the manuscript. All of this process necessitated
2005 [1], other countries have been testing the effectiveness of the
timetabled personnel and time, determining whether the clinical
therapy; for example, in 2014 in Denmark [20], 2014 in the United
work could be loaded. In previous studies, most of the results of
States [22], 2014 and 2017 in Portugal [23,24], and 2016 and 2017 in
dignity therapy were performed by physicians and were not per-
Spain [30,31].
formed by clinical nurses. This study was carried out by nurses
The results of the aforementioned studies are similar to those
throughout the process, and the results showed effectiveness. The
of this study, thereby demonstrating the effectiveness of dignity
result indicated clinical nurses could also use assessment tools to
therapy on enhancing patient dignity. The studies in Portugal
understand psychological distress of end-of-life patients with
found differences in depression, where the experimental group on
cancer and use dignity therapy to assist them in mitigation.
¼
Day 4 (median - 4.00, p < .001) and Day 15 (median
¼ - 4.00, ¼p .010)
Concerning the limitations in this study, the participants were
showed a decrease in depression scores [23]. Their results for
end-of-life patients with cancer, with the study group self-chosen
depression were similar to those of our study. Demoralization is
owing to respect for the patient's wish, so this study did not
an emerging diagnosis that has gained some attention in the past
apply randomization or double-blinded techniques. Initial differ-
decade [12]. A previous study has shown that for end-of-life pa-
ence in the PDI-MV score of the two groups, which might represent
tients with cancer undergoing dignity therapy, the incidence of
group difference, needs to be mentioned as a limitation of the
demoralization decreased from 53.9% to 12.1% (p ¼ .002) [24]. The present study. Although this study indeed followed the patient's
results are similar to those of our study, in which dignity therapy
wish to join either the experimental or control group, dignity
had significant effects on reducing demoralization; however, in
therapy is a unique, personalized, and short-term psychotherapy
previous studies on dignity therapy, few studies have examined
and cannot be shared with other patients, so cross-subject
demoralization as an outcome variable. It is suggested that this be
contamination did not occur. This study had a small sample size,
explored in future studies.
so the results cannot be generalized; consequently, we recommend
Although all the participants in this study had family to
further studies be designed with larger sample sizes in Taiwan.
accompany them during the dignity therapy, in Taiwan, almost
80% of patients are cared for by care workers. Based on the
experience of this study, some suggestions are made as follows. If Conclusion
the patient wishes to accept dignity therapy, the dignity therapist
must contact the family member who is expected to accompany Dignity therapy is a relatively newly developed spiritual treat-
the patient and introduce the therapy to him/her. A date needs to ment. To date, published studies have been conducted only in
be arranged with the patient and family member for an interview. Western countries. Our study results indicated that dignity
Dignity therapy is best conducted from 10 am to 12 noon, 3 pm to therapy could enhance dignity and reduce demoralization and
5 pm, and 7 pm to 8 pm, with each session lasting 60 minutes to depression in the population of end-of-life patients with cancer in
match the maximum duration of physical strength and attention in Taiwan. This study was only conducted in a medical center in
the patients. Patients could tell a sad story or an ugly story if they Southern Taiwan; in addition, this study only recruited those
wish; however, the dignity therapist must let patients understand diagnosed with end-of- life cancer. Future studies could examine in
how words can help and hurt people at the same time and that the detail whether there are regional and cultural differences and
dignity therapy session is not to be used to hurt family and whether the therapy could be promoted among other end-of-life
relatives. Events or phrases that hurt family and relatives such as patients or patients suffering from other illnesses such as
“I hate you,” “I hope you die,” and “I hope you will suffer from amyotrophic lateral sclerosis, cerebral stroke, or renal failure.
retribution” are not to be recorded in the generativity document
and are not to be conveyed by the dignity therapist. In terms of Conflict of interest
editing the text, as per previous studies [1,20] and the experience
of this study, editors should not No conflict of interest has been declared by the authors.
 Y.-C. Li et al. / Asian Nursing Research 14 (2020) 189e195
Acknowledgments
The financial support provided for this research by Chi-Mei
Medical Center, Taiwan, is gratefully acknowledged.
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