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Abstract: Context: The concept of demoralization has been widely used to describe states of existential distress and a self-perceived incapacity to deal effectively with a specific stressful situation. Objectives: To evaluate the psychometric properties of the German adaptation of the Demoralization Scale (DS) in patients with advanced cancer. Methods: Participants with heterogeneous tumor sites were recruited in several treatment and rehabilitation facilities. Concurrent and divergent validity of the DS was analyzed through associations with and group differences between measures of distress, depression, anxiety, and meaning-related life attitudes. Results: From a total sample of 1102 patients, 516 individuals (45%) with advanced cancer were enrolled (male 53%, median age 58 years [range 18–88], breast cancer 21%, prostate cancer 17%). The total mean score of the DS was 29.8 (SD=10.41). Four factors were extracted by exploratory factor analysis, which accounted for 59% of the variation (Cronbach α=0.84): loss of meaning and purpose (α=0.88), disheartenment (α=0.88), dysphoria (α=0.80), and sense of failure (α=0.76). DS dimensions shared between 12% and 62% of the variance. Demoralization was significantly associated with anxiety (r =0.71), depression (r =0.61), and distress (r =0.42). Fifty-seven percent of patients had high distress, 24% depression, and 11% high anxiety. According to different cutoff values, between 16% and 39% were seriously demoralized and 73% had moderate levels of demoralization. Between 5% and 20% of patients were seriously demoralized but not clinically depressed; 60% of patients with moderate levels of demoralization had no depression. Conclusion: Results provide further evidence that the DS is a valid and reliable instrument of high clinical relevance in patients with advanced cancer. [Copyright &y& Elsevier]

Abstract: Context: The Patient Dignity Inventory (PDI) is a valid and reliable instrument designed to measure different sources of dignity-related distress in cancer patients receiving palliative care. Objectives: We investigated item characteristics, factor structure, reliability, and concurrent validity of the German version of the PDI (PDI-G) among patients with cancer. Methods: PDI was translated into the German language following state-of-the-art criteria. In a sample of 112 inpatients with mixed tumor types, principal component analysis, reliability analysis (Cronbach's coefficient alpha), and correlation analysis were performed. Concurrent validity was evaluated by validated measures of distress, demoralization, anxiety, depression, hopelessness, quality of life, sense of meaning and purpose, and supportive care needs. Results: Cronbach's coefficient alpha for PDI-G was 0.96; factor analysis resulted in a four-factor solution, accounting for 71% of the overall variance, with factor loadings ranging from 0.49 to 0.86. Factor labels include Loss of Sense of Worth and Meaning, Anxiety and Uncertainty, Physical Symptom Distress and Body Image, and Loss of Autonomy, showing high internal consistencies ranging from Cronbach's α 0.80 to 0.95. Evidence for concurrent validity was established by significant associations between PDI-G scales and concurrent measures of distress. Conclusion: Although we were unable to replicate the five-factor structure provided by Chochinov, this study gave strong support to an alternative four-factor solution of PDI-G, capturing all 25 items. We conclude that PDI-G is a psychometrically sound instrument assessing a broad range of dignity-related distress issues in patients with cancer. [Copyright &y& Elsevier]

Context: Due to toxicity and invasiveness, allogeneic hematopoietic stem cell transplantation causes severe and longstanding symptom burden. Longitudinal studies on symptoms and symptom clusters (SC) would be helpful to optimize symptom control but are rare to date.Objectives: The objective of this study was to investigate stability of symptoms, extract time stable SC, and determine their priority in symptom management.Methods: In this multicenter study, patients diagnosed with hematologic cancer were assessed before conditioning (T0) and three months (T1), one year (T2), and five years (T3) after transplantation. Symptoms were assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30). Symptoms were stable when rated as present at three consecutive time points. Applying factor analysis, stable SC were composed of symptoms loading on the same factor across all time points. Priority in symptom management was derived from a combination of severity and predictive power for quality of life (QoL).Results: Two hundred thirty-nine patients participated at T0, 150 (63%) at T1, 102 (43%) at T2, and 45 (19%) at T3. We identified three stable SC, composed of rest-tired-weak-dyspnea-loss of appetite (exhausted), tense-worried-irritable-depressed (affective), and nausea-vomiting (gastrointestinal). Fatigue was most persistent and also most severe and predictive for QoL, both as symptom and in cluster (exhausted).Conclusion: Given its high stability, severity, and impact on QoL, fatigue should have priority in symptom management. The treatment of this symptom could be enhanced by also incorporating interventions addressing dyspnea and loss of appetite. [ABSTRACT FROM AUTHOR]

Context: Attachment insecurity refers to difficulty in trusting and relying on others in times of need. Its underlying factors attachment anxiety and attachment avoidance have been empirically associated with impaired coping in advanced cancer and, therefore, should be considered in individually tailored medical and psychosocial treatment.Objectives: The objective of this study was to evaluate the psychometric properties of the German translation of the Brief Experiences in Close Relationships Scale (ECR-M16-G).Methods: We recruited 182 advanced cancer patients from outpatient psycho-oncology clinics of the University Medical Center Hamburg-Eppendorf and the University Medical Center Leipzig, local and external cancer care facilities. We performed confirmatory factor analysis to replicate the higher order factor structure reported in previous research. We conducted item and reliability analysis, also correlation analysis, to examine concurrent validity.Results: One hundred fifty-eight patients completed the ECR-M16-G (women 61%, mean age 57.9, SD = 11.1). We replicated the factor structure with the subscales Attachment Anxiety and Attachment Avoidance as second-order factors and Worrying about relationships, Frustration about unavailability, Discomfort with close others, and Turning away from others as first-order factors. An adjusted model that interchanged factor loadings of items 4 and 10 showed good fit (Comparative Fit Index = 0.94, Non-Normed Fit Index = 0.93, root mean square error of approximation = 0.05). Subscales showed acceptable to good internal consistency (anxiety α = .81 and avoidance α = .78). Attachment insecurity (mean = 3.1, SD = 1.0) was positively associated with depression, anxiety, demoralization (P < 0.001), and symptom burden (P = 0.02) and negatively associated with spiritual well-being (P < 0.001).Conclusion: The ECR-M16-G is a valid and reliable measure of attachment insecurity in patients with advanced cancer and can be recommended as a tool for clinical care and further research. [ABSTRACT FROM AUTHOR]

Context: Distress and anxiety about issues related to death and dying is commonly experienced in patients with advanced disease and a limited life expectancy.Objectives: To evaluate the psychometric properties of the German version of the Death and Dying Distress Scale (DADDS-G) in advanced cancer patients.Methods: We recruited advanced patients with mixed tumor entities (Union for International Cancer Control [UICC] Stage III/IV) treated in two German University Medical Centers during their outpatient treatment. After testing a preliminary version of the state-of-the-art translated original Death and Dying Distress Scale, we analyzed the psychometric properties of the shortened nine-item adapted DADDS-G using validated instruments measuring distress, anxiety, depression, fear of progression, and quality of life.Results: We obtained complete questionnaires from 77 of 93 patients with advanced cancer (response rate: 83%). Participants were mostly married or cohabiting (75%), well-educated, and both sexes were almost equally represented (52% men; mean age 58 years, SD = 12). The total mean DADDS-G score was 13.3 (SD = 8.5). Patients reported to be most distressed by the feeling of being a burden to others. The exploratory factor analysis led to one factor that accounted for more than 59% of the variance. The DADDS-G's internal consistency was excellent with Cronbach alpha = 0.91. The confirmatory factor analysis demonstrated a very good model fit. Death-related anxiety was significantly associated with distress, depression, anxiety, fear of progression, and lower quality of life (P < 0.001).Conclusion: Results provide further evidence that the DADDS-G is a valid and reliable instrument of high clinical relevance for use in patients with advanced cancer. [ABSTRACT FROM AUTHOR]

Context: Hopelessness is a clinically important construct in patients with advanced illness.Objectives: To evaluate the dimensionality, stability, and validity of the Beck Hopelessness Scale (BHS) in cancer patients receiving either curative or palliative treatment.Methods: Following a longitudinal design, we assessed a sample of cancer patients receiving either curative or palliative treatment (N = 315) at baseline and at follow-up after 12 months (N = 158). In addition to hopelessness, we measured depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7), and health-related quality of life (Short-Form Health Survey-8). We analyzed dimensionality, stability, and construct validity of the BHS using confirmatory factor analysis, exploratory factor analysis and correlational analysis.Results: Independent of treatment intention, confirmatory factor analyses resulted in unsatisfactory model fits. Exploratory factor analysis yielded a two-factor solution in both groups receiving curative or palliative treatment. Factor 1 reflected pessimistic/resigned beliefs (Cronbach alpha ≥ 0.85), Factor 2 reflected positive beliefs toward the future (Cronbach alpha = 0.73). Both subscales showed significant associations with anxiety, depression, and decreased health-related quality of life. The factorial structure was partially replicated in patients being reexamined after 12 months (CMIN/DF = 2.130, Standardized Root Mean Square Residual = 0.0716, Comparative Fit Index = 0.904, Tucker-Lewis-Index = 0.883, Root Mean Square Error of Approximation = 0.085). Hopelessness scores were significantly higher in patients reporting suicidal ideation according to the Patient Health Questionnaire-9.Conclusion: Our study demonstrates psychometric limitations of the BHS in patients receiving both curative and palliative treatment, suggesting reduced utility in cancer populations. Given the clinical importance of the construct, a cancer-specific approach to capture the unique meaning of hopelessness in patients with severe medical illness is recommended. [ABSTRACT FROM AUTHOR]

Context Maintaining a sense of dignity in terminally ill patients and enabling a dignified dying are important aims of palliative care. Objectives To evaluate the impact of symptom burden, distress, overall condition, and individual patient characteristics on self-perceived dignity in terminally ill cancer patients. Methods In this cross-sectional study, 61 patients were recruited through a palliative care inpatient ward within 48 hours after admission. Patients completed the Patient Dignity Inventory, a modified version of the Memorial Symptom Assessment Scale, the National Comprehensive Cancer Network Distress Thermometer, and a single-item scale rating subjective of overall condition. Sociodemographic parameters and performance status were taken from the patients' records. Results Dignity total score correlated highest with lack of energy ( P < 0.001), anxiety ( P < 0.001), sadness ( P = 0.002), pain ( P = 0.009), shortness of breath ( P = 0.019), irritability ( P = 0.023), thirst ( P = 0.029), and tiredness ( P = 0.041). Psychological symptoms showed more consistent associations with the different dignity dimensions than physical symptoms except for the dependency dimension. Psychological distress correlated with all dignity dimensions: symptom distress ( P < 0.001), existential distress ( P < 0.001), dependency ( P = 0.020), peace of mind ( P < 0.001), and social support ( P = 0.024). Overall condition was significantly associated with existential distress ( P = 0.013), but not with symptom distress, dependency, peace of mind, or social support. Performance status showed significant association with dependency ( P = 0.001). Conclusion Self-perceived dignity in terminally ill cancer patients is significantly associated with physical as well as psychological symptoms, distress, overall condition, performance status, and comorbidities. Knowledge of these specific interactions is essential for adequate, comprehensive palliative care. [ABSTRACT FROM AUTHOR]

Context: Quality of life (QoL) is a central focus of care in advanced cancer. Specialized instruments, such as the Quality of Life at the End of Life-Cancer (QUAL-EC), may be useful to assess psychosocial issues associated with QoL unique to this population.Objectives: To evaluate the measurement of the psychosocial dimensions of QoL using the German translation of the QUAL-EC-Psychosocial (QUAL-EC-P) questionnaire, including factor structure and psychometrics.Methods: About 183 patients with advanced cancer from the University Medical Center Hamburg-Eppendorf and University Medical Center Leipzig completed the QUAL-EC-P questionnaire. We conducted exploratory factor analysis as well as item and reliability analysis. We examined convergent validity with correlations between the scale and relevant psychological constructs.Results: The sample was 60% female with mean age of 57.7 (SD = 11.7). We extracted three factors accounting for 44% of the variance aligning with the structure of the instrument. The QUAL-EC-P questionnaire showed good to acceptable internal consistency for the QoL-psychosocial total score (α = 0.77), the Life completion subscale (α = 0.77), and the Relationship with health care provider subscale (α = 0.81). The Preparation for end of life subscale had adequate albeit low internal consistency (α = 0.64) because concerns about family were less associated with financial worry and fear of death than expected. The psychosocial dimensions of QoL correlated negatively with depression (r = -0.27, P ≤ 0.001), anxiety (r = -0.32, P ≤ 0.001), demoralization (r = -0.63, P ≤ 0.001), and attachment insecurity (r = -0.51, P ≤ 0.001) and positively with spiritual well-being (r = 0.63, P ≤ 0.001).Conclusion: The QUAL-EC-P questionnaire may be used to assess the psychosocial aspects of QoL and promote their clinical discussion in patients with advanced cancer. [ABSTRACT FROM AUTHOR]