Spiritual and existential distress has been shown to correlate with loneliness, depression, and anxiety.31,32 The connections between spirituality, meaning, and dignity have been examined within the context of aging. For older adults, notions of dignity are intimately tied to being able to serve a purpose, feel important, feel involved, and have a sense of belonging.33 Our study group has examined the issue of dignity from the vantage point of patients approaching death. On the basis on these studies, we have developed an empirical model of dignity for patients at the end of life (Table).34 The Dignity Model suggests that a person’s perception of dignity is related to and influenced by 3 major areas:
• Illness-related concerns derive from or are related to the illness itself, and either threaten to or actually do impinge on a patient’s sense of dignity.
• The dignity-conserving repertoire consists of those internally held and socially mediated approaches a person uses to maintain a sense of dignity.
• The social dignity inventory refers to external environmental factors that can strengthen or undermine the quality of interactions with others and, thereby, a sense of dignity.
On the basis of the empirical Dignity Model, our research group has developed a brief, individual therapeutic intervention that we call dignity therapy.35 Dignity therapy invites patients to address issues, recall memories, and share reflections, which they may wish to offer those they are about to leave behind. Typically, patients share life stories; highlight their values; speak about how they wish to be remembered, their most important accomplishments, hopes, and dreams for loved ones; and provide advice or guidance for important people in their lives. These sessions are tape-recorded, with the therapist helping the patient organize and construct the conversations. Dignity therapy typically comprises 1 or 2 sessions of 60 to 90 minutes each. These sessions are transcribed verbatim and then edited to create a cohesive narrative. The patient receives this “generativity document,” which in most instances is bequeathed to a loved one.