Demoralization affects quality of life in terminal cancer patients in palliative care

Objective: Demoralization implies a persistent inability to cope with a stressful situation and is characterized by feelings of hopelessness and helplessness due to loss of purpose and meaning in life. Although years of research have demonstrated its clinical importance, there are few studies that deepen the relationship between demoralization and health-related quality of life (HRQoL) in terminal cancer patients in palliative care. The aim of this study is to specifically examine the prevalence of demoralization in a sample of terminally ill cancer patients and assess its independent effect on patients' HRQoL, controlling for other clinical and psychological variables. Methods: Data were collected from 372 terminal cancer patients undergoing palliative care. The Edmonton Symptom Assessment System (ESAS) for symptoms of palliative care patients, the Hospital Anxiety and Depression Scale (HADS) for psychological distress, the Functional Assessment of Cancer Therapy Scale - General Measure (FACT-G) for HRQoL and the Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being for spirituality (FACIT-Sp) were used. In addition, Demoralization was assessed using the Demoralization Scale ‐ Italian version (DS‐IT). Results: According to the DS-IT, 48.4% of the recruited terminal cancer patients were severely demoralized, and 13.7% showed moderate demoralization. Demoralization was strongly correlated with HRQoL, which was severely impaired (mean FACT-G (SD) = 53.52 (14.7)). The regression analysis showed that psychological distress (HADS: β = -0.42, p<.001), as well as "Disheartenment" (β = -0.21, p<.001) and “Sense of Failure” (β = -0.11, p=.003) subscales of the DS-IT were the strongest contributors for HRQoL, followed by the "Dysphoria" subscale (β = -0.07, p=.034) of the DS-IT and the “Appetite” (β = -0.09, p=.012), “Lack of Well-Being” (β = -0.08, p=.032), and “Drowsiness” (β = -0.07, p=.035) subscales of the ESAS, with the final model explaining 70% of the variance of the FACT-G. Conclusions: The results of the present study highlight the presence of high levels of demoralization in terminal cancer patients and show that psychological distress and demoralization are the main independent negative factors affecting HRQoL in these patients. From a clinical perspective, the high prevalence and impact on HRQoL highlight the need to adequately assess demoralization and psychological distress in terminal cancer patients and to identify psychological interventions that focus on preventing existential distress and thus improve the quality of life of dying patients and accompany them until the end of life.