Skip to main content Accessibility help

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

  • Miguel Julião (a1), Fátima Oliveira (a2), Baltazar Nunes (a3), António Vaz Carneiro (a4) and António Barbosa (a5)...



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.


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


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.


Corresponding author

Address correspondence and reprint requests to Miguel Julião, Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal. E-mail:


Hide All
Block, S.D. (2000). Assessing and managing depression in the terminally ill patient. ACP–ASIM End-of-Life Care Consensus Panel. American College of Physicians–American Society of Internal Medicine. Annals of Internal Medicine, 132(2), 209218.
Block, S.D. (2001). Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life: The art of the possible. The Journal of the American Medical Association, 285(22), 28982905.
Breitbart, W., Rosenfeld, B., Pessin, H., et al. (2000). Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. The Journal of the American Medical Association, 284(22), 29072911.
Chochinov, H.M. (2002). Dignity-conserving care: A new model for palliative care. Helping the patient feel valued. The Journal of the American Medical Association, 287(17), 22532260.
Chochinov, H.M. (2007). Dignity and the essence of medicine: The A, B, C, and D of dignity-conserving care. British Medical Journal, 335, 184187.
Chochinov, H.M. (2011). Dignity therapy: Final words for final days. New York: Oxford University Press.
Chochinov, H.M., Wilson, K.G., Enns, M., et al. (1995). Desire for death in the terminally ill. The American Journal of Psychiatry, 152(8), 11851191.
Chochinov, H.M., Hack, T., McClement, S., et al. (2002). Dignity in the terminally ill: A developing empirical model. Social Science & Medicine, 54(3), 433443.
Chochinov, H.M., Hack, T., Hassard, T., et al. (2005). Dignity therapy: A novel psychotherapeutic intervention for patients near the end of life. Journal of Clinical Oncology, 23(24), 55205525. Available from
Chochinov, H.M., Hassard, T., McClement, S., et al. (2008). The Patient Dignity Inventory: A novel way of measuring dignity-related distress in palliative care. Journal of Pain and Symptom Management, 36(6), 559–371. Epub ahead of print Jun 24. Available from
Chochinov, H.M., Kristjanson, L.J., Breitbart, W., et al. (2011). The effect of dignity therapy on distress and end-of-life experience in terminally ill patients: A randomised controlled trial. The Lancet. Oncology, 12(8), 753762. Epub ahead of print Jul 6. Available from
de Figueiredo, J.M. (1993). Depression and demoralization: Phenomenologic differences and research perspectives. Comprehensive Psychiatry, 34(5), 308–11.
Hack, T.F., McClement, S.E., Chochinov, H.M., et al. (2010). Learning from dying patients during their final days: Life reflections gleaned from dignity therapy. Palliative Medicine, 24(7), 715723. Epub ahead of print Jul 6. Available from
Hall, S., Goddard, C., Opio, D., et al. (2011). A novel approach to enhancing hope in patients with advanced cancer: A randomised phase II trial of dignity therapy. BMJ Supportive & Palliative Care, 1(3), 315321. Epub ahead of print Oct 9.
Hudson, P.L., Kristjanson, L.J., Ashby, M., et al. (2006). Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: A systematic review. Palliative Medicine, 20(7), 693701.
Julião, M. (2014). Eficácia da terapia da dignidade na patologia psicossocial de doentes seguidos em Cuidados paliativos: Ensaio clínico aleatorizado e controlado [in Portuguese] . Doctoral dissertation. Lisbon: Faculdade de Medicina da Universidade de Lisboa.
Julião, M. (2015). Human dignitas, dignity in care: A precious need, International Journal of Emergency Mental Health and Human Resilience, 17(3), 598599. Available from
Julião, M., Barbosa, A., Oliveira, F., et al. (2013 a). Efficacy of dignity therapy for depression and anxiety in terminally ill patients: Early results of a randomized controlled trial. Palliative & Supportive Care, 11(6), 481489. Epub ahead of print Mar 19.
Julião, M., Barbosa, A., Oliveira, F., et al. (2013 b). Prevalence and factors associated with desire for death in patients with advanced disease: Results from a Portuguese cross-sectional study. Psychosomatics, 54(5), 451457. Epub ahead of print Mar 7.
Julião, M., Oliveira, F., Nunes, B., et al. (2014). Efficacy of dignity therapy on depression and anxiety in Portuguese terminally ill patients: A phase II randomized controlled trial. Journal of Palliative Medicine, 17(6), 688695. Epub ahead of print Apr 15.
Julião, M., Nunes, B. & Barbosa, A. (2016). Prevalence and factors associated with demoralization syndrome in patients with advanced disease: Results from a cross-sectional Portuguese study. Palliative & Supportive Care, 14(5), 468473. Epub ahead of print Jan 6.
Kissane, D.W., Clarke, D.M. & Street, A.F. (2001). Demoralization syndrome: A relevant psychiatric diagnosis for palliative care. Journal of Palliative Care, 17(1), 1221.
Mystakidou, K., Rosenfeld, B., Parpa, E., et al. (2005). Desire for death near the end of life: The role of depression, anxiety, and pain. General Hospital Psychiatry, 27(4), 258262.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed