My father died a basically “good death.” He died, comfortably, at home, in his own bed, clean shaven, surrounded and embraced by his family. My father lived with widely metastatic prostate cancer for 5 years. In those 5 years, he had minimal pain and no episodes of infection or hospitalizations. He did extremely well for 4 years and 6 months, even working. The last 6 months were marked by progressive weight loss and weakness, requiring him to slow down. But up until the day before he died, he was ambulatory, showered and dressed himself, argued with my mother, and was pain free. On a Tuesday morning, for the first time in his long illness, he did not get out of bed. He was drowsy and not completely responsive. My mother called to tell me of the change. I left morning rounds at the hospital, collected a few essential medications, and went straight to their home (the home I grew up in). I spent the next and last 24 hours of his life sitting in a chair at the side of his bed, feeding him drops of liquid morphine and haloperidol to keep him comfortable, free of pain, free of confusion and agitation. My mother slept beside him that entire night. When the hospice nursing aide arrived on Wednesday morning it was clear that my father was very near death. We both bathed my father, and I insisted on shaving him. He had about 4 days worth of beard growth, and I knew he would want to die clean shaven. After shaving the left side of his face, he stopped breathing. I kissed him, thanked him for giving me life, and then I completed shaving the right side of his face.

My good friend and colleague Barney Sneiderman died yesterday. A few months ago he was diagnosed with pancreatic cancer; the day before yesterday, after failed trials of chemotherapy and staying at home—with community palliative care supports—as long as possible, he determined it was time to enter one of our city's inpatient palliative care units. Less than a day later, he was gone. Some readers of Palliative & Supportive Care may actually be familiar with Barney, through his various published works. As a professor of law at the University of Manitoba, he was known for his expertise in health issues and the law and biomedical ethics. He was a frequent speaker to medical professionals on medico-legal subjects, and had a cross-appointment with the Faculty of Medicine at the University of Manitoba. Besides his many publications, the book he coauthored, Canadian Medical Law: An Introduction for Physicians, Nurses and Other Health Care Professionals, third edition, is considered an authoritative work on legal issues relating to patient care and treatment and addresses the most frequent and pressing concerns facing health care professionals and the lawyers who advise them.

Medicine constantly holds the tensions of contrasts. Of life and of death. Of fighting and of folding. Of truth and of deceit. Herein lies the art of medicine. Holding the balance of the rational advance of science against the relative world of values and attitudes. This tension, in turn, reflects the human condition, wherein man is both symbolic and physical.

This past fall (October 2005), my good friend and colleague Lewis Cohen, M.D., of Baystate Medical Center, helped organize a unique conference (cosponsored by the Smith College of Social Work) that represented an early attempt by psychosocial palliative care clinicians, ethicists, and legal experts to grapple with the issues raised by the Terri Schiavo case, which had so captured the attention of the nation and raised tremendous disagreement and debate. As editor-in-chief of Palliative & Supportive Care, I was, of course, quite thrilled when Dr. Cohen proposed the possibility of our journal publishing the main papers from this unique and timely conference. As the readers of Palliative & Supportive Care will recall, this journal has expressed the opinion that the case of Terri Schiavo represented a watershed event in palliative care practice and research (Breitbart, 2005), and we called for more research into the experience of patients who die of dehydration. Of course, the issues raised by the Schiavo case are so much broader and do, in fact, range from palliative care practice and research to ethics and spiritual issues to legal issues regarding decision making at the end of life.

Objective: Depression is particularly prevalent in patients with advanced cancer. Cognitive therapy (CT) is an empirically supported treatment for depression in the general population. However, efficacy remains to be demonstrated in patients with advanced cancer. A prior controlled trial of CT in a group format showed improvements in depression, mood disturbance, and self-esteem; however, these effects were not maintained over time. Studies examining the efficacy of individual format CT interventions that may ensure more long-term maintenance of benefits are necessary. This study assessed the efficacy of CT for depression administered individually in women with metastatic breast cancer and its effect on immune function.

Method: Forty-five women were randomly assigned to either individual CT or to a waiting-list control (WLC) condition. CT was composed of eight weekly sessions of CT and three booster sessions administered at 3-week intervals following the end of treatment.

Results: Patients treated with CT had significantly lower scores on the Hamilton Depression Rating Scale at posttreatment compared to untreated patients. Pooled data from both groups indicated significant reductions of depressive symptoms from pre- to posttreatment, as well as reduction of associated symptoms including anxiety, fatigue, and insomnia symptoms. These effects were well sustained at the 3- and 6-month follow-up evaluations. CT for depression did not appear to have a significant impact on immune functioning.

Significance of results: Findings of this study support the efficacy of CT for depression in this population and suggest that the administration of individual and booster sessions after treatment termination may be instrumental in sustaining the treatment effects over time.

In October of 2005, a two-day conference, “Controversies in End-of-Life Care: Terri Schiavo's Lessons,” was jointly sponsored by Baystate Medical Center and the Smith College School for Social Work. Both the conference and this special issue of the journal are prompted by recognition that the Schiavo case has clearly generated considerable national attention, and it consequently offers palliative medicine, social work, psychiatry, neurology, and allied disciplines a singular opportunity to reflect on our clinical practices and assumptions about the management of catastrophically ill individuals. At the core of the Schiavo case was a bitter family feud, but before it ended, it became a legal battle, a political fight, a disability rights issue, and a macabre media circus. It is heartbreaking that Congress held a midnight session about the health care of one irreparably brain-damaged woman, Terri Schiavo, while ignoring the health crisis of 40 million uninsured Americans (Friedman, 2005).

Objective: This research examines positive life changes that cancer patients may experience following their diagnosis. Although cancer is often believed to have negative impacts on the life of patients, positive impacts have been also discussed empirically. This study focuses on cancer patients' appraisal of positive life changes following their diagnosis and examines how and in which fields they recognize their lives as positively changed based on the study of Petrie et al. (1999).

Methods: A total of eight cancer patients in a cancer support group participated in this research. A group discussion and semistructured interviews were conducted. Content analysis was applied.

Results: The content analysis produced insights into the seven types of cancer-related life changes: improved empathy, greater knowledge about health, renewed recognition of life, change in personal life priorities, greater appreciation of health and life, improved close relationships, and healthy lifestyle change. Negative life changes were also reported.

Significance of the research: This research showed that cancer patients tended to find and appraise their own positive life changes following cancer. The categorization of positive life changes basically supported that of Petrie et al. (1999), but produced an original category: renewed recognition of life. Positive life changes might be seen as a natural process that encourages patients' adjustment to cancer. Understanding positive impacts of cancer could be important in capturing the life-sized features of cancer patients. Future research could expand the view of the impacts of cancer and demonstrate how people recognize them as benefits.

Objectives: This article introduces a new meaning-centered psycho-educational group intervention, called Enhancing meaning in palliative care nursing, designed to support nurses providing palliative care. This intervention aims at increasing job satisfaction and quality of life, as well as preventing burnout in this particular population.

Theoretical frameworks: Its format and content are founded on the meaning-centered psychotherapy approach developed for terminally ill cancer patients (Breitbart, 2001; Greenstein & Breitbart, 2000). Frankl's existential therapeutic approach, called logotherapy, serves as the underlying theoretical framework to this intervention.

Development: Following the presentation of the context and the development of the intervention, its content is described.

Conclusion: A brief description of the ongoing randomized controlled trial testing the intervention is then provided. Finally, the way in which this intervention could contribute to nurses' quality of life and suggestions for future developments are briefly discussed.

Objective: To examine: (1) daily religious and spiritual experiences among localized prostate cancer patients as compared to a national age and race-matched male sample; (2) cognitive-affective and clinical predictors of prostate cancer diagnosis-related increases in religiosity and spirituality; (3) short-term impact of daily religious and spiritual experiences on cancer recurrence worry.

Methods: Analyses of data from a longitudinal questionnaire study among patients (N = 254) diagnosed with localized prostate cancer and data from a random sample (N = 238) of respondents to the national General Social Survey.

Results: Compared to the national sample, prostate cancer patients reported higher levels of daily spiritual experiences. Patients with higher worry about prostate cancer and elevated levels of prostate-related symptoms around diagnosis were more likely to report a diagnosis-related increase in religiosity and spirituality. Positive benefits (reduced recurrence worry) of religious coping/practices were restricted to those patients with higher versus lower level of postdiagnosis increase in religiosity; patients not reporting postdiagnosis increases in religion who are not engaging in religious coping/practice adjusted equally well. Results suggest that the development of religious/spiritual interventions is premature.

Significance of results: This is the first prospective study to report on the prevalence and influence of daily spiritual and religious experiences among prostate cancer patients.

The recent events surrounding the case of Terri Schiavo have highlighted the moral implications of end-of-life care. Among the issues raised by Terri's parents against the withdrawal of her feeding tube was that doing so would be “euthanasia” and, as such, would violate their daughter's Roman Catholic religious beliefs. The emotionally charged rhetoric and the political posturing in this case drowned out both rational discourse and historical memory. Politicians and even a few bishops and cardinals were quick to join the parents in denouncing the removal of Terri Schiavo's feeding tube as “euthanasia” or “murder.” However, the interpretation of the Catholic position on the sanctity of life that led to that moral judgment is not in line with the centuries-long Catholic position on end-of-life care.

Objective: Although spirituality as it relates to patients is gaining increasing attention, less is known about how health care professionals (HCP) experience spirituality personally or collectively in the workplace. This study explores the collective spirituality of an interdisciplinary palliative care team, by studying how individuals felt about their own spirituality, whether there was a shared sense of a team spirituality, how spirituality related to the care the team provided to patients and whether they felt that they provided spiritual care.

Methods: A qualitative autoethnographic approach was used. The study was conducted in a 10-bed Tertiary Palliative Care Unit (TPCU) in a large acute-care referral hospital and cancer center. Interdisciplinary team members of the TPCU were invited to participate in one-to-one interviews and/or focus groups. Five interviews and three focus groups were conducted with a total of 20 participants.

Results: Initially participants struggled to define spirituality. Concepts of spirituality relating to integrity, wholeness, meaning, and personal journeying emerged. For many, spirituality is inherently relational. Others acknowledged transcendence as an element of spirituality. Spirituality was described as being wrapped in caring and often manifests in small daily acts of kindness and of love, embedded within routine acts of caring. Palliative care served as a catalyst for team members' own spiritual journeys. For some participants, palliative care represented a spiritual calling. A collective spirituality stemming from common goals, values, and belonging surfaced.

Significance of results: This was the first known study that focused specifically on the exploration of a collective spirituality. The culture of palliative care seems to foster spiritual reflection among health care professionals both as individuals and as a whole. While spirituality was difficult to describe, it was a shared experience often tangibly present in the provision of care on all levels.

Objective: For people with advanced cancer, the months preceding death can be very stressful. Moreover, cancer-related stressors can arise within multiple dimensions. However, little research has examined how people cope differentially with different types of stressors. The goal of this study was to examine patterns of coping across different dimensions of stress.

Method: Fifty-two patients who were receiving palliative care for cancer were asked to indicate their most significant stressors within social, physical, and existential dimensions. A structured interview was then conducted to describe how the participants coped with these stressors.

Results: Overall, stressor severity ratings were correlated significantly across the three dimensions, although physical symptoms received the highest mean rating. Participants generally used a range of coping strategies to deal with their stressors, but there were clear differences across dimensions in the relative use of problem-focused versus emotion-focused strategies. Problem-focused coping was less frequent for existential issues, whereas emotion-focused strategies were used less frequently for physical stressors. Coping efforts were not clearly related to psychological distress.

Significance of results: Although coping is an important research theme within psycho-oncology, it may be overly broad to ask, “How do people cope with cancer?” In fact, different cancer-related stressors are coped with in very different ways. There is not necessarily any particular pattern of coping that is best for relieving psychological distress.

This article examines narratives of grief and loss and how, under the best of circumstances, they may lead to transformation and growth, even contributing to the greater social good. Using psychodynamic and narrative theories, and examples drawn from mourners who have used their grief in powerful and political ways, I make the case that even grief that has been highly appropriated and contested, as in the case of Terri Schiavo, may ultimately serve important functions. Grief may mobilize mourners by helping them to turn passivity into activity. Grief may mobilize higher-level defenses such as altruism. Grief and loss may lead to a mourner's desire to do for others what was not done for him or her. A necessary part of turning grief into social action is the creation of a coherent grief narrative—first personal and then political. This coherent narrative can be developed using clinical interventions as well. Hence I discuss the clinical implications of helping those who are grieving to create coherent narratives out of shattered assumptions in a process of personal and social change.

Objective: The aim of this study was to compare the results of surveys about attitudes toward euthanasia and related issues that was conducted among palliative care specialists, health care professionals of a cancer center, and first- and second-year medical students.

Methods: By means of an anonymous questionnaire with different hypothetical scenarios concerning physician assisted suicide (PAS) and related issues, 726 members of the Swiss Association for Palliative Care (SAPC), 148 health care professionals of the Institute of Oncology of Italian speaking Switzerland (IOSI), and 140 medical students of the University of Fribourg, Switzerland, were surveyed.

Results: Among palliative care specialists a decreasing number supported PAS, direct active euthanasia (DAE), DAE for psychiatric patients, DAE in incompetent patients, and life terminating acts without explicit request (LAWER). Professionals of the cancer center were more in favor of DAE and PAS than palliative care specialists, but less in favor than medical students.

Significance of results: Significant variations among different professionals exist in attitudes toward euthanasia. The hypothesis that familiarity with the care of severely ill and dying patients is an important underlying factor explaining variance has been confirmed by these surveys.

Objective: The experience of time is strongly related to our momentary mood states. Patients with a life-threatening illness experience an extreme change in mood and suffer from psychological distress that can develop into clinically relevant psychiatric disorders, like anxiety and depression. The aim of this study was to investigate the associations among the subjective perception of time, psychological distress, and quality of life in patients with hematological malignancies.

Methods: Eighty-eight inpatients with hematological malignancies rated how fast time passes subjectively on a visual analog scale and prospectively estimated a time span of 13 min. The Hospital Anxiety and Depression Scale (HADS) self-report measures of health-related quality of life (FACT-G) and spiritual well-being (FACIT-Sp) were employed to assess psychological distress and quality of life.

Results: Those patients who reported a lower quality of life, less spiritual well-being, and more anxiety experienced a slower passage of subjective time and overestimated the 13-min time interval.

Significance of results: Our interpretation of the results is that patients with a life-threatening illness who show symptoms of psychological distress draw attention away from meaningful thoughts and actions and, thus, experience time as passing more slowly. An altered sense of time can be a sign of mental suffering, which should be addressed within psycho-oncological interventions. As this is the first study to demonstrate this relation in cancer patients, further research is needed to investigate the experience of time and its relation to meaning as an issue in clinical diagnostics.

Background: Exercise is becoming an important component of cancer rehabilitation programs. A consistent finding across studies is that patients experience improved physical fitness and reduced fatigue. However, sustained physical activity is essential if the benefits are to be preserved over the course of cancer survivorship.

Objective: This study examined self-reported short-term exercise adherence following a 6-week, supervised exercise program (muscle strength, cardiovascular fitness, relaxation, body awareness, and massage) in a heterogeneous group of 61 cancer patients (mean age 42.9 years, 82% oncological and 18% haematological) from the Body & Cancer Project.

Methods: Semistructured interviews were used to quantitatively assess leisure time physical activity level 1 and 3 months after completion of the program. The study furthermore included 3-month follow-up assessment of psychological distress (Hospital Anxiety and Depression Scale—HADS). Patient statements were selected that best illustrated trends found in the statistical material.

Results: There was a significant postprogram reduction in physical activity from 6 to 10 weeks and from 6 to 18 weeks. However, the patients (half of whom were still undergoing treatment at the time of follow-up) reported a higher physical activity level postprogram compared to their baseline levels. The analyses showed a positive association between the 3-month postprogram physical activity level and pre-illness physical activity level, treatment, and postprogram changes in depression.

Significance of research: Given the significant decrease in postprogram PA level, especially in subjects still undergoing cancer treatment, the study suggests that continuous supervised programs may be required in order to encourage and support exercise adherence in this population. However, randomized clinical controlled trials and more follow-up studies are needed to establish the optimal program length and content for sustained exercise adherence in cancer patients.

Objective: Effective communication is recognized as an essential process to providing quality care, including palliative and end-of-life care. Discussion of prognosis and support needs of patients with heart failure is particularly challenging given the nature of the condition and care across several settings. The objective was to design, implement, and evaluate an interdisciplinary workshop aimed at improving attitudes and skills related to communication with patients and family, health team communication and documentation, and assessment of physical and emotional symptoms.

Methods: A pretest, delayed posttest evaluation design was used to evaluate two 4-h workshops offered to nurses, social workers, and other nonphysician clinicians.

Results: Although baseline reports of skills were high for the participants, significant improvement was noted for objectives emphasized in the workshop.

Significance of results: This project demonstrated the feasibility of designing, marketing a brief workshop, and positively impacting communication and documentation skills.

Objective: The study was conducted to understand the emotional impact of multiple myeloma, as well as the impact of its principle treatment, peripheral blood stem cell transplant (PBSCT). The absence of psycho-oncology research literature on this population prompted the need for a hypothesis-generating investigation. Thus, a qualitative design was used to construct a theoretical model of the trauma relating to diagnosis and treatment of myeloma. The study also incorporates the important period of reflection and growth following treatment.

Methods: The sample consisted of 3 women and 3 men treated for myeloma at a New York City-based cancer treatment center. Data from individual interviews were audiotaped and transcribed. After extensive review, the data were categorized into groups of repeating ideas, themes and broad theoretical constructs.

Results: A five-construct model emerged from the data analysis that integrated a model of trauma and growth presented in earlier work (Auerbach et al., 2006). These constructs roughly correspond with stages of illness, but do not necessarily imply a linear process, as suggested by stage models. The first construct is diagnosis. Patients receive the news that they have multiple myeloma. Initial reactions are discussed and a treatment plan takes form. In the second construct, treatment, patients highlight the physical and emotional hurdles confronted throughout treatment. The third construct, network of safety, presents social factors that play a role in comforting patients throughout illness. Patients recognize the importance of a strong support system during their experiences. In the fourth construct, recuperation, physical energy is regained after an arduous recovery period. This contributes to higher spirits and a motivation to reengage with life. The fifth construct is reflection and new existence. Patients strive to balance a new reality that relapse and death are inevitable, along with their need to live a meaningful life. Many do not yet appreciate how their disease has impacted them, but describe how their interpersonal lives and perceptions have changed, both positively and negatively.

Significance of results: Limitations of the study, future directions for research and clinical implications are discussed.

Objectives: To describe physicians' end-of-life practices, perceptions regarding end-of-life care and characterize differences based upon physician specialty and demographic characteristics. To illuminate physicians' perceptions about differences among their African-American and Caucasian patients' preferences for end-of-life care.

Design and methods: Twenty-four African-American and 16 Caucasian physicians (N = 40) participated in an in-person interview including 23 primary care physicians, 7 cardiologists, and 10 oncologists. Twenty-four practices were in urban areas and 16 were in rural counties.

Results: Physicians perceived racial differences in preferences for end-of-life care between their Caucasian and African-American patients. Whereas oncologists and primary care physicians overwhelmingly reported having working relationships with hospice, only 57% of cardiologists reported having those contacts. African-American physicians were more likely than Caucasian physicians to perceive racial differences in their patients preferences for pain medication.

Significance of results: Demographic factors such as race of physician and patient may impact the provider's perspective on end-of-life care including processes of care and communication with patients.

What would Terri Schiavo have wanted? That remains an unanswered question for many who followed the media frenzy that attended the extraordinary court and legislative battles that preceded her death 13 days after her feeding tube was removed for the last time. What would she have directed her physicians to do if she had “miraculously” regained capacity and awareness of the consequences of her cardiac arrest that left her in a persistent vegetative state? Who would she have wanted to make that decision for her if she were unable to do so? How are we to understand the meaning of statements that she purportedly made about life-sustaining treatments approximately 20 years ago, and how can we apply them to the current situation? This article reflects on those questions from the perspective of two small exploratory studies. These studies considered the meanings and interpretation of statements by terminally ill patients concerning desire for hastened death and the relevance of previously made statements to their current clinical situation.