CALM and the Desire for Death

This chapter considers the loss of the will to live, the desire for hastened death, and suicidality in patients with advanced disease. The challenge of distinguishing the loss of the will to live as a manifestation of depression from nonpathological death acceptance is explored and the clinical implications of such distinctions are examined. The quantitative findings from our longitudinal research regarding the prevalence, trajectory, and correlates of the desire for death in patients with advanced cancer are presented. The qualitative findings from this research revealed three distinct dimensions of the desire for death, only one of which reflects the literal wish to end life. The role of Managing Cancer and Living Meaningfully (CALM) in alleviating death anxiety, in examining the desire for death, in enhancing death preparation, and in improving communication with healthcare providers is considered here.

Dignity Therapy

Maintenance and promotion of patient and family dignity is a core tenet of palliative care and has significant implications for end-of-life experience, with loss of dignity associated with increased suffering and desire for death. This chapter provides an overview of empirical research on dignity at the end of life, including the model of dignity in the terminally ill, measures to assess dignity including the Patient Dignity Inventory and the Dignity Impact Scale, and dignity therapy, an intervention aimed at bolstering dignity, meaning-making, and generativity needs to improve the end-of-life experience for patients and families. These topics are discussed in the context of a proliferation of research in the last decade across a diversity of cultures, languages, and illness groups.

The desire for death in Portuguese home-care palliative patients: Retrospective analysis of the prevalence and associated factors

Objective Desire for death (DfD) is a complex and multifactorial dimension of end-of-life experience. We aimed to evaluate the prevalence of DfD and its associations, arising within the setting of a tertiary home-based palliative care (PC) unit. Method Retrospective analysis of all DfD entries registered in our anonymized database from October 2018 to April 2020. Results Of the 163 patients anonymously registered in our database, 122 met entry criteria; 52% were male, the average age was 69 years old; 85% had malignancies, with a mean performance status (PPS) of 56%. The prevalence of DfD was 20%. No statistical differences were observed between patients with and without DfD regarding sex, age, marital status, religion, social support, prior PC or psychological follow-up, type of diagnosis, presence of advanced directives/living will, time since diagnosis and PC team's follow-up time. Statistically significant associations were found between higher PPS scores and DfD (OR = 0.96; 95% confidence interval (CI) [0.93–0.99]); Edmonton Symptom Assessment Scale scores for drowsiness (OR = 4.05; 95% CI [1.42–11.57]), shortness of breath (OR = 3.35; 95% CI [1.09–10.31]), well-being (OR = 7.64; 95% CI [1.63–35.81]). DfD was associated with being depressed (OR = 19.24; 95% CI [3.09–+inf]); feeling anxious (OR = 11.11; 95% CI [2.51–49.29]); HADS anxiety subscale ≥11 (OR = 25.0; 95% CI [2.10–298.29]); will-to-live (OR = 39.53; 95% CI [4.85–321.96]). Patients feeling a burden were more likely to desire death (OR = 14.67; 95% CI [1.85–116.17]), as well as those who were not adapted to the disease (OR = 4.08; 95% CI [1.30–12.84]). In multivariate regression analyses predicting DfD, three independent factors emerged: higher PPS scores were associated with no DfD (aOR = 0.95; 95% CI [0.91–0.99]), while the sense of being a burden (aOR = 12.82; 95% CI [1.31–125.16]) and worse well-being (aOR = 7.72; 95% CI [1.26–47.38]) predicted DfD. Significance of results Prevalence of DfD was 20% and consistent with previous Portuguese evidence on DfD in PC inpatients. Both physical and psychosocial factors contribute to a stronger DfD.

Romantic Provenance

The chapter considers how seventh chords, half-diminished chords, and diminished chords might fit into the book’s root–theoretical model of tonal function, grounded in the Romantic tradition of Schubert, Beethoven, and Chopin. The chapter works toward a full functional analysis of the Vorspiel and Liebestod from Tristan und Isolde. The phantasy involved in Isolde’s transfiguration is explored from a Lacanian perspective, leading to reflections on how phantasy works to support tonal function. An addition to the canon of analyses of Hugo Wolf’s “An den Schlaf” covers the theme of death, sleep, and the land of limbo in between, offering a corollary to Isolde’s desire for death. These themes weave their way into the outlined theory of harmonic function and offer a precursor to the psychodynamics to come.

Demystifying the Negative René Girard’s Critique of the “Humanization of Nothingness”

This paper will address René Girard’s critique of the “humanization of nothingness” in modern Western philosophy. I will first explain how the “desire for death” is related to a phenomenon that Girard refers to as “obstacle addiction.” Second, I will point out how mankind’s desire for death and illusory will to self-divinization gradually tend to converge within the history of modern Western humanism. In particular, I will show how this convergence between self-destruction and self-divinization gradually takes shape through the evolution of the concept of “the negative” from Hegel to Kojève, Sartre and Camus. Finally, we shall come to see that in Girard’s view “the negative” has tended to become an ever-preoccupying and unacknowledged symptom of mankind’s addiction to “model/obstacles” of desire.

The Interpersonal Needs Questionnaire: Statistical Considerations for Improved Clinical Application

The interpersonal theory of suicide (ITS) has accumulated empirical support; however, less research has investigated the clinical utility of ITS constructs in suicide risk assessment. The current study sought to increase the clinical utility of the Interpersonal Needs Questionnaire (INQ), an assessment of thwarted belongingness (TB) and perceived burdensomeness (PB), among 318 adult psychiatric outpatients while considering statistical methodology (i.e., multicollinearity and partialling). Results emphasized PB in the prediction of concurrent desire for death/suicide when TB was simultaneously considered. The interaction between TB and PB did not enhance prediction of concurrent desire for death/suicide. Independently, PB was a stronger predictor than TB of concurrent desire for death/suicide in the total sample and gender subsamples. Estimated probabilities of concurrent desire for death/suicide across INQ scores and preliminary INQ clinical cutoff scores are provided to enhance clinical application. These findings suggest the INQ could provide valuable information for suicide risk assessment and conceptualization.

Axiology and the mortality of the human being

Awareness of mortality is one of the key aspects of human existence. Death goes beyond the boundary of knowledge, mortality. However, it is actually experienced by man as something inevitable. Death is a fact – the end of life, and the experience of mortality is one of the borderline situations. In the essay, the author puts forward the thesis that the experience of mortality has a significant impact on the human understanding of values. Attitudes towards death be it fear, resignation, indifference, fascination, mourning, sadness, despair after the loss of a loved one, or the desire for death, indicate the wealth of the world of value of axiological experience. The attitude of the person towards death, in some sense, is a test of our humanity, the principal value to which we refer most often. The author of the essay adopts the position of axiological relationalism (or axiological structurism), it implies that values are independent of the subject, they form a network of relational connections, but they are in a significant way connected with culture. The study of these connections: 1) with the world of people, 2) world of things, 3) internal relations that take place between values, allows us to get to know the complex structure of the world of values. In the article, the author analyzes in what sense mortality influences human understanding of values.

King Lear and its Origins

The agreed, major sources of King Lear are the anonymous history play King Leir and Sidney’s Arcadia. To these and other early modern ‘originals’ this chapter adds classical tragedies by Seneca, Euripides, and Sophocles—most conspicuously his Oedipus at Colonus, which was readily available in Latin translation. The ancient tragedies resonate with King Lear thanks to conventions of literary imitation that were well understood in the Jacobean period, but their presence is also symptomatic of a drive within the play to get back to the origins of nature, injustice, and causation. The influences of Plutarch and Montaigne are also highlighted. The portrayal of death (or the illusion of it) and the desire for death, in the play and its sources, are analysed. Focusing on the scenes at Dover Cliff and the division of the kingdom/s, this chapter moves to a new account of the complications of the play’s conclusion in both quarto and Folio texts.

Effect of dignity therapy on end-of-life psychological distress in terminally ill Portuguese patients: A randomized controlled trial

ABSTRACTObjective:Dignity therapy (DT) is a brief form of psychotherapy developed for patients living with a life-limiting illness that has demonstrated efficacy in treating several dimensions of end-of-life psychological distress. Our aim was to determine the influence of DT on demoralization syndrome (DS), the desire for death (DfD), and a sense of dignity (SoD) in terminally ill inpatients experiencing a high level of distress in a palliative care unit.Method:A nonblinded phase II randomized controlled trial was conducted with 80 patients who were randomly assigned to one of two groups: the intervention group (DT + standard palliative care [SPC]) or the control group (SPC alone). The main outcomes were DS, DfD, and SoD, as measured according to DS criteria, the Desire for Death Rating Scale, and the Patient Dignity Inventory (PDI), respectively. All scales were assessed at baseline (day 1) and at day 4 of follow-up. This study is registered with http://www.controlled-trials.com/ISRCTN34354086.Results:Of the 80 participants, 41 were randomized to DT and 39 to SPC. Baseline characteristics were similar between the two groups. DT was associated with a significant decrease in DS compared with SPC (DT DS prevalence = 12.1%; SPC DS prevalence = 60.0%; p < 0.001). Similarly, DT was associated with a significant decrease in DfD prevalence (DT DfD prevalence = 0%; SPC DfD prevalence = 14.3%; p = 0.054). Compared with participants allocated to the control group, those who received DT showed a statistically significant reduction in 19 of 25 PDI items.Significance of results:Dignity therapy had a beneficial effect on the psychological distress encountered by patients near the end of life. Our research suggests that DT is an important psychotherapeutic approach that should be included in clinical care programs, and it could help more patients to cope with their end-of-life experiences.

Meaning-Centered Group Psychotherapy for Advanced Cancer Patients

The ability to sustain a sense of meaning is significantly associated with important elements of end-of-life despair. Meaning-centered group psychotherapy (MCGP), an eight-session group psychotherapy intervention, was developed to help patients with advanced cancer sustain or enhance a sense of meaning. MCGP has been shown to significantly improve spiritual well-being, sense of meaning, and quality of life and to diminish anxiety, depression, hopelessness, symptom burden distress, and desire for death. The mechanism of this benefit is through the enhancement of meaning. MCGP appears to be a beneficial intervention for emotional and spiritual suffering in advanced cancer patients. This chapter describes the theoretical framework and research basis for pursuing an intervention to enhance or sustain meaning. It also describes the development of MCGP, its evidence base for clinical efficacy, and outlines the intervention in great detail.